commission's staff director under my former colleague of which i was the president of the claude pepper fan club -- [laughter] and she served for claude pepper. and by the way, i mean, there was an example. for those of you that were not here in washington in that era -- [laughter] claude pepper and ronald reagan would go to it. ..

overwhelmingly, and it made it with social security actuarially sound for the next half century. that was 1983. so, those folks knew how to get along. >> chairman nelson, ranking member collins and members of the committee, thank you for holding this hearing. and especially for the opportunity to testify about the future of the long-term policy. the perspective that i'm about to share comes from my work over the past 20 years of the office of management and budget as a person responsible for the medicaid budget. and also the last ten or 15 years consulting to a nursing home providers and assisted living providers and working

with a number of my colleagues here on the panel and ideas including the class act. i just want to start by saying as many of you have noted we spent 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 provide it on paid and they do this because most americans are not insured against the financial risk of long-term care and they want to avoid a nursing home bed. so the system is woefully under financed for the job it has to do now and especially that has to do in the future. all of the other problems that we talk about, the delivery system, the work force, the quality-of-care stem from this fact of underfinancing. i'm going to make three points to frame the discussion today that i hope will help you all in the work that you are doing in the future and that will make

the discussion interesting so i'm going to start with something controversial and hopefully the governor will not come across the table at me. the problem we have to solve in my opinion is not one that is a medicaid budget problem and i worked on the medicaid budget for many years and i don't see this as primarily a medicaid budget problem. it is an issue of course. the states have to fund the medicaid programs and there are people entitled in those programs in the governors in the state governments are going to face huge challenges that is true with the issue is managing these challenges even more of a financing gap is going to be created and is going to have to be filled as it currently stands by families in their own personal finances didn't. it's shrinking as a percentage of the budget and at the lowest percentage in decades. medicaid of long-term care spending has grown at an average

rate of less than 10% a year and it's true with older americans as i said in preparing for the demographics they are doing very smart logical things in the budget perspective but they are demonstrating they can and they will exercise the budgetary leverage that they have to produce the number of people there receive long-term services and the amount they spend per person not just in nursing homes. and in fact we see that reflected already in the growing interest among the states and moving people into managed care for their long-term services. in other words relative to the number of people that need long-term care in the future there will be a lot less medicaid spent around in those people. second, my second point is the inability to keep up with the demand points out to the problem that the underfinancing of long-term care creates and contributes to the enormous economic and security which is already a major problem in this

country and this is a big part of it and it is for the majority of american families coming and they think about what they might be facing in the future. when they're faced with this crisis what most americans do is they cobble together a variety of resources to provide what they kim. less than 2 million of the 12th and we talked about today who need long-term care are living in a nursing home and that is because they live in the community where they are the scarcest and where one-third of all american families report providing some kind of caregiving, one-third are now providing some level of caregiving. when they provide this care they do it at a rate of 20 hours per week and that timeous spent doing there really hard physically and emotionally challenging work and caregiving. and they do it while 75% are holding down another job. and we know from industry data that over a million people are paying privately right now for assisted living or some other type of senior housing and costs

$42,000 per year on average. this isn't just for rich people, they are being financed for the sale of homes through contributions from adult children and providers tell me the residence exhaust the resources while an assisted living and have to move into the nursing home to continue care under medicaid because it doesn't cover assisted living. very little was captured in the data. we don't have a good way of getting handle on these expenditures. after working directly with providers analyzing data my conclusion is it is more likely than medicaid is viewed as something to be avoided rather than as a mechanism to exploit wealth protection and as someone whose job it was to work in the efficiency of medicaid to find medicaid savings and i might add i'm telling you there isn't much here to suggest we have enormous opportunities to further tighten medicaid. in fact it is quite the opposite. my final point and this is probably the least popular when there will be made here today is that even when people are educated about the risk of

long-term care and even when they are presented the insurance policies, and they can manage to do that for many americans, we will not address other financing without requiring everyone to purchase a paid in the risk pool. i say this after being a proponent of expanding the coverage through voluntary approaches and analyzing the budgetary impact of these. i learned from that experience and now you that to adequately protect americans against the risk of long-term care needs and correct the ander financing problems we currently deal with some part of the solution for the future must be mandatory participation. we have a debate over private versus public options but it doesn't really mean anything because neither works very well and actually covering enough people with the participation is optional. it's an important debate. the debate between public and private for short but not one we should be having about facing the reality of what it will take to protect americans and in doing so we will address the medicaid budget issue in the

process. i look forward to your questions. thank you. >> thank you. dr. churn off. >> thank you mr. chairman, ranking member collins and members of the committee. we are pleased to be here today to present the recommendations of the long term care commission and i want to begin by saying i'm going to walk us through the highlights of the report. but this is work that mark and i did together and comes from the spirit of fundamental by partisanship that we think is the way forward so i'm going to make opening comments on behalf of and mark will make specific comments to follow. the commission had a very compressed time line set out with a six month schedule and after going through the process we have roughly 100 days, between 90 to 100 days. in that work we have before public hearings with 34 witnesses. over hundreds of public testimony and nine working sessions. september 12 that is required, the commission voted by the bipartisan majority to issue the

final report as the broad agreement of the commission. i want to provide you an overview of the commission work process and the development of the final recommendations. i want to begin by saying that the commissioners worry talented, knowledgeable and really diverse group of people and expectations as commissioners were to identify as much common ground as possible and establish that as a foundation for moving forward on a long-term service support issues but the discussion and areas of agreement and disagreement with the evidence based and we would be open and willing to challenge accepted thinking where we couldn't find substantial evidence. we are pleased with the collegiality and the amount of common ground that is reached. this makes the point that address in long-term services and support issues is not an intractable problem it's something we can work on in a bipartisan way. each commissioner was asked to submit proposals, all proposals for discussion are included in the appendix of the report. the commissioners elected the

ideas they felt merited the most attention and the subset was discussed and developed as potential recommendations. proposals that could not achieve broad agreement were not included as final recommendations. let me state clearly that developing a thoughtful, comprehensive report in 100 days is an important success in and of itself and a direct result of the commission. let me provide you an overview. the report has a clear call to action we think is important for the general public to understand this need and that broad agreement for the problem that we are trying to solve together. the shared vision serves as a framework that supports 28 specific recommendations. let me touch on a few key points is starts with the notion that we must have a fiscally sustainable and effective long-term service support delivery system built on the concept of personal and family centered care. it provides individuals with support and services and the

least restrictive environment appropriate for their needs. it's delivered by a well-trained and adequately support an array of care givers and paid workers. finally, the comprehensive financing requires an approach with really three prongs. the balance of public-private financing to ensure the catastrophic expenses, encouraging savings and insurance for the more immediate long-term service costs and finally, providing a strong safety net for those without resources. the 28 recommendations i could take you through and we don't have the time for that so what i would like to do is kind of box them up and highlight them in a way that is useful today. the three key areas of our service delivery work force and financing with respect to service delivery. i think it hinges on the recommendation that we start gotten with a better balanced. finding that is important since most folks want to be and should be in the community. other recommendations include a

single point of contact a uniform standardized assessment that is used by all providers and engages the family in the individual themselves. accelerating the development of the new generation of quality measures that includes, and community-based services and the experience of the individuals receiving care and payment reforms that focus on outcomes rather than settings. with respect to work force, central to this set of recommendations was a variety of recommendations focused on improving training and support for family caregivers including identifying the family caregiver and assessing the family caregiver as a part of the client care planning team. others included taking on the scope of the practice and delegation integrating the workers more effectively in the team and encouraging the states to improve standards for the home care workers. finally on financing given the 100 days the commission didn't have a single recommendation on financing the debt outlined a

vision as i already noted and then identified two different approaches that could be the basis for the broad discussion. one focused more on public social insurance solutions and the other more on the private market solutions. i will say when you look at both of those approaches, there are some interesting commonalities that sort of bring them together and are right for the further work. the public policy details because funding mechanisms for both to be specified and many commissioners felt it would require considerable data, designed work and careful analysis of costs and consequences before the fiscally responsible proposal could be put forward. finally there were five specific recommendations with medicare and medicaid. next steps that bring us here today, the commission felt very strongly that it's critical to have a follow-on body for the commission to pass the baton for critical economic work that is still needed and not complete.

we also call for a 2015 white house conference on aging in partnership with the council on disability to focus on long-term service and support issues. with that i really want to thank the commissioners for all of their hard work and the staff who gave their summer to give us a product that is done on time. i want to thank mark one more time because his leadership and an engagement is important. we worked as a team and that is going to be critical to get the job done. finally i want to thank you for the opportunity to testify today. >> thank you. but dr. warshowsky. >> i would like to add my own views in more detail. the commission did reach a consensus at the high level on the need for personal savings and insurance coverage have significant government support for the lower income population but we did not agree on the

structures or the proportions. some of the diversions of arose from the last 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 i am referring to the debate on whether medicaid is now an lt c insurance program for the middle income or higher-income households whether there is significant capacity of the working age adults with sevier functional limitations to participate in the labour force and how to improve the private insurance market. focussing on the older population some have expressed the view that medicaid is now program for the poor. but i see that there is a significant extent of coverage for those that are in the middle-income and of groups in the working years and retirement. evidence in the commission as well as the understanding on the medicaid eligibility rules indicated that in many states, significant housing, retirement, life insurance and assets are

set aside in considering the medicaid eligibility and many people who are in the middle-income group and above do in fact get medicaid benefits. still there is much to learn about how significant is the spend down. what is the extent of the gamesmanship in the medicaid eligibility and but additional efforts bring in through the state's recovery and how much do they care about having extended care coverage care options beyond what medicate currently provides? some of us believe that one way to find out on all of these questions, to set up an option for the medicaid card out whereby upon retirement the individuals would have the choice of receiving a lump-sum payment for the government for a significant portion of the expected value of the medicaid budget this would be most for the poor and nothing for the best off. they would review the private permanent long-term care insurance under that benefit design and the pleas of medicaid coverage. turning to the working age

population with functional limitations what we heard discussed indicated conflicting views about the extent of the capacity return to continue to work the significant support for us to be provided without the intended medicaid requirement for inhofe first met. to my understanding that past experience is not encouraging of of that capacity. but i did we also reported the commission's recommendation created in the administration project to assist the states to achieve greater uniformity in state medicaid by and programs. hopefully we can learn much from these products and changes. but even assuming that the results are positive, it is likely that the indicated changes will be costly. in light of the severe fiscal condition and the nation we must be willing to prioritize the needs such as by tightening the currently lose eligibility standards for the workers about age 50 to qualify for disability insurance and medicare. finally, there was a disagreement about the possibility to improve the functioning of the private long-term care insurance market.

we all agree that currently it is a mess. but there was less consensus on why which of course leads to the prescriptions put forward. in my view, the problem is mainly one of inadequate command for arising from the crowd out affect of the medicaid program and also lacks a public understanding. at the same time there are problems on the supply side partly stemming from the restricted state rules on insurance policies become policy designed and tax fraud so some of us propose the following first provide a reference for the long-term care insurance policies for retirement accounts and we feel that in terms of the savings that would arise from medicaid and would cover the cost in terms of lower tax revenues. second, we want to support compensation policies such as the life care annuity. such products would marry the life annuities to the long-term care insurance allowing individuals to finance their

care as well as retirement and combining the insurance and life and annuities to increase the cost and the underwriting standards enabling more seniors to afford coverage. i would also like to note also five of the six republican commissioners voted in favor of the report of the commission, we all stated that the commission's recommendations should not increase existing budgetary commitments to the health care faced by both state and federal government. we believe raising taxes to fund additional commitments is and why is especially given the recent tax increases. in closing i want to echo bruce by stating my appreciation for the effort of my fellow commissioners. they did the impossible and produce an important product on the very tight schedule. i also want to thank him for his incredible leadership he was a great partner that work to install trust and create an environment conducive to the collaboration and dialogue.

>> thank you, dr. feder. >> i will begin again. thank you mr. chairman and members of the committee for the opportunity to testify before you today on a path forward for long-term care services and support. i appreciate it at the outset when you're mentioning of my services as the staff director of the administration that began about 25 years ago. so as you can see i have been at this all long time and hopefully i will make progress before i need long-term care. so we definitely need to get on with it. but the experience most recently as a member of the commission on long-term care as i'm testifying today as well as my experience and i can tell you there is a lot of work to be done. also policy makers are grappling with the challenges of assuring americans affordable access to

quality health care, we have yet to tackle the equally important issue of the long-term services and support. despite the continued political battle even critics of the affordable care act recognize the need for insurance to ensure access to health care and protection against financial catastrophe that there is much less acceptance of the need for insurance when it comes to another health-related risk one for which virtually all americans are uninsured. the risk of needing extensive help with basic tasks of daily living like dressing, bathing or eating generally referred to as long term services and support or long-term care. on the financing that is critical to the building and effective long-term care system the recently concluded commission stopped short of recommendations. but five of us commissioners felt compelled to step up and did not support the commission report and offered an alternative report explaining as

charged body and how congress should accomplish this goal and i request that you include that alternative report that i've submitted with my testimony in the record. as you said about 12 million people have the need for long-term care today and i would remind us why all this is a special committee on aging that 5 million of these individuals are under the age of 65. as you said the vast majority of these individuals, families for help that families can only do so much and when people need care whether at home or in an assisted living facilities or nursing home its costs exceed many families ability to pay. that is where insurance ought to can but private health insurance does not cover long-term services support and few americans have private long-term care insurance which typically costs a lot of offers limited value and is subject to premium increases that can cost because the purchasers to lose coverage they paid for for years.

on the public side, medicare, which older people and some younger people with disabilities rely on for health insurance does not cover long-term care. the federal state medicaid program does serve and has a valuable last resort for people who need long-term services and support, but its protections especially home care and vary considerably from state to state and become available only when people are for have become impoverished taking care of themselves and i would have to take issue with marks comments because the evidence was presented to us is that medicaid is not a program for the rich. the benefits are overwhelmingly going to the low and modest income people. the need for expensive long-term services and support is precisely the kind of catastrophic unpredictable risks for which we typically rely on insurance to spread cost.

these costs are obviously unpredictable for people under the age of 65 and i think we all get that. only 2% of that population needs services. almost half of the long-term care population because it is a small percentage of a very large number of people. but the likelihood of needing long-term care and expensive long-term care is also unpredictable for people when they turned age 65. an estimated three out of ten people aged 65 today are likely to die without meeting any of these services while two out of ten would need more than five a year, five or more and when we think about the risks and the financial terms, half of the people turning age 65 today will spend nothing on long-term care depending on their families when they need it wiley very small percentage will spend hundreds of thousands of dollars. if else you have indicated and as it is often claimed, we

really want people to be financially prepared to manage this unpredictable catastrophic rest, we need to establish a reliable insurance mechanism whether public or private or some combination to which they can contribute. it's easy for experts to agree that we need a public-private partnership, but the challenge is what role is each sector going to play. to effectively spread risk and reach the broadest possible population, public, social insurance that really spreads the risk and everybody heard is that it's in must be at the core of the future policy. private insurance can play complementary role but even its proponents recognize that building the future policy around a private market will at its best to reach eight out of ten americans uninsured. public insurance can be designed in different ways. it can offer relatively country inns of and defined benefits

like or even through medicare or it can offer basic or cash benefits in the new program and it can be funded in different ways in part through taxes like a surcharge on income tax and in part through savings in what medicaid would otherwise have to spend. although i would emphasize what was said at the outset although there can be some savings to medicaid, medicaid is woefully underfunded and we need new financing to support it in the future. regardless of its specifics, social or public insurance programs will protect all of us at risk and required all of us to contribute to the above in closing i want to emphasize that public insurance will not eliminate personal or family responsibilities. rather, it will make shouldering that responsibility manageable and affordable through a private insurance, private resources and family care and no social

insurance mechanism is likely to eliminate the need for an adequate public safety net whether within it or through a continued albeit smaller medicaid program. the enactment and implementation demonstrates that it will not be easy to enact long-term care insurance or public long-term care insurance programs. but we should not kid ourselves. without it, our policies will continue to fail people yawn and old, 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 am going to withhold my questions and i will do a clean up so that we can get to our members. senator collins. >> thank you very much

mr. chairman. about a decade ago, i authored legislation that became the law to allow the federal government to provide a long-term care insurance program for federal and please. was not a subsidized program, but our leased federal employees would be offered had benefit and the advantage of a group program that they could buy in to. there's been some issues in the program, but one of them is that 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 would think that one at a young age can buy affordable long-term care insurance, and that's the protected. i'm curious, doctor, i will start with you on this issue because you talked about one of

the reasons that the long-term care and private insurance market is a mess is an adequate demand. and i'm wondering if the most large employers offered this as a benefit like the fortune 500 companies. >> my understanding is that about half of the large employers offered it as an optional benefit. very few will contribute to it. so it is an employee paid off benefit. but i think the experience is similar to what you indicated in the federal government that many do not use it. i think even very large and will pay organizations about 546% of the workers purchase long-term care insurance and i think there are a couple of reasons for that. as i indicated in the testimony and as we heard by an eminent

economist medicaid does represent a type of social insurance and it is a crowd out of private insurance. that is a significant factor. most of their benefits, retirement benefits or health benefits that are given by employers are tax advantage. this provides an enormous incentive to get the benefit. clearly the long-term care insurance is not tax advantage. and i would say it is a difficult subject to be frank. although it has its downside and its upside, retirement is usually something people look forward to. long-term care unfortunately is a difficult subject. in my opinion, i think it's a subject which is best handled more at retirement which is why i proposed and the set of commissioners supported this in creating the combination policies which would be at the point of retirement such as the life care.

>> i'm very intrigued by that idea and certainly if we make a long-term care insurance tax referred to the way that health insurance is, it seems to me that you would see a larger uptake by employers and employees. on the other hand, we are all aware that is the largest tax expenditure if you will that we have with employer provided health insurance. so there is a cost of doing about as well one. i continue to believe though that another issue is that people are under the misimpression that somehow the medicare program is going to cover them or their normal health insurance for their supplemental insurance program is going to cover them and as people are living longer and if you look at the statistics on

alzheimer's disease, which are truly frightening, it's the need for long-term care that is only going to grow. so i think we need to do a better job at making private long-term care insurance available and attractive to people. let me just ask one more question. my time is rapidly running out. it has to do with home care most people i know what much prefer to receive home care rather than going to a nursing home, and yet we have a very outmoded definition for qualifying for home health care that has a homebound requirement. and that homebound requirement ignores the fact that we have

made technologically advantages that allow people who have disabilities to leave their homes at times. and i'm wondering what you think of changing the definition or qualification for the home health benefits so that it's based on the patient's functional limitations and clinical conditions rather than on some arbitrary limitation on absences from home. i introduced a bill several years ago to change that. we were unable to get much traction for it, but it is my ander standing that the commission did address this issue and if you could tell us what the commission decided. >> certainly. thank you for that question, senator collins. let me start just as a physician for a second in a general

internist. in my years in practice, it is all about function. we need to start there because function in combination with serious clinical illness is what drives the cost and actually what puts pressure on families and systems. bye starting their you get the right answer which is a slightly different answer than the one we have today and you are correct the commission as a whole delivery did. the holmdel requirement is one of those areas we thought needed to be revisited. let me say on behalf of the commission i think people understand the risks that you don't want to create something that just radically grows a program and increases cost so this is something that would need to be done thoughtfully and it's about finding the new definition that helps the right people get the right services in the right place. but the commission as a whole or the republican appointees and democratic appointees came

together to see this as a place where there is a need for the new definition, one that is more efficient and effective and more persons entered. >> thank you. senator scott. >> thank you mr. chairman. interesting panel as it relates to the topic. you are well-educated on the topic and very passionate eye can see in your eyes and hear a little frustration in the number of years he worked on this project without any actual progress and i certainly appreciate that and you go from the mandatory let's all get in the boat together with the free-market solutions and certainly i'm going to follow more on the free-market side but i realize even in the best case scenario we can take it from the two out of ten or three and we can make an improvement drastically on the results and having a couple of these policies i will tell you of the challenges we face it seems to me that when you go into a large

group whether it is the united states government or some of the larger group tied out with, and forming the individual who works for the company at the available benefit is there it's a totally different conversation than getting them to sign up for that benefit so the challenge is when you have these employers and once you have enough agents or folks to help solve the market and motivate to take a second look at what the actual benefit package includes it's very difficult to get people to sign up for something they are not informed about as a part of the process and that is one of the challenges that i would love. i don't want to butcher your name the second time i say it. let's talk about these steps. the misinformation really takes away the motivation. as of the misinformation is that somehow some way your health insurance policy is going to cover this one day and if one does and then you are eligible for medicare and the will cover

it and you don't understand the exhaust of the resources where medicaid becomes a part of it so there is a misinformation in my opinion that has to be addressed. there's a marketing robert kennedy as well and then when you look at the combination policies he merging with long-term care and looking for an opportunity to add the balance in the annuity in the actuarial basis to the reduced rate for the long-term care insurance. so as to make it more accessible to those in the public and then adding a tax cut to that in the attempt to actually increase more affordability and access. is it similar to the runoff is that some other intact to what the life insurance companies have started to doing with the ability to get the life insurance benefit before you expo europe if you know what i'm talking about? >> i'm familiar with those. >> you have adapted to the

cemetery well the. [laughter] >> and getting very close to that place now. >> i will try to address many of those and also there is a great confusion about what the government covers and with insurance covers and what it doesn't. it's really quite pervasive and a lack of understanding and i think a part of that is the good structure. the viewpoint on other issues in terms of the public-private emphasis it was a good structure and i think a part of the responsibility of the government is to create that structure.

our viewpoints in terms of emphasizing and private sector. encouraging the life care annuity the motivation -- >> the life insurance product you've indicated basically in briefed the advantage is you create pulling the populations that currently are excluded from purchasing the long-term care insurance because they are in poor health for they won't be likely to become disabled and therefore they cannot purchase the long-term care insurance, on the combined policy. if you combine the two you attract both populations and it is fair to both populations getting a benefit that they

wouldn't otherwise and i could be offered at a reduced cost. which is a great advantage in terms of creating. as to that a life annuity hybrid is pretty much for the moderate and high-income perhaps for those that are struggling to meet. >> it's for people that have some retirement. >> one final question. on of the mandatory -- i've now written it on too many pieces of paper. >> on the idea that we need some type of a mandatory enrollment

into an insurance in order to actually create economic security for most americans. >> from my perspective and i wish we had more time, my time is about up. do you get five minutes or seven minutes on this committee. >> given the nature of the pre-christmas meeting, please continue. >> none of the other committees will do that. that's why i have that incredibly long compound it runoff unfortunately. help me understand because my perspective on entitlement today is that we cannot afford the ones we have. forget the multiple trillion dollars of debt that is nothing compared to the challenge that we have with our pension plans that are to meet underfunded and exposed to. so we are talking about a couple hundred trillion dollars of

unfunded liabilities we added a new component and i just don't know how -- >> that's a great question. because of my professional background the last thing i mentioned myself and as a budget analyst is suggesting we needed a new government program. after working at those for many years and truly the idea - a pretty good family. there's got to be a way that we can work with the private the changes on the demand and the supply side that what in fact. it's my view people are unprepared. how can they prepare? it's not their fault they are not prepared. i don't have long-term care insurance. i know a lot about it. although my parents -- >> [inaudible] [laughter]

i should point out that my parents are signed up under the federal long-term care insurance of the federal employees i appreciate this especially. we can work with an insurance program so that it is financed in a way that is self funding. we are modeling the class act just a year ago so we are dealing with a situation where we are trying to analyze the premium levels would be under a voluntary approach and the problem that we ran into over and over again is that we saw the premiums low enough. and you end up with an actuarial so 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 without going in that direction, and i think that we know enough now to set it up in a way that the premiums would cover or the tax base or however it is you choose to finance and there are so many different ways that could in fact pay for the benefits that we would expect to pay out that it is a risk. i completely understand and agree with that. >> mauney the year in the headlights look isn't authentic. it's real. my office will called your office. >> senator. >> thank you. i want to again welcome our witnesses today and also offer my gratitude to the chairman and ranking member for bringing us together today. not only do you recognize that

the current system of long-term care financing etc. is unsustainable, but you have a result to continue to convene the committee to focus in on this and i appreciate that very much. i am hoping to sneak into questions for the whole panel if i don't have too long of a run in the. the first i would like to have islamic role and the value and looking at this at the national level. obviously we have to tackle long-term financing at the national level but i know lots of things are going on in the states. in wisconsin we have a program called family care that currently operates in 57 of the seven counties with plans to expand to all.

it improves the cost of the long-term care services by creating a single flexible benefit and includes a large number and range of the services that otherwise would be available and in separate programs. so just as one example of what the state is doing i wonder what we can learn from the innovation that is going on in the state's and how to address the long-term care crisis. i didn't know if he would all want to take a stab at that. >> i will start on behalf of the commission as a whole. when it comes to delivery systems work force the answer is absolutely while there are some things that can be done, the care is delivered locally based on the kind of providers and the surface is that you have in a community and city and state and it is based on the kind of need

and desire of the specific communities and there is a wide variation among the states. so in conjunction with the commonwealth fund produced a report card the public policy institute looked at with the performance of the various states across the country and wisconsin was one of the top performers and it is the robust creativity and persons entered mass of the programs that drives wisconsin's results. are there opportunities to leverage the innovation when it comes to how we deliver services and support families and address the operational work force questions? absolutely. the single biggest challenges the ability to delegate functions from doctors and nurses to other members of the caregiving team. it's all professionally driven in the state law so there are

many opportunities and wisconsin is a leader. the financing question is one that sort of comes back to the federal level and is the notion of the finding of the right framework which is part of the discussion here today the role of the federal government providing leadership would be important but the state, states where the care is delivered and i think there is a lot we can learn from it and a lot of success. >> i would pick up on what bruce said about the financing and in many respects we have seen a lot of innovation living many states towards the greater reliance on the community-based care that is encouraged in the affordable care act but needs more encouragement in terms of incentives in the states to support that. but as noted at the outset, states are already facing

enormous pressures on the program and are not -- you cannot innovate your way out of the budget tightness. even as we have seen improvements on the innovation and some of the states, we see tremendous variation that means there is, and community-based care in some populations in some places and very little particularly to the elderly and others, so the states and as bruce said the care is delivered double local level medical care is delivered double local level we can have the delivery between the person and the character but the financing is critical to make the services available. what we see at the state level and again i emphasize this at the outset is that the states in order to control their obligations create waiting lists. it's not about state innovation and delivery. they farm it out to the managed-care plans that may or

may not have any capacity and often do not have the capacity or the experience to deliver care. so it becomes a shift in the risk and a decline in the insurance protection rather than any kind of protection. finally as we go forward -- and we did some analysis afforded by the foundation to look at the future demand and the importance of the federal financing as it was said for long-term care that if you look at the aging population, in every state the number of the elderly grow substantially, but we continue to see enormous variations across the states. they have fewer younger people to support more older people and again, tremendous variation. and i can say i endorse what was said that if we continue the

financing that we've got, we already have tremendous variation and tremendous inadequacy if we do not create the federal financing support. skype i agree with everything that bruce and judy said. >> the commission did hear testimony on some of the programs. rhode island came in and they have a medicaid waiver and many of us were impressed by that. the program is intended to improve care and to save on costs. minnesota also came in and gave an excellent presentation and that is on the web site. >> it's also true that rhode island when they talked about the waiver they actually had them give more money than less money whereas what we are seeing on the federal policy to change medicaid we are seeing a proposal to take a whole lot of

money out well. >> mr. chairman of rhode island, we basically got paid to have a waiver because the administration of the time. they wanted to get rhode island am, but i don't think that is going to be the common outcome. >> you are all very progressive in rhode island in so many ways. >> senator ayotte. >> thank you mr. chairman and mr. ranking member. i also want to thank you from portsmouth hampshire that works in this area and i appreciate him being here today on this important issue. i wanted to follow-up on this issue of waivers because i think

it is related certainly to the important issue senator collins raised which is how we make sure the definition fits to allow more community and home-based treatment so that we are allowing people to stay in their homes longer because the average cost for care in a nursing home is approximately $80,000 a year so i could see this being certainly important in terms of cost but also in terms of people having a better quality-of-life. so, with regards to the the waivers is it based on what the commission found or should we give the states greater flexibility particularly in this area for the innovative programs that are going to allow more flexibility on the care because i think that also fits in with this obviously the need to define by the overall federal definition that we would come up with, but i see this as an area

states will come up with better ideas than we came up with in washington. >> maybe i will start on behalf of the commission and fellow participants can we in on that as well. this is a place the commission gave a lot of thought and as we listen to the states it was an area of interest for us. i think that he, message is there's a recommendation that talks about simplifying the process and there are so many different kinds they often work in conflict with one another. sometimes they are that far apart if you are the person caring for a family member in that little space between the two you are in trouble. you are not sick enough for this and you're too well for that. i think the notion of a simpler approach to waivers as one that was endorsed by the commission and the other concern raised in that obviously is the issue of individual protections, beneficiary that they deliver on

the services that need to be provided. so in that balancing test is how do you create the kind of flexibility so you get programs like some of the ones we heard from but also make sure that in the process of providing more flexibility we are not losing the services for those who need them and that there is adequate oversight. >> to follow on that, my experience thinking about the ways and which the federal government can do a better job in the flexibility has been that over the years of the last five to six years we have seen a lot of loosening of those restrictions to the point that states in fact have a tremendous amount of leeway and the degree to which people do not have access have a lot more to do with a budgetary issues and of the need to keep the program is limited to the number of people

and spending per person and has to do with flexible the tiahrt of the federal requirement about the states can do. >> senator, with regards to the cost and if the waivers process moving people from nursing homes to home care would save money or cost money and we heard evidence on both sides both from witnesses that came in and ones that we would set the cost, but actually some of the commission members themselves who were providers of long-term care service support were skeptical on that today it and they said that the system pretty much puts people on the right space is already. we didn't hear any consensus in terms of whether that would be a cost saver or spender. >> i think that we have a lot of experience in the home and

community-based care in the years we have been trying to expand and there is general agreement that we get better value for the dollar when we are able to serve people at home and not in institutions when they do not need them. but we have so many people in need that we frankly need to build the systems and we are under serving today so that when we offer more services at home we serve more people which is a good thing but it costs, and with respect to fees issue of flexibility and savings, i think that i have heard representatives of the governors and the medicaid director say that flexibility is not enough. they've got flexibility. what they do not have are the dollars and for many, many years, until recently and i think that that is a function of the politics, the governors in both parties have joined together to call on the federal government to take over the long-term care responsible the

for the dual eligibles and medicaid beneficiaries were also medicare beneficiaries, recognizing that they are lacking resources to do the job. it doesn't mean they cannot be involved in the delivery and there can't be innovative delivery on the ground but they are looking to the defense for dollars. >> since i got one question and and i appreciate all of your answers i'm going to submit questions for the record. and some of the follow-up on some of the things. i appreciate all of you being here. thank you. >> senator warren. >> thank you mr. chairman and ranking member for holding this issue. it just seems like to me this is another example of how the middle class families are getting squeezed. it's hard enough for any family to put aside anything for savings today, given the squeeze on families. and now, we expect families to save for retirement and for long-term care at the same time that many are absorbing the

costs of caring for an elderly family member. so, you know, we have just doubled up here. there is a growing conversation about the crisis in america. and in the face of this, the lack of the basic safety net of long-term care is just more fuel to the fire on the kind of problems that we are going to face. and as you have made it clear, retiring baby boomers are ill-equipped to cover the full cost of their long-term care needs. we have got fewer people that make that lower savings in their retirement than their parents did and the 18% of retired benefits plans. one-third of all the seniors have less as they approach the senior years and have less than a year's worth and one-third have no savings at all so that leads us to medicaid as the sort of backed up program here which can cover some of the cost.

but the current forces the seniors to spend most of their assets in order to qualify. every bit helps but to qualify when they have to sell off all of their assets this has other economic implications. so where i want to start is to ask you, doctor can you tell us about financial instability that selling off assets causes our seniors? >> thank you, senator. i think that when people talk about seniors relying on savings i think that they are insensitive to the variety of the risks that come with getting older. there is the risk of the concern about having adequate resources to cover your needs if you don't know how long you are going to live, but you have to plan for

that. there are ups and downs and what happens to your assets as we have seen painfully in the recent economy what happens in the resources in that area. .. and building their independent life and there is and certainly all the way around. when people talk about relying on your assets in order to take care of those needs, what you're saying is that, that's one lump.

when you use them they are gone. you have so many risks come including i didn't even mention the health care risk and the uncovered health care costs that seniors face. you're using your assets. that's what you've got to protect you against a whole array of risks. and catastrophic risk like jesus need for intensive long-term care is just beyond the capacity of this little -- this nest egg, little or moderate, or in some cases larger, to take care. that's why it's so important that we need some kind of insurance mechanism to which people can contribute in order to give everybody security. >> let me just build on that and frame the question a little differently and asked if i can, ms. tumlinson, if you could explain why medicaid is not a very good substitute for a predesigned, well functioning long-term care system. if you can just the kind of

summarize that for us. >> sure. i'll be thoughtful in this response. so i think the primary -- when you think about what medicaid was really designed to do, it wasn't designed -- it's not designed to protect individuals against risk. it's really designed to be there when everything else has failed, which is really the opposite of insurance. does that -- >> go ahead. a very good point and i think it's critical to understand, a lot of people think, we've got medicaid so i'll be okay. if there's a problem out there. and maybe another way to say it, is to ask, is this a sustainable path that is counting on medicaid to be the safety net, and at best only modest savings that people are putting aside

during their working years. >> when i think but also from the perspective of what i see people doing in the marketplace right now, which is essentially using their savings to purchase something that will keep them from being on the medicaid program eventually. in other words, it's not, in theory what you'd want an insurance product to do is to enable you to purchase the services that you need in a setting that is most appropriate for your needs. whereas a safety net program is really again kind of design something to absorb sort of in the most, you know, custodial and warehousing situation, bare bones funded. it's really again kind of the opposite of what you expect an entrance product, a good insurance product to do. when my own parents, when i encouraged them to buy insurance it was really, my dad said my federal pension will cover the cost of a nursing home. and i said, well, wouldn't you

like to stay at home? let's talk about, let's insure against being in a nursing home. >> mr. triplett, can i ask dr. chernof also to respond? dr. chernof. >> thank you. yes, i think we have public policy -- i said this before i will save incredible view. public policy that is perfectly built for 1972. the reality is, medicaid is the program and its inception was predominant focus on women of childbearing age and their children. that was its kind of constitutional core way back when. the average life expectancy in 1965 was 69. as a physician if i was in practice then you would have just seen the first icus and ccus. the likelihood of surviving girlie man morbid or morbid event like a six stroke or heart

attack, a very different time and place. people are living much longer and will live with it -- with more serious chronic illness and limitations. the reality is our public policy has not kept up with it. the reality is -- i agree anne's description of the role of medicaid. i would just offer to all of you that the hypothesis if we do nothing is incredibly expensive and that medicaid will bear the burden of that. and it will -- we will all bear the burden. families will bear the burden. states bear the burden. federal government bears the burden in kind of an unstructured way. so i think, think about the work of the commission, while we did make a specific financial recommendation and were having a broad discussion about the ranges of ways one might consider solving it, every single commission thinks there needs to be solved. and i think a notion of a different model and one that addresses, confronts the long-term care of this need faces as a way of taking

pressure off some of the public program your and what would it really take, what would it really take to design a program that fundamentally actually shores up certain medicaid but also medicare to a degree. i would just as a doctor, then i will stop by promise, the nightlife in the system is the emergency room. so i get the point that medicare doesn't pay for long-term care, but at the end of day when something happens in somebody's them and you throw up your hands, it's a trip to the emergency room. i will tell you that emergency room doctor takes one look at the person and says upstairs we go. the process begins. so i think what we're having together, us and all of you, is this sort of fun in a discussion about the need to think about a different structure to take on this issue. in the process of shoring up our public programs. >> thank you to the questions addressed earlier to ms. tumlinson about how we're going to pay for this your you give us all the reminded hi comf we don't design a program, we will stay -- still pay for. will just pay for it in some

really terrible way. so thank you. thank you, mr. chairman. >> thank you, ma'am. senator whitehouse. >> well, i hesitate to jump in because as far as closing words go, what senator warren just said, if we don't do something we're still going to pay for it, which is going to pay for in really terrible ways, it's kind of a good closing salvo for the whole thing. but i go after you so i get to go ahead and felt up what was a great closing. -- foul up. i did want to follow up with ms. tumlinson about what we are seeing in rhode island is people who have made the responsible choice, invested their money into a long-term care insurance policy, are now finding that the premium is going up pretty dramatically.

to the point where, for some people, it is really no longer doable. and that's particularly frustrating because you paid in all this time. you kind of have a connection to the policy, if you bail on and makes everything you paid on already look like money down the drain which, in fact, it is. so it strikes me that in terms of relying on the private sector to handle this problem, they are actually going the wrong way in terms of where the prices are headed and where the likely market share of affordable long-term care coverage is headed. is that you're feeling nationally or is that just -- >> all, no, that is definitely national. again, not to beat this drum too much but when my parents premiums went up quite a bit, and that was in a really good program, you know, about the best run i think employer-based long-term care insurance program that exists. i think it points to, you know,

not necessary that the private sector is not up to the task, but that we don't have enough -- we don't have enough people in the risk pool for it to be a stable financial bet for an insurance company, particularly when you're paying benefits on a set of products that are coming to 30 years after you've sold them. when we model this for a class act, incredible challenging thing to do. really, to the insurance companies, you know -- >> out at the actuarial frontier. >> yes, exactly. i wish i had thought of that. yes, exactly. that's where we are standing and it's not very countable. >> given the problems that they have, let me turn to dr. feder. we've known another -- we know each other for a while, judy, welcome, and thank you for being here. you talk in your testimony about private public models. what would a couple of what you think it most likely and sensible models look-alike, very

generally, in terms of bringing private contribution and public participation into this? >> well as i said, senator, and it's a pleasure to see you, that the public, a public benefit has to be at the core. and what i have begun to consider and would like to see us spend more time on and think there is some interest in is thinking of a limited public benefit that would be available to people after a waiting period. that would be determined, and i'm thinking now of the retiree population, we would adopted for the younger disabled population. but the waiting period would depend upon, what your earnings, your lifetime earnings looked at -- look like advertisements for that would give a clear indication for families of what they were expected, what the whole they were expected to pay

before a public benefit would kick in. it would get insurance companies come and i was interested to see recently the genworth has been talking -- >> you would know in advance what the waiting period -- >> that's right, correct. >> you have to buy the first months or years and you would know that going in. in. >> right, and people who have not earned much would have a shorter waiting period. and people who had earned a lot would have a longer waiting period. so it would be adjusted to income. and i think genworth is looking us up at like this because of the tensions companies, the insurance industry has the biggest problem when you're out on the actuarial frontier with the tail, the biggest expenditures. so essentially you're giving them some protection at the backend. so i think that that is something to explore. i think it's very important as we explore options, there's another option which is that you

give a limited benefit up front. that everybody gets it. but at least detail for the insurance industry to cover, and that may be less comfortable for them. but i think we need to look at these options and see what is it that the public sector can do and guarantee that create some space or private sector innovation. that's where i'd like to see us explore. >> the last thing i ask, and it's a question for the record, is this, if any of the witnesses have information on what you believe the government's present exposure to long-term care or liability is right now, as we speak. your hypothesis model, dr. chernof, if you have any way to quantify what the cost is of that, that will help our discussion in terms of being able to try to work with cbo and other people to try to figure out if a going to pay for this anyway, there's a smarter way to

do, i'd like to have that conversation bearing in mind what the experts say we're going to pay for this anyway. >> senator whitehouse, i seem to recall that cms at one point get a present value calculation, sort of a many trustees report for that number. i don't know if they continue to do it. >> i don't know either that's what made a question for the record. anybody who is info can get back i appreciated. ideal back and thank him and her wonderful ranking member for all their leadership on these issues. >> well, it's not clear to me where we go. we've had two different opinions expressed. dr. feder argues that a public benefit is the answer. dr. warshawsky, why don't you give us an opinion by setting aside the financial and political difficulties?

why wouldn't a public benefit help? >> well, those are very large set of sides, senator. >> i understand. particularly in these times. >> i think people need to be given choices. i think they need to design things as best fit their situation, and to be given the support they need in a prudent way. so certainly there is a role for government, but i think they need to be provided as much in the way of choices and opportunities as they can. and that provides the right incentives, because we certainly do want people who can't afford, and i think many can, to finance these costs, and to ensure these costs, that they do so. and that it's not a burden, not

an unfair burden on others for that to happen. and for the more i think that it is -- furthermore, i think it's a strong possibility, strong likelihood that the private sector with the right structure would design different options and different policy designs that would appeal to you, you know, different situations and different needs, which i think is really impossible for a public program to do. public programs, in order for it all to be efficient and to be able to be administered, and we are seeing this right now in the aca, have to be very simple and have to be very straightforward. that's why social security works. if you have, if, in fact, you give people choices through a public program, it's just administratively extremely difficult. >> and herein lies the dilemma. because it is another public

program that we would be creating. but i can tell you from my experience as, before i came to the senate, i was elected insurance commissioner of florida. and the behavior of humans with regard to buying insurance, unless they think they actually need it, they're not going to buy it. and this is almost out of sight, out of mind. if you want to spread that base by getting the young as well as the old intuit, it's going to be very, very hard to get people to buy this interest. what do you think, dr. feder? >> i agree with you, senator nelson. and we have a lot of experience with that, and i'm always interested when we talk about private insurance and long-term care, that we look at -- we're

at the same time looking at our experience with a non-group, the individual insurance market, for health care. and we know that that is a market that is riddled with problems, because, in part, of a desire ensures it to avoid people with preexisting conditions and to limit their risk. and that's what you see unless you have everybody participating. and the idea that i was discussing with senator whitehouse that i put before the commission, and hope we will all consider in the future, is that i think that there is, based on a view, that we can better educate and help people prepare and helping industry respond. if we do, as has been said, set up a structure that creates some clarity about how you can

prepare. so if a public program takes on that tail risk in some ways and tells people based on the resources what they have to prepare for, you can better educate around the dissipation and preparation. but that back in federal program is won, as anne has emphasized, that everybody is participating in, whether through taxes or premiums or whatever we're calling it. it needs to be a shared risk in order to work. >> dr. chernof, i can't help but smile, thinking about how you could get people to buy this insurance well ahead of time. you could have an individual mandate. and if that sounds familiar, we've just had quite a debate about that, and it was declared constitutional by the supreme court.

but it is not easy. let me ask you on a completely different kind of subject. we really had some problems in florida with assisted living facilities basically taking advantage of seniors. nursing homes. you have any suggestions? i mean, we've got people that are starting these things up that are unlicensed. obviously, they are breaking the law, but are we talking about the care and nurturing of our seniors. did your commission suggest anything that we ought to be doing? >> so, you raise a really important question, senator nelson. and actually as a commission,

this is not an area that we had a lot of focus on directly. i think indirectly we add -- we had a real concern that we don't really understand how to think about or measure quality in this space. this is a space that has a lot of resources that are paid for privately or, out of, or our voluntary services. so it is in a different place than it rest of health care lives. and that kind of a rubric then for both regulatory oversight, kind of quality control and integration need a lot more work. but the commission itself, to answer your question directly, didn't specifically going to great detail about these sort of alternative forms of community based support. they are oversight and revelation.

>> actually i think we had more testimony on that than you are remembering, bruce. i think that we had a lot of discussion about -- had we had on workforce side, and we had a great deal of discussion and concern about -- and we also actually in effect we have testimony as to problems, quality problems in nursing homes as well as assisted living facilities. over the years there's been a lot of policy effort to try to mitigate those, particularly on the nursing inside but they persist, inadequate and standards are poorly trained staff. and because assisted medicaid doesn't cover, doesn't finance and assisted living facilities, there's a real concern about an absence of standards, as you say. so i believe that we heard a lot of testimony, and i know in the alternative, our alternative report we made recommendations about -- we address it on the staff on the training site.

there's been an exposé recently of a particular assisted living facility of grossly inadequate training for staff while claiming to be offering special is care for alzheimer's patients, residents. and it was both embarrassing and appalling when you saw on national tv, and it is not a lone example. so we did your testimony not only about the need for, but examples of training programs. i believe the one we heard from within the state of washington. both better standards and training for workers who, which is better for the patients for whom they serve and also creates better jobs along -- accompanied by better pay for the workers who were relying on to care for our families. >> but i would say, and the commission made many recommendations on workforce. your specific question was about

the oversight and regulation and management of these new delivery entities. while we did hear a little testimony in that space, that is not a place where the commission made any recommendations, and the workforce peace is only a part of what it means to operate these different kinds of environments. from the health care perspective, people are only one piece of it and the oversight of things like assisted-living organizations and other kinds of residential care options that are sort of multiplying in front of our eyes, that's a completely different question. and the workforce is an important, but only one piece of that discussion. so the question you raised mayors a lot of careful thought. and candidly, the commission itself didn't get that far into the issue. >> do you want to comment with regard to long-term care for seniors who also have disabilities? does the system work? >> that's a great question,

senator nelson to me back up. the system we have now doesn't work well for hardly anybody. i don't think it works well for over -- older individuals with serious chronic illness or launch a limitation or cognitive impairment. it is a very fractured, gary provider centric system. and it leaves individuals and their families to ge to do the e coordination which is basically missing from most models and most systems of care. we heard about some models that were better, and to our sort of paths to better processes of care. but the commission lays out holders of the commission for things that could be better. so to your question, i think it's even harder for younger individuals. many of the systems that serve them were actually not built for them. they may have been built for older people were built for a different population, and to think for younger individuals with serious functional

limitations or cognitive impairments, they have their whole life ahead of them. they are in a different place in their life trajectory than an older person is, and have different desires and family work. and so i do think we have a long way to go. and it is a particularly long way to go for younger folks with serious needs. >> suppose we enacted a plan for private insurance. then the question comes, who is going to regulate it? when we turned over to the state insurance commissioners? or the state health regulatory agencies? ms. tumlinson? >> well, that's a good question. i think if we move in the direction of creating more incentives for people to purchase private long-term care insurance or reform the marketplace, improve demand and supply and all of those kind of

things, we would continue to regular did at the state level the way it always has been by there has to be more of a federal -- just be more of a federal role in kind of setting the bare bones sort of standards, and i guess you'd call it the parameters around which some of these policies would be designed and how they would work. fundamentally the marketplace is not working so we need some actual marketplace reforms. and i think those have to come from the federal level. i think issues around, you know, regulation around the insurance pools and that kind of thing could continue to operate at the state level. >> senator nelson, i'll just point out, the current setup, radio towards other, obviously states have a main regulatory responsibility, but as part of tax issues, the federal government already does have some role in terms of both design, design of long-term care insurance policies. and one would imagine that if there were additional tax incentives provided, just

naturally it would go that would be an increased responsibility. i'll also note that one of the reasons for the increases in premium is related the federal policy. and that's the policy of the federal reserve board. with very low interest rate. those policies were priced at 76% interest rate. which clearly we are nowhere near that. so there is an interesting mix of federal and state issues at hand. >> commission recommended that you remove the requirement that a patient must stay in the hospital for three days before they can receive services in a skilled nursing facility. now, there are a few of us up here that i agree with that. can you tell us why you ended up recommending that? >> sure. i think that there was a sense

that that rule was greeted in a different time and place. and i would say that the commission felt that what it needs to be is revisited. it does need to be replaced but it needs to be revisited in sort of a model of care we thought through. because the reality, think this day has come down over time, ma that we want -- the goal should be we need to get people to the right care by the right provider. sso by having this three day length of stay requirement there are people who maybe could step down to a lower level of care sooner what are not able to access that level of care. and four are put in a higher level of care because the higher level or a different level of care, for example, said acute rehab, which is actually more expensive than the skilled nursing facility might be, so i think our call was for there to be an opportunity to revisit and remove the three-day length of stay and replace it with an approach that is more sensible and consistent with current care

practices. again, being mindful that it was put there for a reason, which is what i call control mechanism more than anything else, and that taking it away creeps new opportunities. but we do think in the current environment it isn't serving that cost control goal that it was originally put in place to try to achieve. >> i will add that that was the consensus of the commission. and another element of it was that there's been a trend of patients being in hospitals, thinking they were admitted and never actually being admitted and, therefore, that does not count even if they're in the hospital for five days. that struck us as just plain wrong. but it does, it does raise a the question of what is the mechanism that does control that next phase as bruce indicated. and we didn't have enough time to sort of figure out the replacement, but the three-day rule struck us as not the right one. >> we are going to include in

the record an article by bloomberg news that illustrates how difficult it is for seniors to be able to afford long-term care. and this is our last hearing of the year, save for some unusual thing that we might be in session on new year's eve, like we were last year spent will you bring the champagne, if we are? [laughter] spent as a matter of fact, you remember, new year's eve, we were all on the floor, and i spotted one of my dear friends in his tux sitting in the gallery and it went over to him and i said, charlie, what in the world are you doing it? he said, jackie and i went out to dinner and we decided this was the best entertainment in town. [laughter]

>> except perhaps for the performers. >> well, you all have been great. thank you. it's a tough issue. and so thank you for helping us get into it and start to peel back the onion. we appreciate it. happy holidays, merry christmas. happy new year. the meeting is adjourned. [inaudible conversations] >> senators return to washington for legislative business on january 6. the senate will vote on confirmation for janet yellen, the president's nominee to be

chairman of the federal reserve. and the senate is expected to consider extending unemployment benefits, long-term unemployment benefits expired over the weekend cutting off payments to 1.3 million people without jobs. when the senate reconvenes you can see live coverage from the senate floor right here on c-span2. >> you are watching c-span2 with politics and public affairs. weekdays featuring live coverage of the u.s. senate. on weeknights watch key public policy this, and to weaken the latest nonfiction authors and books on booktv. you can see past programs and get our schedules at our website and you can join in the conversation on social media sites. >> all this week on c-span2, booktv in primetime. tonight, a look at the court's >> i've been involved in

politics for 40 years in one way or another. i worked on reagan's campaigns that i worked in his intercession for eight years. the fact of the matter is i have never seen so many people quoting and waving around the question of independence and the constitution. many of you 10 years ago you never gave it a second thought. now i bet it's at the front of your minds. and it is with tens of millions of us. the fact of the matter is, tens of millions of us love this country. we don't want it fundamentally transform. so we have to get to as many of the people as we can, wake them up, educating. i'm not trying to out myself on the back, that's the purpose of this book. that's the purpose of the book but i consider part of the purpose of my ready program.

a number of my brothers and sisters been broadcast which is why we're under attack all the time, these utopian status spent sunday, is selling author, mark levin we'll take your calls and questions live for three hours starting at noon eastern. booktv's "in depth" the first sunday of every month on c-spa c-span2. >> now from the new york public library, a group of women veterans of the iraq and afghanistan wars spoke about their war experiences and the transition to civilian life. this is an hour 40 minutes. >> so i'd like to thank you, everyone, for coming out today, pearl harbor day, for a very

important discussion. my name is alexandra kelly and work with outreach services on veteran programming. and this is the third and final panel discussion we've hosted as part of our new york public library, new york veteran history series. we are truly honored to have some incredible individuals to share their stories on this stage. so this discussion, like the other discussions, really seek to celebrate the complete story. as veterans tell their own stories, old civilians and other veterans can learn from them and begin to engage in more meaningful dialogue that more realistically reflect the experience of our country veterans. in your program you will see more information about our veterans oral history project which is truly the backdrop or by both of these panel discussions and our other public

programs we host at the library. the oral history itself is really an opportunity for anyone to share their story in exactly the way they want to share it here i'm looking for to listen to more interviews with veterans for this project. as we collaborate with the library of congress to make sure that these stories are well preserved for future generations to if you'd like to interview some of for this project let me know. my contact information is on the back of your program. i see many for my faces of people have been interviewed for this project or indicate others for this project. i'd like to thank the women veteran and families network for hosting this event with us this evening and providing some incredible resources and programs for women veterans and their families. would you stand up for a moment? where are you? she is back there. okay. i would encourage you all after today's discussion to talk to

her and ask her about the resources that she has her veterans around the city. she's really amazing to work with. so now i'd like to introduce you to make my blog and, our moderator this afternoon. we work to make sure that this panel was collaborative. asking all of the veterans on a panel what question he wants to ask and what questions would you like us to stay away from. which questions have you been asked quite often, and which questions have you wanted to be asked but rarely ever are? meg is an independent filmmaker and a cultural anthropologist based in new york city. her most recent film tells the story of women who were sent into direct combat in iraq as part of an unofficial u.s. army program. the film won the center for documentary studies film maker award at full frame documentary

film festival and was broadcast on pbs series independent lens in 2008. she writes about media, architecture and activism and the documentary form and mostly silly co-edited sensible politics, the visual culture of nongovernmental activism published in 2012. we are truly honored to have her moderate hispanic accent like to invite meg to give a few opening remarks. thank you. spent high, everybody. i'd like to start by thanking alex kelly and the new public library for inviting me to moderate today. it's a real honor to be on the same stage with people who have served in these post-9/11 conflicts, iraq and afghanistan. my connection to the issue is as a filmmaker. we made a film which we started working on in 2005, finished in

2008, about a group of army women who served in the sunni triangle and were sent out with all-male infantry and dr. rhee units to help deal with some of the tensions that were a rising when they were going into homes and encountering iraqi women and children, civilians. we saw the american women who were doing this work as important historical actors. in an ongoing transmission of the armed services, the transformation to the folder gender integration. and it's a time when we're making the film very little information was available about what was going on in iraq in terms of what the women were doing. and tell the stories of the women, were primary sources of information about the new way women were being used in iraq

into de facto combat integration that was taking place. and since then, of course a new generation of women combat veterans has emerged that have come home from this complex, and generation including the women on the panel today have gotten organized and are changing the narrative about, and the policies about the effect military women and women veterans. they are raising critical issues that the military needs to address including sexual harassment and rape, and are expressing themselves in their writing, their memoirs, poetry, artwork, and are visible on radio, television and film. so with that i would like to get started and have the opportunity to hear some more of their stories. i'm going to introduce each panelist briefly, and then we will start with the questions.

nicole goodwin, all the way down at the end, enlisted in the u.s. army in 2001. she served as a supply specialist and was deployed to iraq in july 2003, for 5 and a half months. when nicole returned to the bronx choose one of the first homeless veterans of the iraq war and was featured in a documentary when i came home, as well as many news programs. she lives in new york city where she is rating her daughter and writing poetry, fiction and nonfiction. she graduated college in 2001 with a ba in english come in creative writing and anthropology. teresa fazio grew up, next to nicole, grew up in white plains to your. she served as a marine corps communications officer from 2002-2006. deploying wants to iraq. she is writing a memoir about her deployment relationship and its aftermath.

teresa has bugs were worked in "the new york times" at war blog and read her writing at the kennedy center in washington, d.c. she lives and works in new york city. rebekah havrilla -- did i say that right? is a former army sergeant and explosive ordnance technician serving on active duty from 2004-2008, and in the army reserves from 2008-2010. she was deployed to afghanistan in 2006-2007. rebekah is really working towards a masters degree in international affairs with a concentration in media and culture from the new school in new york city. raeanne pae recently transitioned from the u.s. army as a captain, having served seven years on active duty. she is currently working as the board event manager and marketing division at new york stock exchange zero net. she deployed to iraq in 2007 as

a company executive officer with the 82nd airborne division's first brigade combat team. while there, she managed logistics and operations for her unit to conduct intelligence operations across southern iraq. in 2010 she deployed to kandahar, afghanistan, as the unit intelligence officer for the 217 air calvary squadron of the 101st airborne division. okay, so these are our panelists, and i'd like to start by asking you to talk a bit about your experience when you first join the military, your reasons for joining the i'd like to start with why you chose to enlist? >> okay, thank you. the reason i chose to enlist was it was a dire situation in my home. pretty much i come from a very

impoverished, dysfunctional family, and there weren't many options open for me to ever get myself at that time. i was very young. i was 19 going on 20. it seemed like the options had run out. and living in the south bronx and living this impoverished life and wanting more and wanting an education and these things motivated me to search for a way out as soon as possible. and that's pretty much why i enlisted. >> i also had a bit of an economic motivation for joining. i did get to pay for college. i did rotc in undergrad and i probably wouldn't have been able to pay for school otherwise. it was pretty expensive. i've wanted the challenge and the camaraderie that comes with it.

>> i'm from the south and everything a male in my family is in the military. so i kind of saw it as an option but also grew up in a very, very privileged environment where women were supposed to stay at home barefoot and pregnant and that was not my thing. i decided that i wanted to pursue military service. it was interesting, because long story short, i had open heart surgery when a young child so it took me almost two years to get a medical waiver to enlist to be in the military. then i ended up going into explosive ordnance disposal which basically i was in a bomb squad. i did a relatively challenging job, but again, economics laid a big role in it. we're in the middle of a war but i'm -- what a college degree and the want of any college debt. that played a part in it but i think there was still like patriotism factor as well, coming from what i would refer

to as the deep south, had that in my family heritage. >> everything that everyone just said actually. i think we all share the common, the idea of the camaraderie, a chance for me a chance to travel and meet a lot of new people. taken out of my comfort zone. i joined my sophomore year of college, joined rotc. it take for school. is good to think once i graduated i wouldn't have school to pay for and i wouldn't have any debt. when i was a sophomore in college, that was 20 -- 2001. post-9/11 that happen, and i got a letter from the rotc department on campus that said we will pay for school but this is an opportunity for you to surf after college. and i thought it would be a great opportunity for me to be a part of something bigger than me, especially after 9/11. so i was searching for a way to in some way give back, and rotc was it. and then it turned out to be a

great experience for me altogether, being on active duty. i got everything that i wanted and then some. >> can you talk a little bit about the others reacted to your decision when you were in college? >> the rotc department or the unit on my campus was pretty active, but it's a small school. a small organization on campus. and so i was in a sorority at the time and a lot of my sorority sisters were just shocked when they came out and said i wanted to join rotc. i'm like five-foot nothing. it really surprise them. to every wednesday on campus we have drills so we had where you do for. at that time it was the olive green uniform. i think they refer to me as the pickle. and it was a joke. i was and they made fun of. it was kind of term of endearment, and it kind of almost raised awareness for

anybody can join rotc if raeanne candidate and she's only five-foot and a female. a lot more people -- i won't say i let that alone but we had a pretty good turnout the next of people wanting to become a part of the program. it was at first really question wants to do this? they couldn't imagine being a part of that organization. funny that later was when is an the arm and i would tell people i was at your in high school and people in the army would be surprised by that once they saw me in uniform. interesting dynamic. >> you shot them both ways. i wanted to talk a little bit about, had each of you talk about what your mama was and how you made your decision and what sorts of skills you learned in the process. get down to some brass tacks. rebekah, you start. >> sure. i wanted to be a dude, special forces but that was not an

option. so i picked what i thought was the next best thing and i went dod. basically like i said, i was in the bomb squad. basically for lack -- i was asked people if they've seen urlacher. that was me kind of sort of exit "the hurt locker" wasn't really all that realistic. but at least people are kind of -- have a place to start for. but we did mostly ied missions, it was either respond to them when people found the or we would respond to them after they went off. iedc a basically roadside bombs. ieds are basically roadside bombs. i did a lot of work when we are in afghanistan because it was the only female with the unit that i was assigned to an attached to, i did a lot of biometric data collection, being a woman and the skill set that i

had, hey, you're a woman and you can find bombs and you also, you know, mingle with a local woman population that all of our men can really deal with. so i got crosstrained in a lot of different skill sets that were outside of the actual job description, but one of the things i do miss it, honestly, kind of awesome and fun. so i do kind of miss kind of the challenges everyday was something different. you never knew what you're going to get you into our what was going -- i relate honestly to being kind of like a policeman or a firefight in some respect. there's a lot of downtime followed by a lot of, like we've got to go, get your stuff, let's hit the road in a very high strung and fund. one of the ironies about being in afghanistan in a bomb squad, doing my actual job was not the most stressful part of the job. it was driving the vehicles

through the mountains. that was the most stressful part of being over there, like driving in a 2010 vehicle on mountain path roads with a 600 property right inside. that was kind of -- just get me there. i can do with whatever with what ever, just get a difference. there there were a lot of interesting contradictions and ironies associated with my position. i always -- they were about when i was in 2004-2008 there were about 50 women in the field, the whole field in the army. so very, very infrequently did you ever see another woman who was in eod. so that definitely kind of an anomaly, which sometimes just being a woman in the military can be an anomaly in and of itself. that was even more isolating in essence, which was challenging but i really, like i said i really enjoy my job, i kind of miss it sometimes.

make something go boom every once in a while. >> so you are in 18 of how many -- >> initially you were in teams of three to four, and you were assigned to different locations. to most of the time you would spend a whole unit over but then our unit was only like a lot of people think about companies being a couple hundred people or so. ours was 20 people. we were very small homage kind of very intimate. everybody knew everybody but then you would be centrally located and then we would be disbursed throughout local areas. so you are only with two to three people at you specifically had in your unit any specific type it is a different set up from what we consider ourselves to be outside of the mainstream military and did things a little differently. it was kind of a unique set up at the time. >> can you give us a sense, so

you would get to you would be told that might be something you need to go check out. your group of three or four would be assigned that task? >> yeah. you never go out by yourself, or you were always, we always have have an escort. i worked with task force part of the time which is basically a counter ied task force to save an intelligence officer, you have people who do post blast analysis would go out and collect biometric data from the actual blast site itself. and then we had our team who deal with actual ordinance were ied is that were not yet exploded. we would kind of sit around and wait. a lot of it was a lot of intelligence base. a lot of it was trying to minimize the risk to everyone else that was always outside the wire, outside doing missions all the time. but yeah, we would get kind of,

we get a call and they would say we think we found something to we need you guys to respond to we always try to respond within 30 minutes but a lot of people who do the escorts was infantry, combat engineers, were usually out on missions of some they might have to come back and get us in our little to vehicles and an escort us out to the side where we were in order for us to take care of what needs to be taken care of. >> raeanne, you were an intelligence officer. spinning i wasn't directly a sign there, we did a lot of work with them. when i was in iraq we were responsible for security force missions for our brigades would basically we ran convoy through the entire country starting in the south but they did a lot in to baghdad and back and. so if there was a threat on any other routes we would assess those threats.

so indirectly report supported them. >> can you talk about your mos or your training that you did in iraq? >> that was my first appointment. it was funny, i study psychology in college, and when i want to become an officer i was told by another cadet, you should have a business degree. i used psychology every single day regardless of my specialty. with intelligence, i think, at first and foremost i wanted to be an officer because i wanted to be a leader. intelligence just happened to be the branch that i chose going in. i really liked intelligence because basically as a new officer, second lieutenant i was responsible for a burial asset platoon, a tactical, unmanned aerial vehicle. to basically drones. we were responsible for

collecting from aerial perspective, collecting imagery of routes, doing a lot of route reconnaissance, things like that. so i was responsible for a 24 person platoon and they operated these unmanned drones for the unit. >> and so, which part? where? >> southern iraq. so i actually when i went into afghanistan i was with a manned helicopter unit. so i went in with some experience from that, understand more of the aerial perspective and what needed to be, the way to look at in terms of intelligence, but we were in southern afghanistan and doing the same thing except now i'm getting with high let's are putting themselves at risk went out several times a day and flying helicopters themselves. these were small aircraft with two pilots, no passengers, single engine aircraft. these things were built in the

'70s and didn't really, in terms of technology, didn't really improve from the '70s used in vietnam. so these guys and women putting themselves at risk every time that they went out, and i'm asking them to collect very dangerous areas in afghanistan. so it was interesting, the dynamics between iraq and afghanistan and what my mission was, but all within the intelligence cycle. >> and in afghanistan, where their mortars, you know, people firing of helicopters? >> yes. the types of aircraft, we had a patchy is that when out and basically the difference between the two, one is more of the ability to target where as the other is small aircraft is going out, not so much an offensive role but more, more, looking for

information, taking pictures literally hanging their arm outside aircraft and then coming back. they were strictly targeted because they are small aircraft. they don't fly as fast as an apache or a black hawk. and so we had a lot of times they came back if they had been shot at that was up to my group that i was responsible for to assess the damage of the aircraft to understand where they being targeted at, at what level? basically to identify capabilities of the enemy and use that as a we're protecting the ground troops. so there were times when our guys, or our pilots, when they would go out, they were directly supporting someone -- every time they were directly supporting someone on the ground, and so oftentimes they were shot at because they were supposed to dish out to those. >> to recent, can you talk a bit about your role? >> sure. no problem.

i was a communications officer in the marine corps and in the marines you don't get to pick. a pic for you what you do. .. a whole lot of multichannel radio communications between different bases. sore