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But in that commission's report and in the leadership that the chairman of the commission brought to it as a successor to George Mitchell, who was then at least on the Senate side here one of our leaders on defining long-term care policy, I think we have the beginning of meeting the challenge of the policy response to long-term care. And so, I am pleased to be on this subcommittee with you and to be able to welcome our colleague from West Virginia.

Senator ADAMS. Senator Rockefeller, I am pleased to have you with us this morning. I want to commend you for your leadership on the Commission in bringing forth the bold proposals that you did. Your leadership in the Finance Committee is particularly helpful to the entire Senate. As chair of the Subcommittee on Medicare and Long-Term Care, you are a key voice in highlighting the special health care needs of America's elderly citizens. And we are trying to do our part here today by addressing these issues.

Welcome to the committee, and we will be very pleased to hear your testimony.


Senator ROCKEFELLER. Thank you, Mr. Chairman, and thank you very much, Senator Durenberger, for those kind comments.

The Pepper Commission was an extraordinary experience actually, and there was a lot to be learned from it. And I think we did move the agenda forward very substantially.

And I agree with you that on long-term care, which has a strong constituency, there was strong agreement. I think even on the acute care side we agreed on much more than we did not agree on even though the vote was 8 to 7. I do not think it was reflective of the unanimity of thinking about the need to get at that. One of the things I think of, for example, is a complete reforming of health insurance. I think that was unanimous. So, I agree with you in what you said.

These are very important hearings, Mr. Chairman, and I guess I need not say that. I want you to know that I very much support your legislation to reauthorize the Older Americans Act. I remember that not only as a governor. Was it 1984 or 1983 when the administration tried to cut it all out? And I remember the outrage from not only the present witness, but from our seniors all across West Virginia. And thanks to the Congress that did not happen.

You know really more than I think anything-polls differ, but I do not think there is anything that causes more fear among people-not just seniors, but among people in general-about the future anxiety that might happen if some terrible accident or disease was to come upon one of our citizens. And that is why I think it is so appropriate to look to the Older Americans Act as a way to aggressively promote long-term care services needed not only by senior citizens, but by the 40 percent of Americans who are 65 and under who need long-term care. A lot of people do not recognize how many young people there are. In fact, I believe, Senator Durenberger, Senator Pepper's approach was under 18 and over 65. Our approach was anybody and everybody regardless of age or income. We felt it was really, really important.

For the last 25 years, the act has been the major force in promoting desperately needed services for the elderly, services from nutrition, transportation, legal advocacy. Senator Durenberger listed a lot of them. And this is classic historic legislation, along with Social Security and Medicaid. It is not usually counted up there, but it is up there right with those in my mind at least in terms of classic social legislation.

And the number of people that it has helped is incalculable, but we have to press on. We have new challenges. We have more that we need to do. There are between 9 million and 11 million Americans of all ages who must depend on others right now for help with basic tasks of daily living, which is the way we describe or calculate long-term care. Millions more than that know the physical, emotional, and financial burden of caring for family members who need that kind of care. And the statistics are one thing. The examples are quite another. And I think Senator Durenberger knows I constantly put out examples because I think they are more interesting than figures anyway.

I think of a family in West Virginia in Mason County where the husband and wife-I would say they are in their late 50's. The husband has had three heart attacks, and he is now absolutely immobile. There is not a single muscle that works in his entire body with the exception of his tongue, but he cannot talk. His mind is as clear as crystal. And so, his wife Millie now for 7 consecutive years has been taking care of him. He has diabetes, so he has to go down to the hospital from time to time.

And when you go to visit this family and you see Millie just barely able to shift him or to help him go to the bathroom, which is an incredibly complicated physical procedure for Millie to be able to accomplish that and sometimes there are neighbors who are available to help her, but more often there are not. And you watch her mental, her physical, her financial, her psychological condition just deteriorate month by month because there is nothing called respite care which is available to her, or apparently insufficient care that is available to her.

And this man communicates. The only way he can communicate is and I do not know quite how he does it because he cannot move any of his muscles. But he somehow gathers himself and then pushes blood into his face, into his head so that he blushes, and you see him blush. And that is the way he says I hear you, I know you are there, or thank you, or I am tired, or whatever it is. That is the only way he has of communicating.

And this is true everywhere. All over this country you have Millies who are being ruined because the long-term care is not there. Our long-term care policy basically is, as you know. You spend yourself into impoverishment, and then you qualify for Medicaid, a very calculated decision on the part of many, very humiliating. And then Medicaid packs you off to a nursing home, which may not be where you ought to be. Medicaid does not want to provide health services at home which is where people really need them and certainly where my Mason County couple friend need to get their services.

Now, the Pepper Commission, as Senator Durenberger indicated, responded to that. And I am very proud of what we did. I think

we let out a very bold blueprint both for access to health care and for long-term care for every single American who needs it regardless of age and the rest of that.

Basically what it does, our plan recommends social insurance for home and community-based care and for the first 3 months of nursing home care for all Americans regardless of income. Now, that is a social insurance program, non-means tested for home health care. That is the way that is going to be done.

Is it expensive? You bet it is expensive, but it is a lot less expensive than trying to handle people with those problems in hospitals or in nursing homes.

Why did we pick the first 3 months for a non-means tested social insurance program? Some would have preferred the first 6 months. So, would I. It would have been a lot more expensive, and we were trying to do something that would be enactable and doable because, in fact, over 40 percent, almost 45 percent, of people who go into a nursing home are in a position to return home before the end of the first 3 months. So, in a sense what we do, we wanted to protect their income, protect their assets, and allow them to go back to their homes, and therefore to be able to live there.

For Americans and for families facing long nursing home staysand we do come to that, of course a very key protection is provided to prevent family impoverishment. And what we basically said, the private insurance market has to come in there. Although it has been very inactive up to this point, it is beginning to grow. There are still I think probably under a million policies that have been sold out there, but it is beginning to grow. And we give them tax treatment which will encourage them to grow.

But we do not allow any family, if it is a single person, to fall beneath $30,000 of income or assets plus their home, plus a few other things. Or if it is a married couple, no family can go under $60,000 of income or assets plus their home and a few other things. In other words, there is a floor beneath which you cannot fall, and if you go one nickel under that floor, then you are picked up by the public program. And thus, no more spousal impoverishment. We end that

To ensure quality care and to keep a lid on excess costs, the Commission recommends relying on case managers-this is a very, very, very important concept, easy to say, but extremely important concept so that they can develop and oversee individual care plans that are tailored to individual needs. Our report looks at benefits that include personal care, homemaker services, respite care, training for family caregivers, more skilled nursing care, rehabilitative services, and other things that Senator Durenberger mentioned.

But the real point I want to make, Mr. Chairman, is that in the Pepper Commission we laid out a very clear, a very specific, and a very bold blueprint. And I urge the members of this subcommittee and, in fact, all of our colleges to support the long-term care recommendations of the Pepper Commission. I think they are the best things that have been put forward. I think we should enact this legislation because it provides the protection that millions and millions of Americans of all ages need right now.

And also, and just as importantly, we have to get legislation going right now because we have to put in place the infrastructure which is necessary to make long-term care available, in fact, for the future as people begin to make more use of it. We do not have enough trained personnel out there. We do not have enough skill, have enough knowledge, enough experience. So, putting in the infrastructure, giving the time for the infrastructure to develop, is terribly important for long-term care. If you were to put the Pepper Commission into full force today on its long-term care, we would not be ready for it. So, that is why we phase it in over a period of years to allow the infrastructure to develop.

I think pilot projects and State and local programs are underway all across this country. You have mentioned one in your opening statement, providing long-term care services to older Americans, and developing that sort of basic level of knowledge that we think we have, but we do not necessarily have that will guide us in forming national policies and the nuances and the different types of approaches to long-term care that we are going to have to do. So, we have to build on all of these efforts, State and national, and then do even more.

In fact, as the Chairman knows, I am very pleased that last October in that wonderful phenomenon called reconciliation, which we will not have now for some years, we were able to enact one part of the Pepper proposal, and that is Medicaid, of course, packs everybody off to a nursing home, and I do not think that is appropriate. Well, in fact, in the Pepper Commission, we got rid of Medicaid altogether because we feel it is an abominable program that does not either serve the people it is meant to and those who it does serve, it does not serve them properly. So, we got rid of it. We just totally got rid of it.

But for the meantime, we have in place now for our most frail and our most elderly citizens a program which causes Medicaid to pay for them to have home health care or community-based care. That is the first time that has happened, and I think it is a good start for our frailest and most elderly citizens.

Now, we have a long way to go. There is a great deal to learn about case management, about case assessment before case management, and cost containment, and how they interact with each other. And cost containment is now a watchword that Congress can no longer walk around. We are not going to get any of these reforms until we face up to cost containment.

So, as I indicated, this is not just for seniors, but for every American who needs it, and in these areas I see the Older Americans Act as a really, really important player.

In the Pepper Commission blueprint, we accepted Federal responsibility for financing some of the key aspects of this program, the social insurance, nonmeans tested parts. But we also sought to give the States the flexibility in the development and the implementation of home and community-based services. Therefore, at least in my view, a logical next step is for the Federal Government to play a more supportive role in helping States like your own, Mr. Chairman, to explore ways to administer and to manage a variety of long-term care service models.


I want to work very closely with you, Senator Adams, on your reauthorization of the Older Americans Act so that we can move long-term care forward. The constituency is out there. Our policy is nowhere.

Now, one example is Senator Pryor's amendment, of which I am an original cosponsor, and that is an amendment to establish a $5 million demonstration program. And people say, well, demonstration programs. That's just fine. Demonstration programs are needed in long-term care. They are desperately needed because we have to find ways to promote and to evaluate the role that our aging network can play in providing long-term care services.

His proposal would compare eight different models in order to identify the best and the most efficient way to provide long-term care services. A demonstration like this could provide valuable, indepth information for the aging network and other health agencies who are struggling to try to balance the question of cost containment and case management and quality assurance.

So, I really think it is vital to ensure that lessons that we learn through demonstration projects and through projects that are already on stream that affect long-term care programs-I think we have to learn lessons from them, and then we have to get those lessons disseminated widely into the aging networks. New efforts have to be made to disseminate the useful information and the useful ideas among all the key Federal health agencies, who are not very sensitive to all of these things, and State organizations that are working on answering the tough questions of cost and of administration.

So, continued experimentation is going to be necessary. The silver bullet is not there. We have to experiment, demonstrate, prove, convince because you are talking about big dollars, and before the States and the Congress are going to commit adequately, we have to show them that this works.

The West Virginia community care program in my view is a prime example. Since 1987 my State has been working to provide community care by trying a whole variety of approaches, and in fact the State ultimately decided to reorganize all of its long-term care services under one office called Geriatrics and Long-term Care. Now, I was Governor for 8 years. That idea did not occur to me. It occurred to my successor. So, each State trying to work out its own way.

This office works closely with our Commission on Aging which stays intact, and it uses powerfully the State's network of senior centers, which are a valuable tool, to provide home and community care. And we have those in every single county in our State. Over 5,500 West Virginians have been served through this program really by a single point of entry, that is, the senior center in a county, for home care, and that is their local senior center.

So, that is a nice start, but we have a lot more to do. And in summary, I think we have to push forward on two tracks to promote long-term care. First we must fight to expend direct services and ultimately build a comprehensive long-term care protection program and, of course, it is my hope that it will be that as envisioned by the Pepper Commission because I think it is sensible and workable.

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