[House Hearing, 118 Congress]
[From the U.S. Government Publishing Office]


                      LIKE FIRE THROUGH DRY GRASS:
                       NURSING HOME MORTALITY AND
                           COVID-19 POLICIES
=======================================================================

                                HEARING

                               BEFORE THE

                      SELECT SUBCOMMITTEE ON THE 
                          CORONAVIRUS PANDEMIC

                                 OF THE

               COMMITTEE ON OVERSIGHT AND ACCOUNTABILITY

                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED EIGHTEENTH CONGRESS

                             FIRST SESSION

                               __________

                              MAY 17, 2023

                               __________

                           Serial No. 118-33

                               __________

  Printed for the use of the Committee on Oversight and Accountability
  
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]  


    Available on: govinfo.gov, oversight.house.gov or docs.house.gov
    
                               __________
                               
                        U.S. GOVERNMENT PUBLISHING OFFICE
52-243 PDF                      WASHINGTON : 2026
=======================================================================
    
               COMMITTEE ON OVERSIGHT AND ACCOUNTABILITY

                    JAMES COMER, Kentucky, Chairman

Jim Jordan, Ohio                     Jamie Raskin, Maryland, Ranking 
Mike Turner, Ohio                        Minority Member
Paul Gosar, Arizona                  Eleanor Holmes Norton, District of 
Virginia Foxx, North Carolina            Columbia
Glenn Grothman, Wisconsin            Stephen F. Lynch, Massachusetts
Gary Palmer, Alabama                 Gerald E. Connolly, Virginia
Clay Higgins, Louisiana              Raja Krishnamoorthi, Illinois
Pete Sessions, Texas                 Ro Khanna, California
Andy Biggs, Arizona                  Kweisi Mfume, Maryland
Nancy Mace, South Carolina           Alexandria Ocasio-Cortez, New York
Jake LaTurner, Kansas                Katie Porter, California
Pat Fallon, Texas                    Cori Bush, Missouri
Byron Donalds, Florida               Jimmy Gomez, California
Kelly Armstrong, North Dakota        Shontel Brown, Ohio
Scott Perry, Pennsylvania            Melanie Stansbury, New Mexico
William Timmons, South Carolina      Robert Garcia, California
Tim Burchett, Tennessee              Maxwell Frost, Florida
Marjorie Taylor Greene, Georgia      Becca Balint, Vermont
Lisa McClain, Michigan               Summer Lee, Pennsylvania
Lauren Boebert, Colorado             Greg Casar, Texas
Russell Fry, South Carolina          Jasmine Crockett, Texas
Anna Paulina Luna, Florida           Dan Goldman, New York
Chuck Edwards, North Carolina        Jared Moskowitz, Florida
Nick Langworthy, New York
Eric Burlison, Missouri

                                 ------                                

                       Mark Marin, Staff Director
             Mitchell Benzine, Subcommittee Staff Director
                        Marie Policastro, Clerk

                      Contact Number: 202-225-5074

                Miles Lichtman, Minority Staff Director
                                 ------                                

            Select Subcommittee on the Coronavirus Pandemic

                     Brad Wenstrup, Ohio, Chairman

Nicole Malliotakis, New York         Raul Ruiz, California, Ranking 
Mariannette Miller-Meeks, Iowa           Minority Member
Debbie Lesko, Arizona                Debbie Dingell, Michigan
Michael Cloud, Texas                 Kweisi Mfume, Maryland
John Joyce, Pennsylvania             Deborah Ross, North Carolina
Marjorie Taylor Greene, Georgia      Robert Garcia, California
Ronny Jackson, Texas                 Ami Bera, California
Rich Mccormick, Georgia              Jill Tokuda, Hawaii
                         
                         C  O  N  T  E  N  T  S

                              ----------                              

                           OPENING STATEMENTS

                                                                   Page

Hon. Brad Wenstrup, U.S. Representative, Chairman................     1

Hon. Raul Ruiz, U.S. Representative, Ranking Member..............     3

                               WITNESSES

Ms. Janice Dean, Family Member of COVID-19 Nursing Home Victim, 
  Fox News Senior Meteorologist
Oral Statement...................................................     5

Mr. Bill Hammond, Senior Fellow for Health Policy, Empire Center
Oral Statement...................................................     7

Ms. Vivian Zayas, Co-Founder, Voices for Seniors
Oral Statement...................................................     9

Dr. David Grabowski, Professor of Health Care Policy, Harvard 
  Medical School
Oral Statement...................................................    10

Written opening statements and the written statements of the 
  witnesses are available on the U.S. House of Representatives 
  Document Repository at: docs.house.gov.

                           INDEX OF DOCUMENTS

Documents entered into the record during this hearing are listed 
  below.

  * Article, CNN, ``Nursing Homes Receive Defective Equipment As 
  Part of Trump Administration Supply Initiative''; submitted by 
  Rep. Raskin.

  * Article, Daily News, ``Still Looking for Answers on COVID''; 
  submitted by Rep. Malliotakis.

Documents are available at: docs.house.gov.

 
                      LIKE FIRE THROUGH DRY GRASS:
                       NURSING HOME MORTALITY AND
                           COVID-19 POLICIES

                              ----------                              


                        WEDNESDAY, MAY 17, 2023

                        House of Representatives

               Committee on Oversight and Accountability

            Select Subcommittee on the Coronavirus Pandemic

                                                   Washington, D.C.

    The Select Subcommittee met, pursuant to notice, at 10 
a.m., in room 2247, Rayburn House Office Building, Hon. Brad 
Wenstrup [Chairman of the Select Subcommittee] presiding.
    Present: Wenstrup, Comer, Malliotakis, Lesko, Joyce, 
Jackson, McCormick, Ruiz, Raskin, Dingell, Ross, Garcia, Bera, 
and Tokuda.
    Dr. Wenstrup. The Select Subcommittee on the Coronavirus 
Pandemic will come to order. I want to welcome everyone.
    Without objection, the Chair may declare a recess at any 
time.
    I ask unanimous consent for Ms. Stefanik to participate in 
this hearing for the purposes of questions.
    I now recognize myself for the purpose of making an opening 
statement.

          OPENING STATEMENT OF CHAIRMAN BRAD WENSTRUP

                    REPRESENTATIVE FROM OHIO

    Today the Select Subcommittee is holding a hearing to 
examine the disastrous must-admit orders that states, namely 
New York, New Jersey, and Pennsylvania, issued mandating 
nursing home residents admit COVID-positive patients back from 
the hospital. Throughout my medical career, I treated many very 
serious infections, usually very vulnerable patients with 
serious comorbidities. The very idea of placing infected, 
contagious patients in a facility with uninfected vulnerable 
patients troubles me deeply, especially when other more viable 
options were available. These must-admit orders led to the 
deaths of tens of thousands of elderly Americans. We hope this 
hearing is step one to providing accountability for the 
thousands of American families seeking answers.
    It quickly became evident that COVID-19 was especially 
dangerous for the elderly. There was a thousandfold higher risk 
of poor outcomes, specifically hospitalization and death, for 
older people relative to younger populations. It also became 
clear that individuals with preexisting comorbidities were at 
an increased risk. Therefore, it was critically important that 
the public health response prioritize these high-risk 
populations to reduce their risk of infection.
    This was understood by the Centers for Medicaid and 
Medicare Services and the Centers for Disease Control and 
Prevention, who put forth guidance consistent with these 
priorities. On March 13, 2020, CMS issued guidance that 
specifically directed nursing homes to only accept COVID-19-
positive patients if they were able to do so safely, and only 
if the nursing homes could properly follow CDC isolation and 
quarantine guidance. This science-based guidance aimed to keep 
COVID-19 out of nursing homes as much as possible. It intended 
to prevent the at-risk elderly population from exposure to a 
highly transmissible virus, and it was designed to avoid 
infections, hospitalizations, and deaths among the most 
vulnerable population.
    While many states followed these guidelines, states such as 
New York, New Jersey, and Pennsylvania, imposed mandates 
directly contrary to this guidance. These states instead 
implemented must-admit orders that effectively required nursing 
homes and long-term care facilities to admit COVID-19-positive 
patients, regardless of the homes' ability to protect their 
patients. These orders unjustifiably exposed America's most 
vulnerable to COVID-19 with predictable and deadly 
consequences.
    Prior to issuing New York's must-admit order, then Governor 
Andrew Cuomo said, ``For nursing homes, this could be like fire 
through dry grass.'' He was seemingly quite aware of the risks. 
According to the most recent available data, New York suffered 
more than 15,000 nursing home deaths as a result of COVID-19. 
Pennsylvania suffered more than 12,500 nursing home deaths, and 
New Jersey suffered more than 9,000 nursing home deaths. Of 
that, more than 200 veterans at state-run veterans' homes in 
New Jersey died as a result of COVID-19, including 89 at a 
single veterans' home in Paramus, New Jersey in what has been 
described as a horror show.
    In Andover, New Jersey, authorities discovered that a 
nursing home was storing 17 bodies in a makeshift morgue. These 
were fathers, mothers, uncles, aunts, brothers, sisters, 
grandpas, and grandmas. They deserved better from our public 
health authorities and from our politicians. They and their 
families were failed by these deadly must-admit orders. 
Unfortunately, it is clear that decision-making by politicians, 
not science or scientists, was responsible for these misguided 
decisions. Science never supported must-admit orders. Science 
did not support rejecting the Federal Government's help.
    The Trump Administration sent the United States naval ship, 
Comfort, and transformed the Javits Center to address capacity 
issues at New York City hospitals. However, Governor Cuomo 
failed to use these facilities at the expense of overwhelmed 
hospital systems. Why? Why did he fail to take advantage of the 
resources offered? Science certainly did not lead state 
officials to fraudulently conceal and cover up the number of 
nursing home deaths in their respective states.
    We learned that Governor Cuomo knew that the must-admit 
order was wreaking havoc on nursing homes throughout New York, 
and so his Administration froze the state's nursing home deaths 
data. In an investigative report on COVID-19 nursing home 
policies, New York State Attorney General Letitia James found 
that the Cuomo Administration underreported the number of 
COVID-19 deaths by approximately 50 percent. Was this done by 
design to not only avoid accountability from the Department of 
Justice but to escape political accountability from the 
American people? My father used to say to me, I do not care 
what you did wrong, but if you lie to me, you are in much more 
trouble.
    Finally, science did not support threatening retaliation 
against one's political enemies. Governor Cuomo threatened to 
destroy New York State Assemblyman Ron Kim, whose uncle died in 
a New York nursing home, for not participating in this 
seemingly fraudulent scheme to conceal the true nursing home 
data. Unlike Governor Cuomo's COVID-19 response, this Select 
Subcommittee was not created to score political points nor to 
sell books, and we owe it to the victims' families to hold 
those who implemented these deadly, deadly mandates 
accountable. And the public officials who engaged in political 
cover ups and manipulated mortality rates for political 
expediency, they must answer to the American people.
    We are not here to Monday morning quarterback or to negate 
the difficulty of decisionmaking during an unprecedented 
pandemic, but once science is clear, those who made wrong 
decisions must be held accountable. We are holding this hearing 
today to look back to help prepare for a future pandemic, to 
determine what went wrong, to recommend how to do it better, to 
ensure that future health policy decisions are based on 
scientific facts, not political calculations. And I suspect 
today we will talk about how changes have been made and suggest 
better ways going forward. That is appreciated. However, we 
must identify wrongdoing and hold people accountable. 
Otherwise, it will happen again, and victims and their families 
will never feel whole again.
    I look forward to a strong on-topic discussion today. I 
would now like to recognize Ranking Member Ruiz for the purpose 
of making an opening statement.

         OPENING STATEMENT OF RANKING MEMBER RAUL RUIZ

                 REPRESENTATIVE FROM CALIFORNIA

    Dr. Ruiz. Thank you, Mr. Chairman. First, let me begin by 
thanking you, Ms. Dean and Ms. Zayas, for being here today. I 
am deeply sorry for your losses. Any death due to COVID-19 is a 
tragedy, and my heart is with you and the families of the 
200,000 residents and staff of long-term care facilities across 
the country who perished during the pandemic.
    Three years ago, a novel, deadly, highly transmissible 
airborne virus took hold, and while we knew little about COVID-
19 and its long-term impacts on human health at the time, we 
did know that our Nation's seniors were amongst our most 
vulnerable when it comes to suffering severe illness and death. 
So, as COVID-19 swept the country and the Federal response to 
the virus faltered under President Trump, states were forced to 
grapple with an unfamiliar public health threat, and, yes, 
policy missteps were made.
    On March 4, 2020, the Centers for Medicare and Medicaid 
Services issued guidance permitting nursing homes to admit and 
readmit COVID-19-positive patients, but only if the nursing 
home could do so safely, following protocols to prevent 
transmissions among residents and staff. However, in an attempt 
to relieve hospital strain in a time of crisis, states like New 
York went beyond this guidance, requiring nursing homes to 
reopen their doors to COVID-positive patients with must-admit 
orders, regardless of safety and capacity to follow guidance 
and protocols. And as a physician, I disagree with that.
    Now, as COVID-19 hospitalizations and deaths have decreased 
exponentially, thanks to the availability of vaccines and 
improved therapeutics, we must build better policies that will 
save lives and prevent harm in the event of another pandemic. 
As Members of this Select Subcommittee, we must develop 
forward-looking policies that promote transparency in data and 
strengthen protections in nursing homes to mitigate current and 
future threats.
    So, we do need to take a look back at our nursing homes. 
Where were we when the pandemic started? Where were we during 
the pandemic with our nursing homes preparedness? We must also 
look to rehabilitate nursing home systems weakened by the 
previous administration's efforts to roll back regulations that 
established guardrails for quality of care and staffing levels, 
leaving those facilities under-resourced and under-prepared to 
combat a deadly virus.
    For example, in July 2019, seven months before the pandemic 
took hold, the Trump Administration's proposed deregulation of 
onsite infection control resulted in facilities cutting 
corners, assigning already overworked nurses to take on 
responsibilities intended for infection control specialists. At 
the same time, the previous administration proposed loosening 
standards to review patient care needs, reduced consequences 
for nursing home regulation violators, and lifted protections 
for residents and families to take legal action in the event of 
mistreatment.
    What is more, the Trump Administration's prolonged failure 
to secure adequate personal protective equipment (PPE) and 
testing kits led to increased transmission in both nursing 
homes and their surrounding communities. For example, a 2021 
National Institutes of Health (NIH) study found that nursing 
homes in the same communities that experienced high rates of 
infection saw extreme shortages in rapid COVID-19 testing. The 
deregulation or removal of protections of the nursing home 
industry, coupled with shortages in COVID-19 tests and PPE, 
were also missteps and contributed to devastatingly high rates 
of nursing home deaths throughout the country, as high as 
nearly one out of every 50 residents at the peak of the 
pandemic, according to AARP.
    So, when the next pandemic rolls around, we must ensure 
that our Nation's nursing homes and long-term care facilities 
are fully equipped to respond to and reduce transmission of a 
deadly novel virus. This means identifying real solutions now 
that will prevent harm and save lives in the future. We cannot 
allow overwhelmed healthcare staff to be left behind, and we 
must adequately equip them with the resources they need to 
provide quality care and services to their patients.
    Under President Biden's leadership, we have taken 
meaningful steps toward this goal. This includes reinstating 
enforcement of Federal nursing home standards, improving 
inspection, and strengthening our healthcare workforce, and let 
us not forget successfully and efficiently delivering 
lifesaving vaccines to our most vulnerable populations, 
significantly reducing the death rate among nursing home 
residents.
    Now, there is still much more work to do, so let us make 
sure we are sufficiently investing in skilled nursing home 
staff and infection control measures, keeping in place 
protections, and let us hold to account those bad actors in the 
nursing home industry who skirted regulations and fueled the 
alarming death toll we experienced during the height of the 
pandemic. We can all agree that we can and must do better, and 
I am confident that if we work together, we can identify 
commonsense bipartisan solutions that put people over politics, 
save lives, and right the wrongs that caused so much suffering 
in this pandemic. Thank you, and I yield back.
    Dr. Wenstrup. Thank you. Our witnesses today are Ms. Janice 
Dean. Ms. Dean joined Fox News Channel in January 2004, where 
she currently serves as a senior meteorologist for the network. 
Both of her in-laws passed in New York nursing homes during the 
pandemic. We express our sympathies to you. Mr. Bill Hammond: 
Mr. Hammond is a senior fellow for health policy at the Empire 
Center in New York. Before joining the Empire Center, Mr. 
Hammond spent almost three decades in journalism. Ms. Vivian 
Zayas: Ms. Zayas is a co-founder of Voices of Seniors. She is a 
mom of six. She unfortunately lost her mother in a New York 
nursing home and has since become an advocate. Again, we 
express our sympathies. Dr. David Grabowski: Dr. Grabowski is a 
professor of health policy at Harvard Medical School, where he 
studies long-term care and post-acute care.
    Pursuant to Committee on Oversight and Accountability Rule 
9(g), the witnesses will please stand and raise their right 
hands.
    Do you solemnly swear or affirm that the testimony that you 
are about to give is the truth, the whole truth, and nothing 
but the truth, so help you God?
    [A chorus of ayes.]
    Dr. Wenstrup. You may be seated. Thank you. Let the record 
show that the witnesses all answered in the affirmative.
    The Select Subcommittee certainly appreciates you all for 
being here today, and we know this is difficult, and we look 
forward to your testimony.
    Let me remind the witnesses that we have read your written 
statements, and they will appear in full in the hearing record. 
Please limit your oral statements to 5 minutes. As a reminder, 
please press the button on the microphone in front of you so 
that it is on and the Members can hear you. When you begin to 
speak, the light in front of you will turn green. After 4 
minutes, the light will turn yellow. When the red light comes 
on, your five minutes has expired, and we would ask that you 
please wrap up.
    I now recognize Ms. Dean to give an opening statement.

                    STATEMENT OF JANICE DEAN

         FAMILY MEMBER OF COVID-19 NURSING HOME VICTIM

               AND FOX NEWS SENIOR METEOROLOGIST

    Ms. Dean. Good morning, Chairman Wenstrup, Ranking Member 
Ruiz, and the Members of the Select Subcommittee on the 
Coronavirus Pandemic. Thank you for inviting me to testify 
today on the horrific, preventable tragedy that unfolded in 
elder care facilities in the spring of 2020 that took the lives 
of over 16,000 seniors in New York State, including my 
husband's parents.
    Mickey and Dee Newman were married for almost 60 years. 
They lived in the same four-story walk-up in Brooklyn for 
decades where they raised three children--Donna, Michael, and 
Sean. Mickey was in the US Air Force and joined the fire 
department of the city of New York, serving for 23 years in 
Engine Company 323 in Brooklyn. Dee was a devoted wife, a 
mother, and a grandmother, and worked at the local dentist's 
office part time. She never missed a birthday or an 
anniversary, and there are still days where my husband has the 
urge to call her on his way home from work, which was part of 
his daily routine.
    Before the pandemic, Mickey had a series of health issues. 
He was in a nursing home for rehab to get into better shape 
before he could join his wife, Dee, in an assisted living 
residence, and then came COVID-19. Sean got a call in the late 
morning at the end of March 2020 and was told that his dad was 
not doing well. He had a fever. His breathing was labored. 
Three hours later, he was dead. Sean had to break the news on 
the phone to his mom in lockdown that her husband died. It was 
the hardest thing he has ever had to do.
    My husband saw his mom once in early April after that to 
bring her some flowers. He could not pass the front desk. He 
saw her in the lobby for only one to two minutes standing ten 
feet away with a mask on. He told her he loved her, and she 
started to cry before he left. He would never see her again. A 
few days later, Dee's health went downhill. She was moved to 
the hospital, tested immediately, and diagnosed with COVID-19. 
The last time Sean spoke to his mother, she told him her throat 
was raw. She had trouble breathing. Despite her ill health, her 
final words were to ask him to buy Easter presents for her 
grandkids and to please write her name on the card. A nurse 
called us the next day to tell us she was in and out of 
consciousness. The next day, she died.
    Our grief and our confusion turned to anger in the days and 
weeks afterward when we learned how elder care homes were 
turned into death traps. Over 9,000 COVID-positive patients 
were piled into facilities for 46 days, and no one told the 
families. Three years later, we still do not know why. Our 
former disgraced Governor, Andrew Cuomo, said more than once 
that COVID inside of nursing homes would spread like fire 
through dry grass. He knew the elderly were the most 
susceptible, and yet he let it happen. He lit the match, and he 
set the fire.
    All of us here today would like to know the origins of 
where the March 25th order came from and why nursing homes were 
prohibited to test incoming patients. It is also worth 
mentioning that while care homes could not have access to 
tests, Andrew Cuomo's friends and family were secretly able to 
secure tests and use state resources to quickly find out the 
results.
    The other question we have never had answered is why were 
not the facilities provided by the Federal Government ever 
used. There were thousands of empty beds in the Jacob Javits 
Center, the USS Comfort ship, and other several ad-hoc 
hospitals, while nursing homes were packed with sick people. It 
was recently revealed that a U.S. Navy admiral on board the 
Comfort ship ``begged the Cuomo Administration'' to send 
patients to the nearly empty hospital ship docked on the Hudson 
River during the height of the pandemic, but instead of 
helping, ``His pleas were met with politics and paranoia.'' 
Many could not see their loved ones before they died or have 
wakes and funerals.
    Instead of doing his job to protect our families, the 
former disgraced Governor was busy getting his staff to write a 
$5.1 million book with various awards, including an Emmy, and 
blaming everything and everyone else for the mistakes that he 
made. He likes to say our advocacy is political, but not one 
grieving family I have met here has told me who they vote for. 
All we have ever wanted was to have a fair, bipartisan 
investigation into why so many of our elderly died painfully 
and alone.
    The death toll in our senior living facilities in New York 
alone is bigger than September 11th and Hurricane Katrina 
combined. There have been hearings and accountability for both 
those tragic events. Why is this any different? And as much as 
I am grateful to be invited here today, having hearings alone 
will not bring justice. We need to learn from this tragedy, to 
turn our grief into purpose, and find out what happened to our 
parents and our grandparents, who trusted us and our leaders to 
protect them. Thank you.
    Dr. Wenstrup. Thank you, Ms. Dean. I now recognize Mr. 
Hammond to give an opening statement.

                   STATEMENT OF BILL HAMMOND

           SENIOR FELLOW HEALTH POLICY, EMPIRE CENTER

    Mr. Hammond. Thank you. Good morning. Thanks for the 
opportunity to testify. We are here today to talk about a 
mistake--I do not know how you want to characterize it--but it 
came to symbolize the worst aspects of the response in New York 
and even nationwide. Obviously, it is about an order that 
compelled nursing homes to accept COVID-positive patients. Even 
viewed in the best light, this was an act of desperation. The 
state had just gone into lockdown. The hospitals were filling 
up. Some projections indicated they might become overwhelmed, 
and so state officials, in effect, were trying to avert a 
crisis in the hospitals by creating a crisis in nursing homes, 
where they knew residents were acutely vulnerable.
    This episode needs to be closely investigated for a number 
of reasons. As you have just heard, thousands of families have 
a legitimate reason to wonder whether their loved one died as a 
result of a government action, but also, we need to understand 
how it occurred so that we can make sure it does not happen 
again, so that future officials will have better options in 
front of them in a similar situation, or maybe just to prevent 
that similar situation from happening.
    During the 46 days this policy was in effect, 9,000 
patients transferred from hospitals to nursing homes. Most of 
them were new admissions. Most of them were not going back to a 
nursing home where they had been before. These transfers were 
probably not the only source and certainly not the only source 
of COVID nursing homes, but they made a bad situation worse. An 
analysis by my colleague, Ian Kingsbury, and I found a 
statistically significant correlation between the number of 
patients transferred and higher mortality rates in the nursing 
homes that accepted them. According to our analysis, the policy 
was associated with several hundred and possibly more than 
1,000 additional resident deaths. The directive tragically also 
appears to have been unnecessary. Although hospitals were 
filling up, they never became as overwhelmed as some of the 
projections indicated, and the system never fully ran out of 
beds, and these alternative facilities, such as the Javits 
Center and the U.S. naval ship, remained largely empty.
    This was part of a chain of policy failures that led to the 
situation. Like most states, New York had not adequately 
prepared for the pandemic. It did not have an action plan, for 
example, for what to do when hospitals filled up during an 
outbreak of infectious disease. It did not have an adequate 
stockpile of PPE. It did not have the tools to know when the 
outbreak had started, which was probably in early February. And 
so, all of that slow downed the state's response and led to a 
situation in late March where the situation appeared to be out 
of control, and officials really had no idea how bad it was and 
how much worse it could get. And that is the context in which 
the Cuomo Administration made this decision.
    They compounded things. Once the decision became known to 
the public, which took a few weeks, and once it became the 
subject of some criticism and controversy, they compounded 
their original mistake by engaging in a cover-up. They pulled 
the directive off the web so that it was not available for the 
public to read. They misstated how it had worked. They 
misstated how it related to Federal policy. They made it sound 
like it was completely consistent to Federal policy when it 
differed in key respects. In particular, their policy did not 
talk about the importance of infection control, and, as the 
Chairman mentioned, they did not talk about how important it 
was to, say, for example, isolate these patients in separate 
wings or floors.
    Also, they said that this really was optional. It sounded 
imperative, but it was actually optional because of a 
regulation the state had that said nursing homes should never 
accept a patient that they cannot handle. It turns out that the 
Governor had suspended that exact regulation seven days before 
he issued the order. Finally, and maybe worst of all in this 
cover-up, they understated the number of deaths. When they 
finally came clean with the full data, which was in response to 
a lawsuit brought by my organization, the number was closer to 
15,000, which is 6,000 more than they had previously 
acknowledged.
    This pandemic, in addition to the tragic deaths in nursing 
homes, it cost millions of lives. It cost trillions of dollars. 
We need to be excavating every mistake, like this mistake, and 
understanding how they play together and preparing for the next 
virus, which we know is coming, and the time to do that is not 
when the next virus arrives. The time to do it is now. Thank 
you.
    Dr. Wenstrup. Thank you, Mr. Hammond. I now recognize Ms. 
Zayas to give an opening statement.

                   STATEMENT OF VIVIAN ZAYAS

                 CO-FOUNDER, VOICE FOR SENIORS

    Ms. Zayas. Chairman Wenstrup, Ranking Member Ruiz, and the 
Members of this Committee, thank you for the invitation to 
testify before the Select Committee on the Coronavirus 
Pandemic. I wanted to first say thank God and the Members of 
this Committee for these 5 minutes that I have this morning to 
share my family story, which echoes that of thousands of 
others.
    Three years ago or so goes by really quickly, except when 
you are grieving. For many, it has been over 1,141 days of 
seeking answers into why our mothers and fathers or other loved 
ones met their fate in the manner they did. We often think of 
nursing homes as places where people or old people go to die. 
However, this is not always the case. There are many patients 
in short-term rehabilitation, such as young people recovering 
from gunshot wounds, or a car accident, or other debilitating 
illnesses, or otherwise healthy individuals recovering from 
routine surgeries or minor injuries. My mother, Ana Martinez, a 
physically, mentally, and emotionally strong woman in her 70s, 
developed arthritis. It was aggressive and hampered her quality 
of life. Following doctor's orders, in our due diligence, she 
underwent knee replacement surgery. Her first surgery, she was 
scared but she was reassured that it was routine and she would 
quickly recover after some physical therapy. After the surgery, 
we were full of expectation that we would see our mother in her 
kitchen again cooking her amazing dishes.
    Our mother was in the midst of recovery at home post-
surgery when she developed a cyst. After treatment at a local 
hospital, she was sent to a nearby nursing home rehab facility 
to receive inpatient physical therapy. It was expected that she 
would gain strength and return home soon. A minor wound lead my 
mom down a path into a nursing home from which she would never 
return. Our daily visits to the nursing home came to an abrupt 
end in the March 2020 when the facility called to notify us 
that all visitation would be suspended for approximately two 
weeks. We never saw our beautiful mother again. She was dead 
shortly after.
    Gasping for air alone, confused, and scared, without her 
daughters who were her translators and caregivers, she could 
not tell us anything was wrong or that she was exposed to 
COVID-19 because she was also kept in the dark. Like many other 
families, nursing homes kept them in the dark as well, never 
telling us that they were admitting COVID-positive patients at 
the insistence of Governor Cuomo. We also had no idea that the 
nursing home failed to have proper policies in place to deal 
with contagious disease.
    Our initial inquiries to our local legislators requesting 
an investigation into the factors that contributed to the death 
of our loved ones were met with roadblocks, vitriol, and 
partisan accusations. That was extremely troubling since my 
mother, a Puerto Rican woman, who, along with most of our 
family, were lifelong Democrats. How could those recovering 
from surgery or the immuno-compromised be locked in a facility 
with a deadly contagion, especially in the care homes riddled 
with complaints and historical violations of not adequately 
following infectious disease protocols?
    In addition to the lockdown policies, they allowed a 
perfect environment for neglect and abuse to run amuck out of 
sight of family and caregivers. If these were not all painful 
enough, out of nowhere, the Governor of New York used his 
powers to give nursing homes legal immunity for their 
negligence, allowing facilities to get away with causing 
needless death due to poor care. We only slowly became aware of 
the behind-the-scenes politics that the nursing home owners 
were the Governor's largest donors.
    Soon after the death of our mother and in a search for 
answers, we found a community of families who shared their 
tragic stories by the hundreds. We formed Voices for Seniors to 
give seniors and their long-term care residents a voice. Other 
daughters and sons, heartbroken by the untimely deaths of their 
parents, such as the Alvino family, who lost her beloved father 
and husband Daniel, to COVID in a rehab facility after neck 
surgery; or John Daly, a loved husband and father and 
grandfather, who no one helped him eat and debilitated prior to 
succumbing to COVID-19; or Robert Nieves, a veteran whose last 
words were, ``I am afraid;'' or Carmela Abbondanzo, who was 
found dead in her bed during a routine nursing call, and 
countless others that my heart cannot bear to recount.
    Being an advocate for the elderly and others who reside in 
long-term care facilities has been a feat more difficult than 
we could have ever imagined, especially when everything is a 
partisan football. We will not let our loved ones die in vain, 
and we will not let this be swept under the rug due to 
politics. When will we see the elderly community elevated to a 
position of dignity and respect that they most certainly 
deserve? Will we see a deep and thorough investigation into all 
the factors that led to this tragedy, both the ones who lit the 
match and those that allowed it to burn? We truly thank you for 
holding this hearing this morning, and we truly and sincerely 
hope that no stone will be left unturned to get down to every 
cause and effect that led to the pain and devastation inflicted 
on so many.
    Now I will address the Hispanic community really briefly.
    [Speaking foreign language.]
    Thank you again.
    Dr. Wenstrup. Muchas gracias, Ms. Zayas.
    Ms. Zayas. Denada.
    Dr. Wenstrup. I now recognize Dr. Grabowski to give an 
opening statement.

                STATEMENT OF DR. DAVID GRABOWSKI

                PROFESSOR OF HEALTH CARE POLICY

                     HARVARD MEDICAL SCHOOL

    Dr. Grabowski. Thank you. Chairman Wenstrup, Ranking Member 
Ruiz, and distinguished Members of the House Select 
Subcommittee, thank you for the opportunity to testify today on 
this important topic. I am here today speaking in my capacity 
as a professor of healthcare policy at Harvard Medical School 
who has studied nursing home care for 25 years. This is 
actually my third time testifying to this Subcommittee on the 
issue of nursing home and COVID. The first time was back on 
June 11th, 2020.
    As part of my remarks that day, I said, ``A key point I 
wish to emphasize is that much of the impact of COVID in 
nursing homes could have been avoided with increased Federal 
leadership, resources, and attention. Rather than prioritizing 
the safety of the 1.3 million individuals that live in nursing 
homes and the staff that care for them, the Federal Government 
has chosen to push the logistics and costs off to the states 
and the nursing homes. By failing to invest in testing, 
personal protective equipment, and the workforce, the Federal 
Government has allowed a problem that started in a single 
nursing home in Kirkland, Washington, to grow into a national 
crisis.'' Three years later, I stand by that statement 
completely. I am not letting nursing home, local, or state 
leaders off the hook. They deserve blame, too, yet more than 
any other entity, our Federal Government failed our nursing 
home residents and their caregivers back in 2020 at the start 
of the pandemic.
    Looking back, COVID completely devastated nursing homes in 
the United States. To date, there have been over 1.6 million 
COVID cases among residents, leading to roughly 176,000 COVID-
related fatalities. Over 3,200 nursing home staff members have 
died from COVID, making nursing home worker the most dangerous 
job in America. Not surprisingly, staff employment levels are 
still down by seven to nine percent relative to their pre-
pandemic levels.
    A key question in directing policy resources is determining 
what factors were associated with COVID-19 outbreaks in nursing 
homes. In a systematic review of 36 peer-reviewed studies, our 
research team concluded that COVID outbreaks were largely a 
function of where you were located versus who you were as a 
facility. This does not suggest there was nothing that could 
have been done to prevent COVID outbreaks. Rather, it suggests 
that Federal policymakers needed to adopt a system-level 
approach to address this problem. It is not too late. There are 
several short-run and long-run reforms that can support nursing 
home residents and their caregivers.
    In the short term, I am supportive of the reforms put 
forward by the Administration in terms of increasing ownership 
and financial transparency and minimum staffing standards. 
However, I would categorize these reforms as necessary but not 
sufficient. We also need to continue to ensure that more 
nursing home residents and staff receive their booster doses. 
Currently, less than one-fourth of nursing home staff are up to 
date with their vaccinations.
    Moving forward, we need transformative system-level 
reforms. I recently served on a National Academies of Sciences, 
Engineering, and Medicine Committee, which offered a roadmap 
forward for these longer-term reforms. The National Academies 
report provides a strategy to move toward a Federal long-term 
care benefit that provides adequate financial coverage of 
comprehensive nursing home care. Medicaid currently plays a 
dominant role as the default player of nursing home care, but 
eligibility is limited by income and asset tests and is 
constantly subject to state budget constraints.
    Too many nursing home corporations use complex ownership 
structures to siphon dollars away from resident care. To 
increase financial transparency and accountability by nursing 
homes, policymakers must collect, audit, and make available 
detailed facility-level data on the finances, operations, and 
ownership of all nursing homes in real time in a readily usable 
data base. A more effective and responsive system of quality 
assurance is also needed for nursing homes. The survey process 
often fails to identify serious care problems, fully correct 
and prevent recurring problems, and investigate complaints in a 
timely manner.
    Moreover, CMS, which ultimately determines a facility's 
eligibility to participate in the program, does not provide 
sufficient oversight of or transparency in the survey process. 
As such, state survey agencies must be given adequate resources 
for increasing oversight of state survey performance and 
evaluating strategies to improve quality assurance activities.
    In summary, we have an opportunity today to begin to 
address problems that we have ignored for far too long. I look 
forward to working with the Members of this Committee on this 
effort. Thank you.
    Dr. Wenstrup. Thank you. I now recognize myself for 
questions. Dr. Grabowski, I do want to say thank you for your 
making suggestions of how to improve the situation going 
forward. Those will be taken into consideration for our report, 
along with other opinions as well. I will say one thing about 
you made it sound like mandatory boosting when I think that 
getting a booster should be based on the person's personal 
health. Let me give you an example.
    I was vaccinated, Pfizer, both doses, later got COVID. I 
did not know until I could not smell garlic salt, right? I was 
told I needed a booster to go to Germany. I could not get my T 
cells checked, but I got my antibodies checked. Strong number 
was 40. Mine was 821. We do run the risk of hyper-immune 
responses, so I think we have to inject personal medicine into 
each person as we decide whether someone should be boosted or 
not. That is just another medical opinion but certainly one 
that we can discuss further, but I just thought I would say 
that as I heard you say that, and I appreciate suggestions 
being made.
    But, Dr. Grabowski, was it known that COVID-19 was 
particularly dangerous to the elderly by March 2020?
    Dr. Grabowski. Yes. The first major outbreak was in 
Kirkland, Washington nursing home facility, so we immediately 
recognized how dangerous this could be for older adults.
    Dr. Wenstrup. Well, you answered my next question with the 
first outbreak. Should that have informed decisions regarding 
protecting nursing homes?
    Dr. Grabowski. Absolutely.
    Dr. Wenstrup. Yes, but a few states, particularly New York, 
New Jersey, Pennsylvania ignored this early evidence and 
directed nursing homes to admit potentially COVID-positive 
patients, regardless of the homes' ability to treat its 
patients. We heard that from Mr. Hammond as well today. As a 
physician, this is contrary to what we are taught, and so why 
is it a bad idea to intentionally introduce an infectious agent 
into a vulnerable population?
    Dr. Grabowski. So, nursing homes with older adults, frail, 
living in close quarters, if COVID starts in a nursing home, it 
is going to spread, and it is very hard to contain once you 
have an outbreak within a facility. And we saw that in 
Massachusetts where I live, New York, all over the country.
    Dr. Wenstrup. As someone who treated a lot of infections, I 
was always grateful when we were able to do, for example, home 
IV therapy for infections because it kept people away from a 
vulnerable population. Mr. Hammond, did Governor Cuomo say 
these were necessary to prevent overcrowding at hospitals?
    Mr. Hammond. I mean, eventually he said that. It was not 
discussed at one of his briefings at the time. It was not 
announced in any way. The nursing homes did not know it was 
coming until they received the memo.
    Dr. Wenstrup. And was Governor Cuomo given alternatives?
    Mr. Hammond. Well, he himself had put a lot of effort into 
building alternative overflow facilities. He received help from 
the Federal Government in building the facility at the Javits 
Center, and the Navy ship was also brought in.
    Dr. Wenstrup. So, in your opinion, were those facilities 
used to the extent that they could have been based on what you 
were able to investigate and see?
    Mr. Hammond. No. I mean, those facilities were used very 
little at all even during the worst of the crisis. I think it 
turned out that it was harder than officials realized to 
transfer patients. Once the facility was available, you still 
have to figure out who should be transferred and how they 
should be transferred. For example, the Navy ship, when it 
first arrived, it said we cannot take any COVID patients. That 
is a huge obstacle in the situation that was presented.
    So, they eventually got that changed, but even then you had 
logistical obstacles to moving patients. Those logistical 
obstacles are the kind of things we need to be thinking through 
now before we are in this similar situation.
    Dr. Wenstrup. Yes, I would agree. You are either taking all 
COVID patients or you are taking no COVID patients, allowing 
more room in the hospitals for non-COVID patients or for COVID 
patients. The Comfort only treated 182 patients, and the Javits 
only treated 1,095. Vice Admiral Mike Dumont pleaded with the 
Cuomo Administration to send patients. This was the Comfort's 
mission, to alleviate concerns related to overcrowding 
hospitals one way or another. Nonetheless, the Cuomo 
Administration failed to utilize this support. Ms. Dean, do you 
think politics was responsible for these Federal resources 
being wasted?
    Ms. Dean. Governor Cuomo liked to blame politics at every 
turn. That was the reason why people were talking about nursing 
homes, asking him the questions all the time. He had the 
resources and he failed to use them, and I think if we uncover 
where that March 25th order came from, who wrote it, I have my 
suspicions. I think it has to do with hospital lobbyists. I 
think there is a money trail. Why were nursing homes the only 
option? So, even though Governor Cuomo likes to blame politics 
and Fox News and the weather, and Mother Nature, he never self-
reflected, and that is something that he should have done.
    Dr. Wenstrup. You have been a fierce advocate, obviously, 
since the beginning on this issue. How has your Governor, 
Governor Cuomo, treated you?
    Ms. Dean. Governor Cuomo?
    Dr. Wenstrup. Mm-hmm.
    Ms. Dean. Well, attacks, belittlement. I believe one of his 
aides said, well, Janice Dean, she is not a reliable source on 
anything except the weather, even though I had two close family 
members die in separate elder care facilities. I am aware of, I 
have not seen them, of texts that were exchanged between Andrew 
Cuomo's brother and the Administration calling me interesting 
names that I do not want to repeat today, but there was no 
sympathy. There was never a gesture of a phone call, no 
condolence cards. I do not think he really met with any 
families. He just decided to write a book talking about how 
great a leader he was.
    Dr. Wenstrup. Ms. Zayas?
    Ms. Zayas. Initially, we actually tried to reach out to 
Governor Cuomo, and in his press conferences, interestingly, he 
kept saying that we were being political. And I think, as 
Janice Dean, said, you know, there were seniors and residents 
who died, who were of every political affiliation, and when you 
are grieving, you are not thinking of politics. You are 
thinking of answers. You are thinking of getting down to the 
bottom of why this happened, one, so that we can have justice, 
and two, so it does not happen again. So, we were saddened when 
he continued to the end to make it a political issue.
    And in the beginning, when we are crying and baffled at the 
order and wondering, like, many families did not know that 
while we were locked on the outside, there was COVID-positive 
patients they were bringing through the back door. And only 
after our belongings of our loved ones were handed to us, 
either in trash bags or in boxes with our parents' name, and 
our questions started to bubble. That is when we realized, 
sadly, that this terrible thing was happening, and it just 
compounded the pain. It is unbelievable how raw the pain is 
even today.
    Dr. Wenstrup. Dr. Grabowski, going forward to the next 
pandemic, as you look back, where these orders a mistake?
    Dr. Grabowski. Yes. I said it at the time, and I said it in 
my testimony. This was a mistake.
    Dr. Wenstrup. Ms. Dean?
    Ms. Dean. One of the biggest mistakes this country has ever 
done.
    Dr. Wenstrup. Ms. Zayas?
    Ms. Zayas. Seniors are in vulnerable positions every single 
day. This is not just a one-time issue. Unfortunately, in the 
path that we have, both Ms. Dean and I, we have realized that 
there are horror stories of all sorts, not just during a 
pandemic, but that the pandemic actually opened up a door to 
really find out what is going on in these facilities. These 
facilities do not have proper PPEs or equipment or training 
every day of the year. It is just compounded when you are 
putting an exorbitant amount of sick people in these 
facilities, and then they are not being separated. Even the 
staff is working with COVID.
    And on the eve of my mother, the last I heard her voice, 
which she sounded like a gargoyle, I was told she was going 
home. They were going to send my mother with an oxygen tank 
with a contagious disease without telling me, and when we found 
out that she was going home and she could not even answer the 
phone when I was calling her. She was excited to go home, and 
when I called her and she did not answer, I became so worried. 
And they were telling me, we are going to send her home with an 
oxygen tank, and I said how? If she cannot breathe, how?
    And we had no testing. We had no idea she had COVID. We 
thought she had a bad cold, and they said we are just going to 
send her home. They kept playing games. They supposedly offered 
her an iPad to talk to me, and I was so frightened what I was 
going to see. If my mother had been sent home with an ambulance 
service directly to her apartment with an oxygen tank, my 
mother would have died alone because I had no idea what was 
going on.
    Dr. Wenstrup. Thank you very much. I would say that from 
the very beginning for this Subcommittee, and this is a new 
subcommittee, this is an after-action review for lessons to be 
learned and to have a better path forward so that we are 
prepared, so that maybe we can predict and protect ourselves, 
and maybe even prevent a pandemic. So, I appreciate all of you 
being here today for just that.
    Now I would like to recognize the Ranking Member for 
questions.
    Dr. Ruiz. Thank you. Let me begin by reiterating my 
condolences for you, Ms. Dean and Ms. Zayas, and for every 
family who lost a loved one to COVID-19. Every life lost to the 
pandemic is a tragedy, and I am deeply sorry for what you have 
experienced. Compassion is a human trait that we need more of 
in our words, our policy, and our behavior toward one another 
to regain our humanity.
    [Speaking foreign language.]
    Ms. Zayas. Denada.
    Dr. Ruiz. In the early days of the pandemic, our knowledge 
of how this deadly novel virus spread and our tools to protect 
the vulnerable from it were extremely limited. As a Nation, we 
grappled with how to prevent COVID-19 from infiltrating our 
nursing homes, and our nursing homes and the Trump 
Administration were not as successful as we needed them to be 
at that time. But the tide of the pandemic turned for our 
Nation's nursing home residents with the arrival of the COVID-
19 vaccine and the rollout of the most effective and efficient 
vaccination campaign in America's history.
    According to AARP data, at the conclusion of the Trump 
Administration, nearly two of every 100 nursing home residents 
in the United States was dying of COVID-19. Six months later, 
in July 2021, following the Biden Administration's massive 
mobilization of resources to get shots in arms, the COVID-19 
mortality rate for nursing home residents fell dramatically to 
.03 per 100 residents. Dr. Grabowski, how did America's COVID-
19 vaccination campaign turn the tide of the pandemic for 
nursing home residents?
    Dr. Grabowski. It was an absolute game changer. Prior to 
the vaccine rollout, if you had a COVID outbreak within a 
nursing home, you were going to see lots of fatalities. You had 
the AARP statistic. I will give you a different one. For every 
five residents that got COVID prior to the vaccine, one of 
those led to a COVID-related fatality. After the vaccine, that 
has actually been for every 25 cases, confirmed cases, only one 
of those residents is dying. So, the vaccine has been an 
amazing success, and today, actually this calendar year, that 
is down to one out of every 50.
    Dr. Ruiz. Mm.
    Dr. Grabowski. So, we have made tremendous progress. It is 
been a real game changer.
    Dr. Ruiz. And how did vaccines reduce the threat of the 
broader community spread and transmission, which your research 
shows drove nursing home infections and fatality during the 
first year of the pandemic?
    Dr. Grabowski. You know, one of the studies that we 
conducted was to look at what is the impact of having kind of 
greater vaccination among staff. Staff live in the community. 
As vaccination rates went up in the community, as vaccination 
rates went up among staff, what impact did that have on 
resident fatalities? And sure enough, there is positive 
externalities to getting staff vaccinated. It does not just 
protect our staff. It actually protects our residents. We saw 
resident fatalities go down.
    Dr. Ruiz. What about the overall community that the nursing 
homes existed in?
    Dr. Grabowski. Absolutely. That was the pathway prior to 
the vaccine. You know, cases came from the community, and if 
you bring it down in the community, you are bringing it down in 
the nursing home.
    Dr. Ruiz. Okay. A crucial component of the Biden 
Administration's effort to protect nursing home residents was 
the implementation of commonsense requirements for healthcare 
workers to get the COVID-19 vaccine. You and your colleagues 
have conducted your own research evaluating the importance of 
these requirements for healthcare workers. What has your 
research shown about the role of vaccine requirements for 
healthcare workers in reducing cases and deaths among nursing 
home residents, and how were these policies associated with 
lives saved?
    Dr. Grabowski. Once again, the Federal rollout of the 
vaccine was incredibly productive, but it was productive for 
residents. Staff were still lagging, and so the mandates really 
brought vaccination rates up for staff. We found that saved 
lives. The higher rate of vaccination through the mandates led 
to fewer COVID-related fatalities for residents.
    Dr. Ruiz. Okay. So, one critical aspect of this mission and 
a top priority of mine as Ranking Member is to ensure that this 
Select Subcommittee remains focused on developing these 
forward-looking policy solutions to prevent and prepare for 
future public health crises. And one critical aspect is 
ensuring that we are working decisively to reduce the threat 
that future novel viruses pose to vulnerable populations in 
nursing homes and other long-term care facilities. What steps 
should Congress and the Federal Government take to better 
prepare for the threat future pandemics pose to our Nation's 
nursing home residents?
    Dr. Grabowski. Right. I have called this a crisis on top of 
a crisis. So, we both need to develop policies to deal with the 
short-term crisis, the next pandemic, but we also need to get 
our nursing home house in order in terms of those long-term 
policies, such as how we pay nursing homes, how we regulate 
them, quality and ownership transparency, so there are kind of 
bigger reforms. And then there are these smaller reforms, like 
investing in personal protective equipment and testing and all 
the infection control infrastructure that is necessary to 
really protect our residents.
    Dr. Ruiz. Under President Biden's leadership, and thanks to 
the investments in lifesaving vaccines funded by the Democratic 
American Rescue Plan that President Biden signed, we have made 
tremendous progress in protecting our Nation's seniors from the 
coronavirus. Going forward, we must learn from the challenges 
and missteps of the early pandemic response, or lack thereof, 
to ensure that we are making our nursing home safer, getting 
ahead of future public crises, make sure that we do not roll 
back protections, make sure that we respond quickly with 
urgency for testing and PPEs, make sure that we increase care 
standards, and that we have transparency and oversight on the 
care standards in nursing homes in order to save lives.
    And I must say that there are a lot of hearings happening 
at the same time, and there is one where there are actual votes 
happening, so you are going to see some of us come back and 
forth, and we mean no disrespect especially to the witnesses, 
when we have to just get up and go. And so, I think that is why 
there are scant Members here, so please excuse our absences and 
running back and forth. Thank you. I yield back.
    Dr. Wenstrup. Thank you. I thank the Ranking Member for 
pointing out the challenges that we are facing here today with 
a variety of committees taking place at the same time.
    Pursuant to Committee Rule 9(c), the Chair may recognize 
Members for extended question time. I, therefore, grant Ms. 
Malliotakis 7 minutes if she needs it, with equal time being 
granted to a Member of the Minority at the Ranking Member's 
discretion. Ms. Malliotakis, are now recognized.
    Ms. Malliotakis. Thank you, Mr. Chairman. I want to thank 
the witnesses for being here today. My condolences to those who 
had lost loved ones wrongfully taken away from them. I am going 
to highlight timeline and the decisions that were made by the 
Cuomo-Hochul Administration in New York that ultimately led to 
over 15,000 of our seniors dying in nursing homes.
    On March 13th, 2020, the CDC and CMS released guidance 
stressing that a COVID-19-positive nursing home resident must 
be quarantined and properly treated. The guidance directly 
forbids nursing homes from accepting patients they were unable 
to properly treat. On March 23rd, the CDC released updated 
guidelines detailing when and how to transfer and discharge 
hospitalized patients. It encouraged a requirement of two 
negative tests or 72 hours after the resolution of symptoms. On 
March 24th, and I know those of us from New York remember this 
very vividly, the Governor, during his daily press conference, 
said, ``My mother is not expendable, your mother is not 
expendable, and we are not going to accept the premise that 
human life is disposable, and we are not going to put a dollar 
figure on human life.''
    Despite those nice words, the very next day, on March 25th, 
the Governor issued his lethal directive mandating nursing 
homes, regardless of ability to provide care, to accept COVID-
19-positive patients discharged from hospitals. The directive 
prohibited the nursing homes from testing the patients prior to 
admittance, and the nursing homes were not even given the 
proper PPE to care for these individuals. This continued even 
after in New York City we had alternatives: U.S. Navy Comfort, 
Javits, South Beach Psychiatric Center, in my district. This 
was directly against the CDC and the CMS guidance and common 
sense.
    It was not until May 10th that the Governor quietly 
rescinded the March 25 directive, and by the time his dangerous 
policy was rescinded, almost 50 days later, over 10,000 nursing 
home deaths occurred, including some in 323 facilities that 
apparently had reported no COVID-19 infections before receiving 
admission or readmission of hospital residents who had been 
diagnosed with COVID-19.
    [Chart]
    Ms. Malliotakis. As I mentioned, there were alternatives 
that Cuomo had even asked for. He ordered some of them to be 
set up, and then he did not use them. On April 7, Mike Dumont, 
the vice admiral of the U.S. Navy, emailed Melissa DeRosa, 
Governor Cuomo's top aide--I have the email here--pleading for 
help to get more patients into the Javits and the U.S. Navy 
ship, Comfort, as they only had 83 and 37 patients, 
respectively. DeRosa then sends an email to the executive 
chamber staff, which to us seems like she was just trying to 
cover herself. And then in a recent interview Cuomo said that, 
``By the time the U.S. Navy Comfort ship arrived in early 
April, they no longer needed the beds,'' which is completely 
false. In fact, over 7,000 COVID-positive patients were 
transferred to nursing homes from the time the ship arrived to 
when the Governor's directive was rescinded on May 10--7,000.
    After his March 25th directive started receiving more and 
more attention during his daily briefings, Cuomo and an array 
of high-ranking government officials, including his top aides, 
DeRosa and the health commissioner, Howard Zucker, who, by the 
way, shockingly, I think, to everyone in this room, he has been 
elevated to serve as President Biden's deputy director of 
global health at the CDC. Well, they began to participate in a 
coverup. Their efforts would result in the true number of 
nursing home fatalities being suppressed for months, and I have 
got another chart, which will show you the difference.
    [Chart]
    Ms. Malliotakis. It was not until the attorney general 
accused Cuomo and his cohorts of underreporting and the Empire 
Center, which we thank Mr. Hammond for being here today, 
winning a court order releasing the complete data. So, my first 
question, Mr. Hammond, your organization did a tremendous 
public service fighting to obtain this information and the 
complete data. How was the information manipulated based on 
your assessment?
    Mr. Hammond. So, starting in April, the state was releasing 
counts, not just of how many people had died generally, but 
also a separate number for nursing homes. And then a few weeks 
later, they modified how they were releasing that to take out 
the cohort of residents who had died after transfer to a 
hospital. So, when they got sick, they got sick enough that 
they needed hospital care, they were probably put in an 
ambulance, taken to a hospital, and then they died in the 
hospital, and the state stopped including those people. It had 
data on how many of those people there were, but it backed them 
out of its daily reports.
    Ms. Malliotakis. And why would they do this, in your 
opinion?
    Mr. Hammond. I believe they were trying to make the 
situation in the nursing homes look less bad than it was 
because it was embarrassing to them.
    Ms. Malliotakis. And because they did not comply with the 
CDC guidance and CMS guidance.
    Mr. Hammond. Yes. They were probably aware, because of the 
order that had been issued, that they were going to be blamed 
for how bad things got.
    Ms. Malliotakis. Now, New York State's Department of Health 
released its report with the manipulated data on the fatalities 
the same day that Governor Cuomo was meeting about his book 
deal. Do you find that to be a coincidence, or do you think 
that there were personal reasons, business reasons, ego, to the 
decision?
    Mr. Hammond. I mean, I cannot get inside anyone's head. It 
is a remarkable coincidence. That report you are referring to 
came out in early July. It was ostensibly a kind of quasi-
scientific analysis of the situation in nursing homes. It had 
been rewritten by the Governor's Office, and they had pulled 
out relevant data and they modified its findings, so.
    Ms. Malliotakis. Okay. Thank you. Fifteen seconds. Two 
important questions. In 2021, Governor Hochul, right, the 
successor and lieutenant Governor to Cuomo, promised that she 
would be transparent to launch a review of what happened in the 
nursing homes. Did she fulfill that promise? Yes or no.
    Mr. Hammond. Not yet.
    Ms. Malliotakis. Okay. And my last question: was there a 
difference in reimbursement rates between nursing homes, 
hospitals, and the U.S. Navy Comfort ship?
    Mr. Hammond. I do not know the answer to that.
    Ms. Malliotakis. Okay. Well, we would like to get the 
answer to that question, Mr. Chairman. I think that is a very 
important question. I want to thank Mr. Chairman for the time, 
and I ask for unanimous consent to submit an op-ed, written by 
Mr. Peter Arbeeny, who is here today, in the Daily News, 
titled, ``Still Looking for Answers on COVID as well as 
Testimony From My District Who Lost Loved Ones in New York's 
Nursing Homes.''
    Dr. Wenstrup. Without objection.
    Ms. Malliotakis. Thank you.
    Dr. Wenstrup. I now recognize Mrs. Dingell for 7 minutes of 
questions.
    Mrs. Dingell. Thank you, Mr. Chairman and Ranking Member 
Ruiz. Let me begin, I first will tell you I am wearing a mask 
because I got COVID last Thursday, the day the public health 
warning expired. I was fully vaccinated and boosted. My 
symptoms were not pleasant this time, but I was not 
hospitalized. I tested negative yesterday and today, but I am 
wearing the mask following CDC guidelines because I do not ever 
want another person to get COVID if we can keep it from 
happening.
    And to all of you, your stories are horrific, but I have 
heard them over and over, and they are not unique to New York. 
They are stories that I started hearing in March, April, May at 
home as well, and they should not have happened, period. It is 
simple. We were not ready for the pandemic let alone were our 
Nation's nursing homes ready, and it is troubling because our 
Nation's seniors are important, and they deserve and entitled 
to live their senior years in dignity and with respect, and no 
life, for the record, is expendable. No life.
    Unfortunately, because we were not ready, the country was 
not ready, and the previous administration's haphazard Federal 
responses, and we are pointing a lot of fingers, and we need to 
understand why what happened happened, so it never happens 
again because we did fail this Nation. We failed our seniors, 
and we failed their families.
    Let me talk about Michigan. We were hit very hard. The 
Detroit News has been running a series of stories on this in 
the last couple of weeks, and among their observations, 
according to the documents released by the government, the 
problems largely occurred amid a shortage of personal 
protective equipment for staff at nursing homes, sometimes 
hospitals, as well as a short supply of COVID-19 tests. Melissa 
Samuel, the president and CEO of the Health Care Association of 
Michigan said facilities did all they could with the resources 
and knowledge available at the time to provide the best care 
for their residents. Healthcare workers and many others stepped 
up and risked their lives to care for COVID patients. As the 
world sheltered in place, dedicated, exhausted, frightened 
healthcare staff kept showing up hour after hour, day after day 
to care for those in need. Healthcare workers and thousands of 
others saved countless lives during this unprecedented, 
unimaginable time. But as you all just talked about, too many 
died.
    I got an early glimpse in many of my cities. Riverview, 
Michigan, I heard from everybody. I heard from the mayor. I 
heard from the fire chief because of the number of runs he was 
having. I heard from the relatives of the Rivergate residents 
and the healthcare workers. They repeatedly lodged formal 
complaints against the Rivergate facility in the spring of 2020 
for failing to properly identify and combat a spike in COVID-19 
infections.
    A self-identified registered nurse estimated that close to 
a hundred patients had the coronavirus at the 168 resident 
Rivergate Terrace, and seven workers had been sent to the 
hospital, according to an April 9, 2020 complaint. The nursing 
home did not have protection. They did not have masks. They did 
not have gowns or tests to keep them safe. I emptied my 
garage--I am a hoarder--of every garbage bag I had. I went to 
the schools and the businesses, and the businesses who had shut 
their doors and begged for garbage bags, and those nurses or 
those attendants wore black garbage bags as gowns.
    I took a collection of gloves from every place I could 
procure them from, and I worked with the Governor's office and 
the autos, and was making calls to China begging, spending 
millions of dollars on PPE equipment to get it shipped but had 
to find somebody we knew and trust to go look and inspect it to 
make sure it had quality. And to make matters worse, the PPE 
that many states were receiving from the Strategic National 
Stockpile was expired with dates as far back as 2010. We need 
to work on that. That is one of the things this Committee must 
do, and in conjunction with the Energy and Commerce Committee, 
to make sure we are never ill prepared as we were and that this 
never happens again.
    Now, I have a couple of questions. Dr. Grabowski, can you 
explain how your research found the troubling correlation 
between community infection rates and nursing home outbreaks, 
and could you try to do this quickly because I have a lot of 
questions?
    Dr. Grabowski. Absolutely. We looked at a lot of different 
factors, and the strongest predictor of whether or not a 
nursing home had COVID-19 was a COVID outbreak in that 
community. It is because the staff were living in that 
community and working in the nursing home, and that was the 
pathway.
    Mrs. Dingell. If nursing homes had been able to receive 
timely and adequate supplies of PPE and testing kits, would 
that have had a meaningful impact in terms of reducing 
unnecessary infection and death?
    Dr. Grabowski. Absolutely. Our work showed huge shortages. 
One in five facilities even during the summer of 2020, very few 
had access to rapid testing. A really important study a few 
weeks ago came out in the New England Journal of Medicine 
suggesting that more access to rapid tests led to fewer 
resident fatalities. The link is very strong.
    Mrs. Dingell. So, I want to build in something you talked 
about earlier, the crisis on top of the crisis. The previous 
administration oversaw years of rollbacks on Federal 
regulations related to the quality of care and infection 
prevention in nursing homes. This was severely felt in a 
nursing home like the one Riverview, and I will tell you 
another story. In Ann Arbor, I had someone call me, and they 
had 12 patients and nobody, nobody to care for them because the 
healthcare workers were sick and would not come in. Nobody. Do 
you know what panic is when you cannot find somebody to take 
care of 12 people? The Riverview facility had no personal 
protective equipment as of March 20, 2020. They did not have an 
isolated area for those with infections and were asking 
employees to sign do not disclose papers, one of the complaints 
alleged.
    ``I am reporting it because it is shameful and wrong to 
watch people die because of a lack of supplies or proper PPE, 
or greed, or proper cleaning techniques, or whatever the hell 
went wrong and continues to go wrong there, but it needs to 
end,'' the nurse said. People are literally dying every shift.
    In addition, persistent inadequate staffing levels have 
been a challenge in nursing homes for years, and it is worse 
now. We are losing caregivers as the baby boomers age, and we 
now know that higher levels of staffing are associated with a 
lower probability of experiencing an outbreak with fewer 
deaths. Dr. Grabowski, can you elaborate more on your crisis on 
top of crisis and how real it is?
    Dr. Grabowski. Absolutely. We have under-resourced nursing 
homes for a long time. We have not held them accountable in 
terms of the quality of care, and also who owns the building 
and how they are spending the money. And then as you just 
suggested, there was a trend toward deregulation of nursing 
homes under the prior administration, especially around 
infection control. The Ranking Member outlined some of those 
steps during his remarks. We were going in the wrong direction. 
That was the longstanding crisis. When you layered the COVID 
crisis on top of that, it only magnified the problem. Thanks.
    Mrs. Dingell. Thank you, Mr. Chair.
    Dr. Wenstrup. I now recognize Mrs. Lesko from Arizona for 5 
minutes of questions.
    Mrs. Lesko. Thank you, Mr. Chairman. I have to say I am 
absolutely outraged over what I heard today from the witnesses, 
and I am so sorry for what has gone on. And when we say it was 
a mistake, that is an understatement, you know. This is awful. 
And so, I want to thank you to the witnesses who are fighting 
for justice and for change.
    I, quite frankly, lay the deaths of these thousands of 
people who died from COVID-19 in New York and other states that 
required nursing homes to take in COVID-19-infected people at 
the feet of the state officials who decided that mandate. To 
show the significance and the difference between what state 
officials' policies did, let me compare the differences between 
New York and Arizona where I live, and Arizona has lots, lots 
of senior citizens, lots of long-term care facilities.
    So, according to the Atlantic's COVID Tracking Project, New 
York had 14,450 deaths across 698 long-term care facilities. 
That is 21 deaths per facility. Conversely, in Arizona, which 
has a very large senior population, there were 2,505 COVID 
deaths across 1,000 long-term care facilities. That is 2.5 
deaths per facility. So, you compare pair 21 deaths per 
facility in New York to 2.5 COVID deaths per facility in 
Arizona, so that is not a Federal problem. That is a state 
problem, and so we have to ask why. Well, unlike New York, New 
Jersey, and Pennsylvania, Arizona never, never required nursing 
homes to admit COVID-19 patients. That is the difference. That 
is the problem, and somebody better be held accountable because 
this pisses me off.
    You can tell I am impassioned, but I have a question to Mr. 
Hammond. Do you think outcomes would have been better in 
nursing homes if the focus was on those populations rather than 
telling healthy people not to go to gyms?
    Mr. Hammond. I think both were necessary, frankly. I mean, 
a lot of people died outside of nursing homes, too, and as has 
been said earlier, there is a connection between the rate of 
spread in the community and what goes on in nursing homes. And 
so, if your staff and your family members are living in the 
community, they are going to bring it with them into the 
nursing home unless precautions are taken.
    Mrs. Lesko. Ms. Dean, we have already discussed Governor 
Cuomo's disastrous and fatal policy decisions and the 
subsequent coverup. The Department of Justice declined to 
pursue an investigation into Cuomo or the other states that 
instituted must-admit orders. Do you believe the Department of 
Justice has good grounds for an investigation?
    Ms. Dean. One hundred percent.
    Mrs. Lesko. Thank you. Ms. Dean, could you explain why you 
think the Department of Justice is not investigating?
    Ms. Dean. That is an excellent question, and I think the 
tentacles are deep, and they spread across states and leaders. 
I think we have to look at the origins of the March 25th order, 
where it came from, who wrote it, and I think those simple 
questions can lead us into a direction. But unfortunately, I 
believe that it involves a lot of people, a lot of money, a lot 
of hospitals and lobbyists, and I think these issues have been 
in place for a very long time. And the one thing Vivian said is 
that the one thing COVID did do is kind of get under the 
floorboards and show us how much rot there is already. And so, 
do not let our loved ones die in vain, you know. Use this 
tragedy to do good for other families going forward.
    Yes, it is very curious that there has not been any 
investigations or subpoenas, or a former Governor on the stand 
telling the whole truth and nothing but the truth.
    Mrs. Lesko. Thank you very much, and I applaud our Chairman 
for bringing up this issue. It is so important. You know, 
somebody needs to be held accountable. This is outrageous, and 
with that, I yield back.
    Dr. Wenstrup. Thank you. I now recognize Dr. Bera from 
California for 5 minutes of questions.
    Dr. Bera. Thank you, Mr. Chairman. You know, a couple 
things. As a young doctor, I did work in board and care 
facilities and skilled nursing facilities, and everything that 
you say in terms of the conditions and so forth are true. I do 
think we should do oversight. We should take a look at how we 
can protect America's seniors, protect nursing homes, raise 
those standards. Mr. Chairman, I also think we pushed billions 
of dollars through the American Rescue Plan, through the 
Coronavirus Aid, Relief, and Economic Security (CARES) funding. 
I think it is worth our doing oversight on seeing how those 
dollars have been utilized and spent. You know, much of the ARP 
dollars were to actually improve services, ventilation, et 
cetera. It is worth doing oversight, so would love to work with 
you on that.
    I also, I am not going to focus on looking forward. I 
actually want to try to understand the decisions. I am a 
Californian, used to be chief medical officer in Sacramento 
County, also in my time in Congress have focused on global 
health security pandemic preparedness so early on was paying 
attention to this. Had the first hearing in Congress and 
chaired that hearing on, at that time, the novel coronavirus. 
It was not lost on any of us that older patients, older 
individuals were much more vulnerable. Older individuals that 
had co-morbid conditions were much more vulnerable. You saw 
that in, you know, early data coming out of China but also in 
Italy. And, you know, for those of us in California, we saw, 
you know, what was happening in New York.
    Early on in February/March 2020, we were already making 
contingency plans working with our hospitals. For the life of 
me, I cannot understand why anyone would take a COVID-positive 
patient and put them in a nursing home. You know, that is 
medical malpractice, in my mind, and that is a decision I 
cannot understand. Yes, there were plenty of places. We had 
trailers. We looked at our college campuses with the dorms and 
so forth, and lots of discussion of where you could isolate 
patients where they can convalesce until we knew they were no 
longer contagious or infectious.
    Mr. Hammond, maybe this is a question for you. I know the 
New York attorney general looked into what some of that 
decisionmaking process was. Can you share with me what the 
findings were?
    Mr. Hammond. I am not necessarily sure what the attorney 
general found, but it has been confirmed that the Greater New 
York Hospital Association approached the Governor's office and 
recommended this policy. They were being pressured by the state 
to expand their capacity. I believe they were being told they 
needed to find 50 percent more beds, so they were supposed to 
convert any available space, the cafeteria, what have you. And 
they came back to the state and said, you know, you could help 
us if you would take these patients who are stable, they have 
recovered, they are stable, they are still positive, and if you 
make the nursing homes take them from us, that will clear some 
space. So, it was the Hospital Association that recommended it.
    Dr. Bera. Okay. And, again, just recalling some of the 
horrific images that we were watching in California coming out 
of New York, it is legitimate to think about how you free up 
capacity if you have really acute patients that you need in the 
hospital, but again, there were alternatives, right? I mean, it 
was not rocket science to say put them in a nursing home, if it 
was a Javits Center, if it was a hospital ship. We were 
thinking about in Sacramento County getting them into, you 
know, college dorms and providing support. Are you telling me 
that nobody is actually trying to find the answer of who made 
those decisions and, you know, how those decisions were made, 
and----
    Mr. Hammond. I am not aware of any investigation right now. 
There was, at one point, an investigation out of the Eastern 
District of New York.
    Dr. Bera. Okay. Mr. Chairman, I think it is worth, you 
know, trying to find out, you know, if there was a Federal 
investigation, if the FBI looked into this or others. You know, 
we cannot bring back your loved ones, and I am sorry about 
that, or any of the loved ones. But it is important to 
understand how these decisions were made, who made these 
decisions, whether there was undue influence one way or another 
in those decisions. I am not a lawyer. You know, it is not 
necessarily about liability, et cetera, but if we do not 
actually know the truth, we cannot actually help you find 
closure, and, you know, help us move forward.
    So, you know, all of us are elected officials, and we have 
responsibilities, and sometimes bad decisions are made. But we 
have got to try to understand why those decisions were made and 
help those inform us as we move forward. And again, I am sorry 
about your losses, and, Mr. Chairman, would love to work with 
you on trying to understand how these decisions were made and 
who made the decisions. Thank you, and I yield back.
    Dr. Wenstrup. I am with you on that, Dr. Bera. I now 
recognize Dr. Jackson from Texas for 5 minutes of questions.
    Dr. Jackson. Thank you, Mr. Chairman. Thank you to our 
witnesses for being here today. I really appreciate your time. 
I just want to start out by just making some quick 
observations.
    At President Trump's direction, CMS and CDC worked together 
and in acted quickly to put out and continuously update 
critical guidance and recommendations to state and local 
governments and long-term care facilities to assist in 
mitigating the spread of COVID-19 virus against our most 
vulnerable population. However, a handful of Governors, as we 
have been discussing here, across the United States decided to 
go against the Trump Administration's guidance and made 
irresponsible, politically motivated decisions to knowingly 
introduce coronavirus to nursing home residents and long-term 
care patients, resulting in thousands of people dying 
unnecessarily.
    While thousands of these residents and patients were dying 
at alarming rates and family members were prevented from saying 
their goodbyes, these Governors were simultaneously being 
praised and applauded by left-wing news outlets and Democrat 
public officials for how they were handling the pandemic in 
their state and, most importantly, for their refusal to follow 
issued guidance that had the Trump Administration's stamp on 
it. It was a large part of why they did not do some of what 
they did, in my opinion.
    As many of my colleagues have pointed out, one of the most 
detrimental decisions these Governors made were forcing nursing 
homes to accept admissions of COVID-positive individuals. 
Specifically on March 25th, 2020, the New York State Health 
Department issued a directive that stated, ``No resident shall 
be denied readmission or admission to a nursing home solely 
based on a confirmed or suspected diagnosis of COVID-19,'' and 
``Nursing homes are prohibited from requiring a hospitalized 
resident, who is determined medically stable, to be tested for 
COVID-19 prior to admission or readmission.''
    The New York State Department of Health also issued a 
report titled, ``Factors Associated with Nursing Home 
Infections and Fatalities in New York State During the COVID-19 
Global Health Crisis.'' They issued this on July 6, 2020, and 
updated it on July 20, 2020, and updated it again on February 
11, 2021. Even in the most recently updated version, the report 
still states, ``Admission policies were not a significant 
factor in nursing home fatalities,'' and ``The data do not show 
a consistent relationship between this Administration and 
increased mortality.''
    Mr. Hammond, you and your colleague, Mr. Kingsbury, 
analyzed the coronavirus deaths in long-term care facilities 
using data and information released by the New York State 
Department of Health. Is that correct?
    Mr. Hammond. Yes.
    Dr. Jackson. Would it be fair to say that the New York 
State Department of Health's report I just mentioned 
contradicts the findings of your analysis?
    Mr. Hammond. Well, I would put it the other way around, but 
yes.
    Dr. Jackson. Okay. Did your analysis find any correlation 
between the admission of new COVID-positive residents and 
higher death rates in the nursing homes that received them?
    Mr. Hammond. Yes, it did.
    Dr. Jackson. Thank you. In Governor Cuomo's book, he wrote, 
``The Trump forces had a simple line. Thousands died in nursing 
homes. It was true, but they needed to add a conspiracy, which 
was that they died because of bad state policy and that 
mandated and directed the nursing homes to accept COVID-19-
positive people. And these COVID-positive people were the cause 
of the spread of the disease in the nursing home. It was a 
lie.'' According to the Washington Post, this book is an 
``impressive road map to dealing with a crisis as serious as 
the one we have faced.'' To each of the witnesses, I would like 
to ask if after hearing all of the information today, would you 
agree that Cuomo's book and the official reviews from the 
mainstream media that promoted Cuomo's book as factual, 
influential, and an example of outstanding leadership, are an 
example of disseminating disinformation? Ms. Dean, I will start 
with you.
    Ms. Dean. I think his book was one of the main reasons why 
he hid all of the information, and I hope someday we can use 
the words in that book against him in a court of law.
    Dr. Jackson. I would agree with you. Thank you. Mr. 
Hammond?
    Mr. Hammond. I did not think the book was accurate or well 
done, and to the extent people thought it was, I think they 
were misled.
    Dr. Jackson. Ma'am?
    Ms. Zayas. He was worried about his image, and promoting a 
book in the middle of a pandemic, not at the end where you can 
have more foresight, in the middle of pandemic while my mother 
and all these other seniors were gasping for air and died 
alone.
    Dr. Jackson. Dr. Grabowski?
    Dr. Grabowski. I did not read Governor Cuomo's book then, 
and I am not planning on reading it now.
    Dr. Jackson. Do you think the statement I just read, the 
quote from the book, was disinformation at the time?
    Dr. Grabowski. You know, once again, I am not here to 
defend him or anything about his book, but I am not planning to 
go back and revisit what he wrote. I want to think about 
nursing home policy going forward.
    Dr. Jackson. All right. Thank you. I yield back.
    Dr. Wenstrup. I now recognize Mr. Garcia from California 
for 5 minutes of questions.
    Mr. Garcia. I thank you, Mr. Chairman, and I first want to 
thank all of you for being here. I know that it is hard, 
particularly for witnesses and those that have lost family or 
friends, and I just want to say that I also lost both my mom 
and my stepfather during the pandemic. My mom was a healthcare 
worker. So, this is a very serious topic, and obviously the 
issue around nursing homes is really tragic, and I think it is 
that is a horrific experience that we went through that was 
going on across the country.
    I want to make sure also that as we review our actions 
around COVID-19, that we remind ourselves how uncertain we were 
at the very beginning. We did not have a lot of information. We 
were unsure what the standards were around washing hands, 
simple things. We were all panicked about groceries, about 
shopping, about what would be available with the supply chain. 
There was a lot of uncertainty. We lost 1.3 million Americans. 
We lost 1,300-plus residents just of my own community. I was 
the mayor of Long Beach the entire time. We have our own health 
department in the city. And so, managing all of that, 
particularly during the time when the spread was happening in 
nursing homes, was horrific.
    I also would agree that the Governor of New York made some 
very serious mistakes. I think that is pretty clear, I think to 
anyone, you know, whatever side of the aisle. I think we need 
to learn from those and recognize that there is a lot of loss 
of life amongst our elderly and our senior population, and that 
is something that is very serious, and I take it very 
seriously. But I also want to put in perspective that in the 
early days of the pandemic, the Trump Administration, I also 
believe, failed in leadership.
    We had overwhelmed hospitals. We did not have a lot of 
standards in our nursing care facilities. We did not have 
enough beds available in our system. So, those are things that 
are true. We also had shortages of PPE, and I remember as mayor 
having to personally go out and get PPE from other places, even 
outside of our own country, to get it to nursing homes and 
nursing facilities. It was not even always directly given to us 
by the state or the Federal Government. So, these are not new.
    In 2019, the Trump Administration also proposed a rule to 
relax Federal requirements that nursing homes employ for onsite 
infection prevention specialists, so these are things, I think, 
that were huge mistakes. We also, I think, need to talk about 
the fact that nursing homes in general have not been well 
supported. Even before the pandemic, we know that low wages, 
poor benefits. I talked to numerous workers at our nursing 
homes in Long Beach that were suffering from issues around 
being overworked, having too many folks to take care of, and 
this was happening we know not just in New York, which we 
talked a lot about today, but nationally.
    Now, Federal law requires all nursing homes to maintain 24 
hours of licensed nursing coverage per day, including a 
registered nurse and onsite 48 hours, but does not otherwise 
specify additional staffing requirements. I just want to note 
the Centers for Medicare and Medicaid Services' data showed the 
average staff hours for all nursing homes nationwide failed to 
meet Federal recommended minimums, and certainly that also 
helped cost lives and the health of so many. So, staff 
shortages which were in place at the time meant low-quality 
care, folks seeing more patients, and certainly the spread of 
infections.
    We could have absolutely been better prepared. The Federal 
Government absolutely, under the leadership of President Trump, 
could have done more to prepare us and certainly given guidance 
to cities and to states. And so, I think there is a lot to 
learn from, certainly from places like New York where horrific 
tragedies happened but also within the Administration at the 
time. I want to note that low pay and lack of employee benefits 
did cause us issues in the pandemic, not just in nursing homes, 
but also in our hospitals.
    I want to just ask just quickly, Dr. Grabowski, what does 
your research show about the role of the cohorting orders as 
opposed to factors like community spread and the shortage of 
PPE and testing?
    Dr. Grabowski. Yes. So, our research really supports the 
idea that this was a system-wide problem. Nursing homes all 
over the country were impacted. I think one of the 
representatives said Arizona had much lower rates than New 
York. Well, Arizona also had much lower community spread. Look 
at the state where I live and work, Massachusetts, relative to 
New York. If it is in the community, it is in the nursing 
homes. We never had this mandate in Massachusetts, yet we had a 
lot of fatalities among our nursing home residents and a lot of 
cases and deaths among our staff.
    Mr. Garcia. And briefly, how did the widespread shortages 
of PPE actually lead to really this mishandling? We had huge 
national shortages. I strongly believe the Trump Administration 
failed in that respect. How did that lead to community spread 
and, as a result, impact nursing homes?
    Dr. Grabowski. Absolutely. So, PPE is essential. It is our 
armor against COVID. Far too many nursing home staff lacked 
adequate PPE. Once again, the data that we put together during 
the summer of 2020 suggested one in five nursing homes, even by 
the summer, was still reporting a severe PPE shortage.
    Mr. Garcia. Thank you, sir, and I just again want to remind 
us that supporting our care workers is really important moving 
forward. Thank you, and I yield back.
    Dr. Grabowski. Absolutely.
    Dr. Wenstrup. I now recognize Dr. Joyce from Pennsylvania 
for 5 minutes of questions.
    Dr. Joyce. Thank you for yielding, Mr. Chairman, and thank 
you, Chairman Wenstrup and Ranking Member Ruiz, for holding 
this hearing today. And thank you to our panel of witnesses for 
appearing on this critical topic.
    In the early days of the coronavirus pandemic, grievous and 
critical errors made by public health officials in New York, 
New Jersey, and in Pennsylvania, my home state, had disastrous 
consequences for our seniors. And it is clear now that those 
whose duty was to protect our most vulnerable and high-risk 
individuals, failed and fell short of the oath to first do no 
harm. On March 13, 2020, CMS issued guidance for nursing homes 
and long-term care facilities, intending to serve as a 
blueprint for individual states to best prevent and control 
COVID-19 outbreaks in nursing homes. This was not a directive 
for nursing homes to unsafely accept COVID-positive patients 
back into the nursing home.
    Furthermore, CMS administrator, Seema Verma, said that 
``Under no circumstances should a hospital discharge a patient 
to a nursing home that is not prepared to take care of those 
patients' needs.'' Yet only three days later, the Pennsylvania 
Department of Health issued guidance mandating that nursing 
homes accept patients even after they had tested positive for 
COVID-19. Must-admit nursing home orders willfully and 
deliberately disregarded CDC and CMS guidance.
    Now, Admiral Rachel Levine, then Pennsylvania secretary of 
health, moved her own mother out of a personal care home as 
patients with COVID-19 were being moved in, a decision that 
ultimately led to more infections and more deaths among our 
state's seniors, while shielding her own family, which was a 
luxury that was not afforded to many Pennsylvanians. These 
disastrous public health policies led to an insurmountable 
amount of pain and grieving for families who lost loved ones. 
My office received calls from constituents who were refused the 
chance to visit dying spouses, parents, and grandparents. Yet 
this Committee has been stonewalled by requests for more 
information regarding these must-admit orders. It is time to 
have accountability. It is time to have accountability for 
failures and coverups that led to thousands of needless deaths.
    Dr. Grabowski, given the guidance issued at that time in 
March 2020 by CMS, was there a good rationale for the must-
accept orders issued in Pennsylvania and in other states?
    Dr. Grabowski. As I said earlier, that policy was a 
mistake.
    Dr. Joyce. I agree. It was an incredibly lethal mistake 
that was made. Ms. Zayas, I understand your group has members 
from Pennsylvania as well.
    Ms. Zayas. We do.
    Dr. Joyce. Can you please describe the end result of these 
orders and the impact that they had in my home state, the 
Commonwealth of Pennsylvania?
    Ms. Zayas. Regardless of the state, it devastated families 
even until today because I know that Pennsylvania families, New 
Jersey families, New York families all reach out with an eerie 
story of how their loved ones met their last days. And those 
that persisted in nursing homes with a lockdown and afterwards, 
they were treated like zoo animals. You could not see your 
family except through a glass door or through some electronic 
device.
    We have devastated our families because seniors are the 
center core of our families. My mom did not get to meet her 
grandchildren or her great-grandchildren, and we are going to 
continue to stand for them because they are the center of our 
families, and I am sure everyone feels the same, whatever state 
we are in.
    Dr. Joyce. I think that is such important information that 
you bring to us here today. One of the purposes of this Select 
Subcommittee is to gather information, to be proactive, to have 
that understanding when moving forward, and, unfortunately, we 
might face another pandemic, what appropriate steps need to be 
taken. Your information and the other panelists being present 
today allow us to formulate those opinions. I thank each and 
every one of you for participating here today. I thank you, Mr. 
Chairman, and I yield the remainder of my time.
    Dr. Wenstrup. Thank you. I now recognize the Ranking Member 
of the full Committee, Mr. Raskin, for 5 minutes of questions.
    Mr. Raskin. Thank you kindly, Mr. Chairman. I want to 
extend my sympathy to everyone here who lost family members in 
this nightmare.
    In the early weeks of the pandemic, public health experts 
projected that nursing homes and long-term facilities would be 
sharply hit by COVID, and the Federal Government's lethally 
chaotic response exacerbated staffing shortages and deprived 
nursing homes of protective equipment and testing kits that 
they needed. President Trump pledged to ``deploy every resource 
and power that we have to protect older Americans,'' and yet 
the last administration failed to nationalize the supply chain 
and fully utilize Federal Emergency Management Agency (FEMA)'s 
capabilities to provide adequate PPE testing and resources to 
nursing homes and long-term facilities.
    Public reporting revealed that supplies were limited, did 
not arrive at all, or were unusable. I want to enter into the 
record a CNN article titled, ``Nursing Homes Receive Defective 
Equipment as Part of Trump Administration Supply Initiative,'' 
Mr. Chairman.
    Dr. Wenstrup. Without objection.
    Mr. Raskin. Thank you.
    As a result, nursing homes were left with scant supplies of 
PPE, testing, and other resources necessary to protect their 
residents and staff. Even more, the Trump Administration took 
steps to relax Federal oversight and infection control in 
nursing homes during the pandemic. Some nursing homes left 
unregulated gave hydroxychloroquine to COVID-positive patients, 
a treatment shown not to be useful or safe for the coronavirus, 
and by May 2020, residents and workers in nursing homes and 
long-term care facilities accounted for roughly 40 percent of 
total COVID deaths in United States.
    Dr. Grabowski, how did the Trump Administration's failures 
to offer a national testing and PPE procurement strategy and 
corresponding deregulation of the nursing home industry 
undercut efforts to limit the spread of COVID-19 in the nursing 
homes?
    Dr. Grabowski. Sure. The Trump Administration pushed out 
the procurement to the states, which then pushed it out to the 
nursing homes. So, nursing homes were competing with one 
another for testing kits and PPE, and they were competing with 
hospitals. And unfortunately we put our nursing homes, with the 
frailest and most vulnerable individuals in our system, at the 
back of the line when they should have been at the front of the 
line to get these supplies.
    As you noted, later the Trump Administration did send two 
weeks of supplies, but much of that was defective. I had been 
on TV, not as much as Ms. Dean is on TV, but occasionally 
during that time period, people would see me on TV talking 
about PPE. Staff started sending me this defective PPE just to 
show me, so I had this arriving to my office at Harvard. It was 
a complete and utter debacle.
    Mr. Raskin. So, instead of a coordinated nationwide 
strategy the way some countries had, we had this dog-eat-dog 
system at the lowest levels and a race to the bottom, 
basically.
    Dr. Grabowski. We should have nationalized, as you said, 
the supply chain. We used the Defense Production Act, you will 
remember, for ventilators. We never used that for PPE. 
Representative Dingell already described going to China, trying 
to use trash bags. That is completely unacceptable.
    Mr. Raskin. So, one of the driving factors in the nursing 
home infection and high death rates was the surrounding 
community spread of COVID. I remember when some nursing homes 
in my district were hit and the people there were convinced 
that it was the staffers who had been taking it, essentially, 
inadvertently, unwittingly from facility to facility. How would 
the unprecedented rate of COVID spread across a given community 
have a direct impact on the spread of COVID within the long-
term facilities and nursing homes?
    Dr. Grabowski. It both came from the community and then, as 
you suggested, it was staff working across facilities. There is 
a really elegant study that used cellphone data was able to 
track staff moving across nursing homes and spreading the COVID 
virus across those nursing homes. So, when we lack PPE, when we 
lack testing, there is really good evidence to suggest COVID-19 
was coming from the surrounding community. And as you 
suggested, the secret weapon of COVID-19 was that it was 
asymptomatic. You know, this was not anything these staff did 
wrong. They thought they were okay. We did not have testing or 
PPE, and so they were bringing it in unknowingly.
    Mr. Raskin. Alright. So, we had no Federal strategy, and I 
remember in Congress, we were begging for a national strategy. 
And then there were all kinds of conflicting signals sent out 
about hydroxychloroquine, ``this will disappear in April.'' 
``This will all go away.'' ``China is doing a great job.'' ``I 
am in constant touch with China,'' and so on. What should the 
Federal Government have done and what can we do next time in 
the early months of a pandemic to prevent, like, this rapid 
spread?
    Dr. Grabowski. The Federal Government next time needs to 
own the problem from the beginning. As you said, nationalize 
the supply chain, ensure that every nursing home in the country 
has adequate supplies, personal protective equipment, rapid 
testing. We also need to support the workforce. Far too many 
nursing homes had staff shortages. Staff were getting sick. 
Staff left in large numbers. We lost hundreds of thousands of 
staff. This was the most dangerous job in America. There were 
incredibly high death rates, and so staff, not surprisingly, 
went to work, you know, in other parts of the economy. Some 
have come back but not all of them, so we have a big shortage 
right now.
    Mr. Raskin. Thank you, Mr. Chairman. I yield back.
    Dr. Wenstrup. I think if you check the record, there were 
strategies in place. They may not have been perfect, but there 
were strategies in place, and with that, I would like to 
recognize Dr. McCormick for 5 minutes of questions.
    Dr. McCormick. Thank you, Mr. Chair. First of all, I 
appreciate everybody being here today. I appreciate your 
heartfelt testimony, the experiences that you have had that 
have made you who you are and why you are involved. In my 
experience, over 20 years in the military and finishing up as 
an ER doc, and matter of fact, from the beginning of the 
pandemic, I was serving as a night shift yard doc, full-time, 
working in the ER, being exposed to fevers. We did not know 
where it came from and trying to figure out what this novel 
virus would do to our patient population, and we got it wrong. 
I will tell you when the novel virus hit you or any novel 
disease, you do not know what to do. That is a fact. So, the 
healthcare professionals, the people with the scientific 
background, the people who understood how viruses work, how 
they propagate, how they create inflammation, got it wrong. We 
were going off of old technologies, old assumptions, and I 
remember we were intubating people that probably should not 
have been intubated. We did not use nonsteroidal anti-
inflammatory drugs (NSAIDs). We did not use steroids. We did 
not take into account how this virus could be different from 
other viruses we knew in the past.
    Let me tell what else I witnessed as an ER doctor. I 
watched family struggle with this. Once we were no longer able 
to allow families into the ER, I watched people die by 
themselves. I held the hands of people who were dying, and 
looked in their eyes, and told them I was going to do my very 
best but knew there was very little I could do because we did 
not know what to do. I watched and prayed with people, knowing 
that the outcome was going to be very poor and knowing that we 
were doing some things very wrong over time.
    And realizing as it continued, I became very aware that the 
government was the biggest problem of all. They did not help 
this pandemic. They got in the way of the conversation. They 
interjected themselves between the professionals and the 
patients. They kept families apart. They did not let people 
even die with dignity or any choice in their own healthcare. 
Let me ask you this. This is my take-home is, why do we keep on 
turning back to the government to solve the problems that the 
government created? That is what I get out of this. Every step 
of the way, the government has biased us and been wrong almost 
every step.
    Let me give you some examples. Origins. When you bias 
people on where the origins came from because the government 
seems to think they know where it came from, you cannot 
actually determine if we funded the origins of this or how it 
got here because we cannot have honest conversations. This is 
the government getting in the way. Vaccinations. Whether they 
benefit you or they are a detriment to you, when you politicize 
something, some people that should have had it did not get it, 
and some people that should not have had it got it later 
because of government involvement.
    Treatments. We already know the government was weighing in 
on it way before they had any clue what was good for you, and 
that biased medical scientists and doctors to do the wrong 
thing because government was involved. Patient placement. I 
think we have covered that here today. Travel, masks, school 
openings, business openings, censorship of physicians who were 
treating patients because the government was supposedly the 
expert instead of the physicians, making people think this was 
a political disease rather than a virus.
    We have trampled all over individual rights, the ability to 
self-determine, the ability to think on ourselves and actually 
have an honest access to information to make good decisions 
rather than biased information coming from a government that is 
biased already because of what you guys already said, 
lobbyists, people who put money in their pocket, people who 
want power, people who love the fact that they can make 
decisions for you because they seem to think that their 
experts, or because they are powerful and we have to succumb to 
them, that we the people are subjected to a government.
    When you say we need to be ready for the next one and say 
we need rapid testing, for what? It will not be COVID. The next 
one will be something else. The problem is we keep on thinking 
that the government is going to prepare us for the next thing. 
We have to have a flexible model. We have to allow scientists 
and doctors and hospitals to be ready on their own, to prepare 
them by not overburdening them with regulation and fees and 
non-reimbursements because of special interests not allowing us 
to get hospital systems healthy.
    I do not have any questions for you because I know you are 
the solution, not me. You guys have already talked about the 
hurt and contamination of this conversation because of the 
government involved. So, I hope we have a real conversation 
about where the government should not be involved and how they 
actually hurt the conversation. And when we politicize any 
disease, and I love how sometimes my colleagues from the 
opposite side of the aisle say we should not make this 
political. By the way, Trump is at fault. This is not a helpful 
conversation.
    Let us get the government out of the way and empower the 
people to deal with the disease or whatever else problems they 
have in life. And with that, I yield, sir.
    Dr. Wenstrup. Thank you. I now recognize Ms. Ross from 
North Carolina for 5 minutes of questions.
    Ms. Ross. Thank you, Mr. Chairman, and, first, I would like 
to express my deepest sympathies to all Americans who have lost 
loved ones to COVID-19 and to our witnesses who have lost loved 
ones.
    As lawmakers, we have an obligation to ensure that seniors 
are protected and cared for, whether they live in nursing 
homes, assisted living facilities, independent housing or 
reside with their families. The Biden Administration has been 
working hard to fix a desperately broken nursing home system. I 
was a state legislator, and we worked to try to help the 
nursing home system as well. And I do not know what the answer 
ultimately is, but it definitely has to be investing in our 
seniors.
    Prior to the pandemic, the Government Accountability Office 
reported that the nursing home industry had been failing to 
maintain basic infection control standards, like hand washing 
or wearing masks, even before the pandemic. Seniors fared no 
better when the coronavirus flooded into their nursing homes 
from outside communities, likewise reeling from the same 
failures of the previous administration to deliver timely or 
even usable PPE, testing kits, and vaccines.
    Dr. Grabowski, how could the Federal Government have better 
supported states and nursing homes early in the pandemic?
    Dr. Grabowski. Once again, states and, particularly, 
nursing homes really struggled to acquire personal protective 
equipment, really struggled to get rapid testing. There was a 
role there for the government to fill that gap. Once again, 
when you put nursing homes in a market where they are competing 
with all these other entities, they were not in the front of 
the line where they should have been. They were pushed to the 
back of the line. They ultimately ended up getting faulty PPE. 
There were gaps in sort of coverage across facilities. It was a 
complete debacle. So, this is not an area when it comes to the 
lives of our older adults that we should just let the market 
work this out. There was a role there for government to help 
the state and the nursing homes.
    Ms. Ross. Okay. And because of the American Rescue Plan and 
the most successful vaccine campaign in the history of this 
country, the rate of deaths among nursing home residents fell 
from nearly two deaths per 100 residents in January 2021 to a 
low of .03 in July 2021. Doctor, in that timeframe, how did you 
see the Federal Government apply lessons learned from earlier 
in the pandemic to ensure that past mistakes were not repeated?
    Dr. Grabowski. Absolutely. There is a role for the Federal 
Government here. It is not sitting on the sidelines or pushing 
the problem down to states and nursing homes. It is actually 
engaging with them, and we saw that with the mandate, for 
example, for booster vaccines for our workers and nursing 
homes. That was an incredible success, and I think we, 
hopefully, will continue to see that kind of engagement and 
centralized role for the Administration going forward.
    Ms. Ross. Okay. And this Administration also has expanded 
inspection activities and targeted more aggressive enforcement 
measures for high-risk nursing facilities, supported good-
paying nursing home jobs and training, increased industry 
transparency and accountability. And for the first time in 
nearly 40 years, the Biden Administration will soon update 
Federal staffing standards to ensure higher-quality care for 
nursing home residents. Doctor, again for you, how do these 
steps move the ball forward on addressing systemic problems in 
nursing home care that have been ignored for far too long?
    Dr. Grabowski. Yes. All three are incredibly important. Let 
me go in reverse order, the staffing. We have far too few staff 
in our buildings. This was true pre-pandemic.
    Ms. Ross. Right.
    Dr. Grabowski. It has been true during the pandemic. 
Staffing is central to good, quality nursing home care and good 
quality of life. We need more staff in this sector, so the 
minimum staffing standard is a great start there. Once again, 
in terms of transparency, we want to know who owns these 
buildings and what they are doing with our money. Those are 
great steps. And then regulation, we need to invest in 
oversight and enforcement. As you said, that was declining 
under the prior administration. That has actually been turned 
around here, and I actually think, you know, we need to address 
some of the gaps right now in funding for state survey 
agencies. I think that is a real area of priority going 
forward.
    Ms. Ross. Okay. And then just one question that affects my 
home state of North Carolina. Would Medicaid expansion help 
with funding or nursing homes?
    Dr. Grabowski. So, I am also from North Carolina, and so 
this would help for the non-elderly----
    Ms. Ross. Yes.
    Dr. Grabowski [continuing]. But not for the older adults. 
So, we have shown in our research that expanding Medicaid did 
lead to better long-term care for non-elderly Medicaid 
recipients. Thanks.
    Ms. Ross. Thank you very much, and I yield back.
    Dr. Wenstrup. I now recognize Ms. Tokuda from Hawaii for 5 
minutes of questions.
    Ms. Tokuda. Thank you very much, Mr. Chair. You know, 
living in a nursing home during the pandemic became a death 
sentence for approximately 176,000 Americans, and today, 
nursing home staff continue to have one of the most dangerous 
jobs in our country. According to the CDC, there are 15,600 
Medicare- and Medicaid-certified nursing homes and 1.7 million 
beds providing care to our constituents in every district 
across our country. Dr. Grabowski, we know nursing home 
residents and workers were a vulnerable population during the 
COVID-19 pandemic. Now, three years later, would you say they 
are more or less vulnerable if faced with evolving or new 
rapidly spreading viruses?
    Dr. Grabowski. You know, I think we are in much better 
shape relative to COVID, but moving forward as new pandemics 
occur, we need to apply the lessons that we have all been 
talking about here and apply good policy going forward. I do 
think we have staffing shortages in some of our buildings, and 
that is going to be an issue going forward. We really need to 
fortify the workforce.
    Ms. Tokuda. Thank you. Building on that, you know, and 
definitely staffing shortages is a severe crisis right now our 
public health infrastructure is facing. If there is one 
critical lesson we have learned from COVID-19, it is the 
importance of sustained and adequate investments in programs 
that ensure the health and safety of our Nation's nursing home 
and long-term care residents, from resources for adequate 
staffing as we just talked about, to oversight and monitoring.
    Yet as we are having this hearing, House Republicans 
continue to hold America's full faith and credit hostage so 
that they can push draconian cuts to crucial Federal programs 
meant to protect nursing home residents from harm. For example, 
Republicans' Default on America Act contains a 22-percent cut 
to the Centers for Medicare and Medicaid Services State Survey 
and Certification Program. CMS's survey and certification 
efforts help the agency determine whether nursing homes and 
other providers are meeting basic quality and safety levels and 
whether to pursue any remedies.
    As a result of the pandemic, about a third of all nursing 
homes are overdue for an inspection. At the start of this year, 
many had last-reported inspections prior to the pandemic, and 
now under Republican budget proposal cuts, this backlog would 
be compounded with CMS unable to complete 38 percent of 
required home and safety recertification surveys of our nursing 
homes and home health agencies, leaving 1.4 million seniors at 
greater risk of dangerous and unsanitary conditions.
    Dr. Grabowski, what happens to Federal oversight over 
nursing home operations and quality of care if funding is cut 
by 22 percent? Are we able to ensure that nursing home 
residents are adequately protected from threats to their 
health?
    Dr. Grabowski. That would be an absolute disaster. I was 
part of, once again, a National Academies committee. We 
recommended increasing funding. This was at baseline, and now 
this is talking about going in the other direction. Once again, 
these are frail older adults, many with Alzheimer's and 
dementia. They are not able, in many instances, to monitor 
their own care. There is a real role for survey and 
certification to come in and ensure that all care requirements 
are being met.
    Ms. Tokuda. Absolutely. These vulnerable Americans need 
advocates. They need family members to be able to share their 
concerns, have their concerns addressed. You know, in addition 
to cutting funding for CMS, Republicans' Default on America Act 
would also impose a 22-percent cut on the Administration for 
Community Living's Long-Term Care Ombudsman Program. The long-
term care ombudsman's work is to identify, investigate, and 
resolve complaints made by or on behalf of nursing home 
residents.
    Dr. Grabowski, tragic things happen when people do not have 
an advocate, a way to raise concerns, to take actions. We have 
heard those heartbreaking stories right here in this room 
today. What will happen if we cut ombudsman funding, reducing 
the resources dedicated to investigating residents' concerns 
about their treatment and their safety. Will these horrific 
cuts as proposed by House Republicans doom us to repeat these 
fatal mistakes of the past?
    Dr. Grabowski. When the Ombudsman Program is properly 
funded, it is incredibly successful. Once again, that National 
Academies committee that I served on, we recommended increasing 
funding and making sure that the Ombudsman Program was working 
well across the country. Once again, some areas it is working 
really well. Other areas it needs further support. We do not 
want to make cuts. Once again, that is going in the wrong 
direction.
    Ms. Tokuda. Absolutely. No cuts. Let us learn from the 
mistakes of the past. The reality is, again, when we were 
looking at the pandemic, American deaths, one in ten of all 
COVID-19 deaths in America was linked to a nursing home at the 
height of our pandemic. One in every 50 nursing home residents 
died of COVID-19. No more cuts. Stop these draconian threats on 
our people, and let us learn from those lessons past. Thank 
you, Dr. Grabowski. I yield back my time.
    Dr. Wenstrup. Thank you. I now recognize the Ranking Member 
for the purpose of a closing statement.
    Dr. Ruiz. Thank you, Mr. Chairman. In all that we do as 
Members of this Select Subcommittee, our focus must remain on 
preventing harm and saving lives in the event of a future 
public health threat. And as we look ahead to the future and 
work to craft policies that prevent future loss of life, there 
are lessons we must learn from our COVID-19 response.
    As I mentioned at the start of this hearing, we lost 
200,000 residents and staff of long-term care facilities across 
the country to this pandemic. Two hundred thousand of our 
fellow Americans perished due to COVID-19. And while at the 
time we knew little about this deadly novel airborne virus, and 
while at the time we lacked access to vaccines, testing, and 
therapeutics, we now have the responsibility to take the 
resources, tools, and knowledge we have gained over the last 
three years to create better policies that protect our health 
in the future, policies that prioritize compassion and center 
our attention on defending our most vulnerable populations, 
especially the elderly, who were and are at highest risk of 
severe illness, hospitalizations, and death from COVID-19.
    This work must include promoting transparency, 
strengthening protections and standards in nursing homes, and 
correcting course on the failed policies under the Trump 
Administration that left seniors more vulnerable to infection, 
severe illnesses, and death to COVID-19. I hope that these 
guiding principles can serve as a model for our work in this 
Subcommittee. And while in many ways with the Biden 
Administration, we have already taken steps toward this goal by 
reinstating, reinforcing Federal nursing home standards, 
improving inspections, and strengthening our healthcare 
workforce, there is much more work to be done. And now we must 
continue on this path, not reverse course with harmful budget 
cuts that harm our seniors' health.
    So, I hope at the end of the day we have moved the ball 
forward, that together we can put people over politics, save 
lives, and right the wrongs that caused so much suffering in 
this pandemic. Thank you.
    Dr. Wenstrup. Thank you. As I have stated many, many times, 
the goal of this Select Committee is to have a better path 
forward, to admit to our mistakes, to learn from our mistakes, 
to correct our mistakes, and to provide accountability for any 
mistakes that were made, especially if mistakes were made 
because of political motives or personal motives. Decisions are 
to be made on data, and sometimes there was no data, as 
everyone has pointed out, but sometimes decisions were made in 
spite of the data. What were the motives? Were they political? 
Were they personal?
    With COVID, many lessons have been learned. Our eyes have 
been opened to too many things, shamefully for our Nation that 
we had so many deficiencies. We talk about PPE. We talk about 
medications themselves. Our supply chain is reliant on China 
and other countries. We are not an independent Nation when it 
comes to our supply chain, especially in medicine. Look at your 
generic medications. Look at our protective equipment.
    If you had told me when I was in Iraq that my protective 
equipment and my pharmaceuticals as a surgeon there relied on 
China, an adversary, how did we get here? This is not any one 
administration. We have done this to ourselves over the last 50 
or 60 years. You know, we have learned that not everyone was 
adhering to standards, even pre-COVID, but COVID opened our 
eyes to a lot of things. But in some places, standards were 
being adhered to, and it was mentioned community rates matter. 
They do matter. That was an important piece of data for all of 
us. In many communities, if the community rate was high, it was 
high in the nursing homes. Is that the only factor, or was it 
the fact that maybe some nursing homes were not adhering to 
guidelines?
    You know, we have areas where it may have a high rate in 
the community but a lower rate in the nursing homes, and if so, 
why was that? Mrs. Lesko brought that up, the difference 
between Arizona and New York, where many of the vulnerable 
people in America happen to live in Arizona. Through this time, 
we have looked at community rates versus in-school rates. You 
were safer in school than you were at the grocery store, or, 
better yet, at the liquor store, which was open, yet we kept 
schools closed, or some did.
    I look at early on, some of the things that we saw and 
learned that one size does not fit all. You know, we had a 
legitimate fear, and we said let us go to lockdowns. I get 
that, but when you keep them up and you tell people not to go 
to the doctor, that is a problem. Those were decisions that 
were made as well. I actually had a sheriff in one of my rural 
counties call me and said, I just want you to know I had a guy 
71-years-old. He was scheduled to have his painful hernia 
repaired. They called him and canceled it, and he took his own 
life because he was in so much pain. There were no cases in 
that county at the time. One size does not fit all. One-size-
fits-all can be very dangerous.
    When I look at COVID, I look at it as something that should 
have united this Nation, and instead it divided us, and why? 
Because it was a Presidential political year. That is my 
opinion. It divided us. Politics took over. We see political 
organizations having influence on CDC guidelines. That should 
not be the case. Medicine does not deserve that. I have seen 
even on this Committee gratitude for the vaccines and the 
vaccine delivery, and I give credit to the vaccine delivery. 
That was an impressive, impressive maneuver, largely provided 
by our military as far as actual delivery, but I do not hear 
anybody who is, you know, talking about that from this side 
giving kudos to Operation Warp Speed itself.
    There were mistakes from both sides of the aisle, from 
every avenue here. Get the politics out of it. We see mandates 
coming from a politician saying you must get the vaccine. I am 
pro-vaccine, but I am not in a position to say that there may 
not be some adverse effects for some people and that some 
people might have questions on a mandate that says you get this 
or you lose your job and there is no conversation with the 
physician. What are we doing? I heard time and time again from 
patients who said when I talk to you, Dr. Wenstrup, I am more 
likely to get the vaccine, but when I am being told I have to 
get it by a politician, that is a problem. I just want to be 
educated, not indoctrinated. There is a huge mistake that we 
have made in this country. I do not know if any of you have 
noticed throughout your life, but Americans do not do well with 
``because I told you so.'' It does not work in America.
    Listen, I want to thank those who provided testimony for 
today's hearing. I know it is very personal, and I think it 
hurts all of us, and I think across both sides of the aisle, 
that pain is felt. And I want to share with you publicly, you 
know, that we are going to try to relieve the pain in any way 
that we can going forward. It is hard to comprehend how as a 
society, states implemented mandates that resulted in loved 
ones dying alone without a single family member there able to 
say goodbye. It is hard.
    This hearing and the testimony provided today from those 
directly affected by the deadly orders enacted in New York, New 
Jersey, and Pennsylvania is essential to have as we move 
forward in our investigation into the nursing home policies 
enacted by state officials and the coverup that ensued. These 
orders were more than a mistake. They were a deadly decision. 
They were medical malpractice by people that do not have a 
medical degree or a license to practice medicine.
    I think that we can agree that vaccines were extremely 
helpful to protect our elderly in nursing homes, but this 
hearing and this investigation is about the decisions made 
prior to the development of the vaccine and what actions were 
taken to avoid culpability for the deaths of thousands of 
Americans. Today we heard important testimony that New York 
Governor Andrew Cuomo loved to blame politics at every 
opportunity, and then he turned to attacks, belittlement, and 
name calling when challenged. He did not meet with the victims 
of families or show sympathy to those who were hurting. Instead 
he wrote a book. Governor Cuomo had resources at his disposal 
to protect the vulnerable, and he failed to use them. The 
Comfort and the Javits Center sat virtually empty.
    The orders from New York prohibited testing of incoming 
patients for COVID-19. They mandated that nursing homes and 
long-term care facilities accept COVID-positive patients. This 
was directly against the CDC guidance, the CMS guidance, and, 
frankly, common sense, at least common medical sense. In New 
York, over 10,000 nursing home deaths occurred in the 50 days 
before Governor Cuomo's mandate was rescinded. Today we heard 
concerning testimony regarding the manipulation of data from 
Governor Cuomo's own office. The Biden Department of Justice 
chose not to investigate the state orders nor the ensuing 
coverup. We will.
    Today we are able to have bipartisan agreement that seniors 
were failed and too many died. While others blame the Trump 
Administration, the fact is these deadly nursing home policies 
were not implemented nationwide. Instead, they were developed 
and enacted by states with, honestly, Democrat Governors--New 
York, New Jersey, and Pennsylvania--and against the guidance 
provided by the Trump Administration from CMS and CDC. And that 
is the key, not the Administration, but the CMS and CDC, which 
should be agnostic of politics.
    Those who are responsible for these mandates must be held 
accountable. The victims and their families deserve 
transparency and to know who created these must-admit orders, 
and they deserve the opportunity to hold them accountable. We 
cannot simply just blame one or the other and move on when 
families are missing their loved ones and missing the closure 
that comes with accountability.
    The Select Subcommittee on the Coronavirus Pandemic will 
continue to examine the deadly policy decisions surrounding 
nursing homes, and we will continue to investigate the failed 
leadership of state officials during the COVID-19 pandemic. And 
we will continue to provide, as best we can, a path forward for 
America that is much better for America and has accountability 
and science behind it.
    And without objection, all Members will have five 
legislative days within which to submit materials and to submit 
additional written questions for the witnesses, which will be 
forwarded to the witnesses for their response.
    Dr. Wenstrup. And with that, this hearing is adjourned. 
Thank you, everyone.
    [Whereupon, at 12:14 p.m., the Select Subcommittee was 
adjourned.]

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