so really you cannot talk about, you know, favoring this group or that. because one example that been asking, you know, the headquarter -- we need weapons. we need weapons. they refuse to give them. suddenly they overtook the headquarters. one thing that always -- refuse to give them even weapon from maybe -- [inaudible] we have other propaganda from the other side saying the gulf country is giving the head of intelligence and stories and -- [inaudible] you know, none of the weapon is from the syrian army. >> yeah. no, i really appreciate your making this point. and i think i would emphasize, again, just how much humanitarian aid the kuwaitis are --

how much work they are doing. and these charities are doing sort of, you know, they are really the unsung hero of the humanitarian crisis in syria. over and over again the kuwaitis are the only -- they're the ones that are first donor in every case for humanitarian work. i think there's an aspect of this, too, that is sort of -- i think i mentioned one example that where do you exactly draw the line on this? so, you know, if you're supporting a hospital that is run by a particular brigade is it humanitarian aid? does it have sort of a lethal component? it's a very sort of spectrum. it's not sort of black and white. and, you know, i think that you raise one of the questions that makes this so complicated is that, yeah a lot of money probably goes to things that are very much needed on the ground, you know, these rebel brigade understand if they're controlling an area, it also means that, you know, the bakery. that also means the hospital. and it means providing for people. and no one else is doing that,

frankly. because these groups are the only groups that have access to the area. i appreciate your point, sir. thank you. >> i also add. the paper was not about states sending assistance but private individuals. and a lot of assistance for weapons comes in the form of money. so the groups on the ground can then buy the weapons they need, whether they do deals with some low-level guy in the syrian army or go across the border to buy the weapons. creates full of weapons are not showing up. the money to buy them is. tom, did you have a point? >> i was just going say i'm in touch with the guy who does a substantial amount of this kind of fund raiding. it's clearly people give money the specific kind of weapons. one case in kuwait recently which he attended where he was able to raise money for the -- [inaudible] they raised enough money for 11.

and there was a certain amount of macho bidding going among high profile individuals who attended the event. i'm going bid for three and i'm going bid for three. that kind of attitude. but i think money is given specifically for purchasing weapons where there's weapons that come from i don't know. >> you had a question here? >> my name is -- [inaudible] muslim center. i have two quick questions. there was a report this week about ten kuwaiti shias -- [inaudible] working in hezbollah. i was wondering for you can elaborate more about the fact that the shia community in kuwait is going for hezbollah and in syria and what kind of funding and what -- fighting with the syrians regime and stuff like that. the second one is, [inaudible]

the manager said and i agree with him. there's a fear now when you concentrate on the issue like this without making distinction i thank you for making the distinction between the -- [inaudible] organizations that are helping and the ones who are buying weapons and raising money for weapons. you really are going to -- is there a fear that maybe the government of kuwait now -- being sanctioned and then the syrian part-time -- underground are going suffer. thank you. >> well, so on the shia angle, i unfortunately don't know more than i've already said. i think it's something i would like to look in to further. it's clear that fundraising is happening. i don't know the extend but i imagine it is probably exriebl to what is happening on the sunni side in terms of money. and kristin, maybe you can help me here. i believe there are long

standing historical ties between sort of support for less bo -- hezbollah that coup tapped in the networks. i've seen lot of reports of, you know, sunni and cute waities going there to fight. i don't have anything confirmed i can tell you. >> i don't have any specifics on what is happening now. it is interesting the where the community in kuwait was also a real center for especially across the gulf. you had some activists that came from iraq and setted in kuwait and set base there and had influence in the national network throughout the entire goal and some linking in to syria as well. and those who are parlayed as well to business context on another side. there's activist communities and you have at the higher level business that are working with

the syrian government. the syrian crisis is really -- it's really struck a chord with people. and that's because it's such a terrible conflict humanitarian wise. it's a visual conflict. we're seeing -- people feel very close to it because the images we see on youtube and twitter.

there's a lot of connection in the gulf of syria. in that sense it's a close personal conflict for many people in the gulf. i think every gulf country's government has realized the population is deeply motivated to help the syrian people. and saudi arabia has taken a very interesting strategy to channel the relief in to one public campaign. so they had a huge telethon where they, you know, they got the religious establishment involved. they got, you know, the charities involve. they got all the tv networks and just everybody was give together one pot. and i think this was their way of channeling that -- those emotional responses and very, very sincere desire to help in way they could then use for humanitarian purposes. but that was a bit more controlled. so you had them anyone trying to do fund raids and sort of outside that umm umbrella was asked to join that in a way. then the saudi government through, i believe the saudi red

cross move in that to use that for humanitarian work. gulf countries understand their citizens want to help. they have taken the strategies as sort of a way to, you know, turn that in to really active philanthropy. >> thank you. tom? >> there's a sort of bigger picture issue here as welt, which is that -- one is a specific recommendation are deemed to be a vulnerable in the counter terrorist finance effort. so things like are talking about may well be scrifn by -- driven by the fact that controlling where charitable monies are going not just where they're going but being received from is something which the

global threat finance community looks at closely. now there are -- there's a not forum for this but there are unintended consequences of nap but monetarying where they are going. so trying to corral that going through safe corridor where you know with the money is going. something that countries are heavily incentivized to do if they want to get a clean bill of health. >> another question here. >> thank you. [inaudible] iraq embassy. thank you for an informative panel. very informative. one question maybe a little bit of personal experience on what kind of insurgency which i was young and crazy. i was part of an 1990 uprising in iraq.

we if control some provinces in iraq. [inaudible] there is much more so the gentleman has a point. yes, a lot of weapons is captured. as we if -- [inaudible] my question is -- [inaudible] which is private and which is public and what state em boldment. you already alluded to the fact they are supportive and active. and people -- [inaudible]

a matter of structure problems as -- [inaudible] you alluded to that the people who are fundraising are using a lax system against the government that implements it are using the margin of freedom relative larger than others. look the other way rather than structure failure. i wash interested to hear the panel's view. thank you very much, again. >> we'll start with beth and move down. >> sure. i do think that the cute waity government is aware it's going on. they may not know the extent of it. i don't know how deeply. it may not be a case --

for kuwait to do anything about it. so one of the complications is as kristin alluded to is a lot of people involved are politically support at the moment. so one particular individual that you actually mentioned is former parliamenttarian. you know, on twitter he said let's give -- let's get people to the street. there would be 10,000 people in would kuwait city tomorrow. that person you're dealing with is particularly difficult. but there was one example that i thought was very telling is, you know, there was a great story about two different fundraising events were held. one was held with the presence of one of the mp who supports the syrian opposition. one was held to be the mp.

and they were both in public. the one with the mp wasn't touched. the police sortful came and they were like too complicated. they didn't break it up. the way the donors look at the mp is sort of as a political cover. a way to give them a space more to corporate. they are providing space for other people to race money and creating a huge headache for the kuwaiti government. >> this was a time of really broad opposition activity in kuwait. you had the opposition at that time taking a majority of the parliament in one election and really threatening to be able to constrain the family in new ways. they were some people were

calling for pushing for parliament having been able to choose a prime minister. they forced their move on a prime minister. i don't think it was an empty threat. they sort of lost the game against of the government. but they i think particularly in 2012 there was a vulnerability for the government and pushing against the opposition that was very, you know, resurgent at the time. and the particular the government had, because you had a lot of, like, politics comes from the street. they couldn't negotiate with the mp because the mps themselves were controlling everything. you also had a lot of new kind of triable politics that were new. that the government wasn't controlling very well at that time either. a lot of --

were turning oppositional but the map meant that the government itself was very reliant on the shia political blocs to keep their political opposition. and everybody knew this. tipping made sort of like, you know, you see president obama and the united states not wanting to tackle certain issues where you have vulnerabilities. the same thing in kuwait, they didn't want to take on some of the groups on what was a popular issue at the time. syrian giving support to the syrian ands lean looking -- look like they were deny within the community. there was a lot of competition

within the family. i don't know if it -- syrian issue. but at least there's a potential that again on what has been in the past a very popular issue coming out in a position that is unpopular maybe plagued against you within another competitor within the family. i think one thing that is interesting to think about, a lot of the height of this is sort of past now, and the ruling family has more influence right now and seems to able to try to control this. a lot of ways they actually got because of the fear they had that it was going to be imported to kuwait. and people started to think it's getting too hot. so this message that the government was employing national unity became resident, i think, to a lot of public. that might be give a little bit more space for the kuwaiti government to do a little bit more on the issues.

>> tom? >> anything i would add is obviously not just the donor who are raising the money, but clearly within the establishment within the most -- [inaudible] i don't know anything about kuwait in these terms. but i would imagine going against the kind of organizations is extremely difficult for the authority. one of the questions that comings up regularly how should they be controlled distributed, you know, and different countries take views to that.

where is home? what is the real danger that you see here? is it i don't mean to underplay this. is it simply about syria, and what is going on in kuwait or is it something larger about a trend the role of big money in big conflicts. i must say, as i have listened to the conversation today, i've sort of run back and forth between sort of a -- this is a way it should be but it doesn't sound like the end of the world. then i come back to the tight of "playing with fire" and igniting sectarian conflict at home. maybe i'm hearing something i

should. i would love to get some clarification there. i must say in listening to it also reminds me of the action we express at home about the role of outside money and big money in the electorial politics. if you can expand on that, it would be helpful. >> thank you. >> yeah. i think the thing that scare me most thinking about this and the impact it will have. by home i guess kuwait and more broadly the geographic rerchtion. the thing that scares me the most, i fear that what is happening with the donor community now is just the beginning of the birth that is not going to disappear easily or willinging and established new

networks. these networks aren't just in kuwait, they extend far in to saudi arabia, qatar, bahrain. these are groups 0 that have access to one another in an ininstay contain use and easy to access yai. these are not networks going to be quashed easily. and i think the longer the syrian conflict goes on the more entrenchted the networks get. and the bigger they get and the her extreme they get. watching the conflict in syria doesn't privilege moderate ideology. it privileges ideology that take an extreme interpretation of the events that are happening. because they are just so graphic.

i can map them to bahrain. i can tell you how the salafi communities are connected to nose in kuwait which are connected to those in qatar. i can show you donors in syria together having raised money through kuwait. these are nearings -- networks not going disappear. >> thank you. there was a question in the back. yeah. >> dan -- [inaudible] elizabeth, thank you. it's been useful my question about the story you told. there was a public site on twitter for a donor -- [inaudible] as we know now they started consolidating their gains. since they took over the warehouse for the fmc on december 6, and 7th. they started setting the command

structure in stone. i'm wondering if there was an end to the story and eventually worked it out and now those groups being under the same command structure and the two leaders working closely together. just wondering what happened there. >> yeah. i don't know if there was like a meeting and they took hands and had tea and everything. they did sort of both come under a lot of flak for that fight. i imagine they both sort of backyard off from their positions. there's an opportunistic alliance, i think. hopefully it has more staying power in the sense it gives more coherence to the important question who is the syrian opposition.

work together and pool the efforts. >> questions? >> yes. please. to see a more lively scenario being -- syria where different opposition groups control different areas. i was whether or wondering what impact. whether -- [inaudible] would increase division among different donors. >> thank you. >> i don't, honestly, have a lot

i can add. all the donors i'm aware of have stressed the need for the structure integrity of syria. that's something that the gulf countries themselves also really emphasize. so i don't imagine they would take kindly to the frackerring syria. i don't imagine they would stop fighting if it took place. >> yes. question over here. [inaudible] thank you. i have a quick question on turkey. the donor transfer money to syria to turkey. of course, i know that there are two separate issues. monies to -- [inaudible] help the syrian refugee and the other to get -- [inaudible] and all of that. this group are pro i think --

[inaudible] is there any role in the money in the trait. what kind of transactions are in fact in terms of the transfers money transfers to turkey. >> i don't know of any role of turkey in term of the money transfer. you're talking about exchange houses. the role of turkey in sort of the financial movement that i'm aware of is in term of cash. so the easiest place to go in and out of syria is the turkish border with syria in the northern syria. so a lot is the cash money would be moved to turkey, and then literally walked over the border by one of the guys. that's the involvement i'm aware of by turkey.

but, you know, i personally do not report on turkey, so i don't know the specifics. from my reporter colleagues, i know that it's sort of the border has become sort of a wild, wild west. and, you know, there are shops set up with military fatigues and, you know, i think you have a good story maybe that would be helpful here. >> yes. so i guess two points on turkey. first something of an antidote. he was telling me -- [inaudible] under the pressure to upgrade its compliance with that regime. and i think turkey demonstrates to some extent how much power

these recommendations have. if you read some of the reports on the credit rating agencies, actually they refer -- [inaudible] the fact turkey not cleared its name, they may have downgraded its credit rating, because being sort of blacklist or gray listed by the fatf would have made it more difficult for them to access capital markets. fating that money. >> [inaudible] >> hold on a second. wait for the mic. >> [inaudible] in the october the fat refused to -- [inaudible] in term of the concerts. as far as i know. while syria was in -- [inaudible] on the decision?

i have no idea. how fatf makes the decisions. [inaudible] six members of the -- [inaudible] the request of turkish government to released from the monetary. there are 11 countries on that. including yemen, kuwait, et. cetera. but turkey -- [inaudible] mainly to beth and tom. but if you have an opinion, kristin, feel free to jump in. the general mood in d.c. isn't a conflict that we should be involved in. there's nothing we can do to

really affect the course of it. i think a number of people will hear, beth, and read your report and hear what you're saying. and they'll say, look, the united states could have done all it wanted to to fill the vacuum and provide assistance in syria. [inaudible]

give your psh. first of all, there is -- and i'm sure you'll be aware. there's a significant concern in europe about the blowback effect of the conflict in syria. the number of people choosing to travel from the european countries to syria is quite considerable. ..

but without money, the general view is without money perhaps there would be less willingness to travel than from a european that's probably the most interesting thing about the discussion. >> i guess i would go back to a conversation that i had yet at the end of 2012, during a conference in delhi that was meant to try to unify dysuria opposition, i remember vividly talking to one of the local military guys that had been brought in to that conference. i remember talking to him and he was basically making his case, pleading that the fighters there that meant that she had to nonexistent at this point that

any flow of funding was made in this way or that way. there's really something to that. we are being asked to meaning hundreds of millions of dollars. that would be easily outweighed the wise words they decided to get their act together and not clear whether, the opposition rather than just individual parts of it. i think there was a moment perhaps been more unified support could have brought the opposition together. i now think that moment has passed. i'm not convinced anymore that western support would be able to unify the opposition given how fractiousness become, which basically leaves us in a position where i don't know what

can i do the damage that's been done after this point in terms of creating a coherent syrian opposition. i do think make any both countries on board the project is unified on the story of syrian opposition would be a positive thing. i think the gulf countries are extremely important and getting on a successful geneva discussion moving forward. is the regime going to attend geneva? are the rebels going to attend geneva? how about saudi arabia? to me, that seems they can equally important question and one where we could have a little more influence. yeah, the u.s. missed its moment. >> just one follow on. you have to ask yourself the question come away with money come from if they didn't compromise coming from?

if you look at north africa, even if we address the money that are traveling at the moment, maybe we'll been a. >> i'm somebody who thinks the u.s. is too revolved in that region. i can definitely understand sort of the desire to pull back and there's not much appetite in the american public. a see that as an indictment of u.s. policy. i think if the u.s. are playing a much stronger leadership role, and this result we get is what you get from a usb is strongly present in organizing and taking a leadership role in syria. whether we should have taken an inferior or not, i'm not completely sure yet. i hope policymakers everydayness in thinking about it.

the u.s. is going to be less forward and a lot of our policies through the close states have shown they will step up. from saudi arabia right now they're going to be more to it in the region. the case in point was not even a state were talking about. they're talking about private actors have a big effect and how this effect behind it. regardless of what our policy in syria is going to be, and this is a good case study for thinking about how the u.s. is going to play this new role. what role can i play in between not doing much of anything am not playing in all and role. how can we start to manage and work through some of these real outcomes that, were not playing a strong role. we have the perfect opportunity right now working with the ran. i hope we don't sort of leave everything to chance.

>> thank you all very, very much for an excellent panel. [applause] [inaudible conversations] >> why did you write this book quick spring day, you're busy. the >> as you are. >> yeah, that you are like seriously busy. >> now, i wrote "lean in"

because i matter how much progress women have made, the world, get ready for the bloodroot here, the world is so overwhelmingly run by men. >> i'm shocked. >> i'm not so sure how that's going. [laughter] [applause] >> climate change. >> gridlock in washington. >> women have made great progress in the generation of mothers and economic grandmother within its own it this still true man run every industry and every government. that means the decisions i made the most impact our world, women's voices aren't only heard it bester and the corporate boardroom, tca meeting, drew at the town hall. i wrote "lean in" to address the

issue openly come out openly about the stagnation women are facing at the top 10 to give practical advice to women and men who want to do their part to change it. >> i think radio is the longest and best form of media that love. what we do now is unprecedented. only c-span too long anymore. read books to talk to the author seriously. it's tremendously revealing when enough has had their book read these days because they don't get many people who've read their books and know what

they're talking about with page notes. it's so rewarding to them. i get a great deal of satisfaction there back in the highest is that the best interview i've had on this book tour. loved the interview on things that matter, his new collection of essays. that makes my day. i like radio. three hours is an abundance of time and i can do so many different things. >> senators return to washington for legislative business on monday, january 6.

>> the chairman and vice-chairman of the bipartisan commission on mont term care testified before the senate aging committee last week to said more americans should purchase long-term care policies. senator bill nelson of florida chaired the almost two-hour long hearing. [inaudible conversations]

>> at afternoon. long-term care is an issue that comes up repeatedly. it's an issue that many of those noddle may have a legislative interest in, but a personal stake as well. many of us have spoken in prior hearings about caring for our parent as well as planning for our own futures to alleviate some of the decisions for our children. currently, about 12 million americans have long-term care needs. that number is rising rapidly. across the country, middle-class families are going through the

same tough choices on how best to care for elderly parents. medicare and most traditional health insurance plans don't cover long-term care expenses. and while private long-term care insurance is available, most people don't have it because they see long-term care hasn't been that they'll never need. well, traditionally, who's going to deliver long-term care services client do we have the right workforce with nursing home costs rising, some families turning to assisted living facilities were trying to provide care at home. all of these situations raise additional questions and potential challenges.

all of us have heard from constituents about the trade-offs that they have to make to provide care for their loved ones. i give you an example. chair in front inglewood shared that she is a full-time caregiver for her 79-year-old mother who is pair of eyes after a stroke. she wrote that every cent i have goes into helping my mother at home. her mother cannot cook, clean or even wash yourself. so i'm sure that many of our colleagues here which share similar stories because they are obviously quite common. more than half of the long-term care in this nation is delivered

through family caregivers. euro estimate value of such care is roughly 231 -- $234 billion annually. despite these enormous costs, most americans have done little or nothing to prepare for their future long-term care needs according to a recent study from the foundation. so our current system of providing long-term care is unsustainable for both the government and for families. cbo predicts expenditures for long-term care are likely to increase from 1.3% of gdp to as much as 3.3% of gdp by 2050.

but as we continue to struggle to find ways to address it, but don't be naïve to believe that we are going to find a solution in just one hearing. but we need her. the panel that we have assembled will give us a wide array of ideas far as to debate as we strive to find a bipartisan solution. it and so i want to thank our witness. i want to thank our bipartisan coleader, senator collins. senator collins, if you would share with us. >> thank you very much, mr. chairman. at these indicated, more than 12 million americans rely on mont term care services and support or a routine activities

daily living and to maintain their quality of life and their independence as possible. i appreciate your calling this hearing to explore the options for improving our current long-term care financing and delivery system. as the senate cochair of the bipartisan congressional task force on alzheimer's disease, i am particularly concerned and sensitive to the complex care needs of alzheimer's patients and their caregivers. i therefore particularly look forward to discussing ways to provide more support to the 62 million family caregivers who 2009 provided an estimated

$450 billion in uncompensated long-term care, more than double the value of all paid long-term care. long-term care is the major catastrophic health expenses faced by older americans today. these cuts will only increase as our nation ages. it is not just what is your greater or older americans. it is also the older americans are living longer. americans 85 and older, are so-called oldest old are the fastest-growing segment of our population. this is the very population that is most at risk of the multiple health problems that can lead to disability and the need for long-term care. at the same time, declining

birth rates mean there will be fewer family members and paid caregivers to care for our nation's growing aging population. today there are approximately seven potential caregivers for each person over 80 bytes has tried to indicate. by the year 2030, there will be only for her. by number 58, that number drops to fewer than one in three. as a consequence, more people will have to rely on fewer caregivers. what does that mean? by the implications for the quality of care that will be given? it is clear we have to do more to support family caregivers and to recruit and retain a robust

and confident long-term-care workforce. while there is the need for public and private dining enough long-term services and support, i do believe that is due more to encourage americans to provide for their own long-term care needs. many mistakenly believe that medicare for their private medical insurance policies will cover the cost of one term care should they develop a chronic illness or cognitive impairment like alzheimer's. unfortunately, far too many do not discover that they simply don't have coverage until they are confronted with a difficult decision of placing a frail parent or loved one in a long-term care facility and face the shocking realization that they will have to bear the cost

themselves. americans should consider their future launch term care needs just as they plan for their retirement or purchase life insurance to protect their families. private planning for long-term care will not only provide families with greater financial security, but also will ease the growing financial burden on the medicaid program and strength and the ability of that program to serve as the want term care safety net for those americans most in need. again, mr. chairman, thank you for calling this hearing and i look forward to hearing from eyewitnesses. >> out of the spirit of beneficence and felicity, i would in the spirit of the season extend to our two most

distinguished committee members the opportunity to say a word or two before we turn to our witnesses. >> let me say first of all, i appreciate, mr. chairman, you holding this committee and ranking member collins because it's an important issue. i come before you say son, grandson and former governor that dealt with these matters personally. i can tell you there's not a greater thing we can do to have dignity and respect a persons life as they grow older then tried to have been living independent lifestyle. i give you one story. my grandmother is 85 years of age. i used to see her all the time. one time i start patients very lethargic and sitting there. i think grandma. she said everything's okay, honey. i told my mother, go see grandma gad because my mother always wanted her to live with us and always wanted to be independent. this one time one time i went to visit her patients is okay, i'll come visit the kids. she stayed for 15 more years,

lived to 100 years of age. the thing about it when she was lonely. poor nutrition. she was trying to feed herself, was a cook them properly. it's right before your eyes and you don't see it. when you do, you see the difference in life it makes. i took that with man became governor. the main ring i wanted to do was create programs that your attention to how people can live independently. recent progress in west virginia. i used my lottery funds and table games licensing fees. 100% went into long-term-care for independent living. the fair program basically all it said was whatever you could pay, you pay. we help you. we sent people in. a lot of people did not family support. for so much we can do. we have to be the best partner

they've ever had. the assertion of federal to the local levels. we had a lighthouse program for as long as the health allowed. we had the fair program from a family with alzheimer's in homer spit. just a break. there's some compassionate things we can do and it doesn't break the bank to do it. i'm so thankful you've dedicated your life's too helping most of us who've been on the frontline. my mother is 91. it wasn't for sisters and nieces take care of my mother, we've never put her in a nursing home and that's not what she intends to be or what she wants be. if they don't have the support, we have to give them the support we can live independently. will help us to guide them we look forward to your testimony. >> senator scott. >> thank you, mr. chairman. the holiday season has begun. democrat, republican, democrat and republican.

>> i'm feeling lonely over here. >> i just didn't want to get to your left, sir. >> you are, welcome. anywhere, anytime, senator scott. >> thank you very much. i will tell you, as senator mansion is talked about, the issue of long-term care is one that i take seriously and have experienced personally. to my grandmother is 77 when she passed away. she had parkinson's and alzheimer's are the last seven years of her life, my family, my mother and aunt spent an inordinate amount of time taking care at their home. fortunately, we have the resources to do so. there's a lot of folks when he the demographic breakdown of who can stay in a home and you cannot. unfortunately, minorities pay a heavy price for not having resources and adequate time to care for loved ones.

we had a unique experience in a very special way. i think it's a wonderful opportunity to take care of those who took care of here. unfortunately, we've experienced that. it's a very powerful picture of those who've had the opportunity to care for loved ones. that's why it's incredibly important for a country. second experience has been at the guy in the insurance industry for the last 23, 24 years understand the activities of daily living and how many people have not been educated on the opportunities to make a decision when you're young enough to make the decisions for the payout is either an exhaust all your resources trying to get down to the $2000 or $3000 level or medicaid kicks in. and south carolina, the expensive than a $1.2 billion medicaid trying to help folks who've exhausted all resources. to have a conversation at the

nation and how the government can play an important role is a very decision. thank god for the chairmen and ranking member that had the foresight to put the position. i look forward to the robust discussion about the future opportunities in creativity and marketplace that will provide the resources and future planning that gives us real hope that more americans will retire and live for the rest of their time with dignity, to include the last years of their life. thank you. >> thank you. we are going to start with ms. anne tomlinson. she is the senior vice president at alethea health. she will set the stage on what the current landscape is like. and then, we are going to hear from members of the long-term-care commission.

they are going to share. dr. bruce chernof, president and ceo of the skin foundation. dr. chernof served as the chairman of the long-term-care commission. dr. mark warshawsky. we are going to year from dr. warshawsky, adjunct scholar at american enterprise institute he is the commission space chairman. i meant, dr. judy feder. doctors feder is a professor at georgetown public policy institute and fellow at the urban institute and also served at the pepper commission staff director under my former colleague of which i was the president of the claude pepper fan club.

she served. either way, there was an example for those of you who were not here in washington in that era. claude pepper and ronald reagan would go to it. but at the end of the day, they were personal friends were than they could work it out together. one of the great examples of battles with leadership of the speaker, tip o'neill was when social security was within six months of becoming a graft in 1983. they said we are going to take off the table so that you can't hit your opponent over the head with it. it appointed a blue-ribbon panel. they made the recommendations on what to do, send it to the congress. we passed overwhelmingly.

it made social security actuarially sound for the next half-century. that was 1993. so those folks knew how to get them on. >> chairman nelson current ranking member collinson members of the committee. thank you for the opportunity to testify about the future of long-term care policy. the perspective i'm about to share comes from my work over the past 20 years first at the office of management and budget is the person responsible for the medicaid budget. also in the last 10 or 15 years consulting to nursing care providers, and working at the number of my colleagues here on the panel and the budgetary impacts of a whole variety of ideas for reform, including the class act. i just want to start by saying,

as many of you noted, we been well over 200 billion, but we pay for very little care. we depend on over 60 million americans to provide most of the care and they provided unpaid. they do this because most americans are not insured against the financial risk of long-term care they want to avoid the nursing home bed. the long-term-care system is woefully underfinanced for the job it has to do now and especially in the future. all of the other problems we talk about, but delivery system, workforce, quality of care all stemmed from the fundamental fact of vendor financing. i'm going to make three points of our discussion today that i hope will help you all in the work you are doing in the future and will make our discussion a very interesting one. i'm going to say was something a little controversial and hopefully the former governor will not come across the table at me.

the problem we have to solve in my opinion most primarily is actually not one that is the medicaid budget problem. i worked on the medicaid budget for many years. i don't see this as primarily a medicaid budget problem. it is an issue of course. students had to thumb their medicaid programs. this people entitled to services under those programs. governors and state governments will face huge problems. the real issue is in managing these challenges come even more of a financing gap is going to be created and that gap is going to have to be filled as it currently stands by families to their own personal finances and unpaid caregiving. long-term care is shrinking as a percentage of the medicaid budget. at its lowest percentage in two decades. it has grown at an average rate of less than 5% a year. it is true we won't have any more older americans. in preparing for demographics,

there's dirty demonstration that they can and will exercise the budgetary vipers they have to both reduce the number of people who receive medicaid long-term care services in the amount they spend per person in all settings. not just nursing homes. we see that reflected in moving people into managed care for the long-term services. another was a relative to the number of people who need long-term care, there's a lot less medicaid to be spread around among his people. my second point is the inability of medicaid to keep up with the growing demand points to the real problem is that the end of financing of long-term-care creates and contributes to enormous economic and security, which is ardea major problem in this country. it's an insecurity for the majority of american families. they think about what they might be facing in the future. when the face of the crisis,

most americans cobble together a variety of resources to provide what they can be at less than 2 million of the 12 that we've talked about today who need long-term care are living in a nursing home. that's because they live in a community where medicaid dollars are the scarcest and a third of all american families are poor providing some type of caregiving. a third of all american families are providing some level of caregiving. when they provide this care, they do it at a rate of 20 hours per week. but time is spent doing the really hard for me physically and emotionally challenging work of caregiving. they do about 75% are holding down another job. we know from industry data that over a million people are paying privately for right now for assisted living or some other senior housing and it costs $42,000 per year on average. this isn't just for rich people. the services or finance for the sale of homes their contribution for adult children and providers

so many residents exhaust resources on assisted living and have to move into a nursing home to continue care under medicaid because medicaid doesn't cover assisted living. very little is captured in our national data. we can have a good way of getting a handle on expenditures. after years of analyzing data, my conclusion is medicaid is something to be avoided rather than a mechanism to exploit the wealth protection and someone whose job it was to work on improving the efficiency of medicaid to find medicaid savings and he wasn't shy about it. i'm telling you there's not much here to suggest we have enormous opportunity to further tighten medicaid did in fact, quite the opposite. my final point and not least popular point me here today is even when people are educated about the risk of long-term-care and when they are present and, they manage to do that for many americans. we will not truly address vendor financing without requiring

everyone to participate in the risk pool. i say this after being a proponent of expanding coverage through voluntary private approaches in analyzing the budgetary impacts of these i learned from that experience in mountain view to adequately protect americans against the risk of long-term need, in order to correct the end of financing problem we currently deal with, some part of the solution must be mandatory participation. we have the vigorous debate over private versus public insurance options, but it doesn't mean anything. neither works very well on the participation is optional. it's an debate. the debate between public and private pressure, but not one without the reality of what it will take to protect americans in doing so will address the medicaid budget issue in the process. i look forward to your questions. thank you. >> thank you. dr. chernof. >> thank you, mr. chairman. ranking member comments and members of the committee.

are please to be here to present the vision and recommendations of the long-term-care commission. i want to walk us through the highlights of the report. this is work mark and i did together and it comes to me spirit of fundamental bipartisanship, which we think is the way forward. going to make opening comments on the whole report and mark will make specific comments to follow. it follows the now, there is a compressed timeline. we are setup with a six fix my schedule after going through the appropriations process, with roughly 100 days to do our work. and nowhere, we at four public hearings with 34 witnesses. over 100 submissions and i'm working sessions. on september 12, as required by the law, the commission voted to issue the final report as a broad agreement of the commission. the commission's work process in the development of the final

recommendations. the commissioners for a talented, knowledgeable and diverse group of people in our expect patients were would identify as much common ground as possible and establish that as a foundation for moving forward on long-term service and support issues. the discussion areas of agreement and disagreement would be evidence-based and we would be open and willing to challenge accepted thinking we couldn't find substantial evidence. we are pleased with the collegiality and not of common ground reached. this makes a point addressing long-term services and support issues is not intractable problem. in the process all proposals included in appendix appendix a of the report. commissioners split of the ideas that don't merit the most attention in this subset was discussed and developed as the potential recommendations. they could not achieve broad agreement were not included as a

recommendations. developing a thoughtful, comprehensive report of 100 days is an important success in the commissioners dedication. let me provide you a report. it's very important for the general public to understand this need. by broad agreement for shared version that we are trying to solve together. the shared vision serves as a framework that supports 28 specific recommendations. let me touch in a few key points. it starts with the notion they must have a fiscally sustainable and effective long-term service and support delivery system. it's built on concepts of person and family centered care. it provides individuals with supports and services in the least restrictive environment appropriate for their needs. it's delivered by a well-trained and adequately supported array of family caregivers and paid workers.

finally, the comprehensive financing requires an approach with three prongs come into the public and private financing to ensure the most catastrophic expense is, encourage savings and experience for immediate long-term service and support and finally providing a strong safety net for those without resources. the 20 recommendations i could take you through them and we don't have the time for that. i would like to box them up and highlight in a way that is useful in our discussion today. the three key areas or service delivery workforce and finance with respect to service delivery, it hinges on recommendations at the start with a better balance of community-based and institutional care choices. finding the balance is important since most folks want to be and should be in the community. other recommendations include a single point of contact. a uniform and standardized assessment is about providers and engages the family in the individual themselves. accelerating the development of a new generation of quality

measures that includes tom community-based services and experience of individuals receiving care in promoting paneer firms that focus on outcomes rather than settings. with respect to work for some essential to a set of recommendations was a variety of recommendations focus on improving training and support for family caregivers, including identifying the family caregiver in the chart and assisting the family caregiver as part of the care planning and care team. other important work for its recommendations include taking on practice and delegation of integrating direct care workers and encouraging states to improve standards for home care workers. finally in financing, given the hundred days, the commission did not have a single recommendation of financing but did but did outline accommodationist adverting noted and identified two different approaches that could be the basis for a broader discussion. one focused on public social

insurance solutions and the other based more on target market solutions. i will say when you look at both of those approaches, there's really interesting commonalities that bring them together and are further work. the public policy details, cost and funding mechanisms are made to be specified in many commissioners felt it would require considerable new data, design work and careful analysis of cost and consequences before a fiscally responsible proposal could be put forward. finally, verify specific recommendations relative to medicare and medicaid. next steps, one of the things that brings us here today, the commission post on what is critical to a follow-on body for the commission to pass along modeling work still needed and not complete. we also called for a 2015 white house conference on aging in partnership with the national council on disability to focus on long-term services and support issues. with that, i want to thank the

commissioners for all their hard work. our staff who gave their summer to get us a product done on time. i want to thank mark webber time because his knowledge, leadership and engagement is really important. rick is a team from day one and that is critical to get the job done. i finally went to thank you for the opportunity to testify today. >> thank you. dr. warshawsky. >> thank you amateur ben nelson can can a sender and members of the committee. her name is mark warshawsky. i would like to admit to some of financing issues in more detail. the commission to reach a consensus on the need for personal savings and insurance coverage and significant government support for the low-income population. but we did not agree on structures for proportion. some of the divergence arose from the lack of empirical clarity on several aspects of the problem, which we try to

address in the commission, but we didn't have enough time and resources to resolve them. in particular our debates on whether medicaid is now in ltc insurance program for the higher income households, whether they're significant capacity of working age adults with severe functional limitations to participate in the labor force and how to improve the private insurance market. focusing on the older population, some have expressed the view medicaid is now program for the poor. i see significant extent to medicaid coverage for those in the middle and come in above groups and working years into retirement. evidence presented to the commit and a medicaid eligibility rules indicate in many states significant housing, retirement life insurance are satisfied in considering medicaid eligibility and many people in the middle income group in above do in fact get medicaid benefits. still, much to learn about how

significant. what is the true extent of gamesmanship in medicaid eligibility? what would additional offers spring into and touristy recovery and how much of the elderly care about leaving the quest or have have expanded care coverage -- care options beyond that medicaid currently provides. some of us believe one way to find out on all these questions to set up an option for medicaid carveout whereby upon retirement , individuals would have the choice of receiving a lump sum payment for a significant portion of their expected value of medicaid benefits. this is the most for the poor, little or nothing for the bad stuff. retirees visa payment to purchase permanent long-term care benefit design in the place of medicaid coverage. turning to the working age population of functional limitations, with little regard indicated the return or continue to work a if significant supports were provided that the

intended medicaid requirement. to my understanding, past experience has not encouraged above that capacity. we'll support the commission's recommendations to create a demonstration project and assist states to achieve greater uniformity in state medicaid diane for lgf says. we can learn much from progress and changes. even assuming results are positive comments likely the changes will be costly. in light of severe physical condition, we must be willing to prioritize needs such as typing the current release eligibility standards for workers about age 50 to qualify for disability insurance and medicare. finally, there is a disagreement about the possibility to improve the function of the private long-term care insurance market. we all agree currently it is enough. there was a fair consensus, which leads to the put forward. in my view, the problem is one

of inadequate demand arising from a crowd artifact of the medicaid program and also public understanding. at the same time, their problems in the supply side stemming from the restrict a staple as an insurance policy design of federal tax law. some of us propose the following. first, provide tax preference for long-term care insurance policies to retirement and hope accounts. we feel that in terms of saving what arrestor medicaid, and this would cover the cost in terms of lower tax revenues. second, we want to support combination policies such as the lifecare annuity. such projects would finance care as well as retirement. combining long-term care insurance and life annuities would decrease combined cost and ease underwriting standards and obtain coverage.

i'd also like to note that we all stated the commission's recommendation should not increase in existing budgetary commitment to health care fix by state and federal governments. we believe entitlement commissions given recent tax increases to pay for the aca. i want to have cobras by setting my appreciation for the tremendous effort of fellow commissioners. he did the impossible and produced a project in a very tight schedule. i also want to thank resource incredible leadership. he was a great partner to work diligently to install trust and create an environment conducive to collaboration and dialogue. thank you. >> thank you. [inaudible] >> turn on your microphone, please. >> i will begin again. thank you, and members of the

committee for the opportunity to testify before you on the path forward for long-term service and support. i appreciated the outset your mentioning my service as staff for, which began about 25 years ago. i've been active a long time and hope will make some progress before any long-term care. we definitely need to get on with it. in the experience most recently as a number of the congressional commission on long-term care on what i am testifying to be fond of long as my experience and i can tell you there's a lot of work to be done. although policymakers are grappling with challenges to the sharing to quality health care. we tackle long-term services and support. despite the continued battle,

critics of the affordable care to recognize the need for insurance to ensure access to health care and protection against financial catastrophe. there is much less acceptance of the need for insurance when it comes to another risk one for which virtually all americans are uninsured. with basic tasks of daily living , generally referred to as long-term services and support for long-term care. on the financing that is critical to the building an effective long-term care system, the recently concluded commissions up short of recommendations. five of us commissioners are compelled to step up did not support the commission report and offered an alternative report explaining is charged why and how congress should accomplish this goal and i request you include that alternative report that i've submitted with my testimony in the record. as you said, about 12 million

people had the need for long-term care today and i would remind us while it is the special committee on aging the 5 million of these individuals are under the age of 65. the vast majority. families can only do so much. whether in an assisted living facility or nursing home, it exceeds most ability to pay. that is where insurance to kick in. private health insurance does not cover long-term services and few have private long-term insurance, which typically offer a value in the subject to increases because purchasers to lose coverage. on the public side, some younger people with disabilities rely on health insurance does not cover long-term care.

the federal state medicaid program does serve as the value of last resort for people who need long-term services and support, but it's protection vary considerably from state to state and have become impoverished taking care of themselves. i would have to take issue with mark's comments because the evidence that was presented to us is medicaid is not a program for the rich. benefits are going to low and modest income people. the need for expensive long-term services and support is precisely the kind of catastrophic, unpredictable list for which we typically relying on to spread costs. these are unpredictable for people under the age of 65 and i think we all get that. only 2% of the population needs

services. it is almost half the long-term-care population because it is a small% of a very large number of people. the likelihood of needing long-term care is all i predict about when they turn age 65. an estimated three and 10 people are likely to die without needing any of these services while two in 10 will meet more than five a year of service. whether that can financial terms terms, half the people today will spend nothing on long-term care, depending when they need it, while a very small percentage will spend hundreds of thousands of dollars. fnc vindicated, we really want people to be financially prepared to manage this and predict it will, catastrophic risk. we need to establish a reliable insurance mechanism, whether

public or private or some combination to which they can contribute. it is easy for experts to recruiting at public or the partnership. the real challenge is what role as each sector going to play? to effectively spread risk in which the broadest possible population, public social insurance that spreads risk and everybody participated in an emphasized must be at the core of future policy. private insurance can play complementary roles, but even its proponents recognize that building future policy around the private market without best elite eight in 10 americans uninsured. public insurance can be defined in different ways. it can offer relatively comprehensive and defined in a fit like cory venter medicare or it can offer basic cash or benefits in the new program. it can be funded in different ways. in part through taxes a

surcharge savings from medicaid would rather spend. although to emphasize although there can be some savings to medicaid. medicaid is woefully underfunded and we need new financing to support it decent system in the future. regardless of the specific public or social insurance program will protect all of us at risk and required all of us to contribute. i want to emphasize that public insurance will not eliminate personal or family responsibility. rather, it will make it manageable and affordable through private resources and family care. it is likely to eliminate the need for an adequate public safety net. whether within or three continued, albeit smaller medicaid program.

the enactment and implementation of the aca demonstrates that it will not be easy to enact long-term care insurance, public long-term care insurance program. but we should not kid ourselves without it. our policies will continue to feel deeply done in old come in now and in the future who need care. building an effective long-term care insurance system with public protection at its core is the only way to enable americans to prepare for the risks we all face and building it is our responsibility. thank you. >> thank you. i'm going to withhold my questions and i'll do cleanup so we can get to our members, senator collins. >> thank you, mr. chairman. about a decade ago, i offered legislation that became law to allow the federal government to provide a long-term-care

insurance program for federal employees. it is not a subsidized program and the vantage of a group program they could ride into. there have been some issues with the program. one of them is not very many federal employees signed up for the program, which really shocked me because if you look at the demographics of this country, one with the ink that one at a young age can buy affordable long-term care insurance and must be protected. i'm curious into her warshawsky, i'll start with you on this issue. because you talked about one of the reasons that the long-term-care private insurance market is quote, ms, is inadequate demand. i am wondering if most large

employers offer this as a benefit. >> may understand the path of learning chairs offer it as an optional benefit. very, very few will contribute to it. so if an employee health benefit, but about half a loughery. the experience is similar to what you vindicated in the federal government and many do not use it. i think even very large, well-paid organizations about 5% or 6% workers purchase long-term care insurance. there's a couple reasons. as indicated in the testimony and as we heard by an economist at medicaid does represent a type of social insurance and it is a crowd out of private insurance. that is a significant factor.

most other benefits, retirement benefits or health benefits given by employers or tax advantage. this certainly provides an enormous incentive to get the benefit. clearly long-term care insurance is not the tax advantage benefit. that is a difficult subject to be frank. although health has its downside and upside, retirement is usually something people look forward to. long-term care is a difficult subject. in my opinion, is a subject best handled at the point of retirement, which is why i've proposed in some of the commissioners supported those in creating a combination of policies, which would be at the point of retirement such as lifecare annuity. >> i am very intrigued by that idea. certainly if we made long-term care insurance tax preferred the way health insurance is, it

seems to me you would see a larger uptake by employees. on the other hand, we are all aware the largest tax expenditure with employer provided health insurance. so it is the cost of doing that as well. ..

insurance available and tractive to people. doctor, let me just ask one more question, my time is rapidly running out. it has to do with home care. most people i know would much prefer to receive home care rather than going to a nursing home, and yet we have a very outmotive definition for qualifying for home health care that has a home bound requirement, and that home bound requirement ignores the fact that we make technological advantages that allow people who have disabilities to leave their homes at times.

and clinical condition rather than some arbitrary limitation on absences from home. i introduced a bill several years ago. but it's my understanding that the commission did address this issue, and you can tell us what the commission decided. >> certainly. thank you for the question, senator colins. you know, let me start just as a physician as a second and a general internist from my years in practice. it is all about function. we need start there. because function -- function in combination with syria's clinical illness is what

drives costs and actually what really puts pressure on families and systems. so by sort of starting there you -- i think you goat right answer, which is a slightly different answer than the one we have today. radically grows a program and increases cost. it's something need to be done thoughtfully. it's about finding the new right definition that helps the right people get the right service in the place. the commission as a whole, republican appointees and democratic appointee to see it as a real place. whether there's a need far new definition, one, frankly, more e fesht. >> thank you.

>> senator scott. >> thank you, mr. chairman. an interesting panel, honestly, as it relates to the topic. you essential well-educate on the top i think and very passion nail. -- passionate. i see it in your eyes and frustration you have work order the project without any progress. i appreciate that. you go to the mandatory" lets get in the vote together." certainly i follow more on the free market side. i realize even with the best case scenario we take it from three and four question improve it drastically the results of it. having sold couple of policies, i'll tell you part of the challenge we face, it seems to me, is that when you go a large group, united states government or some of the larger groups i dealt with informing the individual that works for the company that the available benefit is there totally

different conversation than getting them to sign up for the benefit. so real challenge when you have the large employers unless you have a enough agents or folks to help sell the market and motivate folks to take a second look at what the actual benefits package include it's difficult to get people to sign up for something they are uninformed about as a part of the process. that's really one of the challenges i would love to have -- i may call you mark. i'm going butcher your name the second time i say it. [laughter] to talk about this. i think there's a misinformation really takes away the motivation. the misinformation somehow somewhat your health insurance policy is going cover this one day. if that doesn't you are eligible on medicare and that'll cover it. they don't understand so you to exhaust all of your resources for medicaid to become a part of it. there's a misinformation, in my opinion, that has to be addressed, number one. and a marketing opportunity as well. when you look at the hybrid

combination policies emerging with long-term care are we looking if are opportunity to have the created different editorial basis to then reduce the actual rate for the long-term care insurance so as to make it more assessable to those in the public and adding a tax preference to that in an attempt to create more affordability and more access. is that where we're going. is it similar to the longest run -- on american history right now. is that similar to the fact what the life insurance companies have started doing with the ability to get some of your life insurance benefit before you expire 25 or 50% of your life. if u yo know what i'm talking about. >> i'm familiar with that. >> senator scott, so you have acaptained to -- adapted to the senate very well. [laughter] >> i would like to hear myself talk. i'm getting closer to the place now. yes, sir.

there's ample evidence about what the insurance coverages. there was a survey done by professor jackson at the harvard law school and university of illinois. it's quite pervasive lack of understanding. and i think part of that is that there really isn't a good structure right now. and in this, i think we all agree on the panel regardless of viewpoint on other issues in term of public/private emphasis. there isn't a good structure. i think part of the responsibility of governments here is to create that structure, and in terms of our viewpoint in terms of emphasizing the private sector and private resources that would include the tax incentive, and also include, as indicated,

encouraging the life care annuity. the motivation there is a little different than -- the insurance -- life insurance product you indicate is basically in brief the advantages you create pooling a population that currently are excluded from purchasing long-term care insurance. because they're in poor health or the insurance companies think they might be likely to become disabled; therefore, they cannot purchase the long-term care insurance. it's those attractive to the insurance company in term of the life annuity segment of a combined policy. if you combine the two, you attract both populations. it is fair to both populations because they are both getting the benefit they wouldn't otherwise. and it could be offered at the reduced cost. and most significantly, it could be offered to pretty much everybody as with very minimal

underwriting. which is a great advantage in term of creating the opportunity for more private long-term care insurance coverage. to that end with the life annuity hybrid. it would pretty well for those folks typically in the moderate income level and highs perhaps those folks struggling to make the end meet. >> it would be. it's for people who have some retirement access. >> yes. >> thank you. one final question. on the mandatory. i wrote down what you said. i have written it on too many pieces of paper. >> right. on the idea that we need some type of mandatory enrollment to an insurance product in order to create economic security for most americans. >> so from my perspective, i wish we had more time. do you get five minutes or seven

minutes in this committee? >> well, given the solicits nature of prechai's meet -- prechristmas meeting, please continue. >> thank you, sir. no other chairman on any of my other committees will do that. that's why i had that long compounded run-on sentence, unfortunately. help me understand, my perspective on our entitlement today is we can't afford the ones we have. any construct we work we is -- i forget in multiple -- that's nothing compared to what we're speaking to. the the real challenge we have the pension plans underfunded our health care we are already exposed to. we're talked about a couple hundred trillion dollars unfunded liabilities and we had an -- added a new component. >> no that's a great question. i'm glad you asked. i will tell you, it's, you know, again, because of my professional background last thing i would imagine doing is a

budget analyst suggesting we needed a new government program. i was trying to control the ones we had. so, but after looking at this for many, many years, and truly, you know, the idea -- i've been a pretty big fan of, you know, there's got to be a way question actually work with the private long-term care insurance market to create, you know, both changes on the demand and supply side that would in fact really give many more americans a true opportunity to insure, because right now it's my view there isn't an, you know, we say people are unprepared. well how can they prepared, really? it's not their fault they're not prepared. there's really, i don't have long-term care insurance. i know a lot about it. [inaudible] >> i know some agents that will help you. [laughter] i should point out my parents are signed up under the federal employees. so thank you.

i think there are ways in which we can work withen insurance program so that it is financed in a way that it is self-funding. and we worked on this a lot, actually, in my company when we were modeling the class a act just a year ago. so we were dealing with a situation where we were trying to analyze what the premium levels would be under a voluntary approach. and in the big problem that we ran in to over and over again was that, you know, you set the premium low enough. the fact of the matter is, i haven't been able to figure out a way to come up with a public policy that would do what we need what it country needs without going in that direction. and i really do think that we know enough know to set it up in a way that the premiums would

cover or the tax base or whatever -- however it is you to choose to finance it. there are so many different ways. could in fact pay for the benefits that we would expect to pay out. but you're right. it's a risk. i completely understand and agree with that. my deer in the healths look -- headlights look is not authentic. it's real. but you have a resolve to continue to convene this committee. so focus in on this. i appreciate that very much.

i'm hoping to maybe sneak in two questions for the whole panel. the first focus is sort of the role and value of innovation in looking at this the national level. obviously we have to tackle and debate long-term care financing at the level. in wisconsin we have a program called "family care" currently operates in 57much our 72 plans with to extend to all. the gist it improves the cost-effective coordination of long-term care services by creating a single flexible benefit. it includes a large number and range of herman health and long-term care services that

otherwise wash available in separate programs. so just as one example of what a state is doing, i wonder what we can learn from innovation that is going on in the states on how to address our long-term care crisis. i don't know if you want to take a stab at it. >> maybe i'll start on behalf of commission as a whole. i think when it comes to delivery system, work force the answer is absolutely. there's something done on the national level, care is delivered locally. they are delivered based on the kinds of providers and array of services you have in a community, in a city, in a state. and based on the needs and desire of specific communities, and there's wide variation among the states. so we in cob junction with the commonwealth fund produced a report card that the aapr book

looked at looking at the perform of various states across the country. and wisconsin was one of the top performers. it was number five in the country, and it is the robustness and creativity and -- of the programs that really drives wisconsin's results. so are there opportunities to leverage state innovation particularly when it comes to how we deliver services, how we support families, and how we address some of our operational work force questions? absolutely. the single biggest challenge in building teams, for example, the ability to delegate functions from doctors and nurses to other care members of the care giving team is state-based. so there are many opportunities. wisconsin is real flared that. i think the financing question, honestly, is one that comes back to a federal level. i think the notion of a broader -- finding the right framework

which is part of our discussion today the role of the federal government in providing some leadership and thinking about it would be important. the state -- states are where that care is delivered and i think there's a lot we can learn from it. a lot of success out there. senator, i pick on what bruce said about financing. i think that really in many respects the ball game. i think we have seen a lot of innovation in some states. a move in many states toward much greater reliance on home and community-based care. that is encouraged through the affordable care act. you can't innovate your way out of budget tightness. even as we have seen improvements in innovation in some states, we see tremendous

variation across states. that means that there is home and community-based care available fairly widely to some populations in some places, and very little particularly to the elderly and others. the care they delivered at the local level with medical care delivered at the local level, we can have the delivery between the person and the care giver. the financing is critical to making those available. what we see at the state level, again, i emphasize at the outset, is that the states in order to control their obligations create waiting lists, shift is not about state innovation and delivery. they farm it out to finally as

we go forward. i'm happy to provide you we did some analysis supported by the foundation to look at the future demand of the importance of federal financing as bruce said. for long-term care. if you look at the aijting population, in every state we continue to see enormous variation across states. if we don't create a federal

financing support. they have a medicaid waiver. many are impressed by that. it intended to improve care and save a cost we basically got paid to have a waiver because i think the administration at the time

wanted to earn courage waivers. so they made this one to kept rise in. i don't think it's going to be the common outcome. you are all very impressive in rhode island. in so many ways. >> senator ayotte. i want to followup on the issue of waivers. because i think it's related certainly to the important issue that senator colins raised, is which is how do we make sure the definition fits to allow more community-based and home-based treatment so we are allowing

obviously people to have to stay in their homes longer because the average costs for care in a nursing home is approximately $90,000 a year. so i can see this being certainly important in term of cost but also in terms of people having a better quality of life is it based on what the commission found. should we give states greater flexibility particularly in this area for innovative programs that are going to allow more for examplability on home and community based care. i think that also fits in with this, obviously, would be defined by the overall federal definition we come up with. this was a place the commission gave a lot of thought to. and i think as we listen to the

states, it was an area of real interest for us. there are so many different waivers. they work in conflict with one another. sometimes they're just that far apart but the problem is it's you're the person caring for a family member that is in that little white space between the two waivers you're in trubility. you're in the thick enough for this. you're not needy enough for this. i think the notion of a much simpler approach to waiver was one endorsed by the commission. the other concern raised that have obviously, is the issue of beneficiary preace. they deliver on the services that need to be provided. so, you know, in that balancing so you get praments like the one west heard from. but make sure in the process of

providing we're not losing services for those that need them. if i may just to followup on that point, you know, my experience states have a tremendous amount of leeway and are the degree to which people do not have access to home and community-based services has more to do with budgetary issues than the need -- spending per person than it has to do with flexibility around the federal requirement about what states can do. whether the waiver process in

moving people from nursing homes to home care would save money or cost money they were skeptical. they said the system is pretty much puts people in the right spaces already. we did not hear a consensus whether it would be a cost saver or a spender. to build on that i think we have a lot of experience with the home and community based care over the many years we've been trying to expand it. i think there is general agreement that we get better value for the dollar when we are able to serve people at home.

and not in constitutions when they don't need them. we have so many people in need. we need to build the system and underserving today so when we offer more services at home we serve more people. which is a good thing. but at costs. i have heard representative of the governors and the medicaid director say flexibility is not enough. they have flexibility. what they don't have is the dollars. i think it's a function of politics. governors in both parties have joined together to call on the federal government to take over the but they're looking to the

fed for dollars. >> well, since i got one question. i appreciate all of your answers. i'm going to submit some questions for the record and some of the followup on some things you said. so i appreciate all of you being here. thank you. thank you, mr. chairman. for holding this hearing. another important one. it's another example how middle class families are getting squeezed. it's hard enough for any family to put aside anything for savings today given on the squeeze on families. we expect families to save for retirement and for long-term care at the same time that many are absorbing the cost of caring for an family member. we dpubled up here. there's a growing conversation about the retirement crisis in

america. in the face of this, the lack of safety net on long-term care is more fuel on the fire on the kind of problems we face. retired baby boomers are ill equipped to cover the cost of the long-term care needs. we have fewer people. they have lower savings of retirement than their parents did. only 18% have retired benefit plans. a third of all seniors have less -- as they approach the senior -- they have no savings at all. so that leaves us with medicaid. as sort of the backup program here. which can cover some of the cost but the current system forces seniors to spend most of their assets in order qualify. every bit helps but to qualify when they have sell off all

their assets, it has over economic implications. so where i wanted to start is to ask you, doctor fetter, can you tell us a little bit about the financial instability that selling off assets causes our seniors? >> thank you, senator warren. i think when people talk about seniors relying on savings, i think they are finance long-term care i think they are insensitive to the variety of risks that come with getting older. there's a risk of a concern about having adequate resources to cover your needs. you don't know how long you are going to live. you have to plan for that. there are ups and downs in what happens to your assets, as we have seen painfully with our recent economy. what happened to resources in that period. there's the ability to deal and

assist your children in taking on their new lives and enabling them to do what parents did for -- grandpas did for the now parents. i'm a grandmother and look forward to supporting my grandchildren and encouraging them in the education and building independent lives. what your saying that is a one lump. when you use them, they're gone. so you have so many risks including i didn't even mention the health care risks. uncovered health care corse -- costs that seniors face. you use the assets.

that's what you've got to protect them -- it's just beyond the capacity of this little -- little or moderate or in some cases larger to take care of. that's why it's so important. that we need some kind of insurance. in order to give everybody security. let me build on that and frame a question a little bit differently and ask if i can, if you can explain why medicaid is not a very good substitute for a predesigned, well-functioning long-term care system. if you can smawrs summarize that for us.