download the app for free today. >> the senate special committee on aging held a hearing on improving medicare and medicaid services for people who are eligible for both programs. chair bob casey spoke about proposed legislation called the pace expended act which help streamline the medicare medicaid systems. this is about 90 minutes. sen. casey: good morning. today's hearing will focus on

seniors and people of disabilities who depend on medicare and medicaid in their lifeline as a lifeline i should say. over 12 men americans are eligible for both medicare and medicaid including almost half a million in pennsylvania. these americans are expected to know which services medicare covers, which services medicaid covers, and which services are not covered at all. they might have one insurance card for their primary care doctor, one for their behavioral health and one for prescription drugs and the list goes on. they might have a doctor who takes their medicare insurance but not their medicaid insurance. not only is this confusing and frustrating, it creates unnecessary hurdles for people trying to get the care that they need. all americans deserve a health care system that they can

actually use it, not one rife with stumbling blocks. we will hear today from jane doyle from northeastern pennsylvania not far from where i live. she lives in monroe county in the northeastern corner of our stay. jane will share her harrowing story of navigating the complexity of these benefits. not only for herself but also as a caregiver for her mother. she will also describe how she lives in fear her doctors whom she trusts to keep her healthy will no longer take her coverage. we'll also hear from dennis heaphy about his coverage that combines medicare and medicaid and how that lets him remain independent. but it was quite a road to get to that independence could certainly there is work to be done. jane experience and dennis's story make that very clear.

i'm grateful our ranking member, senator scott, and i agree on this point. today we are introducing the pace expended act. this bill will reduce administrative barriers that prevent the development and expansion of pace programs in pennsylvania -- pace programs. in pennsylvania, we call them life programs. in most of the country, they go by the name pace. these programs enable people with medicare and medicaid to receive all their benefits through a single organization providing primary care, long-term care and more in one place. pace enables people with a high level of need to stay in the community rather than receiving care in a nursing home if that is there preference. this is the preference for the majority of older adults as well as people with disabilities.

that is why i am committed to expanding access to home and community-based services. last year the senate passed the american rescue plan, which included 12.7 million dollars in emergency funding for states for these services. these home and community-based services. states are using these resources to help more seniors and people with disabilities access care and to pay the heroic home care workers the hazard pay and the bonuses that they deserve. this investment in the rescue plan of $12.7 billion was a good first step, but we need to do more and invest more to ensure people with disabilities and seniors can receive care in their homes. that is why i lead 40 democratic senators in introducing the better care, better jobs act last year. that is senate bill 2210. this bill would make a permanent

investment in home and community-based services. it would help states provide better care for seniors, people with disabilities and their families and it would ensure there is a strong and supported workforce to provide those services. it would lead ultimately to better care. these are a few of the many issues faced a people that have to navigate both medicare and medicaid. we will hear from several witnesses today who will highlight how we can continue to improve care for all of these americans. i will turn to ranking member scott. sen. scott: thank you, mr. chairman for working together on the pace expended act. it is good for the country to see bipartisan coalition working on behalf of the country and not on behalf of democrats or republicans but on behalf of americans. one of the things i appreciate about this committee is we put seniors first. not red ones or blue ones, black

ones are white ones are wetlands, just seniors. that should be a mission for our nation and those in elected offices. certainly to follow the example you are leaving by. i appreciate your work on the pace expended act and the one-stop shopping concept is something that is really important when you have so many lawyers of complexity in your life as you age. if we can eliminate any of it, it helps all of it become more digestible and easier to handle for the seniors so thank you very much for your hard work on that issue. one of the reasons why this legislation is so important is we have nearly 12 million americans and 150,000 south carolinians who are due eligible. there eligible for medicaid and medicare. if you can imagine, as you describe seniors with chronic conditions having multiple caregivers, multiple places to go and if you think about medicare, the national program

run from the federal government, medicaid, a program run from the state government. getting those two to work together is not as easy as it should be. anything we can do under the direction of making that happen is going to be in the best interest of the seniors across this nation and certainly the seniors in south carolina that i know and love so much. i will say that the biden administration needs to consistently and continuously work on making sure those agencies that serve our seniors like the social security agency is i'm thankful to see that after 15 of my colleagues and i wrote a letter to president biden asking for field offices to reopen we are at least seeing them move in the direction of telework for those agencies. i think it is important for us to have an opportunity to have our seniors have the place to go whether virtually or in person

when the pandemic subsides for them to find the help they need from the agencies that they desperately want it. where the focus is we have is trying to figure out the jigsaw puzzle of the due eligibles. i will say the issues are challenging in many ways paired as opposed to the key about how to explain it, i thought i would use examples of two folks who are due eligible in south carolina who have benefited from having caregivers and care managers, case managers who understand and appreciate the complexity of the situation. we have in south carolina a program known as healthy connections prime that allows for three providers to serve about 15,000 people over 44 counties to help the dual eligible concept become a little easier.

since the program started in 2015, we have seen improvements throughout the state. one member of the program was living in his car homeless. his care manager noticed the signs that something was not going well. the care manager educated the young man about the plan benefits that assisted him and helped him find glasses, a place to stay, hearing aids and dental work. another member from florence of south carolina having gradually declining over the -- had been declining over the past several months. his daughter who serves as his caregiver noticed he was having more and more difficulty even with his walker and he did more support. his care coordinator worked with his daughter and the gentleman dr. on the needs and soon thereafter a wheelchair was ordered, covered and delivered. the member and the daughter

reported they were relieved and felt much safer at home. they were able to get their appointments scheduled because of the support being provided. to help states further improve coverage, i have introduced legislation to provide further assistance to state medicaid agencies to help integrate coverage. we created a $100 million grant for states to improve care coordination for their duly eligible population. states can use the funds to hire personnel that have experience with the medicare program or train existing personnel or help in a fishy area with the enrollment process. studies have shown integrated care improves health outcomes such as decreased rates of hospitalization and readmission. i look forward to hearing from our witnesses about what else we can do as congress members, senators to improve the lives of our dual eligible population.

sen. casey: before we moved to our witnesses, i want to note that we are joined by senator collins, former chair of this committee and for senator rick scott who was here earlier. we are going to have senators moving in and out because of a busy day of engagements. we will go as people arrive and grateful to have everyone with us today. that missed -- let me start with our first witness. dr. ho is a figaro. -- dr. jose figueroa. he is a -- his research focuses on the health-care spending and poor clinical outcomes among older at risk populations with complex medical needs. he is practicing hospital

physician at brigham and women's hospital in boston were he provides care to many americans with medicare and medicaid. i want to thank him for being with us today to share his expertise with the committee. for our second witness, i will turn to ranking member scott. sen. scott: i am pleased to welcome eunice medina. eunice is a new south carolinian but someone who has a deep understanding of this issue. eunice serves as the chief of staff and deputy director of programs for the south carolina health and human services. the state department of hhs is the agency responsible for running our medicaid program, which provides health coverage to more than one million south carolinians. the department operates the healthy connections prime program, which coordinates care

for south carolinians who are duly legible. her testimony today comes from her more than 18 years of experience working on this issue in south carolina and florida where she moved from. she has dedicated her career to working on behalf of older americans and americans with disabilities. those who are our most vulnerable and need this assistance the most. she is one of the thousands of public servants who work every single day to make the lives of south eric -- south carolinians better. welcome to this hearing and welcome to south carolina. sen. casey: next, i will introduce dennis heaphy. dennis is a health justice advocate and researcher at the disability policy consortium. dennis is also a commissioner on the medicare and chip payment access commission known as

macpac, the nonpartisan body that provides recommendations for congress on ways to improve the medicaid program. he also happens to have both medicare and medicaid should he is on the front lines helping states create programs that serve the needs of people by medicaid -- with medicaid by meeting them where they are. you for being with us today and sharing your expertise with the committee. our fourth and final witness is jane doyle from pennsylvania. jane has two children and three grandchildren. well they don't live close by, she is able to connect with them through daily phone calls. jane described herself as an artist at heart and loves to paint. jane happens to receive medicare and medicaid because malt -- because of multiple sclerosis.

she also helps care for her mother who has medicare and medicaid as well. thank you for being with us today and sharing your personal story with the committee. we will turn next to our witness statements. we will start with dr. figuero.: you may begin. dr. figueroa: thank you, chairman casey, ranking member scott and honorable members of the committee. thank you for the opportunity to testify today. i am an assistant professor of health policy and medicine at harvard university. i am a practicing physician in hospital and medicine at the brigham and women's hospital. for my research, i focus on how best to improve the quality of care delivered to the sickest and most vulnerable patients in our country including the dual eligible population which are those as mentioned who qualify for the medicare and medicaid programs. as a physician and researcher, i

can attest to the fact navigate in our health care system is complex for anyone. these challenges are from were difficult for the 12.3 million dual eligible patients living with disability, serious mental illness, frailty, multiple chronic conditions and living in poverty. because of these vulnerabilities, dual eligible people are more likely to require hospital care, nursing home care, long-term care, home-based care, hate your health and at increased risk for experiencing poor health outcomes. a great failure of our health care system is so much of dual eligible patients time is lost navigating the complex and confusing rules and regulations of two programs, which they must do in order to ensure they get the care they need. this is valuable time they could instead be spending at home with their family and with their friends.

as a physician, one of the most frustrating realities for caring for a dual eligible patient is an ability to help them throughout this process. countless hours are spent by clinicians, care coordinators, social workers trying to determine what should be the safest discharge plan for patients while the same time trying to coordinate the care across multiple different providers across different clinics. this often results in a prolonged hospital stays and deconditioning of our patients while they wait. as stewards of health care system, we have an obligation to deliver better care for dual eligible people. one important way of doing so is by promoting care models that offer true integration between the medicare and the medicaid programs, financially and clinically across the entire continuum. integrated programs when done right have the potential to improve the efficiency, the affordability and the quality of

care dual eligible patients receive. today there are three major types of fully integrated care models. they include the program of all-inclusive care for elderly known as the pace program, medicare advantage, and the state level medicare medicaid plans under the cms financial alignment initiative. in my submitted testimony, i have outlined what the experience has been with this programs -- with these programs are the big take away is well we have limited and mixed evidence on the success of these programs, there are some reassuringly positive signals that suggest integrated care when done right can improve the quality and efficiency delivered to dual patients. with more time and experience, we expect these programs to get better. to date, only one in 10 duals are enrolled in an integrated care model.

nearly 50% across our country do not have access to one. in my written testimony, highly recommendations on how we can make integrated care for duals better. congress should consider policy options that help states adopt and expand integrated care models especially in the 14 states that do not have one program. integrated models must also offer meaningfully better value than the status quo and should cover all services patients need from primary care to long term and behavioral health services. the enrollment processes must also be easy. patients need adequate unbiased support to ensure they make an informed decision about what program is best. we need better transparency on performance, better timely data, and need to adopt better

measures to capture what is truly matter -- what truly matters to patients. thank you for your time. sen. casey: next we will turn to ms. medina. you may begin. ms. medina: thank you, chairman casey, ricky member scott and members of the committee for the opportunity to participate in today's discussion. i currently serve as chief of staff and deputy director at the south carolina department of health and human services could part adjoining south carolina's agency, i spent 17 years working with florida's medicaid population in various capacities. i spent more than a decade of my career working with seniors in the foot department of elder affairs where i manage multiple programs. in 2013, i assisted the medicaid agency in transitioning medicaid beneficiaries into what is known

as florida state statewide medicare managed program. the following year, i joined the florida agency where i worked to ensure health plans offering long-term services were doing so in accordance state and federal climates. ended up overseeing 15 -- 3.5 million beneficiaries. in 2020 when i joined south carolina's medicaid agency and i have spent much of my first year analyzing how to help the state by evaluating its medicaid program and assisting the agencies developing a plan to improve quality of care and cost efficiency. south carolina's population that is eligible for medicare and medicaid have multiple options for receiving services could according to did -- receiving services. over 59,000 are enrolled in our dual special needs plan. 15,000 are enrolled in our financial alignment initiative.

22,000 are enrolled in one of our four community-based labor programs appeare -- labor programs. in 2015, our state chose to participate in the federal demonstration program to evaluate opportunities for integrated care for seniors. unlike other states, south carolina chose to start off the program with a focus on those 65 years and older. this month marks are seventh anniversary sense of money the program should i'm happy to spend our anniversary discussing lessons learned. we have found any cases where beneficiaries did not meet services, the utilized services only -- that wrongly covered in limited amounts.

another lesson was the importance of care coordination at the individual and aficionado level and the importance of fully assessing beneficiary needs. we have a big decision to make as a state in deciding whether we want to take advantage of the alternative offers by the proposal that cms issued on january 7, 2022 or explore other options. medicaid waiver programs are made up of more than just duals. when states are looking to the great care, the need to consider the capacity of the agency to manage programs. which may include individuals eligible for full programs under medicaid. this is the approach that florida took. florida consolidated programs that serve as medicaid home and committed to best service

programs and nursing facility population over five years. if someone is enrolled in one of these plans, they can receive medicaid medical and long-term care services to when possible, the -- long-term care services. streamlining programs and focusing efforts on funding and innovative program can avoid confusion and administrative burden among dual beneficiaries and providers. florida's model presents opportunity to further coordinate care. chief among them being the integration of medicare data to i truly believe each -- medicare data. our state will be looking for solutions that allow flexibility in how to align our programs. opportunities to align processes across medicare and medicaid products and how to shift to a

model that embraces these flexibilities. resources that would allow states to strengthen their agency to support these changes would be most welcome to thank you for allowing me to principate in today's discussion on a topic i am passionate about and a population i have dedicated my career to serving. sen. casey: thank you for your opening statement 10 will return next -- opening statement. we will turn next to mr. heaphy. i think you might be muted. mr. heaphy: apologies. chairman casey, ranking member

scott, members of the senate special committee on aging, thank you for the opportunity to testify about my experience as a duly eligible in an integrated plan. i want to give special thanks to senator casey for his support of the disability -- this of april -- the disabled community. in senator scott, several of my family numbers have moved to south kaelin and love the state i'm here to speak to you from the perspective of a disability advocate and member of an integrated model in massachusetts. when care was established to improve the health and oneness of persons 21 to 64 with medicaid and medicare. a better aligning both funding sources in a single health plan. one care was designed to place increased weight on home and community-based services. emphasizing independent living

and recovery. i became a member of one care when it began in 2013 out of fear of losing my independence and my health in the system and an algorithm driven short-term medically focused plan. i believe in the potential of integrated care and service care . which are comprised of many stakeholders but largely consumers are not family members. truly whole person centered care meets the person's medical and other needs helping the person to live in a meaningful life and community.

it means ensuring i have the home and commute debate services i need including durable medical equipment, wheelchairs, technology, medical supplies. it means having ache care plan i create it with my team in the direct line of communication with my nurse practitioner or physician assistant who can respond directly to my needs to reduce my chances of having to go to the emergency department or being hospitalized. i have experienced integrated care at its best. my nurse practitioner coming to my home regularly. my pcas help me with my activities of daily living. when i developed a bone infection that required surgery,

many hospitalizations and over a year of recovery rather than going into a skilled nursing facility rehab, my care team supported my decision to do recovery at home. my care team provided training for my personal care attendants and increase the number of hours. acupuncture was provided weekly to control my spasticity. my autoimmune specialist even though an out-of-network provider was regularly consulted. most health plans do not provide people like me these types of services. thankfully, i usually do not need intensive services. what i need most are home and community services and support

in the care planning process with people i know and trust. frustratingly, even though it is designed to be fully integrated, a whole person plan, when care seems to be moving away from the original model. i went to the emergency department for the first time in years because i could not reach a medical person on my plan but instead could only get to the after hours answering service. not knowing what to do i drove my wheelchair to the hospital a mile up the road. if i'd been able to reach someone with medical knowledge, i would not have gone to the emergency department. lack of a care plan or let -- or just gift partner to reduce access to services. the state is taking the concerns seriously and working with implementation counsel, disability advocates and the one

care plans themselves to address what appears to be a departure by the plans from the original intent of the model. we will be heard and we can make change. not every state is like massachusetts. every states needs to develop an integrated care system. thank you for the opportunity to speak with you today and i look forward to answering your questions. sen. casey: thank you for the opening statement and we will turn next to ms. doyle. ms. doyle: good morning, chairman casey, ranking member scott and members of the senate special committee on aging. i name is jane doyle. i have lived in pennsylvania for the past 32 years. i have two children and three grandchildren living in the

suburbs of atlanta and boston. i am honored to have this opportunity to testify to help make positive change toward better health care for everyone. i have experience for myself and my family several different kinds of dual eligibility when i was diagnosed with multiple sclerosis. i applied for social security disability so i also qualify for medicare. i still was able to work part-time and i also access medicaid through a special program. it allows people -- excuse me. it allows people to work and still earn higher incomes but otherwise qualify for medicaid to pay premiums for the medicaid benefits. it was a relief to have affordable insurance that covered out-of-pocket costs and i found it quite purposeful to continue to work. since 2017 do to further medical

circumstances i have been unable to work. i qualify for regular medicaid. in 2020, pennsylvania required medicaid through managed health care. from the eight doctors i see, i don't believe any of them are enrolled in the new system. so far, i have been fairly lucky. most of my doctors have continued to see me but they must write off the balances after medicare. i recently received a balanced bill from a new doctor who may not have been aware they were permitted to balance bill because of medicaid. i doctors say the new system is complicated and the rules are different across the region for networks. i also worry that since many doctors don't take the managed care and these programs try to cut cost, the quality i receive

suffers. during the pandemic, i had three operations. one which resulted in reversible nerve damage. this resulted in me needing neurosurgery and i had to travel 100 miles to philadelphia to get that care. my mother is also dually eligible. she is enrolled in medicare and began to need more help. she needed the kind of long-term care medicare does not cover. she paid for home health care out-of-pocket costing around $7,000 a month. for 24 years as a widow, her money was running out at 87 years of age kid thankfully in pennsylvania, medicaid has a special program known as waiver. this provides home care. our family viewed this as a great alternative to a nursing home setting for our mother. but to qualify, someone must first apply for medicaid and

then apply for waiver. the process is very long and difficult. it involves several applications, documentation from medicaid and doctors, choosing a provider to oversee your case and finding a home health care agency with enough staff to meet our mom's needs. eventually we did not have enough money to pay for one more day. i was fortunate to have stumbled across the pennsylvania health flow project. they helped to expedite my mother's case. as you can imagine, the stress of not knowing how we were going to care for her mother was insurmountable. i have talked about the mother my -- the trouble my mother faced becoming dually eligible, the challenges i experience as a dually eligible person. i would like to tell you what would happen if i stopped becoming dually eligible. if i lose medicaid, i would not be able to buy medigap insurance

to cover out-of-pocket costs because i have a pre-existing condition. for those of us with a pre-existing condition, medigap is allowed to deny your insurance if you have medicaid when you first sign on for medicare. as a result, i am stuck to it i cannot increase my income or savings because i will no longer have medicare since i cannot -- i would no longer have medicaid and i will not be able to have medigap. i would face much higher costs with having medicare and no other insurance. this is a loss -- a lot for one person to navigate. there are sources to help like the pennsylvania health flow project and the medicare rights center national helpline which i have reached out to.

i ask you today to do whatever you can to ease the burden of people like me and my mother who have faced challenges. while these programs are important, they are not easy to use. to make these programs actually work, he needs to be much easier for people like myself and my mother to enroll and find the care. thank you again for the opportunity to speak with you today. i look forward to answering your questions. sen. casey: thanks very much. i appreciate your testimony. i will start with jane doyle for the first question. jane, i wanted to again thank you for your testimony. these stories that are shared by you and other witnesses help all of us when we are trying to formulate policy, especially on complex issues like health care and in this case the challenges that dual america -- dual eligible americans face. in your testimony, you talked

about your mother receiving long-term care at home. you take -- you stated your family viewed this as a great alternative to a nursing home for our mother as it would allow her to stay independent and involved with us. it is so important for americans to be able to receive care in the setting they prefer. everyone should have the option to stay close and connected to family if that is their choice. can you tell us more about why home and community based services were so important to you and your mother and your family? ms. doyle: in our particular situation, it was my mother's personal choice and we wanted to honor that. . although my mom was college educated, my mom was a homemaker and she was not accustomed to a lot of outside socializing at her home was her life.

but the second piece to that question in short, the quality of the care that we receive from home care and the family pitching in was far better than what we had experienced in short extends in rehabs following hospitalization. nursing homes that provide rehabilitation were grossly understaffed even prior to the pandemic and i can assure you that from a recent hospital visit, that understaffing is even worse. it is hard to leave your loved one and go home at night not knowing if someone is going to answer your loved ones call bell or simply place a couple of water within their reach. sen. casey: second question i

will move to dr. figueroa. you told us about your experience not only as a researcher but also as a provider for people who have medicare and medicaid. your testimony spoke to the importance of having various options for people when it comes to integrated care models. one of the models you mentioned is the pace program. or the life program in pennsylvania. we have 7000 pennsylvanians that rely on pace for their care. many of whom would otherwise be receiving care in a nursing home. hundreds of thousands of others with medicare and medicaid in pennsylvania, there are others i should say that may not live near a pace program and may not know it is an option available to them. as i mentioned, ranking member scott and i have introduced the pace expending -- the pace

expending act. can you share with the committee how expanding a program like pace might be able -- better able to support individuals with both medicare and medicaid? dr. figueroa: thank you, chairman casey pimp the pace program -- chairman casey. the pace program as i mentioned provides all health care services for adults would otherwise be in a nursing home. the primary objective is to keep patients at home safely as possible for as long as possible. the key to the pace programs are three things. what is their fully integrated financially. two is they have to -- have a multidisciplinary team. a one-stop shop that includes nurses, doctors, their best, social workers, case managers all with one common goal, that they are fully accountable for the care of the patient across

the entire care. number three is a maximize again what matters most to patients is keeping them at home in their communities with their loved ones. one example is every time someone joins the pace program, they give them comprehensive -- they do really comprehensive patient assessments, a review of all their medical needs. they get them in communication with all prior physicians and they try to ascertain what matters to the patient. what values do they appreciate? the second thing is they create a plan that is unique to each individual patient based on the values. they coordinate all the care as i mentioned. it is usually an adult day care type program where the multidisciplined team operates. they often are communicating with family members.

i think expending the pace program is a good option especially in areas where there are no integrated care models. we can dig about ways of expanding the program. you can scale existing pace programs by increasing current capacity. the second thing you can do is you can think about spreading the pace program, which you need to offer incentives to other areas and states where there is no integrated care program or experience among the local health care providers in participating in pace program. there is a big challenge for the health care workforce to actually be certified to deliver pace type care or nursing care. that is a challenge that needs to be overcome. the last thing you can the cabal is changing the scope of the program, which means expanding to other patient populations who do not currently qualify. i would be interested in seeing

if the pace program model would be beneficial for younger people with disabilities or younger people with serious mental illness. that might be a potential avenue. sen. casey: i will turn to the ranking member scott. sen. scott: having the chairman on your left and the former chairwoman on your right, the best i can do is defer to her first 10 sen. collins: -- to her first. sen. collins: thank you, ranking member scott. i want to thank you both for holding this very important hearing. dr. figueroa, i want to start with you. as we have learned today, listening to the testimony and we know from our own experiences doing casework in our state offices, the dual eligibles population is extremely diverse.

many people think of it as old, poor and sick. that does not capture the diversity of those who are in the dual eligible population. for example, a dual eligible might be an 80-year-old woman who requires assisted living services and has spent her remaining income on medical expenses. it could be a middle-aged woman with diabetes and pulmonary disease who requires a variety of specialists. it could be a young person with disabilities who lives at home and requires assistance with the activities of daily living. some dual eligible people are not actually costly but the minority makes the duals overall

one of the most expensive groups for both medicare and medicaid. my point is that what is dragging the caused is different for each subpopulation. as we see reforms to increase -- to improve the care and lower cost wherever possible, how should we evaluate policies that might better integrate care knowing that there is not one way? could you give us some guidance on that? dr. figueroa: thank you, senator collins. i think you bring up a great point. we should not expect given the diversity of the population you described, we should not expect one strategy will work for everyone. a strategy that might work in urban areas might not work in rural areas.

what we need is we need that are data to understand what works for what specific population. in order to get to that level of understanding, we must do a better job at making the care, how we care and the different programs and plans that care for dual eligible patients, we need to understand their effectiveness. we need to understand how well they perform for these populations. we need to understand what patient experience is like. we need to ask more questions of patients to determine if they think their care is meaningfully different under these programs. at the moment, we often have very lagged data that does not help us make decisions for patients today to improve care for tomorrow. the evaluations are from data in 2012, 2013, 2014 and we are trying to make decisions for

2022. that is challenging to understand which care models to refer patients to. and i'm assuming for policymakers to figure out what solutions they should be up amending at the federal and state level. if we can somehow make it a better and more transparent and also be able to drill down which programs work for the young duals with schizophrenia versus with the older frail adults living in a nursing home, we can expand the models that make more sense. sen. collins: thank you, dr. appeared the second issue i went to touch on with you briefly is the challenges posed by the workforce issues that we are dealing with. their wares -- there was a recent survey of long-term care facilities in maine that found that 94% of main providers were experienced -- of maine

providers were experiencing a staffing shortage and more than half of respondents replied their situation was at a crisis level. at the same time, we know that these interdisciplinary teams are an important component of integrating care for dual eligibles. could you comment on the workforce challenges affect our ability to adopt and scale integrated care models for dual eligibles? is this a scenario that should be more of a focus for congress? dr. figueroa: yes, i agree it should be an area of more focused of congress. we as you said have staff shortages across the country and i think the covid pandemic took -- really exposed that

vulnerability in our health care system to if you think of nursing home -- health care system. if you think of nursing homes, urging homes had significant staff shortages the nursing homes with those shortages were more likely to be decimated with the covid-19 -- by covid-19. one thing we can think about in terms of improving the workforce, one is we need to compensate the workforce in certain areas better. we need to provide appropriate living wages so we have less turnover and we have more people, good people wanting to work in the health care sector. we need to think about training a diverse workforce. we cannot expect to have doctors in all areas of the country caring for the majority of patients. in some areas, we need collaborations with doctors and other types of professionals. we can think about expanding community health workers.

shortages are a big problem. what kind of policies can we promote, workers working side-by-side with clinicians and other health care providers, one thing we can consider is how we pay for community health care workers. we should think about appropriately paying workers and not them providing volunteer services because they care about the community and the people who live in the community. those are things congress and states can consider. sen. collins: thank you again . sen. casey: i just want to acknowledge as well we will have senators coming in throughout the hearing should senator braun was with us and will be joined by others soon. i want to turn to ranking member scott for his questions. sen. scott: thank you, mr.

chairman. south carolina's first major effort targeted towards improving care for duly eligible individuals. ms. medina, can you talk about the lessons learned during this project and how do you envision its future moving forward? ms. medina: thank you, senator scott. there has been great success in south carolina with our dual demonstration program. it was the first attempt serving our duals both in the medical services and long-term care services together. having said that, we are at a point in the program -- it is a demonstration and we have in working with our partners at the centers for medicare and medicaid services to figure out what our next steps. i think there are opportunities to figure out what really works best in the state and what we

can take from the experience with healthy connections into whatever we decide to design for the future. sen. scott: i have introduced legislation that would provide states with one time grant resources to improve care for duly eligible beneficiaries. one possible use of this fund as for state medicaid offices to expand their understanding of the medicare program. is this something you think states would benefit from and what other witnesses like to weigh in if they think is necessary? ms. medina: i definitely think when it comes to medicaid agencies, obviously the focus is heavy on the medicaid populations, medicaid experience and that knowledge that goes with it. as dual integration has become such a hot topic, agencies are looking internally to better

understand the medicare rules and processes, especially those that participate out of the dual demonstration program or that are managing their dual special needs plans in their state. i think there is an opportunity we would welcome to further increase our institutional around medicare so we can make the best decisions for our state. sen. scott: any other panelist like to weigh in on the question as it relates to one time grant money going to states to help bridge the gap in understanding and appreciating the complexities of the two programs? i will continue with ms. medina. >> sorry. there's a potential opportunity for increasing capacity and competencies within offices to connect -- collect data,

medicare and medicaid information so states can start developing a system that works to understand. that is all i would say. better data collection systems. sen. scott: thank you, sir, for your comments. with the balance of my time i want to ask ms. medina one last question. there is always a natural tension about the amount of federal involvement in administering large programs like medicare. i believe states of the best laboratories for treating their own unique populations. do you believe that you have the appropriate amount of flexibility to provide cubs it -- coverage to duly eligible individuals? ms. medina: as a state medicaid agency, we definitely have to navigate really complex authorities when we want to design programs that best fit

our agencies and our population. so, absolutely. there are definitely delays sometimes in new processes or new guidance that the issue, but we continue to work with them to figure out what are the best pathways that we should take, especially when it comes to the various options states have in how to implement their programs and the corresponding authorities. sen. scott: thank you. mr. chairman, with my last 30 seconds, i would like to point out the importance of both having experts and people who are actually dealing with the dual challenges of this complex system. thinking about dennis's comments about having to take his wheelchair a mile to a hospital to get care. or thinking about our other witness who has spoken so

clearly about not only, jane doyle, her situation, but her mother's situation. there is something about hearing from experts who can help illuminate the necessity of direction, but i think it is also incredibly informative and important to hear from witnesses who understand the real-life pain and challenges that come with a system built for them, but not really. and so, i think having a good balance has been helpful for me today. chair casey: very well said by the ranking member. very complicated issues and very personal. we will turn next to senator warnock. who is joining us virtually. sen. warnock: thank you so very much, mr. chair. my state is when on the most critical states in that program and our country and it is created to expand access to

health care for low income children, for families, and people with disabilities. because the affordable care act allows states to expand medicaid, there are more than 10 million americans who qualify for medicaid due to a disability. many of these same individuals also have medicare. there are currently more than 300,000 georgians eligible for medicaid due to disability. however, that number would be higher if my home state of georgia would finally expand medicaid, expand the lifeline program to more low income individuals. individuals who live in the coverage gap, 275,000 georgians in the medicaid coverage gap. 500,000 uninsured georgians. 646,000 georgians who would

qualify for free and affordable health coverage if georgia joined the other 38 states and the district of columbia in expanding medicaid. mr. heaphy, in your testimony you highlighted that not every state has provided innovative ways to make sure people have access to health care services like yours had. can you talk now about the implications of living in a state that has not expended medicaid to those with disabilities and you are no longer eligible to the program? mr. heaphy: i would not be here testifying. i would probably either be in a nursing home or isolated in my home, or not alive. and i am not being hyperbolic

about that. it's very challenging for anyone with a disability to be able to live, even with medicaid services. but without eligibility, it's even more devastating. i think something that needs to be considered too is work requirements. that for someone like me, i love working. the importance of working to me, it's porten to me. -- it is important to me. and the ability to work in massachusetts is great. however, the work requirement scares me, because it would disproportionately impact folks with substances disorder, mental health diagnoses, folks who may not have been able to demonstrate the level of disability that is required to

be eligible for medicaid under the medicaid requirements. and so for me, access to medicaid is the first step towards accessing health care, and the lack of ability to get medicaid is really just -- it's really a human rights issue as well as a civil-rights issue. and so, i would not be able to live in another state. as a matter of fact, i live in massachusetts because of the health care system here. i have been offered jobs to go to other states have not been able to take those jobs because of the lack provided. in massachusetts i can increase the amount of money i make and still make medicaid benefits. the ability to maintain medicaid benefits over time that supports my ability to work. and so what is important is really to look at how to

incentivize the ability for people to get medicaid and work at the same time without penalizing people who cannot work. i don't know if that answers your question or not. sen. warnock: sure, it absolutely answers my question. and to your point, after just 10 months of arkansas's medicaid work requirement for example, some 18,000 poor and disabled folks lost their health care coverage. after just 10 months. i live in a state that hasn't expended medicaid. what i am hearing from you is you might not be alive if you were just in the wrong state, in the wrong zip code. i happen to think that health care is a human right. and if it is a human right, it is not a human right in 30 states. it is a human right in all 50 states where we have an affordable care act law that has

been on the books for 10 years. thank you so very much for your courage today. mr. heaphy: thank you. chair casey: thank you, senator warnock. i will continue with my questions, and may turn to the ranking member after that, and then i think we will have senator gillibrand after that. i want to turn back to jane doyle. you highlighted how difficult it was to help your mother apply for and enroll in the care that she needs. in your testimony you talked about, quote, several applications, and having to attach, quote, hundreds of documents. hundreds. you also describe your own experience applying for medicaid at different points in your life while you had medicare, while you are working, and when you could no longer work. at various points you turned to nonprofit organizations like the

pennsylvania health law project and the medicare rights center for help. i imagine there are so many people listening at home who can relate to your story. as ranking member scott made reference to, it is so important to hear from people who are living through these challenges. jane, are there things that you could have -- or that could have made the application and enrollment process easier for you, and easier for your mother to navigate? ms. doyle: thank you, senator. well, it was a little more clear for basic medicaid for myself. but for my mom, it wasn't. in short, i think the answer would be to make the whole process quicker. but that might not be exactly realistic.

a certain degree of prudence obviously certainly needs to ensure compliance of the program. but i will say, for what we cann i -- we call in pennsylvania as a nursing home level care medicaid, the big issue i had was the $7,000 asset mark. and so, with the $7,000 asset mark for a person with very, very high needs, that money is spent very quickly. first, as i mentioned in my testimony, you have to qualify for medicaid, and not everyone is already qualified for medicaid. and then you go on to the next application of waiver. so these dual applications can take two to three months. and as you can imagine, $7,000,

when $7,000 a month is going out for high needs, that is not going to last you that aeration. so possibly that limit may be able to be increased to allow people the time needed to get through the process. maybe one way. the other way, maybe integrating. we have talked a lot about that during this meeting. but possibly integrating that process of applying for medicaid and waiver together may make that more efficient. also in my case, this may be local, but it would really be great if government and local government updates their website to make sure they have the correct forms online so that people can access those and that you can upload those documents that we mentioned earlier.

that would be far easier than having to photocopy a book to get down to the county assistants with your process. the other thing that i will talk about, there's a lot of programs for help to reach out to, but i myself found myself making numerous phone calls before i found the correct source. and i can't imagine that elderly people with maybe fewer skills or a bit of confusion, i cannot imagine how they might get through the process. i would suggest perhaps more awareness and designate maybe one agency that yields people to the right resource. that might be helpful. my first resource, which

unfortunately was not all that helpful, was the local office on aging. i did not find them particularly resource knowledgeable. but i think elderly might tend to go there. that might be a good place to start for people to find out where they need to be guided for specific issues for this massive, massive system. chair casey: thank you very much and thank you for giving us your perspective, from a very practical perspective you have, which is very practical. i will turn to our ranking member scott. sen. scott: thank you, mr. chairman. i will also note some of the comments we have heard about the importance -- i am appreciating the path back to work for medicaid and the challenges we face. in dennis's situation, i think there'll always be a carveout or

a second look at a concept for offer to work. i believe president clinton's approach in his 1992 campaign that he was actually able to pass through was overall good for the country, good for people, and frankly, something i completely support. i do believe we should always take into consideration special exceptions when necessary, but the path forward i think is a good one overall. dr. figueroa, may i ask you a question about the challenges you find dually eligible beneficiaries facing when receiving care? i think chairman casey did a really good job of simplifying this web of challenges of paperwork, and the springs of challenges that come along with binders you are trying to find your way through when you're looking for help in all the wrong places. because paperwork jigsaw puzzle seems to be missing a few pieces. but beyond that, can you talk about some of the other

challenges that dually eligible beneficiaries face when receiving care? dr. figueroa: thank you, wrecking member scott. as you mentioned, the administrative web and complexity is a law to access health care. it is a law that people have to climb over to access health care. as we mentioned, these are very vulnerable people living in poverty. some people with limited health literacy, some people with limited computer proficiency. and in that law, it is insurmountable for some. and these are the people that need care the most. these are the people that want to be in a home living with family and their friends. and these are the people that are unfortunately stuck behind this wall. and this wall prevents them from, for example, if they need medical equipment to be at home and they have to call two different insurance programs,

they sometimes have to wait to be denied by the medicare program before they can ask the medicaid program, can you cover this medical equipment i need to be safe so i can get around my home safely, so i don't have to fall at my home. the two different programs sometimes as well in getting payments for their hospital care and trying to figure out is sharing between the two different programs. also in terms of how long can they be in a nursing home and how many days is covered by the medicare program before the medicaid program kicks in. so it is all a wall that complicates the lives of noxious patients and families, but also to us, the clinicians in the health care providers. and instead of us spending time

taking care of the patients and improving their health, we're spending time on the phone trying to figure out how to get them what they need. and that is a problem in our country and we need to fix it. the way to do it is by integrating everything, creating one true program, having one pot of money where the people and the health care providers that are responsible for the patients can use to ensure they can cover everything the person needs. sen. scott: thank you very much. ms. medina, dual eligible program and only a fraction of those who are eligible for these plants. how can states enroll more people in plans that work for them? ms. medina: in south carolina i hope to approach this in two ways. first by streamlining our programs. as i mentioned earlier, when you have so many options, it is hard

for beneficiaries to really understand which direction to go. so we offer them one really good program or just a couple. i think that makes things easier for them. i also hope to bolster our customer service approach. i think that the state medicaid agencies are truly a safety net for beneficiaries and providers, and we need to have a responsibility to be available for them when they encounter these roadblocks we see today. sen. scott: thank you very much. chair casey: ranking member scott, thank you very much. i want to move to a question for mr. heaphy regarding home and community-based services. i mentioned earlier we have legislation to provide more of those opportunities. and you had mentioned in your testimony the importance of those services in keeping you

independent and giving you a high quality of life. i note on page three of your wrist and -- of your written testimony use", what i need most our home and community-based services and supports. you later noted your personal care attendant often participates in conversation with you and members of your care team. your testimony spoke to the importance of making sure that these services are available to all who are eligible, and the inequality and availability of these services across states. so that's why we've introduced the better care better jobs act. from your perspective, mr. heaphy, how would a robust investment in these services impact the lives of people with medicare and medicaid across the country? mr. heaphy: i think -- so many

things come to mind, but first is to recognize hspc as a means of offsetting institutional bias for folks who have medicaid and medicare. myself, i'm someone who is nursing home eligible. and for me, i would be in a nursing home, as i said before, if i did not have the hs bs services. i think it is important that when people be it with remain in the community with folks they love, people in their family, rather than being isolated in an institution and away from folks who provide support. i also think it is important that states maintain a commitment too, allowing people to stay -- increased choice, personal satisfaction associated with former residential settings of

smaller size. people with disabilities living in smaller settings are also more likely to achieve positive outcomes and to experience improved personal support related to quality of life versus living in a larger setting. i think probably the most important aspect of a cbs to consider is it's important to look at a lifesaving approach and recognize the needs of children of families are very different than adults or older folks. and if it's solely determined on medical necessity it does not take into consideration the developmental milestones of kids with disabilities. i think for those of us who learned how to drive and know how important that milestone was in our lives, to go

independently and go do things for ourselves, it is also true for children with disabilities. to have an opportunity to have a wheelchair they can actually use, one that meets their needs in terms of meeting a milestone is really important. so an expansion of understanding what the determination of need is. i think it is also important that rehabilitation service should not be the default. whether it be adults with developmental disabilities or mental health diagnoses. that the promise of integrated care is to really provide tailored services that really meet the person's needs and provide integrated opportunities to live in the community. i've experienced that here myself, as a dual eligible. and if i were not able to shape my services, i think i would be

in a very different situation. i guess i would also say, this is really important -- they are so woefully underpaid and unappreciated. they are in homes doing work that nobody else wants to do. a lot of folks cannot do the work. and yet the amount of money they make is not there. mine engage in what is considered nursing level activities. that includes changing my wound care and assisting with my bowel program. they are doing all this work and not receiving the money that they really need to live in the community. an example would be in massachusetts, which is very generous, they make over $17 an hour. however, a living wage in boston is over $19 an hour. and for someone who has a child, it is over $39 an hour for a

person to have a living wage. so, as it's being thought about and determine, that the wages of folks doing this direct community work needs to be considered. the last thing i would say is it is really important that the consumer model necessitate it. because i am a consumer employer, they work for me and not an agency, i am able to direct my care to them, and am able to apply my schedule. i am able to travel for work, do things in the community that i would not be able to do in an agency. there is definitely a place for the agency model. however, for folks like myself who really need that flexibility to engage in the community, we need that opportunity to live in

the community using -- with covid, not for my personal care attendants, i would have been devastated. the relationship we have with each other, they were dedicated and came to my home during covid despite putting themselves at risk. so i cannot say more about making sure that these folks get reimbursed at adequate rates. chair casey: thank you so much for your personal testimony, based upon your own experience. and being a voice for those workers who are among the folks that we hope to be helping with some investments in home and community-based services that are not available today. mr. heaphy: and if i could just add one more thing. chair casey: quickly because i want to turn to the ranking member. mr. heaphy: i think it would be really helpful to institute the

national core indicators throughout the country. and also -- just to give us a better sense of the quality and access. the other thing i would say is having that national snapshot of how states are performing is critical. chair casey: thanks very much. we are waiting for some other senators who had to juggle things. we hope they arrive, but in the interim, ranking member scott -- sen. gillibrand: i just joined, if you want to call me. chair casey: oh, senator gillibrand, right on the money. sen. gillibrand: i have competing hearings. a quick question for the whole panel. how should we be incorporating community health workers into medicaid plans? and do you have examples where this is already being done,

particularly when it comes to navigating services? dr. figueroa: i can go ahead and start, if you don't mind. i think community help care workers play an important role as a liaison between the health care system, social service organizations, and the patients in their community. they are generally well trusted people who understand the values in their community as well. it's a potential workforce that we should tap into. especially in areas with limited workforce and limited healthcare infrastructure. but the key for successful community health worker relationship with the patients is they must be integrated with the care team. if there only in the community and not necessarily degraded with the care team, it is not going to be a successful relationship, unfortunately. so we are really trying to promote integration is key.

i do know one example, massachusetts, for example, under the 11/15 demonstration, massachusetts made all of their patients participated in aco's and within that there was a lot of funds going into hiring community health workers, training community health workers. operating in western massachusetts where there is not as much providers as eastern massachusetts. to date about one million people are in these medicaid aco's. in a recent survey we show that providers in aco's think that community health workers are operating with social service -- and improving patient experience. sen. gillibrand: thank you, mr. chairman. chair casey: thank you, senator gillibrand. we're going to move to our closing statements at this time.

i want to thank of course ranking member scott for hosting this hearing with me, and the work that he has done on the legislation that we have introduced. so, i want to thank him for that work. i also want to thank our witnesses for their invaluable input. and as we noted earlier, their personal experiences. as we heard today, people with medicare and medicaid face many challenges in navigating the health care system generally, but in particular, these challenges that our witnesses outlined today. this challenge that they face will impact their overall health and their quality of life. so we have work to do. the people that testified today, whether it was jean or dennis were others, -- or others who shared their stories, these stories help us in congress to formulate policy and proposed

legislation to make these programs work better. the health care -- their health care system should provide support for them, rather than adding yet another headache and so much confusion. jane, for example, jane doyle, for example, should not have to worry about getting a surprise bill in the mail after a doctor's visit wondering if she is on the hook for that bill or not. dennis should not have to go to the emergency room because he cannot get a hold of his plan's care team who were supposed to be there to help him. we need to make sure that the care delivery models available to people with medicare and medicaid meet their needs, and meet their preferences. that is why we must pass the pace expanded act that senator scott and i have introduced, to increase the availability of these programs. and it is why we should make a

permanent investment in homeland community-based services to help seniors and people with disabilities remain with their families in their communities. so, we're grateful for the testimony of our witnesses. and now i will turn to ranking member scott for his closing statement. sen. scott: thank you, mr. chairman, for holding once again a really important hearing for so many americans who are looking for more information, and frankly, more reasons to be hopeful as they deal with climbing health and to many other challenges that come with aging. today we learned about the challenges of caring for dual eligibles. there are numerous gaps in policy knowledge that contribute to these challenges. as the son of a caregiver, as i have said a number of times, my mother has been a nurse's assistant her entire career. last week i was visiting her at the hospital, and this week is

her 49th year at the hospital. and she loves her patients, she loves what she does because she really loves the thought of making a difference. in today's world i think we need more people dedicated to a mission, whatever that mission is for you, we should all be thankful that people have a mission of providing care for those who cannot care for themselves. the supporting care for dual eligible individuals act will help fill some of those gaps. this legislation will help states provide the care of its population so desperately needs and somebody today only reinforce if not amplifies the importance of that truth. i will make two other points that i think is really important. number one, dennis and so many others have done a really good job of helping us to understand and appreciate the importance of home health care.

you can sometimes get into a senior facility, or as my mother working in a hospital, so many people prefer their care to be given in the environment that is best for them, and that environment so often is at home. i think all that we can do to help people receive the care they need in the place of their preference is really an important part of health, because peace of mind and health are so often synonymous. not only is there a mental health component, but there is physical health being delivered in your home where you are accountable and where you know things are. it cannot be overstated, to be honest with you. i think that very often that providing home health care is actually better overall in a system that has limited resources. and it does not seem that way to you, but when we are spending over $550 billion or so for medicare and nearly $400 billion

for medicaid and over $400 billion for veterans benefits as well, we run into the challenge of limited resources. i think we can take our resources further by focusing on a delivery system that is so often at home. the final comment i would make is that as we think through the unbelievable challenges of the pandemic, one of the more important points is delivery system a virtual health care. to have patience, as we spoke about today, being able to see their doctors from their homes when possible, really helpful. and i hope we continue as a nation to move in the direction of providing virtual health care as a priority, and as a priority delivery system, because not only will it help us take care of our patients, it will help us

spend the limited pot of resources in the most effective way possible abiding care for those who just really need it. so thank you again mr. chairman for this hearing. i look forward to the next one. chair casey: thanks very much. i want to thank you again and thank all the witnesses again for their expertise and their time today. if any senators have additional questions for the witnesses or statements to be added, the hearing record will be kept open for seven days until next thursday, february 17. thank you all for dissipating. -- for participating. we are adjourned. [captions copyright national cable satellite corp. 2022] [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. visit ncicap.org]

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