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interesting and newsworthy highlights. these points of interest markers appear on the right- hand side of your screen when you hit play on select videos. this makes it easy to get an idea of what is being debated and decided on in washington. and now a hearing on the state of assisted living facilities. one witness of a family member in assisted living details the poor living conditions and cost of care. the senate hearing is abetted one hour and 40 minutes. >> the senate national committee

on aging will come to order. as chairman, my top priority is keeping our promises to older americans the senate special committee on aging will come to order. as chairman of the ag committee my top priority is keeping our promises to older americans and to americans with disabilities. we owe it to every person with a disability, and their family, to have the necessary information to decide when, where and how to receive care as they age. that has motivated by advocacy, for example, for home and community-based services. every american wants to receive care. every american who wants to receive care at home should be able to do so. and the workers providing that care must be paid, in my judgment, a living wage.

it is similarly motivated by work to ensure nursing homes are providing safe and quality care for all of the residence. we need to address the chronic underfunding and understaffing for the state agencies that conduct nursing home oversight. so they can effectively protect the health and safety of residents. in this core mission of the aging committee it brings us to today's topic. the topic of assisted living. and that landscape. it's been 20 years since this committee held a hearing on assisted living. with the dramatic growth of the assisted living industry in recent decades it is long past time for congress to re-examine this model and ensure that it is meeting our nation's needs. the best estimates reveal that nearly 1 million americans live in more than 30,000 assisted

living facilities across our nation. and that is almost certainly an undercount of that number. assisted living facilities are state regulated residences that support assisted-living while offering help with activities of daily living, like bathing and medication management. they also often provide meaningful engagement and activities for the residence. assisted-living was first envisioned as a social model for residents who needed lower levels of support. today, people living in assisted facilities are older, require more care, and have healthcare needs similar to that of those who reside in a nursing home. the needs of the assisted- living population change. as those needs change we need to know if assisted-living facilities are meeting the needs of those residents or the

needs of their families. one major issue i hear about a lot is cost. assisted-living facilities are widely unaffordable to the average american and their family. a recent survey found that 80% of older adults would be unable to afford four years in an assisted living facility. the average annual cost is $54,000 a year. but the costs can be substantially higher depending upon the location and the type of care that a resident requires. the more assistance and care a resident needs the more they pay. and in some cases residents and their family don't know the total cost until they receive their monthly bill. the substantial costs and often hidden fees make it nearly impossible for older adults and their families to accurately budget for long-term care.

that's one of the reasons why i'm starting today. i'm asking pennsylvanians and people across the country to share their stories and their bills with us. i want to hear from you about the true cost of assisted living and understand whether families have the information that they need to make it difficult financial and healthcare decisions. i just want to hold up the website address for those who need it. you can go to -- to share your stories. it's very important we hear from you. hear from people about their own experience as family members. as people who are paying the bill and also expecting the promises when someone becomes a resident of

an assisted living facility. it is only by hearing the stories, only by hearing about those experiences can we bring the needed change that i know we all agree has to come. the assisted living industry is also facing the same workforce crisis that we see across other long-term -- and beyond long- term care. it's also true in the context of childcare and so many other parts of our healthcare and care layers today. -- landscape. workers struggle to support their families because the workers are paid an average of $15 an hour nationwide. workers provide a higher level of care to support residence and their growing needs, especially residents with dementia. but training requirements and worker support look very different in each state.

as we hear from our witnesses, these challenges make it harder for families to find the information that they need about assisted-living facilities, including how much it will cost, the quality of the services they receive, and how safe their family member will be. a recent washington post investigation found that since 2018 more than 2000 people have left assisted-living facilities unsupervised and have been left unattended outside. 98 of these 2000 incidents have resulted in the death of the resident. and those are just the cases that have been reported. the findings of the post investigation demonstrate how urgent it is that congress better understand this industry. it has also been significant reporting by the new york times and kfs in a series written before the end of last year.

to help in our understanding i have sent letters to three of the largest corporate owners of america's assisted-living facility. these letters request information about cost, workforce, safety, and availability of information about the quality of services in assisted living facilities. i hope the response to the letters will improve transparency in the assisted living industry and help to inform policy solutions to address some of these concerns. as families are making difficult decisions about where to age they deserve to know that their loved ones are safe. i think we can all agree on that. and assisted-living providers making promises they cannot keep is a violation of trust. as we continue to increase the quality of long-term care for older adults it is time we

prioritize efforts to improve the assisted living care option. if we say we are, as a nation, the united states, the greatest country in the world that we have to have the best. not second, not third, the best. long-term care in the world. we're not there yet. those who called assisted- living facilities home, you have to remember, this is their home. they are residents. where they live and where their families come to see them. if those older adults and people with disabilities are calling this facilities home they should have quality, affordable care. i look forward to hearing from our witnesses today and i will turn to ranking member for his opening statement. >> thank you, chairman casey. in 2050, if you think the

problem is bad now, one in four americans will be 65 years of age or older. with an aging population that we know is coming at us think goodness we have hearings like this to highlight what you are going to do about it. sometimes the market doesn't do the job. i do want to say, ideally these things are crafted through the market with states leading the way. i say that for one big region. -- reason., the budget committee. how you would add something even further to the list of things you want to do when we are now borrowing $1 trillion every six months instead of annually. and that has just changed over the last five years. so we have to be careful. it still has nothing to do with a problem or issue that's out

there. this is about highlighting who can do it best and how you get there. a chronic workforce shortage. when i traveled -- in indiana, pre-covid, that was the number one issue. it's about double now the number of jobs in my own state. i think it's close to 130,000. it was 65,000. and caregivers, a large percentage of home that assistance is given by independent contractors. small business owners. we need to figure out how to enable that and make it easier how you actually have your curriculums in various states and school systems that show the full spectrum of what jobs are out there and where the needs are. senator kaine and i introduced the jobs act which allows students to use federal pell grants for high-quality, short-

term job-training programs. that's a good federal program. it is increasing the flexibility of how you can use it. senators rose, collins and i introduced the train more nurses act. which reduces all nursing grant programs to find ways of increasing nursing pathways. happy to hear, some things do work well here. that passed by unanimous consent last night in the u.s. senate. somehow we have to get over to the house and do the same thing. the federal government should make it easier for people to enter the healthcare workforce and for families to take care of their loved ones by making sure that it is energizing the people that may be interested in it and the places they are probably going to be doing the heavy lifting. right now, for instance, the biden administration is saying one thing and actually doing another. it happens to do,

where i come from, the world of small business. independent contractors, retailers, individuals that make their living out of running a small business. the independent contracting rule that is out there, which would make them more difficult, could eliminate many of the existing caregiver jobs for that reason. so you've got to make sure you're not wanting to do something and then working with another agency that would make it more difficult. i like nursing homes, that are regulated by both federal and state agencies, assisted-living facilities are primarily upregulated by states. to increase safety and transparency indiana requires staffing, dementia training, and maintains a website that discloses reports and enforcement actions. states and assisted-living facilities are also working to find ways to include existing resources to include seniors.

indiana is using a combination of state and federal tools to provide more affordable assisted-living. as a result, indiana has seen affordability and quality improve. however, there's always more work to be done. some of my colleagues may have attempted to call for a shift towards increased federal involvement and regulation. and i would say, be careful. help us givebacks -- give best practices out there. -- it's normally done more effectively and more affordably at lower levels of government. i believe the states are best positioned to meet the growing need. i'm glad that we hear, at the federal level, this is a big microphone. it has to highlight the issues. as what we are doing here today. thank you to all of the panelists for being here. i'm interested to see what we can come up with. thank you, mr. chairman.

>> i'm grateful for the time and work that goes into an appearance of our witnesses. our first witness this morning is ms. patty from gainesville virginia. her first husband, john whitney, had dementia and lived in an assisted living facility at the end of his life. she will share some of her and her husband's experiences when she supported him in an assisted living setting. patty, we are grateful you are here today. thank you. our second witness is dr. jennifer kraft morgan. dr. morgan is from georgia. dr. morgan is a professor and director of the institute at georgia state university. she studies issues related to long-term care dementia and the healthcare workforce. thanks for being with us today. our third witness is dr. julie. i will turn to ranking member

bron for that introduction. >> she is the copresident of management systems. she's been in the long-term care arena for nearly 30 years. she focuses on providing care for -- and 82 facilities across the country. she leads on several state and national associations, including the indiana healthcare association board of directors and the national center for assisted living board of directors. thank you for testifying here today. >> thank you. our fourth and final witness is richard millett. he is the executive director of the long-term care community coalition. this coalition works to provide families with unbiased information about nursing homes, assisted living facilities, and other long-term

care settings. thank you for being with us today. can we turn to our first witness. >> good morning, chairman casey and members of the senate special committee on aging. my name is patty. thank you for allowing me to share this testimony. my experience with assisted- living for my husband, john, through the middle stage of dementia. i will focus on my experiences and observations that i believe are most relevant to the national focus. in 2013 my husband was diagnosed with dementia. although this dementia is similar to alzheimer's it manifests itself a bit differently. it is important that caregivers be informed and trained appropriately to ensure the comfort, safety and security of their patients. some key systems, a loss of sense of smell, rem sleep behavior disorder which causes individuals to violently act

out, often falling out of bed. visual hallucinations, marked fluctuations and attention, and gastrointestinal issues including severe constipation. all of which my husband experienced. loss of memory often occurs much later in this disease process. i took several free courses on caregiving for individuals with dementia, including a virtual reality dementia experience. which helped me to understand the challenges that people with this disorder face. and most importantly, why they become fearful and combative. i mentioned this to provide a basis for my ability to recognize problems with care as i saw it. these courses offered prevention for professionals at reasonable costs. in june of 2017, when my husband's degree -- disease was progressing rapidly, i moved to

virginia to be near family. they cared for him alone at home until generate 26, 2018, when he attempted to strangle me in my bed. the state determined that john should be placed in long-term care facility. i found him a room in an assisted living facility in virginia that specialized in memory care. he moved in the first week of march in 2018. i provided the management team with john's history, his diagnosis, and disease progression. the following is a list of issues that i observed in the memory unit during my daily visits with john. poor facility design. there were blocks of rooms built around a large central room with a tv. the central room was extremely -- and high levels of noise can easily agitate dementia patients. activity stations were set up for residents.

-- pvc pipe, some longer than a baseball bat. these were weapons and waiting and you can guess what happened. the hallways and the room blocks are isolated, making it difficult for staff to monitor. there were many incidents where they were no staff around. a woman fell by tripping on a raised area of hard flooring. nobody saw her fall. i found her bloody and staggering down a hallway. a company knowledgeable about dementia care would not design a facility this way. they would certainly understand that people with dementia have problems with gait and balance. there were cameras in place but they only used them for reviewing incidents after the fact. they were understaffed. too many patients were assigned to each caregiver.

in the morning each caregiver needed to give their assigned residence up and dressed and ready for breakfast. they only gave residents a shower when necessary, as they were always pressed for time. caregivers needed extra time to spend on residence with advanced stages of dementia as they were required to move from their bed to a wheelchair and be hand fed. after lunch the caregivers would place most of the residence in chairs and made room while they worked, giving the advanced change -- stage patients back to their bed. after lunch my husband urgently needed to empty his bowels. when i was there i try to help him but it was hard for me as i had a broken arm at the time. i could not find anybody so i did the best i could. and often, when i was not there, he soiled himself while waiting for help.

i once believe i saved a man's life. i was with my husband in a room off of the main activity area. i heard someone crying for help. i ran into the hallway and found an old man on the floor trying to protect himself from being beaten with his own cane by another resident. i called for help, quickly moving closer and redirecting the attackers attention. they kept them busy while calmly calling for assistance trying not to further agitate him. it took several minutes before a staff member finally heard me and came to help. night was no better, as staff levels were lower, allowed by state regulations. the placed residents, who had trouble sleeping, in front of the tv while they dealt with other residents. inadequate staff training. most of their caregiver staff were trained as nurses aides but nothing specific to memory care that i can see. i witnessed them providing new hire dimension training care in a conference room. this consisted of a member of

the management team showing -- movie and pointing out behaviors that demonstrate dementia problems. i saw that movie and it was not appropriate for training purposes. i observed several instances where caregivers and nurses displayed limited knowledge of working with dementia patients. particularly those in the middle stage of the disease who became more feel for -- fearful and combative. nurses running 20 patient, causing a resident to become combative. quick, erratic hand movements, frightening the individual. another example, the tv was on at 9:30 p.m. with extremely high volume. several residents were seated in chairs and wheelchairs in front of the tv. anyone who understands dementia would never do this. they were overstimulating these residents instead of allowing them to relax and quiet their minds for sleep. finally, at one point the director of the assisted

facility told me to spend less time there and let them do their jobs. well i could not abide because i felt they weren't doing their jobs. in closing, unless things change i can never recommend using a second facility for a loved one unless things improve. i'm hoping that you find my testimony helpful and that the committee will find a way to set some national standards for appropriate levels of staffing and training for that staff. this would be a huge step in improving assisted living. thank you for your time. >> thank you very much. i appreciate your testimony. dr. morgan? >> good morning, chairman casey, ranking member braun, and the members of the committee. i'm delighted to be here. thank you, patty, for sharing that story. assisted living is a large and growing long-term care option for individuals who need or want additional support for activities and daily living. there are approximately 36,000

committees in the u.s. with approximately 820,000 residents, employing about 500,000 workers. a.l., often seen as the public by interchangeable with skilled nursing homes, was built and regulated as a social model of care. this community based care is less restrictive and strives to be homelike. they vary greatly in the amount of care they need from person to person. rising acuity levels mean that as they age in place they would likely require more health services. while these services could overlay a.l. services, much like they would if the person needing care was at home, these are not provided directly by the a.l. communities. the haphazard growth of this model and the tensions between social care and healthcare inherent have spurred, caused by scholars, to be reimagined. most a.l. residents need help with medications and three or more activities of daily living. a.l. residents depend on the care network.

the consolation of can and know can involve a range of medical care does provide social support to coordinate care, to engage residents in activity, and bring needed supplies. these care works also play an important role in advocating for residents and negotiating care with staff. about 42% of a.l. residents have a dementia diagnosis. but we can assume this is underreported as many older adults are not screened, tested or diagnosed with dementia despite showing symptoms in memory, thinking, or making decisions that impact everyday life. like all people with chronic disease, people living with dementia have good days and bad days. person centered dementia care is needed to tailor care and support to individuals in ways that account for preferences, life experiences, communication styles and support needs that change over time. the average monthly cost of a.l. is $4500. as such, a.l.'s inaccessible it to most americans.

on the special long-term care it is often needed. seen as a step between unpaid care by loved ones and nursing home care a.l. provides an important long-term care option. when the care needs of a loved one exceeds the capacity of the care network the person and their care network is forced to navigate with little support or education, a variety of options, none of it are covered by health insurance. if they have significant financial resources a.l. is a useful and attractive option. if not, managing the care system means they will reduce working hours, build precarious care or financial arrangements across families, higher personal-care support, or simply cross their fingers and hope that it all works out. 66% of the a.l. workforce are aids or direct care workers. direct care workers in a.l. and across long-term care are predominantly women, people of color, and disproportionately immigrants. the typical direct care worker, as senator casey said, makes

about $15 an hour. works 36 hours a week in assisted living, and works for a for-profit company. a.l. workers, like most direct care workers, tend to go to this line of work to give back to make a difference because they value elders or because it's a calling for them. unfortunately, the system we have set up works against them. direct care workers in long- term care settings experience low wages, few benefits, heavy workloads, dangerous jobs, and little to no career mobility. in her book, and of ski disrupting the status quo, senior living. they might shift." she lays out the problems facing senior living. a.l. is marketed to those who can afford it with hospitality mindsets. they advertise and compete with beautiful campuses, luxury food and furnishings, and concierge services. this model encourages friends and families to think about this next step as though they are going to a hotel or resort.

this framing, where residence of guests and staff are encouraged to cater to their whims, increases what dr. will thomas of the charter calls, the three plagues of long-term care. helplessness, boredom, and loneliness. by encouraging passively we leave residents with few opportunities for giving back or creative pursuits. instead, long-term care that is person centered, community minded, and empowering for residents, staff, and care partners has a much better chance of success. my recommendations include, improved standardized initial education training, initial and continued educational training for direct care workers, and all staff and assisted living. professionalize the direct care workforce. incentivize and reward the employers who deliver high- quality care, increase access to assisted living, improve care coordination and resources for people living with dementia and their care partners, and support standardization of modern resources for state- based oversight and transparency.

thank you. >> thank you, dr., for your testimony. miss simpkins, you may begin. >> thank you. -- thank you for inviting me here today to be part of this important discussion on assisted living. a topic that is very near to my heart. my name is julie simpkins and i am the comanager of garden -- solutions. we provide -- the fifth-largest assisted-living provider in the country and have communities in five states. illinois, indiana, ohio, maryland, and west virginia. i have dedicated most of my life to senior living, with over 30 years in the assisted- living sector. this is my calling and i would like to speak with you today about the unique model as we share thoughts on how we can work together on important issues facing those who need and work in assisted living.

garden is uniquely focused on offering affordable assisted- living to low income seniors. our company was founded in 1999 and -- creation of illinois supported living program which is a waiver based program. as we expanded into four other states our commitment to serving this population remains. many in garden communities require assisted care through these programs. garden has been limited in where we can offer our services due to the variability with state medicaid waiver programs. it depends on the availability of state programs, state reimbursement levels, and the number of available waiver spots . offering affordable assisted- living exclusively, or even for majority residents like garden, requires an entirely different business model altogether. we have had to persistently sneak out -- seek out tax

credits to stay viable. therefore, we support efforts to make long-term care, including assisted-living, more affordable to low and middle income individuals. with a rapidly growing elderly population we need a public and private partnership to incentivize more developers for these models. when we talk about assisted- living it's important to note that every state, every community, and every resident is different. efforts to standardize all assisted-living communities would be both unworkable and irresponsible for resident care. state regulations appropriately recognize a diversity within assisted-living while holding our profession accountable and they are consistently up dated -- nature of our sector in residence. meanwhile, garden is committed to exceeding the state requirements while we believe it is the best interest of our residents. we take memory care as an example. something is top of mind for this committee as well as our residents and family. every staff member receives education and training for dementia related diseases, as well as training as a certified

dementia practitioner. we owe a report to the state immediately, even if something is as technical as a resident walking out the door and instantly returns with a staff member. we know they didn't leave our community and our staff immediately addresses the situation. but we still report it. the recent reports that are ultimately fatal or heartbreaking. my thoughts and prayers go out to the loved ones of those residents. i serve in leadership positions on numerous national organizations dedicated to long- term care. and i know these tragic incidents are extremely rare and not indicative of the living experience. the overwhelming majority of families and residents of a life-affirming safe experience. assisted-living providers are committed to upholding policies and procedures, as well as continuing to learn all that we can about dementia care to prevent these incidents. it is critical that policies and regulations protect residents while still supporting the freedom of movement and independence. assisted-living is a critical aspect of the long-term care

continuum and dedicated to deliver person centered care to our seniors. we need collaborative, comprehensive solutions that ensure our ability as assisted- living communities to continue doing what we do best. providing safe, quality care to our residents. from expanding more affordable long-term care options to workforce programs, to addressing the growing caregiver shortage, these efforts could make a real difference. we must all work together to ensure current and future assisted living residence are seen safe and enjoy the highest quality of life possible. thank you for your time and i look forward to answering your questions today. >> thank you for your testimony. we turn to our fourth and final witness. >> good morning chairman casey and members of the committee. thank you for meeting to testify today on this important issue. my name is richard and i'm the executive director of the long- term care community coalition. it is a national nonprofit,

nonpartisan movement dedicated to improving care and quality of life for residents in nursing homes and assisted living. we conduct research of long- term care policies to the extent of which essential standards of care are realized in the lives of residents, more technically the elderly and frail. in addition to conducting analysis and advocacy they educate and engage residents and those that work with them so that they are aware of their rights equipped to overcome the challenges that so many of our seniors face when they need residential care. our interest in assisted living is long-standing. we appreciate your commitment to ensuring that the proms of assisted living is realize in the lives of our growing senior population. assisted-living emerged in the 1980s as an alternate to nursing homes for seniors who want to live in a congregate of sex -- setting with meal preparation and access to activities and transportation. over the last 40 years three development have drastically changed the nature and character of the assisted- living sector with both

positive and negative. the needs and frailty of assisted-living patients has dramatically increased. assisted operators have -- sophisticated and large-scale corporate models, including ownership by real estate investment trusts him a private equity, and other sophisticated private investment structures. and three, public payment for antigovernment interest in assisted living has increased significantly. assisted-living facilities now care for people who, in many ways, still have the same needs and vulnerabilities as residents. assisted-living residents are older on average than those in nursing homes. approximately 40% to 70% of living assisted residents have also resort cognitive -- they have heart disease and depression. about half need help with addressing walking and need help with bathing. those with dementia retrieve -- receive antipsychotic drugs.

we have failed to keep up with these trends. as some assisted living can be wonderful places to live and work too many take in and retain residents with whom they are unable to provide safe care and good living conditions. too many residents and families are at risk for financial exploitation, even fraud. too many seniors and families get taken by promises of quote, unquote memory care. when in fact these are often marketing terms and inaccurate representations of specialized care. the absence of any federal quality or safety standards, coupled with the virtual absence of reliable information and the quality of safety and cost to assisted-living have made assisted-living a sector ripe for investment by sophisticated private enterprises who can shuffle around resources and take profits with little regard for the promises made to seniors and the families. these problems occur at every economic level. from a $50,000 a month paid to luxury assisted-living, to the 20% of seniors who have access through public funds, like

medicaid waivers. it doesn't have to be this way. 40 years ago, when nursing homes were in crisis, congress took action. from numerous reports to the growing course of local and national news reports of neglect, disastrous -- and financial shenanigans. it is clear we have reached that point now with assisted living. we recommend three things. one, establish and implement national standards to promote quality, safety and integrity in assisted living. two, establish a national assisted-living database. where information and metrics are at the public needs to address quality. three, promote resident and family engagement to ensure that assisted-living is truly an at-home community-based service. as i mentioned earlier, assisted-living expenses can average on alarming. we can all agree that the lives of seniors should not be left to chance, ambiguity, and insecurity. thank you again for inviting me

to testify today. >> thanks very much for your testimony. i will begin the first round of questions. but i want to note, for the record, we have senators that are in and out because thursday is a pretty busy hearing morning . we will have senators. some here, some will be here to ask questions. folks will be appearing intermittently throughout the hearing. so far i know that senator rick scott was here and senator blumenthal was here. we will be awaiting others after my questions and those of the ranking member. i want to start with you, patty, but your own experience. i want to start by saying how much i appreciate, and the committee appreciates your willingness to share a personal story that happens in hearings like this on a pretty regular basis. an individual comes forward and talks about their own experience or that of their family.

from a distance it might seem easy. i can't imagine how difficult it is to recount difficult, painful moments and doing it in the interest of helping others. we are grateful for your willingness to do that. telling your story is a very important part of the work we are trying to do together. i know that your husband was in an assisted living facility. as you indicated, paying privately for those services to ensure that you would get the care he needed for dementia. and i've heard from my own constituents back home similar stories. for example, angela was a constituent of mine from johnstown, pennsylvania. the southwestern region of our state. she wrote to me and said her father was in one facility that charged $7200 a month.

that's very high. that works out to about $90,000 a year. and angela shared, and i'm quoting here, there's always a sense that no one cared for the residents beyond their monthly payments. that's one experience. that is one person's personal experience. i wanted to ask, based on your expense with your husband, did the facilities he lived in deliver on the care that they promised to provide? >> thank you, senator. thank you for appreciating me coming in to do this. i think the good news is it has been six years and am able to do it without getting overly emotional. no, they did not deliver. they deftly overpromised. and i understand that they were absolutely a memory care facility specialized in it. they knew what they were doing.

his basic needs were not often met. you can hear from some of the examples that i gave. and i observed other people the same way. they would actually recommend that you pay an additional private caregiver to come in to give them the care they really should have gotten but to their staff was just not there to get it done. do understand. their staff was friendly, caring. they were wonderful people who weren't trained and they were just overwhelmed. but they definitely did not deliver. by the way, it did come out of my pocket because my husband had chosen not to do lawn care insurance. that number the woman gave you was low. that was my starting figure. it cost me closer to $13,000 a month. >> we are grateful for you sharing your own story and experience. i want to next turn to richard.

you mentioned a need for more substantive and meaningful ways for residents who might choose a particular facility with their families to know which services they receive, how much those services cost, the outcomes for residents living in a specific assisted-living facility. for a family searching for care , and you hear about this all the time. i'm not sure there is anyone in this room he doesn't know someone who has had the experience of having to search for care and try to navigate it. it's obviously difficult to find the information that folks need about assisted-living facilities. and sometimes they only have the word of an assisted living provider. perhaps someone else who has had their own expense they can rely upon. can you elaborate more on the challenges families have in finding both accurate information and unbiased information about services,

about costs, about care outcomes for residents in assisted living facilities? >> thank you. essentially, there is no independent validated information on assisted-living for the consumers, for policymakers or for the general public. families have to rely on facilities, facility marketing materials. they also quite often rely on companies like, a place for mom , and other consumer resources that are not independent of the industry. companies like caring.com and a place for mom that get facilities to be listed. that is not independent either. that's not something that people can rely on as being necessarily accurate information of what they will pay for and what they will get. the state websites are the last resource. they tend to be very clumsy. i haven't looked at every single one. flimsy. i'm sorry.

often what we see as they list the facility, the administrator, the phone number, the address. sometimes there's a little bit of information. but you cannot, in my experience, ever get into finding out really what the staffing is, what the cost of it would be, or what the quality has been. >> going back to your testimony, you mentioned the three recommendations. the first one was established for national standards to to promote quality safety and integrity in assisted living. the second was established in the national assisted-living database. is that what you are referring to? >> yes. there's nursing home care, home health care compare, hospital compare other medical website. there should be an assisted living compare. >> look, it's pretty fundamental. people should have the opportunity to place reliance upon a source that is objective

. and to use your word, independent. i think that's true in any walk of life. why would someone settle for relying upon assertions by those who are operating facilities? i think that's pretty elementary. we haven't reached that point yet in terms of a change in policy. i know i'm over time but i will turn to our ranking member. >> thank you, mr. chairman. first, i want to ask ms. simpkins a question. that idea of transparency and information. to me, i don't know how you can say that would be good. i've been a proponent since i've been here that this place ought to focus as much on that as anything. we are a portal of information that if you collated properly would seem to

make sense. and i think that goes across the spectrum of healthcare as well. i have been the most vocal senator in our healthcare system that it is broken. we do not have transparency or competition. it's almost like an unregulated utility. you get your bill after you've had a significant healthcare scrape or a bad accident. you've got to hold your breath to see how much it's going to cost and if you can afford it. patty, you mentioned that it was $7200 a month and it could have been more. that's in virginia. correct? and it cost me close o $13,000 a month. cost me close o >> $13,000 a m >> yes, but that's not the number i gave you. his room charge was $7800 to start. actually $7900 to start. it cost me close to $13,000 a month. >> $13,000 a month. that sounds unaffordable. >> if he had passed away rather quickly by the length of time

he had been in there it would have used up all of my nest egg. >> that has been the kind of stuff that i've been appalled by since the time i have taken on healthcare reform in my own business 15 or 16 years ago. how lucky the industry would tell you it's only going up 5% or 10% each year in your healthcare premiums. sooner or later people can't afford it and something has got to give. i was noticing your background, ms. simpkins, you have focused on low income. some people are going to be able to afford it despite the quality of care and the level. but most people would not. in indiana and the four other states where you operate, what would that range be per month as you compare to $7000-$13,000 a month. when it was all in it seemed closer to the higher figure. just curious. >> thank you, ranking member braun. the range that a resident or

family would pay under the home and community-based services is really nothing. in illinois there's a small personal portion. it's based on resident income and allowing them to do things to still have money in their pocket. in indiana there's no personal -- the state of indiana will pay for those services through the state. >> in your facilities, for low income individuals, there's basically very little out of pocket? >> there's very little out-of- pocket. there might be some personal portion based on what they actually receive at income but it doesn't go over anything that a social security amount is. >> how much would you be able to generalize that across the rest of the country? >> to model that program? you can model the program. >> are other states doing that? >> there are other states that are doing it. i will say, illinois supportive living program and ohio are

doing really well. recognizing that there is a need within their state. there is an underserved population. there are people that cannot afford it. that's what we were founded for. that's our business model, to say how we are going to do it. we work with states that has medicaid waiver programs in place with great reimbursement that makes sense. >> mrs. vessemeyer, you have not qualified for any low income opportunities. is that what kept you into what seems to be outrageous in terms of cost per month? >> that's correct. even though we were both retired they look at all of your savings. if you have a decent ira out there that counts. >> so it begs the question that -- then, is the low income across the strata being served adequately?

that would almost seem to be surprising to me if that were the case. what we are seeing on the other side, there just wouldn't be many families that can afford it. i don't know what the criteria and the cut off is. can you fill me in a little bit? it sounds like in indiana, especially if there are other options to choose from other than just your organization, that the low to middle income strata are being served well. is that a fair statement or not? >> that's a fair statement ranking member braun. >> and you think that is the case across the country as well? because you serve on some boards. i think you have that information. >> it is not across the country. nationally, there needs to be programs in each state to provide access to affordable assisted living and they are not all there yet. >> generally, and that's at least a little bit surprising, generally, it is a focus at the

other end of the spectrum. the low and middle. especially the low that do not get adequate services. i think that's something that you need to get those practices spread out to where we at least can get that in most other states. then you have to tackle something like this. i don't know how wealthy you would have to be to be able to afford that easily and for a long time. something has got to give. i will rest with that. i have another round of questions if we do it. >> thank you ranking member braun. we turned out to senator kelly. >> thank you, mr. chairman and thank you to all of our witnesses for being here today. mr. mollot, the arizona republic paper of record in my state published a series of investigative reports about the state of long-term care facilities in arizona and these journalists spent more than a year on this investigation. they reviewed police reports, footage in some facilities.

analyze regulatory reports from the state and they interviewed families and experts. what they found was, fair to say, horrifying. they reported graphic stories of a resident dying after being attacked by a >> reporter: who had received her medication in time. another report of assisted living resident being sexually assaulted by another resident. an incident of violence among residents that often are reported because they are required to be reported under state law. they highlighted the failure of state agencies to investigate these cases in a coherent, transparent way that would allow families looking for a safe place for their loved one to know what really goes on in these facilities. and i think a lot of us knew there were issues in the system.

we can do that. but i don't think we knew how bad it was. since these articles were published arizona's governor has put together a strong legislative package to standardize inspections, promote transparency for residents and their families, and empower our adult detective services to investigate appropriately. and the state legislature is looking at proposals. mr. mollot, are these the type of steps that can help tackle these issues? >> i believe so. the details matter. these are very nuanced issues about caring for people with dementia and ensuring that things are recorded appropriately and there is good oversight. as much as possible, we would hope that estate would be looking to implement policies and practices that prevent bad things from happening. as well

as, of course, ensuring that when they do happen that they are rectified and reported appropriately. >> so arizona can't be the only state that is facing these challenges. >> not at all. >> should the federal government maybe consider having a role here in providing oversight for assisted living facilities? >> i think it's time for the federal government to step in. as i mentioned in my testimony 40 years ago, nursing homes were in crisis and congress stepped in to initiate action. we are here now with assisted living as well. the same population in terms of number of people are in assisted living as they are in nursing homes. we don't know what's happening to them. we don't know the care that they are receiving. a lot of it is private. not all of it. unfortunately, there is a lot of fraud. >> apparently, more than 20 years ago this facility helped facilitate the creation of an assisted-living workgroup which was made up of 50 organizations. and this work group was tasked with coming up with

recommendations for best practices in assisted living facilities to ensure a more consistent quality landscape across states. the result was a 380 page report with a lot of recommendations. these were hard to agree upon. so what is happening with these recommendations since this report was finished? >> i haven't read it in a long time but i am familiar with it. frankly, on the federal level nothing has happened. as ms. simpkins said, we do see things going on in the states but generally speaking the states are not inclined to take action on the work they do. hopefully that will be different in arizona. it really is time, i believe, for the federal government to step in and ensure that whenever someone accesses dementia care that means something. it's not just a term. and wherever they go for safety

, wherever they are going into, they know what the expenses are going to be. >> thank you. i do want to note, for my constituents, resource created by aarp arizona and by the arizona republic following this investigative series that i mentioned, it's a background or long-term care. definitions of different terms, what families should look for, and what questions to ask. folks can find this on the aarp arizona and my office will be posting this on our social media accounts. i will submit this for the record as well, mr. chairman. i urge arizonans or anyone else interested to check it out. thank you. >> thank you, senator kelly. it will be accepted for the record, not just submitted but we will turn next to senator vance. >> thank you, mr. chairman.

welcome to our witnesses and thank you for being here and all of our guests. i want to direct my a question to you, ms. simpkins. i am particularly concerned by some of the estimates i have seen about labor shortages that are long-term care facilities, not just now. sort of an immediate problem of not enough people at some of our elderly care facilities. i saw an estimate by 2030, we will need, given people will retire and drop out of the workforce. we also have changing demographics in this country. we are older as a country. i read we will need an additional 7 million long-term care givers at these eldercare facilities. that seems like a shocking estimate to me. it is hard to imagine how we can hire effectively 1 million additional people per year at these facilities given the arty existing labor shortages. i'm curious if you think that estimate is within the

reasonable range and if it is not, highly more workers do we need over the next 5 to 10 years? >> thank you for the question. i have not heard 7 million, i have heard 5 million. i would be interested in your information and will follow up and send you the information i have we got hit by the pandemic really hard for healthcare workers left and they are never coming back. they said this is heart and we will not do it for assisted living has recovered pretty well. what we also need to do is build for aging workforce is and our seizures are aging but we are doubling and tripling numbers. having a really intense effort on what that means to both recruit and retain. i would like to share what we are doing. from a recruitment standpoint, that is how we are recovered. we were able to get creative. we looked at people and said, what you need? what will help your household? we knew we need to increase

wages. even in the age cbs environment , you can have great methodology. and then we looked at retaining. as people come into the assisted living and they stay because they are so passionate about it in honor of their passion, we need to create something for them. from the first interview, we asked them what the invision six months from today, one year from today, three years from today. we want them to envision a future with us and a future with the assisted living industry. and then we have to meet that need by career pathing, career mapping and we have done a lot of that. what we have realized through the interviews and people saying, this is my career path, we also need a skill path. we need to provide them with the resources whether it is through a nursing grant, additional education that we are reimbursing for, additional training that they need but if you are going to commit to working with in the space in a workforce, you need to create

and having a we workforce sets could be passionate and have the tools they need and the want to stay. >> got it. appreciate that. one additional thought. you hear about these cases of allotments at some of our eldercare facilities. and they are rare. we have close to 1 million americans in eldercare facilities right now. maybe 2000 per year, that is a small number but i worry with increasing labor shortages whether that number goes up. i have heard some suggestions that you would fill the labor shortage gap by expanding certain immigration programs, certain visa programs. the one where i have bear, is that if you take a person caring for an elderly citizen, you want to make sure there is not a language barrier, especially with people in dementia. they might leave some cognitive capacities.

i appreciate the work you are doing and your answer to the question. are you worried we might see an increase over the next two years or do think not? >> we need to plan for how our seniors are aging and the additional care needs. we do that through person centered planning. i believe dr. kraft morgan mentioned that. our prayer -- claire plans all right what a resident needs. someone could have the same diagnosis and their needs are completely different. if you are not having person centered plan for the individual, which is collaborative family, with the resident as much as they can dissipate and caregivers, you will not have the best plan to keep them as safe and secure as you can print on the immigration side, i would -- there is an opportunity with unused visas to start bringing -- if you think about the workforce -- start bringing healthcare workers. there are some markets that we

are within that have the residents who have language barriers. we have's bash -- staff to speak polish and spanish. >> senator wickens. >> thank you, mr. chairman. thank you to all of our folks that are testifying. appreciate you taking the time to help us out today. i resemble the great state of nebraska. in nebraska, we have skilled nursing facilities and assisted living facilities that are scattered throughout our state. it is incredibly important to take care of the 20,000 people who require care at the 500 different facilities we have. they can get that care for about $3875 a month. anybody who is providing assisted living services in the state of nebraska and has four or more residents is designated

as a for assisted living facility that is regulated by the state and licensing bret as governor i signed into law a assisted living facility act to update the standards and requirements that we have for our assisted-living facilities. they are critical, especially in rural parts of nebraska and to help take care of people and we want to make sure we continue to have that service for our folks. assisted-living facility is a regular at the state level which allows states, you know, flexibility to be responsible of consumer demands. are there any states doing exceptionally good job that we can draw lessons from? states that have good programs or things that should be adopted across the country? >> i can speak for the states in which we operate. illinois, indiana and ohio have exceptional programs. with that, one of the things we

noted in reporting all of the states will require reporting of anything that were talked about previously. >> are there characteristics that you think have led or approaches that the states are doing a good job? what are they doing right? you mentioned the reporting print that is an important factor. are there other things you're doing that i say this is why they have good systems? >> because we have access in a state and a state that is, were assisted-living is regulated and talking about home and community based service. access to the let regulators, axis two families. access to everyone -- you have this local model that can create and innovate and come up with best practices. i am a big proponent. there is nothing proprietary when it comes to caring for a senior and someone that is what the states are doing well.

my fear is, if you move the conversations further away, we will no longer have those things. i talk about indiana specifically. the state program, medicaid waiver program is dynamic. they promote and encourage having a local model where there is collaboration and innovation. that is where we come up with best practices. that is also a model. >> thank you that leads into another question. this committee held a hearing that highlighted the nursing home inspection system. as you know, nursing homes are regulated at the federal level and heavily regulated. assisted-living facilities are subjected to the one-size-fits- all regulation, what can we do as lawmakers to ensure that assisted-living facilities do not have the same problems we are seeing in skilled nursing facilities? how do we protect about the local model and best practices?

>> from the state level, we encourage the states. if we even talk about reporting the critical events, reporting bows through the federal government. under the hcbs services, each state has an obligation to report up to have a federal funding . they also are well aware of the transparency that comes from any opportunity, once the states report up, we have a transparency and the opportunity to see what home and community-based services are doing across the nation. we have a window and more models i'm sure there is more state that are doing well but i cannot speak to those today. >> getting back to the idea with the federal government, how do we preserve that ability of local folks to be able to tailor how they are doing the regulations? to make sure that we are not pushing a one-size-fits-all answer? >> from our perspective we need to tell our story much better.

there are really good stories to tell from a state perspective with home and community based services and we need to do a better job talking about the stories and the things that are going on within the states. the innovation that has happened, the times providers have sat at a table before there is a rule change. but face to face with someone to say if this changes, how does impact the resident you are caring for and your workforce caring for the resident? >> that interaction with people doing the job before rule changes are made with the regulators so we do not have unintended consequences with regard to the rules that are made that will harm the care that as being delivered in assisted-living facilities ? is that bear? >> that is fair. i like the way you put that >> thank you very much. >> we will turn next to senator warnock. >> i would be remiss in this moment it but i did not just take a moment to remember the legacy of the late first lady roselyn carter, who i was

privileged to know and whose mission was to uplift our caregivers. her extraordinary work demonstrates how a healthcare system that leaves so many drowning in caregiving cost cost most of us will one day face. it is a healthcare system that fall short of its basic obligations. dr. morgan, in your experience how does the cost of assisted- living burden seniors with caregivers and their family skimmer >> the cost of assisted-living is both financial and emotional. for many americans, we have a system where there is not access to assisted-living. in some states, there are medicare waivers that cover a larger portion of those who need it at

the lower income. there are also states that have virtually no waiver programs so that the only people that can afford assisted-living are those who have the significant financial resources. the middle till -- middle tier of america reduce their working hours, they set up these arrangements across families to pay for assisted living, if that is what they can do. they bring in people who may not be trained to support their person living at home. they make these purpose areas -- precarious work and family arrangements to make it through with whatever long-term care they have for their loved one but if they're lucky not to get assisted-living, they are still coming after work and bringing incontinence supplies and they are still bringing the snacks and engaging the residents. it is another job on top of the

job they are trying to do if they are still working -- if they are still able to work. that is really important and young onset dementia as well. and young onset dementia, these people are still learning. they have young onset dementia and the families have very few options for thinking about their forward retirement. retirement is not what we an app doing. we end up mortgaging everything to care and clean out our savings in order to support this person living with dementia, who may not be able to be at home for a long of the young onset dementia have this sort of things that patty was talking about. we have a different course of the disease and it is really difficult work of people to care for those folks at home. even if they are able to afford assisted-living for time, they run out of resources. and then what did they do ?

sometimes they can get into nursing home placement. sometimes there is good nursing homes to go to. not always it is awfully precarious for many folks. >> thank you. your experience with this underscores the ways in which this cost not only the families but all of us. it has implications for our workforce and our economy so we have to have long-range, comprehensive thinking about this. the chair has been a leader in this and i am happy to join him. i was happy in joining him at the gao looking at how federal healthcare, affordability programs, like medicaid and medicare interact with assisted- living facilities, how we can do better bear. and whether families choose an assisted-living facility or in- home care, they need help meeting caregiving cost the

average cost of $4500 a month, that is the average cost. you point out the ways in which, for example, with early onset dementia people's retirement funds actually are drained just taking care of the individual. that is why i support efforts to lower caregiving cost for aging adults. it is a critical issue for our country. i will continue to work with my colleagues on this committee informed by the expertise of people like all the folks on our panel to improve access to long-term care for families across georgia and across the country. thank you so much for you work in this area. >> senator warnock, thanks for your questions. i will now move a little bit out of order. we will move to a second round as we are waiting for senators to ask their first round questions, some of whom are on their way.

i will start. i note ranking member braun has questions as well. dr. morgan, i will turn back to you. your testimony provided an overview of the well-trained staff in assisted-living facilities. we heard the direct care staff can have as few as six or eight hours of training only before beginning their care duties. they might be responsible, in some cases, for 20 or more residents. the constituent of mine that i mentioned earlier, angela, said, in part, when i mentioned my concerns about my father falling repeatedly, the facility nurse said, falls are just part of aging. i'd ask you, dr. morgan, our falls and other accidents in assisted-living just part of aging or are there procedures, strategies, rules, that can be put in place to address the risk that older adults face? >> falls is a really important topic in aging. there are a lot of great tools

that people can use. the national institute on health has a great -- falls is about prevention. educating staff is vital. there environmental audits that can be made. some may have this training in place but, certainly, it is an important aspect of initial and ongoing training that the workforce should do. the other thing that is tricky about falls is that there is a fear of falling but has a real impact in whether you will fall. and a fear, families, who are scared that their mom or dad will fall. one of the things that my father would say to his patients, if you do not use it, you lose it. in aging, it is important to keep up with balance and balance exercises and keep strength training and doing those sorts of activities.

certainly, assisted-living and other places could do that to really help with improving balance. we know that balance is really important in terms of predicting mortality. if we think about it and we support fall prevention, that is what we can really make a difference. that is also educating families. if you use your assisted devices, if you get up slowly, if you manage her medications, it makes sense do you really think about falls a fall can really have an impact on the trajectory of aging for sure. it is really important that long-term care take that seriously. >> thanks so much. i will cut myself short here. a little bit of a jump ball between the second round questions and the first round question. i think i will start with someone who is arriving.

thank you, senator warren. >> that is very gracious. i will yield back to you since you have not done it. i will be here at the tail end. >> thank you, both. thank you for holding this hearing. i appreciate that we are having this hearing. i appreciate your leadership on ensuring quality care for seniors in assisted-living facilities. this issue is not a new one for me. in july 2020, my office released the findings from the first national survey of covid- 19 in assisted-living facilities. revealing that about 7000 residents have died from covid in just the first half of 2020. in many ways, the threat of covid in assisted living facilities was just as serious as it was in nursing homes but these facilities received little help and little

attention. before that, in 2018, i released the first ever national assessment of quality care issues in assisted-living facilities, which was completed by the government accountability office at my request that report revealed that over 20,000 serious health and safety problems occurring at assisted-living facilities in just 22 states. from physical assaults, two medication errors, to unexplained deaths. in the years since my office did that work, new studies have revealed additional problems in assisted-living facilities. mr. mollot, you leave the long- term care community coalition, which is dedicated to improving the quality and accountability of senior living facilities . can you say a word about what kinds of threats seniors assisted-living facility space and how serious the risk is?

>> thank you. i think there are two major risks and both of them are serious. first, due to the increasing needs and vulnerability of people who go to assisted-living , the risk of harm has gone way up. people are vulnerable. people are depending for significant dementia care. we just do not know -- we often don't know when terrible things happen as you noted from the geo report. secondly, due to the increased sophistication of operators, we have private equity, we have realty investment trust that is circling around. the risk of financial exploitation has gone up tremendously in recent years. >> your keyword, we just don't know. these are serious problems that have been going on for years. but we hear so much less about what is going on in assisted- living facilities than we do in other facilities like nursing homes.

why do you think assisted- living facilities received so much less attention to nursing homes? >> it is an interesting question. in this '70s and '80s, we had scandals in the nursing home world. that led congress to pay attention and take action. i think that is where we are now. we are hearing more and more stories that the geo reports from 1999 and a recent report you mentioned, washington post and times reports that senator casey mentioned. local news reporting from around the country, over and over missing these issues are coming up and now it is time to take action. >> with nursing homes, we put in federal standards got more federal oversight. assisted-living facilities are governed by a patchwork of state laws, without any meaningful federal oversight. that means no national standards that assisted-living facilities are expected to make.

that is particularly worrisome because private equity firms and real estate investment firms have gone on a buying spree of senior and assisted-living facilities. we know how their model works, private equity comes in, strips the assets and cuts the staff and since the quality of care down the tubes. mr. mollot, your organization has looked carefully at the data and you heard from the residents of these facilities. in private equity constitutes an assisted living facility assassins jobs, what impact does that have on the residents? >> workers are the most important proponent of care in any setting, especially nursing homes and assisted living. that could be devastating for residents. as we don't have a lot of data directly on assisted-living, we have some on senior care in general and nursing homes.

in other care settings we know when private equity comes into a sector, they pillage it. >> in other words, more people will suffer when private equity comes in. we need to do more here. at a minimum, the biting administration should require additional reporting on problems at assisted-living facilities . in fact, that is a pretty recommendation from the 2018 gao report while they are making progress on implementing this recommendation, they should finalize it quickly. this is gone on long enough without oversight. congress must look at ways to improve accountability, transparency and quality of care in assisted-living facilities. again, i want to say to the chair and ranking member, thank you for holding this hearing. to the ranking member, thank you for graciously letting me do this.

i'm trying to cover two earing simultaneously. i appreciate you letting me ask these questions. thank you for being here. >> thank you, senator warren. braun is again conceding to a colleague. senator fetterman. >> thank you. a credit to senator warren, that is outstanding questioning as well too. thank you. ms. simpkins, your website states that your operating margins are consistent among the top in the country. i understand that your company manages upwards of $700 million from the low income housing tax credit program and a majority of your residents rely on medicaid through medicaid waiver. miss simpkins, is it fair to say that your company is viable because of government subsidies?

>> thank you for that question, senator fetterman. it is viable for a few reasons. we do have investors. we are grateful for those who want to invest in affordable assisted-living otherwise we would not be providing to 6000 seniors today who are on medicaid waiver. we also need a viable business plan. it needs to be a business plan when it talks about our margins when you look at affordable housing it is able to have margins with our investors that have certified training and have education reimbursement and look into different workforce opportunities. the third thing that happens is that you have to have a service plan. you have to have a plan that is focused on quality outcomes and is focused on high resident satisfaction and high employee satisfaction.

what you see on our website. i thank you for noticing that. we are redoing our website and i will be glad to send you a link as soon as it done. we will post our quality outcomes and employee satisfaction results. that should probably be in march. i will send you a link. >> of course, that would be grateful. also, i am glad that there are investors and they are a critical part of it. i think we are able -- it is safe to say that the subsidies from the government is also important too. >> it is definitely important. we need both to have a viable business. >> that is not a criticism or attack. i'm just wanting to establish that. given the government undeniable role ms and your operations, why do you believe that a company should not be able to use federal dollars to make a profit? i do not just anyone, of course

, earning a profit. if you are making that kind of profit -- maintaining that at the same time, a federal care standard. >> thank you for the question, senator. the federal funds go into the state and the state decides on what that program look like and what it will be. the opportunity at the state level is that we can have conversations with our state regulators and improve upon practices, shared best practices across the continuum. senator warren mentioned the 2020 report that she had uncle vaped we were part of that report and are outcomes were really good in comparison to others. we relied heavily on the state regulators and the resources within the state to help coach and educate with everything we needed to do. i do not believe that could have happened at the federal level with the amount of attention we could get from the

state. >> i want to be clear that earlier, of course, that we count on other investors to allow you to operate. i do not have an issue with you generating a profit. that is one of the reason people are in desperate in fact, that is why it works. i'm grateful that it does really, this line of questioning was not an attack or is not anything other than establishing that because we are partnering through that kind of subsidy, that we really -- i think we should maintain those kinds of federal standards as well too. because all of them combined together to allow this to work and provide that kind of very important service. would you agree that? >> they are providing a very important service.

senator, i actually appreciate your line of questioning. if we did not have these kinds of discussions, even differences in opinion, opposing views and different views, that is where great idea comes from an improvement in evolution comes from. i appreciate questions today. >> thank you. >> thank you senator fetterman. we will now turn to ranking member braun >> what we have been hearing here is what i like about a committee like this. you are hearing a broad array of viewpoints. healthcare has been something i have wrestled with long ago in the whole spectrum from early childhood through when you are needing to look at how you will spend your last years, it has been cloaked behind closed doors , large insurgent companies and hospital where we spend most of our money on the way to, or nursing home, assisted living. if you're lucky enough to live it out in your own about, it is swamped with transparency and

where we can see. ms. vessenmeyer's story , how can someone like that happen? that was in virginia. hearing $3800 a month in nebraska, every state will have a different cost of living, a different cost structure. that idea of transparency portal and at least some things that are going to make it easier to shine the light on the issues that are out there to me, when you're against that, you're trying to hide something. for instance, on the bigger picture, this is an interesting combination of individuals, myself, senator sanders, senator grassley, senator smith, senator hickenlooper. that is two republicans and three democrats. competition in transparency, if you want to be in the biggest part of our economy, healthcare

and especially at the tail end of our lives, be up there and be open. ms. simpkins, i was wondering. you have done a good job, like senator fetterman said, your payer is coming through the state and federal government and you are aimed at low income. what is your cost, roughly, to do what you are doing? that is across the five states? we heard $3800 here and i just asked my staff that is closer to $4500 in indiana per month. you are servicing low income residents. what is that cost structure look like? >> thank you for the question. i am trained -- >> that would mean you have a business, without giving any trade secrets away, what does it roughly cost in those states to provide a service? your pay our is mostly from

government and the case over here did not have that advantage. you saw what happened. that was in a state like virginia which would have been moderate on cost. >> the thing i am struggling with -- i agree with the transparency, those are things that we will have the conversation today of the cost of care making sure those don't have hidden fees. what i'm struggling is that the expense i depends on the state. >> let's jesse indiana been. i went to get an idea with the variation in cost across the country. and then, whoever is in any component of healthcare should be always willing to make it easy for us to understand. on healthcare, it leads up to assisted living or nursing homes, it is terrible in my own

business, i tried to create healthcare consumers that you can actually manage her own well-being and even when i attempted it, it was not easy but we did it. >> thank you for the clarity. the cost of care we look at indiana, specifically, i think the best gauge is probably our operating margin the cost of care of insurance and workforce and cost is gone up 15 to 20% sometimes it is higher. >> you can give me a range too. >> the operating margins will be roughly between 20 to 28% but when everything is consider, that is debt load. >> that is operating margins. i'm talking about what the government ends up paying per month. >> i would be glad to send that to you. >> i don't want to belabor the point. just the difficulty of this, you guys are doing a good job by all standards. we have got to have transparency across the spectrum of healthcare.

when you get to the tail end of life, i think it is important along the way. and tell the industry and everything in the healthcare embraces transparency and competition, do not be surprised if there is going to be more of an interest to show how to do it from the federal level. i am a believer that is not necessarily the solution but it can end up even costing more. unless you at least embrace what is done and all other industries, which is make it easy for people that want to buy your services know what it will cost. embrace competition, do not try to keep people out of the business. you will never find solutions in healthcare. it is now up to 20% of our gdp. it is three or four decades ago it was only 5% of our gdp. it is breaking the bank even through the programs we offer here, that the elderly depend

on, medicare and social security on retirement. something has to give >> i understand and i will send you that information. it is not that i am willing to share. i'm willing to share with everyone to share but i do not want to speak on what those numbers. >> i respect that. and thank the other panel is a for enlightening us on the subject. >> thank you wrecking member braun. we could spend a lot more hours on these issues. we are grateful for all of you helping us. i will have a closing statement and i will turn to ranking member braun and we will wrap up . i know a vote if it has not started is about to start. assisted living facilities are a growing piece of the long- term care continuum. more work is needed to ensure these facilities are quality facilities and that they are safe and that cost is transparent and clear to

families. as ms. vessenmeyer stated in her testimony today, assisted living facilities must provide what older americans need to be saved and to be healthy as they age. this hearing has demonstrated that assisted living facilities face similar challenges to other long-term care options, including maintaining a well- trained workforce, providing safety, high quality services and being affordable. throughout my career, i have been working to improve care, to improve transparency and quality throughout the long- term care sector. we have a responsibility to make sure every american can age with dignity and a safe place of their choosing. that is why i have for my colleagues to expand access to home and community-based services, improve nursing home oversight and strengthen the long-term care workforce. and now we are going to continue work on assisted-living.

as the sector grows, we must work to provide similar protections and safeguards that are in place for residents and their families as we all strive to improve the nursing home contacts. we want to ensure that any facilities and corporate owners that violate the trust of american families are held accountable. i look forward to working with my colleagues to ensure everyone that needs long-term care has safe and accessible options. one way we will do that is to determine the cost of assisted living are to families and how federal dollars are being used to ensure these funds are being used responsibly. that is to paper quality care among with all of my democratic aging committee colleagues, we have sent a letter to the government accountability office asking them to conduct a study of assisted living cost and how

available and transparent that information is to families. as i said in my opening statement, i want to know more about what people are paying for assisted living and to have people tell their stories as we heard similar stories today. again, we will be asking people from across my home state as well as the country to share stories and to share your bills with us, if you want to do that. we want to hear from you about the true cost of assisted living and understand whether families have the information, the information that they need to make this difficult financial and healthcare decision for a family member and for the family. i will turn to ranking member braun for his closing remarks. >> thank you, mr. chairman. thank you, again, to all the witnesses. this committee is unique and that you really cannot craft legislation out of it.

a lot of it from this discussion happens to other committees. always keep that in mind. we heard how critical it is that federal policy supports the caregiving workforce. senator vance pointed that out back in indiana. i mentioned how workforce in general has a lot to do with our school systems. making sure that they emphasize career and technical education along with four year pathways. across the country, maybe a third of jobs need the four year degree. we need a better high school education for many of these issues so that you can hit the ground running. it should be policies from here and they should focus on boosting workforce. i think we all kind of agree on that. many bills are out there to do that and to make careers in healthcare easier to attain. got to make sure you do not work

across purposes, like some of the policies that are going through the labor agencies. they are wanting to make it harder for independent contractors and individuals, were a lot of this assisted- living help comes from. want to make sure we don't work across purposes. we heard how states and the providers themselves are doing things, sadly, not all states seem to be doing it well. you cannot have many instances of that and say that you have an industry that is working. that should be the rare exception and not the rule. and then when we talk about how this place actually helps. when you are promoting transparency, it can bring our partners together. i have seen that. two ends of the spectrum. no one should ever be against being able to have more information to make a good decision. when it comes to standards, i

think that is important. databases, that is all something we can do sharing with all the states. i think those are good ideas. i am encouraged by the conversation we have had today. that is how you get better ideas , really good practices. this should be something, who is ever doing it the best, you need to shout it out so the rest of the country can participate thank you, again. >> thank you ranking member braun. i wanted to thank our witnesses for contributing both our time and expertise of course, bringing your own personal stories and your own personal experiences to this issue. if any centers have additional questions for the witnesses or statements to be added to the record, the record will be opened for seven days until next thursday, february the first thank you for participating today. this concludes our hearing.

on thursday president biden is set to give the annual state of the union address. ahead of the speech we are asking what issue is most important to you? to precipitate scan the qr code on your screen or go to c- span.org/poll to add your voice to the conversation. a look here at the voting so far. the president will speak before a joint session of congress, where he is expected to outline some of the policy priorities and share his thoughts on the state of the country. this will be the third state of the union address of his presidency and likely his last speech in front of congress before the 2024 presidential election. we will keep this poll open leading up to the president's address. a reminder, our live coverage of the state of the union begins thursday at 8:00 p.m. eastern with a preview held by

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c-span is your unfiltered view of government. we are funded by these television companies and more, including medco. ♪ ♪ along with these other television providers giving you a front row seat to democracy. randi weingarten, ahead of the federation teachers union joint becky pringle to discuss opportunity and practical still associate with career and technical education. they were interviewed by washington post opinion editor alexi mccammond .