U.S. GOVERNMENT PUBLISHING OFFICE

32–636 PDF WASHINGTON : 2019

S. HRG. 115–473 

TURNING 65: NAVIGATING CRITICAL DECISIONS 

TO AGE WELL 

HEARING 

BEFORE THE

SPECIAL COMMITTEE ON AGING 

UNITED STATES SENATE 

ONE HUNDRED FIFTEENTH CONGRESS 

SECOND SESSION 

WASHINGTON, DC 

JANUARY 24, 2018 

Serial No. 115–13 

Printed for the use of the Special Committee on Aging 

( 

Available via the World Wide Web: http://www.govinfo.gov 

AGING-G33-GPO with DISTILLER

(II) 

SPECIAL COMMITTEE ON AGING 

SUSAN M. COLLINS, Maine, Chairman 

ORRIN G. HATCH, Utah 

JEFF FLAKE, Arizona 

TIM SCOTT, South Carolina 

THOM TILLIS, North Carolina 

BOB CORKER, Tennessee 

RICHARD BURR, North Carolina 

MARCO RUBIO, Florida 

DEB FISCHER, Nebraska 

ROBERT P. CASEY, JR., Pennsylvania 

BILL NELSON, Florida 

KIRSTEN E. GILLIBRAND, New York 

RICHARD BLUMENTHAL, Connecticut 

JOE DONNELLY, Indiana 

ELIZABETH WARREN, Massachusetts 

CATHERINE CORTEZ MASTO, Nevada 

DOUG JONES, Alabama 

KEVIN KELLEY, Majority Staff Director 

KATE MEVIS, Minority Staff Director 

AGING-G33-GPO with DISTILLER

(III) 

CONTENTS 

Page 

Opening Statement of Senator Susan M. Collins, Chairman .............................. 1 

Statement of Senator Robert P. Casey, Jr., Ranking Member ............................ 3 

PANEL OF WITNESSES 

Jim Borland, Acting Deputy Commissioner for Communications, Social Security Administration, Washington, DC ................................................................ 5 

Anna Maria Cha ́vez, J.D., Chief Strategy Officer and Senior Vice President, 

External Affairs, National Council on Aging, Arlington, Virginia ................... 6 

Mehrdad Ayati, M.D., Adjunct Clinical Assistant Professor, Geriatric Medicine, Stanford University, Stanford, California ................................................. 8 

Sharon Hill, Apprise Volunteer, State Health Insurance Assistance Program, 

Vanderbilt, Pennsylvania .................................................................................... 10 

APPENDIX 

PREPARED WITNESS STATEMENTS

Jim Borland, Acting Deputy Commissioner for Communications, Social Security Administration, Washington, DC ................................................................ 34 

Anna Maria Cha ́vez, J.D., Chief Strategy Officer and Senior Vice President, 

External Affairs, National Council on Aging, Arlington, Virginia ................... 44 

Mehrdad Ayati, M.D., Adjunct Clinical Assistant Professor, Geriatric Medicine, Stanford University, Stanford, California ................................................. 61 

Sharon Hill, Apprise Volunteer, State Health Insurance Assistance Program, 

Vanderbilt, Pennsylvania .................................................................................... 68 

ADDITIONAL STATEMENTS FOR THE RECORD

Medicare Rights Center Support Letter for the BENES Act ............................... 70 

Centers for Medicare & Medicaid Services Support Letter for the BENES 

Act ......................................................................................................................... 73

Better Medicare Alliance Statement for the Record ............................................. 75 

AGING-G33-GPO with DISTILLER

AGING-G33-GPO with DISTILLER

(1) 

TURNING 65: NAVIGATING CRITICAL 

DECISIONS TO AGE WELL 

WEDNESDAY, JANUARY 24, 2018 

U.S. SENATE, SPECIAL COMMITTEE ON AGING, Washington, DC. 

The Committee met, pursuant to notice, at 9:30 a.m., in room 

SD–562, Dirksen Senate Office Building, Hon. Susan M. Collins, 

Chairman of the Committee, presiding. 

Present: Senators Collins, Fischer, Casey, Gillibrand, 

Blumenthal, Donnelly, Warren, Cortez Masto, and Jones. 

OPENING STATEMENT OF SENATOR SUSAN M. COLLINS, 

CHAIRMAN 

The CHAIRMAN. Good morning. The Committee will come to 

order. 

For the next 12 years, 10,000 Americans will turn 65 each day. 

Last month I officially joined that club. 

By median age, Maine is the oldest state in the Nation and is 

aging the most rapidly. Mainers age 65 or older accounted for 19.4 

percent of the population of the state in 2016. That is a twentytwo percent increase from the year 2010. 

No matter where in the country you live, when Americans think 

of turning 65, we traditionally think of Medicare and Social Security—as well we should. Today, more than ever, there is also an opportunity to plan for a brand-new chapter of life as more Americans are living far longer. 

More than one out of four Americans who live to age 65 can expect to live into their 90’s. Americans age 85 and older are the fastest-growing segment of our population. For many seniors, this longevity means an additional three decades following what was once 

considered the time to retire. We need to plan to age successfully 

and achieve a new chapter of continued growth in our lives. 

At the same time, we must make those all-important decisions 

regarding Medicare and Social Security. As I know from my own 

visit to the Social Security office in Bangor, Maine, where people 

were extraordinarily helpful, there are important decisions to 

make, and the programs can be very complex to navigate. So it is 

best to start considering options before that 65th birthday comes 

around. 

For example, the enrollment window for Medicare is limited, and 

there are penalties for late enrollment. The clock to sign up begins 

3 months before the 65th birthday and extends for 3 months afterward. Signing up late, particularly for Medicare Part B, can lead 

AGING-G33-GPO with DISTILLER

2 

to a hefty penalty that lasts for life. It can be confusing to navigate 

these hurdles and to choose the right package to suit individual 

health care needs. 

Those who are collecting Social Security benefits when they turn 

65 are automatically enrolled in Medicare. Increasingly, however, 

Americans who are healthy are choosing to work longer, as our 

Senate Aging Committee showed in its annual report issued last 

year when we chose to look at America’s aging workforce. For 

many Americans, working longer wisely means delaying Social Security and then being able to collect much higher monthly benefits 

later. 

How does one know which decision is best? What is the optimal 

time to claim Social Security benefits to ensure financial stability 

in the long run? When should you begin considering Medicare options to maximize care and reduce costs? Those are some of the 

questions we will be examining today. 

We will also explore another issue: While we have formulas to 

help guide us through the best Medicare and Social Security decisions, there is no simple formula for healthy aging. If we were to 

create a checklist for healthy aging, what would it include? 

There are proven choices that one can make to maximize health 

and well-being. While genetics determines about twenty percent of 

longevity, lifestyle and environment dictate the other eighty percent. 

Staying physically active, eating well, conversing with friends, 

reading engaging books, doing something meaningful every day, 

and taking proactive steps to improve wellness all contribute to 

healthy aging. Most people know that physical, social, and cognitive engagement is good for you. Few people realize that it remains critical at every life stage, but especially in older adulthood. 

Even for those who face multiple chronic conditions and frailty, 

proactive actions can reverse a negative life course and lead to a 

healthier future, but that can be difficult in states like mine which 

are very rural and where people may feel isolated from one another. 

I would like to share with you the story of ‘‘Sandy,’’ a healthy 80- 

year-old woman. One icy winter morning, she stepped outside to 

take her dog out. She slipped and broke her right leg. Once an active woman, Sandy found herself unable to walk. Following surgery, rehab, and physical therapy, she was able to get around with 

a walker, but stayed home for days at a time. She felt down in the 

dumps. Her daughter convinced her to try a program called ‘‘A 

Matter of Balance’’ offered through MaineHealth, which is a hospital system based in Maine. This program reduces fear of falling 

and improves balance. For Sandy, the program literally changed 

her life. Each week she regained strength. She traded the walker 

for a cane, and soon afterward she shed the cane, too. Today Sandy 

is a coach for that program. She is able to walk miles on end and 

feels like she has her life back. 

Sandy’s story shows that even after falls, we have the capacity 

to get back up and age well. It also shows how important those programs can be in helping a senior regain his or her life. 

Today more and more Americans have a chance to live to 100. 

The second fastest-growing age group in the United States is 100 

AGING-G33-GPO with DISTILLER

3 

and older. Turning 65 once meant that it was time to retire and 

slow down. Today it is an opportunity to prepare for a lifetime 

ahead—a lifetime of living, learning, and loving. A lifetime of financial security if the right decisions are made. As individuals and 

as a society, what do we need to do to get there? What choices 

should we make? How can we disseminate useful information to 

the senior population? 

I look forward to our discussion on these important issues, and 

I am pleased now to turn to our Ranking Member, Senator Casey, 

for his opening statement. 

OPENING STATEMENT OF SENATOR ROBERT P. CASEY, JR., 

RANKING MEMBER 

Senator CASEY. I want to thank Chairman Collins for this hearing and for her opening statement today, and I also want to thank 

her for the good work she has done in what has been a long week 

here in the Senate. 

Every day 10,000 Americans turn age 65 in the United States of 

America. Ten thousand people every single day—that is a staggering number. And today we will hear that people turning age 65 

face their own staggering number of decisions at that time in their 

life. 

They must be thinking about a range of issues: claiming Social 

Security, about signing up for Medicare and about how to get what 

they need to stay healthy. These are not simple decisions. There is 

no one-size-fits-all choice for those individuals. 

That is what I hear from my constituents in Pennsylvania, specifically through our constituent services team, and we hear about 

it day after day. Our office regularly works with Pennsylvanians 

who missed their window to sign up for Medicare, for example. 

They are people with a cancer diagnosis who have no way to pay 

for care simply because they did not know the right time to sign 

up. They are people who made an honest mistake, who did not 

know they needed to sign up for Medicare. It could happen to any 

one of us. Now they are paying higher premiums for the rest of 

their life. 

Almost 26,000 Pennsylvanians—26,000—are paying a lifetime 

late enrollment penalty for Medicare Part B. Nationwide almost 

700,000 Americans are on the hook for that lifetime penalty. The 

average penalty amounts to almost a thirty percent increase in a 

person’s monthly Medicare premium. That is outrageous and unacceptable, especially considering that most retirees are already living on limited and often fixed incomes. 

Medicare is one of America’s great success stories, and it is our 

sacred responsibility to make sure that people can make the most 

of the Medicare benefits that they have earned. 

So that is why I introduced the Medicare Beneficiary Enrollment 

Notification and Eligibility Simplification Act. Good news, we have 

an acronym, the BENES Act—B-E-N-E-S. And what that act does 

is to make sure that every American receives a notice before they 

turn 65 that explains when to sign up for Medicare and what can 

happen if you delay. That is the least that we can do for so many 

Americans. This bill would also make sure that fewer people experience a gap in health coverage. 

AGING-G33-GPO with DISTILLER

4 

In fact, this change would update parts of the Medicare law that 

have not been revisited since the program was created more than 

50 years ago. I am proud of that legislation because it is bipartisan 

and it represents how Congress should work. 

We should hear about what is not working and what is most 

challenging for our constituents. 

We should design solutions to fix those problems—in a bipartisan 

way—and we should be able to pass these laws because they help 

the people we serve, the people that deserve that kind of law. 

So I look forward to today’s hearing, and I hope we can illuminate some of these problems—the same problems that Chairman 

Collins and I can work together on to fix. 

Thank you, Madam Chair. 

The CHAIRMAN. Thank you very much. 

Before turning to the introduction of our witnesses, I do want to 

recognize and welcome our new Committee member, Senator Jones 

from Alabama. We have had the opportunity to work very closely 

together the last few days. In fact, you have probably seen way 

more of me than you would have liked. But I am delighted that you 

have joined the Aging Committee, and I think you will find it to 

be a great Committee. And you are sitting next to our Committee’s 

most diligent member, and if you follow her lead, I am sure that 

you will have a great experience. So welcome. 

Our first witness today is Jim Borland, the Acting Deputy Commissioner for Communications at the Social Security Administration. Mr. Borland will discuss the spectrum of tools and resources 

available to help Americans choose the right retirement benefits 

that are right for their individual needs and circumstances. 

Next we will hear from Anna Maria Cha ́vez. Ms. Cha ́vez is the 

chief strategy officer and senior vice president of external affairs at 

the National Council on Aging. In her home State of Arizona, she 

launched the Governor’s Aging 2020 Initiative and created the Arizona Division of Aging and Adult Services. 

Next I would like to introduce Dr. Mehrdad Ayati, an adjunct 

clinical assistant professor of medicine at Stanford University. Dr. 

Ayati is a board-certified physician in geriatric and family medicine. He studies the physiology of aging and how to promote wellbeing through disease management and prevention. 

And I will now turn to our Ranking Member to introduce our witness from Pennsylvania. 

Senator CASEY. Thank you, Madam Chair. I am pleased to introduce Sharon Hill from Vanderbilt, Fayette County, Pennsylvania. 

And I also want to start by congratulating Ms. Hill. I am told that 

you have now your seventh grandchild? 

Ms. HILL. Yes. 

Senator CASEY. Congratulations. And it is a grandson, correct? 

Ms. HILL. Yes. 

Senator CASEY. That is good news. We need some of that around 

here. 

Sharon is a volunteer with Pennsylvania’s APPRISE program. 

For four years she has worked weekly to help counsel Pennsylvanians and their families, providing them with information to make 

the most of their Medicare benefits. Sharon will tell us how she 

came to this counseling work and why it is so important to help 

AGING-G33-GPO with DISTILLER

5 

people better understand Medicare. She will also tell us about the 

common questions that she helps people with and the missteps 

that families make when they lack key information. 

I also want to recognize her granddaughter, August, who is here 

with us at the hearing. August, thank you for being here today and 

for supporting your grandmother. You must be very proud of her, 

and I hope we will see you back here providing your own testimony 

before Congress someday. 

Thank you, Sharon. We are grateful you are here. 

The CHAIRMAN. Thank you very much. 

We will now start with Mr. Borland. 

STATEMENT OF JIM BORLAND, ACTING DEPUTY COMMISSIONER FOR COMMUNICATIONS, SOCIAL SECURITY ADMINISTRATION, WASHINGTON, DC 

Mr. BORLAND. Thank you. Chairman Collins, Ranking Member 

Casey, and members of the Special Committee, I am Jim Borland, 

Acting Deputy Commissioner for Communications at the Social Security Administration. Thank you for inviting me to discuss how we 

provide information to help workers and their family members decide when to claim Social Security retirement benefits and when to 

enroll in Medicare. These decisions are important, and we are 

mindful of our responsibility to provide information to help our 

claimants make informed choices. We believe that workers need to 

be thinking about their claiming decisions before they arrive at the 

field office. This is why our outreach and education efforts are crucial. The decisions workers make about starting retirement benefits 

are very important, as they will affect payment amounts for the 

rest of their lives. 

For this reason, even before individuals apply for Social Security 

benefits or enroll in Medicare, we provide objective information 

that they may use to plan for retirement. We do this in a variety 

of ways, including our Web site, publications, outreach, and the Social Security Statement. The Social Security Statement in particular shows information on lifetime earnings as well as estimates 

of future benefits workers and their families may receive based on 

those earnings. Individuals may access their Statement at any time 

through a personal, online My Social Security Account. 

We also currently mail statements to individuals aged 60 and 

older who are not receiving Social Security benefits and do not 

have a My Social Security Account. In fiscal year 2017, 15.6 million 

My Social Security users accessed their Social Security Statements 

nearly 46 million times, and we mailed around 13.5 million statements. 

In addition to basic benefit information, the Statement includes 

information on how work affects benefits, how a worker’s claiming 

decision affects survivor benefits, how to avoid Medicare late enrollment penalties, and information on average life expectancy. 

Another valuable resource is our Web site. Each month nearly 15 

million people visit us online to get the information they need to 

make informed decisions about their benefits. Our Web site includes our Retirement Estimator, which is a powerful, popular, and 

accurate tool. It uses an individual’s actual earnings information 

from our records and allows him or her to input a few pieces of inAGING-G33-GPO with DISTILLER

6 

formation to receive an estimate of benefits. It returns benefit estimates at age 62, at full retirement age, and age 70, or at any age 

in between. According to independent surveys of customer satisfaction, our Retirement Estimator is one of government’s highestrated Web sites. 

We recognize, though, that not everyone chooses to use the Internet. Our committed employees assist the public in a variety of 

ways: through face-to-face interaction in our field offices; by telephone, including over our national 800 number; in response to online applications; and through the mail. 

We also have over 100 public affairs specialists who, along with 

our field office managers, participated in more than 6,000 outreach 

events last fiscal year. With an estimated audience of more than 

3.7 million people, these events range from small rural gettogethers in public libraries, senior centers, churches, and veterans 

organizations, to large gatherings like county fairs, state fairs, senior expos, and employer meetings. Whether the attendance is in the 

tens or in the thousands, SSA employees are there to help Americans better understand their benefits. 

We also play a key role in signing people up for Medicare. Although the Centers for Medicare & Medicaid Services administers 

the Medicare program, Social Security is responsible for enrollment. We provide information and Medicare enrollment options for 

those who become eligible whether or not they are already receiving Social Security benefits. 

We continue to strengthen our partnership with CMS to improve 

our communications with those nearing the Medicare eligibility age 

of 65. We have updated the statement insert for older individuals 

to strengthen the message about when to apply for Medicare and 

to make information more prominent. We have also clarified language about late enrollment penalties in many of our publications. 

By establishing the Social Security and Medicare programs, Congress took action to provide seniors with benefits based on their 

earnings to sustain them throughout their retirement. As stewards 

of these programs, our job is to help workers make well-informed 

decisions that are best for their individual circumstances. 

I thank you for the invitation to be here today, and I look forward to answering any questions you may have. 

The CHAIRMAN. Thank you very much. 

Ms. Cha ́vez. 

STATEMENT OF ANNA MARIA CHA ́ VEZ, J.D., CHIEF STRATEGY 

OFFICER AND SENIOR VICE PRESIDENT, EXTERNAL AFFAIRS, NATIONAL COUNCIL ON AGING, ARLINGTON, VIRGINIA 

Ms. CHA ́ VEZ. Chairwoman Collins, Ranking Member Casey, and 

members of the Committee, thank you for the opportunity to speak 

with you today on behalf of the National Council on Aging. I am 

their chief strategy officer and senior vice president for external affairs at NCOA. We are the Nation’s oldest aging advocacy organization. 

Life after 65 has changed dramatically since NCOA started in 

1950. Where retirement once meant a few years of leisure buoyed 

by a secure pension, today’s older Americans have both the gift and 

AGING-G33-GPO with DISTILLER

7 

challenge of planning for a bonus 20 to 30 years of life. Yet few are 

prepared. 

Traditional defined benefit retirement plans have mostly disappeared, and Americans’ individual savings for retirement have 

not caught up. And longer life also brings new health challenges. 

Women face unique hurdles. They begin retirement with the 

challenge that has followed many throughout their lives: the pay 

gap. Lower pay means less money saved. Women who choose to 

leave the workforce to be a parent or a caregiver have fewer Social 

Security benefits built up, and women of color face an even deeper 

disparity. Over seventy percent of older Hispanic women and over 

sixty-four percent of older African American women are economically vulnerable. 

At NCOA we know there are proven, cost-effective ways to help 

Americans navigate life after 65. With the help of thousands of 

partners, our programs address two essential pillars of life past 65: 

health and economic security. 

Health is essential to independence, but older adults are disproportionately affected by chronic conditions such as diabetes, arthritis, and heart disease. The good news is that chronic conditions 

can be prevented and managed. One example is the Chronic Disease Self-Management program available both in the community 

and online. It improves health and saves money. With help from 

Congress, NCOA hopes to bring this program to thousands of older 

adults. 

Falls are another significant health concern, and the facts are 

alarming. Every 11 seconds an older adult is treated in the emergency room for a fall, and every 19 minutes an older adult dies 

from a fall. These falls cost Medicare $31 billion a year. But falls 

are preventable. Programs offered in communities such as A Matter of Balance, as you mentioned, Senator Collins, and tai chi can 

reduce falls by as much as fifty-five percent. NCOA leads two national initiatives to combat falls, and every September we sponsor 

Falls Prevention Awareness Day to spotlight the issue. Thank you 

to Senator Collins and Senator Casey for sponsoring the 2017 Senate resolution. We really appreciate it. 

Social isolation and loneliness are a problem for millions as well. 

Older adults without adequate social interaction have a mortality 

risk comparable to smoking 15 cigarettes a day. In the community, 

senior centers are a beacon for older adults seeking social connections. They are a gateway to the Nation’s aging network, connecting seniors to support as well as fun and friendships. NCOA 

runs the National Institute of Senior Centers to promote excellence 

and best practices. 

When it comes to health, we believe prevention should be a national priority. Investing in programs like these improves seniors’ 

quality of life and saves money. 

Economic security is just as critical. Today half of older adults 

living alone struggle to meet their monthly expenses. I want to 

share just two ways that NCOA is working to change this statistic. 

First is benefits access. Less than half of eligible seniors are enrolled in public benefits programs. We support local benefits counselors, and we offer BenefitsCheckUp, a free, online benefits 

screening tool that has helped nearly 6.5 million people. 

AGING-G33-GPO with DISTILLER

8 

Second is improving Medicare. Anyone who has turned 65 can 

tell you how overwhelming it can be to understand and enroll, and 

making poor decisions can hurt you, through higher costs, coverage 

gaps, and even lifetime penalties. And we support the bipartisan 

BENES Act introduced by Senator Casey, which aims to simplify 

enrollment. Thank you for your leadership. 

Continued funding for low-income benefits, outreach, enrollment, 

and full funding for the Medicare State Health Insurance Assistance Program are critical. SHIPs provide local, in-depth counseling 

to Medicare beneficiaries, their families, and caregivers. 

Americans want help navigating life after 65. That is why NCOA 

developed our own innovative approach called the ‘‘Aging Mastery 

Program,’’ which we fondly call ‘‘AMP.’’ AMP brings together our 

best knowledge into a fun, engaging program that gives seniors a 

pathway to age well. More than 10,000 seniors have graduated so 

far. 

So, in conclusion, aging well means making informed, deliberate 

choices. At NCOA we offer tools and solutions to help seniors do 

just that. We look forward to working with the Committee to develop even more resources to help people navigate life after 65. 

The CHAIRMAN. Thank you. 

Dr. Ayati. 

STATEMENT OF MEHRDAD AYATI, M.D., ADJUNCT CLINICAL 

ASSISTANT PROFESSOR, GERIATRIC MEDICINE, STANFORD 

UNIVERSITY, STANFORD, CALIFORNIA 

Dr. AYATI. Madam Chair, Ranking Member, and distinguished 

members of the Aging Committee, thank you for inviting and giving me this opportunity to discuss the challenges regarding the 

aging population in the United States. My name is Mehrdad Ayati. 

I am a board-certified geriatrician and educator. I am presenting 

myself as a physician who has treated and managed and continues 

to treat thousands of senior Americans. 

As well said at the beginning, today the number of Americans 

ages 65 and older is approximately 49 million. Currently, there are 

about 7,000 geriatricians in practice in the United States. We need 

about 20,000 geriatricians to staff up for the need we have right 

now. 

This aging population is faced with multiple challenges on the 

path to healthy aging, and I am giving my opinion as a geriatrician 

about these challenges. 

Number one, lack of experts in the field of geriatric medicine and 

gerontology. Unfortunately, our health care and education systems 

have not been designed to train enough senior care providers who 

can specifically manage seniors. As we age, our physiology changes. 

And, therefore, it is crucial to be managed by health care providers 

who have been educated and trained in this field. 

In the U.S., eighty percent of seniors have at least one chronic 

condition; forty percent of the seniors take at least five medications, not taking into account over-the-counter supplements and 

herbal remedies. They see many different specialists and are prescribed a number of different medications through each, which can 

result in polypharmacy or overmedication and drug cascade syndrome. 

AGING-G33-GPO with DISTILLER

9 

The next challenge is lack of scientific and research-backed medical information regarding healthy aging. Despite the fact that we 

live in an era of advanced technology, with massive amounts of information on the subject of aging available, the validity of much of 

such information is highly questionable. For example, misleading 

marketing campaigns in every corner are enticing our seniors to 

take drastic measures such as taking unregulated vitamins and 

supplements or undergo harmful diets to live longer and healthier. 

This is regardless of the fact that the scientific data collected over 

many years indicates such over-the-counter supplements and drastic diets are not contributing to better health and could even be 

detrimental to our health. 

The next challenge, the elderly are becoming more racially and 

ethnically diverse. In 2014, about fifteen percent of people age 65 

and older lived in a home where a language other than English 

was spoken. Currently, we lack the resources to address the challenges of these growing ethnic and racial groups. 

The next challenge, which is most important one, we live in an 

anti-aging society. In traditional society, the elderly hold an exceptional status in their community. They are considered very sage, 

are highly respected, and have a central position in the family and 

their community. In the U.S. that is not true. Older adults are 

often forced out of the workforce and replaced by cheaper and unskilled labor. They usually retire to the solitude of their houses. 

They become isolated and lonely, and as a consequence, they develop depression and cognitive impairment. Later they may be institutionalized and set aside by the society they built and the children they raised. They can even be easily mistreated, cheated, and 

taken advantage of. 

The next challenge, lack of infrastructure and resources. Our 

seniors face a lack of appropriate resources in the areas of transportation, affordable housing, senior centers, organized and affordable social activities, and qualified health care centers. 

And the next, financial difficulties. A large number of seniors are 

living in poverty. Often they are faced with a hard choice between 

paying their rent or mortgage, buying the many medications they 

cannot survive without, or purchasing food. Too often they become 

not only financially but also physically dependent on their children, 

which are known as the ‘‘sandwich generation.’’ 

Next is robotic mentality. We live in a modern society where 

more is considered better. This kind of mentality tells us that for 

every single problem, there should exist a quick fix—even if there 

is no logic behind it. ‘‘Modern medicine’’ dictates that things should 

be fixed with either medications or interventions or procedures. 

But in reality, the statistics do not support this. 

And the last challenge is Medicare expenditures. As the Medicare 

system is set up today, it does not pay for the medically necessary 

services, which can have tremendous impact toward a better physical and mental quality of life for older adults. 

Thank you again for this opportunity, and I will be happy to answer any questions and discuss about how we can fix that. 

The CHAIRMAN. Thank you very much, doctor. 

Mrs. Hill, welcome. 

AGING-G33-GPO with DISTILLER

10 

STATEMENT OF SHARON HILL, APPRISE VOLUNTEER, STATE 

HEALTH INSURANCE ASSISTANCE PROGRAM, VANDERBILT, 

PENNSYLVANIA 

Ms. HILL. Thank you, Chairman Collins, Ranking Member 

Casey, and members of the Committee. Thank you so much for this 

opportunity to testify today. It is a real honor to be here. 

My name is Sharon Hill. I am 63 years old and a resident of 

Vanderbilt, Pennsylvania. I have two sons and seven grandchildren 

and my youngest grandchild, Logan, was born Tuesday. My granddaughter August has joined me here today. She volunteers with me 

at many of the senior centers that I go to. I am a volunteer with 

the Pennsylvania APPRISE program. Nationally, APPRISE is also 

known as the State Health Insurance Assistance Program—SHIP. 

In addition to volunteering with the APPRISE program, I work 

cleaning my church. I also care for my 89-year-old father and help 

care for my 92-year-old neighbor, who is blind. I have a disability 

myself and rely on the support of state and federal programs to remain active and engaged in my community. 

I have been an APPRISE volunteer for four years. I initially saw 

an ad in our local Senior Times newspaper, asking for volunteers 

to help people with Medicare issues. At that time I was on Medicare due to a disability and had recently been left with $67,000 in 

medical bills after a cancer diagnosis. I also recalled the difficult 

decisions my parents had to make about their Medicare coverage. 

Both events were behind my interest in volunteering for the APPRISE program. 

To be an APPRISE volunteer, I had to attend many training sessions. At these sessions I learned about the different parts of Medicare, including Medicare Parts A, B, C, and D, as well as Medigap. 

I also learned about the programs that can help low-income seniors 

and people with disabilities. This would be like Medicare Extra 

Help and even Pennsylvania-specific programs that help individuals who have high medical expenses. I was trained on how to use 

the computer system and enter information into the Medicare Plan 

Finder. Each year we receive refresher training to provide volunteers with any updated information that the insurance companies 

are offering. 

However, the more I learned, the more I realized I did not know. 

People have a lot to consider when signing up for Medicare, and 

the decisions can be daunting. I wish I would have known about 

the resources sooner, because if I had known the program that I 

am on now, MAWD, I would not have had the intense medical expenses that I had earlier. 

It is because of my own experiences that I am passionate about 

the APPRISE program. APPRISE is the only place that older 

adults can go, in person, to get unbiased information. This helps 

them with their Medicare decisions. As a volunteer, I give speeches 

at local senior centers and provide in-person counseling sessions. 

Each counseling session is 60 to 90 minutes long, and during Medicare open enrollment season, we are very busy. 

Sometimes people come in with specific questions about their 

coverage, and other times we are starting with the basics. It is 

common for people to make Medicare coverage decisions based on 

the well-intentioned advice of friends, family, or other places. What 

AGING-G33-GPO with DISTILLER

11 

I have learned during my time as an APPRISE volunteer is that 

people do not have all the information they need to make the best 

decisions for their health care or financial needs. 

Making a bad decision when signing up for Medicare can have 

unintended, lifelong consequences. When I see people with gaps in 

their coverage or seniors paying lifelong penalties, it is often because of misinformation. Knowledge is important in helping beneficiaries maximize their benefits and avoid the pitfalls of lifelong 

penalties. 

Thankfully, as an APPRISE volunteer, I am trained to help those 

that are having trouble with their Medicare due to misinformation. 

We can liaison with organizations to appeal a decision or screen 

people for programs that help cover the cost of their medications. 

APPRISE counselors not only provide information, they help beneficiaries navigate a complex system and serve as advocates. We 

also find that once people come to APPRISE for help, they come 

back each year to be sure that their coverage is right. 

People’s lives are changing, and they need to be educated or they 

will fall through the cracks. It is because of this that I tell everyone 

I meet about the program. APPRISE counselors do not make Medicare decisions for beneficiaries. We instead provide them with information so that they are able to make the best choices for themselves. 

Again, I thank you for the opportunity to testify before the Committee, and I look forward to answering any of your questions. 

The CHAIRMAN. Thank you very much, Mrs. Hill. I think you just 

gave a compelling case for why it would be a mistake to implement 

the administration’s proposal to eliminate altogether the SHIP program. And I am pleased to say that that has been rejected by the 

Appropriations Committee on which I serve. And if anyone needs 

further proof, I am quoting your testimony. 

[Laughter.] 

The CHAIRMAN. Dr. Ayati, I want to start with you. You gave a 

very compelling statistic about the number of seniors, more than 

forty percent, who take at least five prescription medications plus 

over-the-counter supplements and herbal remedies. And this obviously can lead to overmedication, but also something that I understand is called ‘‘drug cascade syndrome,’’ in which the side effects 

result in yet another prescription for the senior. 

I met last year with a physician in Maine who is doing house 

calls on seniors, and the first thing he has them do is bring out all 

the prescription drugs and over-the-counter remedies that they are 

taking. And in every case he has been able to reduce the number. 

It really was extraordinary. He did before and after pictures of the 

number of bottles of pills, and it was incredible. 

So elaborate a little bit more for me on why this problem exists 

and why there is not better coordination among all of the specialists that a patient may be seeing. 

Dr. AYATI. That is a great point. Thank you so much. 

I believe the biggest problem for older adults these days is exactly as you said—polypharmacy/overmedication. The first reason, 

which I think is just all of that, when we come to the conclusion 

for everyone turning 65, I like to decide if the package about their 

benefit of Medicare, we should give them some basic information 

AGING-G33-GPO with DISTILLER

12 

to be careful about polypharmacy in the future, because as we age, 

the risk of chronic disease is going to be higher, and then there is 

going to be more chance that we get medication. 

One of the reasons is because of the way that we train our students, the way we train our doctors. We actually have 16,000 physicians that have been trained in our medical schools in the U.S., 

and the way we train them—which I also have been trained in the 

same way—we wanted to not disappoint our patients. We want to, 

when the patients come to our office and they have a problem— 

that is what I said about robotic mentality. Quick fix means that 

there should be a medication to fix the problem. 

We forget sometimes to discuss pros and cons of treatment intervention, talk about side effects and adverse drug events that can 

happen. As we discussed, the physiology is changing, and as we 

age—and this is not happening when we are 60. It is happening 

when we are even 20, 30. Every decade our physiology is changing, 

and we become more susceptible to adverse drug reactions. 

One thing that has happened is that, again, the patient and doctor, they are expecting. The reason patients go to the doctor’s office 

is because, ‘‘Finally I am going to get a medication.’’ And then 

when they come out from the doctor’s office with that medication, 

they take it, there is no follow-up, because one of the big problems 

is that we do not explain therapeutic endpoint for medication. I 

give you this medication because I wanted to reach this therapeutic 

endpoint, and if you do not, we need to stop that. I cannot tell you 

how many times I have been in the public places and just discuss 

about this topic, and a lot of people, when I ask them, said, ‘‘I take 

18 kinds of medication, and I do not know why. I do not know why 

I am taking this medication because the doctor just prescribed it 

for me, and I just keep asking pharmacy to refill it for me.’’ 

Now, patients do not know, and the physicians also, they do not 

follow that. We have some of the programs encouraging the doctors 

and hospitals to do medication reconciliation, which is going 

through the list and making sure that they are taking all these 

medications or not. But I think we should have another conversation. We should really go at one point and tell the patients that you 

have to, every visit when you get your annual wellness with your 

Medicare with your doctor, review all the medication. And if you 

are not really a candidate to continue this medication, do not. 

Many times I have 90-year-old patients that is only bone and 

skin on the bed, not able to eat, and they give a high-dose cholesterol medication. When I am calculating, the cholesterol medication 

is for preventing a stroke in 5 and 10 years. I am calculating myself, what am I treating for? Why am I giving cholesterol medication to somebody that is not even able to take a sip of water? And 

we just keep refilling this medication. 

I am glad that I have this opportunity. Many times I have a hospice patient that has a prognosis of less than six months or maybe 

two weeks. They are crushing vitamins and supplements in applesauce, and the person is not able to swallow, and we are force-feeding with a spoon to the mouth of these people. Why? This needs 

to be changed. We need to bring first public education, asking all 

the people when they start turning to Medicare to have this information. You need to discuss about your medication. And the next 

AGING-G33-GPO with DISTILLER

13 

thing, go to a medical school and train the doctors that it is OK 

if you tell your patient that maybe a strategy of watch and wait 

is the best strategy rather than jumping to prescribe another medication for that. 

The CHAIRMAN. Thank you very much for that thorough answer. 

I have many more questions, but I will save them for the next 

round. 

Senator Casey? 

Senator CASEY. Thank you, Madam Chair. 

Sharon, I will start with you, and I am using your first name. 

I hope you do not mind. 

Ms. HILL. Fine. 

Senator CASEY. We are pretty formal around here, but if you are 

from Pennsylvania, I think it can be informal. But I want to thank 

you for being here and for your testimony. You can tell—this is 

probably the first time you have ever testified. You not only did it 

well, but you already got action. Senator Collins is already working 

on something based upon what you said. It is a great country, 

right? 

Ms. HILL. Yes, it is. 

Senator CASEY. But thanks so much, and I was talking before 

about the legislation I have, the BENES Act, and I was struck by 

a lot of what you said, but in particular, one line jumped out at 

me. You said in your testimony, ‘‘People have a lot to consider 

when signing up for Medicare, and the decisions can be daunting.’’ 

And that is a pretty good summation of one of the points we are 

trying to make today. These are difficult decisions. We are hoping 

we can pass the BENES Act so we can prevent common Medicare 

enrollment mistakes. 

Maybe if you can elaborate a little bit more on your experience 

with engaging with people that are trying to make these decisions 

and the need for clear and easily accessible information to make 

those decisions. Can you tell us a little bit more about that? 

Ms. HILL. I think one of the funniest things that we run into are 

when couples come in to do their Medicare, and they think that 

they have to agree on a plan for each of them. And when they find 

out they can each get their own plan, they think you have given 

them, you know, another piece of candy, because they are really 

happy about that so that they do not have to limit somebody’s medical information because somebody else needs more pharmaceutical. 

And a lot of the things when you come in, sometimes they do not 

think they want any pharmaceutical or Part D insurance because 

they do not take any medicine. And, you know, you try to explain 

to them that you have got to put something in there because if not, 

down the line if you ever do get medication, you are going to pay 

a lifelong penalty on top of your medication. 

And then there are decisions. In western Pennsylvania, we have 

got the two factions going on. We have the UPMC and Highmark, 

and you have got to walk people through that distinction, too. Do 

you want this or do you want that? And this doctor or this hospital 

that you used to go to does not handle this company anymore, so 

we need to get you—you know, which do you want to choose? And, 

you know, make that decision. 

AGING-G33-GPO with DISTILLER

14 

So it is not as simple as going in and saying, ‘‘I am 65, just give 

me something to use,’’ because a year of the wrong program can 

leave you in a lot of medical distress and bills. 

Senator CASEY. That word ‘‘navigate’’ that you and others have 

been using is an apt description, I think, of what some are up 

against. 

In the remaining time I have in this round, Sharon, I wanted to 

ask you as well, where you said in your testimony knowledge is important to avoid the pitfalls of lifelong penalties. The reality for a 

lot of people is they are paying penalties. I said before our constituent service people hear about this all the time across Pennsylvania, and I know you have seen it up close. 

Can you share with us why it is important for seniors to have 

access to not just information but unbiased information provided by 

an APPRISE counselor? 

Ms. HILL. Certainly. If someone comes in to one of our training 

sessions and they say, ‘‘I got this letter, and it says I have a penalty,’’ well, your heart just sinks because you know there is going 

to be a problem. And, you know, they end up being in a pickle, 

more like somebody in a canoe without a paddle, because sometimes when people say ‘‘penalty,’’ they think, ‘‘Oh, OK, I owe my 

$10, and then I am done.’’ What they find out is it is a lot more 

than $10, and it is every day for the rest of their life. So I do not 

think that part of it is emphasized enough in the information that 

we have right now. It is just listed as a penalty. I think it definitely needs to say ‘‘long term’’ so that they would know. 

Also, the problem with the prescription penalties is that if they 

are not taking medication, they do not see a need for a prescription 

plan. But then all of a sudden, 10 years later they are taking a 

heart medication. Now they have got heart medication medicine, 

which is expensive, and then lifelong penalties on top of it. So it 

becomes very frustrating. 

The best that we can do when we have someone like that come 

to us is to try to backtrack to see if we can find, you know, did Social Security, did Medicare, did the people’s H.R. department— 

where was there a breakdown in the information? So that sometimes we can go back and see if we can get maybe a lower penalty 

or on rare occasions no penalty. But it is a long process and a difficult one that people find themselves in. And it is very sad. 

Senator CASEY. Well, thank you very much for that. That is the 

real life of it. Thank you. 

The CHAIRMAN. Thank you. 

Senator Cortez Masto? 

Senator CORTEZ MASTO. Thank you. Welcome, all of you. Thank 

you so much for being here. And I am going to start with you, Mr. 

Borland. I noticed you were taking notes, and that was my first 

question because I think Mrs. Hill is really—it is important to get 

her feedback because she is on the front lines interacting with seniors and talking with them. And to me, the first step in all of this, 

obviously, is the awareness and education. But if what we are providing to them is not enough information for them to make an intelligent decision, then we are missing out on providing that educational piece. 

AGING-G33-GPO with DISTILLER

15 

So my first question is to you. A couple of things. One, thank you 

so much for having the online My Social Security Account that people can access and gather that information. I noticed you also talk 

about doing outreach through telephone, face-to-face, field office, 

community gatherings where you are going out into the community 

to talk with individuals, libraries in rural communities, everywhere. But to what extent do you coordinate with the states? I 

know in the State of Nevada we have a Division of Aging Services, 

and they do a lot of outreach and education. They work with people 

like Mrs. Hill. In my state, how do you coordinate with them to 

make sure that we are leveraging those additional resources to get 

the educational information out, at the same time getting feedback 

on what we should be putting out there to make sure that our seniors have the most important information they need? 

Mr. BORLAND. Thank you for that question, Senator. I was listening to Mrs. Hill speak and thinking how fortunate we are to have 

people like her who are dedicating a portion of their lives to helping the Social Security Administration be more effective in ensuring that seniors have access to health care. I can tell you from personal experience that our claims specialists do many, many, many 

referrals to the State Health Insurance Assistance Programs because at Social Security, while we are responsible for enrolling people in Medicare, for explaining the consequences of not taking Part 

D, not enrolling in a prescription drug plan, we can only go so far. 

We are not in a position to assist folks with selecting a plan. What 

plan is best for them, what medications, that is not part of our conversation. We can explain why you should coordinate Part B if you 

have an employer-provided health insurance plan. But our role is 

not to help you choose a plan. 

We do, I will say, thousands of referrals to the State Health Insurance Programs every single week, and I can talk a little bit 

later about some of the work we are doing with NCOA and CMS 

to improve access. 

Senator CORTEZ MASTO. Are there additional resources that we 

can help you obtain that can make sure you are doing a better job 

or more interaction at the state level with individuals on the front 

line? Is there more that we can help you with what you could be 

doing? 

Mr. BORLAND. So I think that we have strong coalitions. For example, with the National Council on Aging, every year when we 

send our low-income subsidy notices out to those who may be eligible for a subsidy in paying their Part D premiums, we provide that 

information broken down by Zip code to NCOA who provides it to 

the SHIPs so that they can do specific outreach. They know where 

folks are. They know what their service demand volume is going 

to be. We have strong partnerships. We can always strengthen 

those partnerships. 

Senator CORTEZ MASTO. Yeah, I guess my concern is—and I am 

running out of time, so I will wait until the next round, but, Ms. 

Cha ́vez, I am going to ask you to weigh in on this. That first contact is so important, and I think if we lose people by passing them 

off, we should probably figure out how we stop that opportunity 

where we lose people in that gap. That first contact to me is the 

key, and how do we keep them involved instead of passing them 

AGING-G33-GPO with DISTILLER

16 

to the next—I do not know—state agency or whoever. And, Ms. 

Cha ́vez, do you have any comments on that? 

Ms. CHA ́ VEZ. Sure. I think, again, that is why it is so important 

that the Senate bill that Senator Casey has introduced is all about 

consumer education, really alerting people that this deadline is 

coming. Although turning 65 is a great opportunity, there is also 

some responsibility an individual has to take. 

What I have also noticed is that it is critical—and we have done 

this for decades—is not only working with the federal agencies but 

also working with other community-based organizations across the 

country who are in communities and know these individuals who 

may need extra help. So, for example, we run benefit enrollment 

centers where, again, we train volunteers, staff members at local 

organizations to actually walk people through sometimes very complicated federal programs. And what we have found is there is a 

need for both. There is a need for education from the federal agencies directly into their mailbox, or Facebook, because a majority of 

seniors are on Facebook every day. And so how are you communicating to seniors in a way that they want to be communicated to 

through the federal agency avenues, but also funding and supporting local community-based organizations to do the one-on-one 

training. 

The CHAIRMAN. Senator Warren. 

Senator WARREN. Thank you, Madam Chairman, and thank you 

for holding this hearing. Very important. You and the Ranking 

Member come up with good things for us to talk about. 

Now, two days ago, Congress passed a short-term budget that 

will keep the Government open for another three weeks. I believe, 

though, we need to look beyond the bare minimum and to stop 

lurching from crisis to crisis just to try to keep the lights on. 

This is a moment for us to be able to focus on our core values 

and to choose carefully about what we invest in. And I, along with 

members of this Committee, believe that government should invest 

in our seniors. And that starts with making sure that the Social 

Security Administration offices are fully funded so that seniors can 

get their hard-earned Social Security checks when they turn 65 

and when they enroll in Medicare. 

So, Mr. Borland, you are the Acting Deputy Commissioner for 

Communications for the Social Security Administration. SSA has a 

budget for staff and other resources. Can you just say a word about 

what the Social Security Administration does with that money? 

Mr. BORLAND. Thank you, Senator Warren. I would be happy to. 

We have over 1,200 field offices across the country. We dedicate 

over fifty-six percent of our entire budget to staff, that is, folks who 

work in field offices, hearing offices—— 

Senator WARREN. But could you say a word about what they do 

for seniors? 

Mr. BORLAND. Sure, I would be happy to. So on any given day, 

someone walking into our field office may be coming in to file a retirement claim or a combination retirement and Medicare claim. 

They may be coming in to file for disability benefits, to get a replacement Social Security card. If they are already receiving benefits, disability benefits, they may be reporting their wages, which 

can impact their benefit amounts. 

AGING-G33-GPO with DISTILLER

17 

We are doing program integrity reviews to ensure that people are 

still eligible for benefits on a continuing basis so that we do not 

create overpayments. 

But we are also—and I think this is something that is less understood—we are providing a tremendous amount of information 

and counseling in a way. People have lots of questions about Social 

Security, and our front-line staff are very knowledgeable, very well 

trained, and they interact with the public every day to ensure they 

are making informed decisions. 

Senator WARREN. So that is powerfully important. People have 

rights, and you make sure that they get what they are entitled to. 

It is clear to me that the Social Security Administration’s work is 

very important and that the field offices are critical to making sure 

that Americans get the benefits that they are entitled to. But cuts 

to the Social Security Administration budget in recent years have 

resulted in staff shortages, field office closures, and longer wait 

times. 

So, Mr. Borland, despite years of underfunding, Senate appropriators have proposed a more than $400 million cut to the Social Security Administration budget for this year. Now, that is nearly four 

percent of your budget. Can you just say a brief word about how 

those cuts would affect seniors who are applying for benefits? 

Mr. BORLAND. So, first of all, I would like to say that at the Social Security Administration we believe that if we receive the President’s fiscal year 2018 budget request, we will be able to address 

the agency’s priorities. But to give you a couple of examples, how 

does budget impact the service that we provide? For every $100 

million, that will buy you 826,000 retirement and survivor claims. 

That is taking the claim, adjudicating the claim, and making the 

payment. It will buy you 51,000 disability hearings. 

Senator WARREN. So let me just multiply that by four, since 

those are the numbers we have got here. We are looking at around 

200,000 hearings for Americans trying to get their disability benefits and more than 3 million claims processed for retirement benefits for seniors. Is that right on the numbers? 

Mr. BORLAND. That sounds exactly right. 

Senator WARREN. Well, thank you, Mr. Borland. You know, here 

is how I see it: Social Security and Medicare are contracts that we 

make with each other. Americans have paid into Social Security 

and Medicare on the understanding that the government would be 

a good steward of their money and that they would have the protection available when they need it. The government cannot be a 

good steward of Social Security and Medicare if it does not have 

the money to run the Social Security offices. 

You know, this one should be easy. I believe we should increase 

the funding for the Social Security Administration so that you have 

the resources that you need to make sure that our seniors get the 

benefits that they have earned. Thank you. 

Thank you, Madam Chair. 

The CHAIRMAN. Thank you. 

Senator Jones? 

Senator JONES. Thank you, Chairman Collins. 

I have a couple of things just to go briefly. Ms. Cha ́vez, I was 

especially struck by testimony giving the statistics about the chalAGING-G33-GPO with DISTILLER

18 

lenges of women of color and Hispanic women, seventy percent, 

sixty percent. Obviously, that is because of the pay gap, which, if 

it had been worked on years ago, that would not be a problem. But 

the fact is we are where we are. 

And I know that we have to be concerned with the budgets for 

Medicare and Social Security and other things, but is there something that can be done from the federal policies, knowing that 

these women have often no choice—or I would say very little 

choice, they are either caregivers, they drop out to raise their children, all of which contribute to society in so many other ways. Is 

there anything that you can suggest from a federal policy standpoint that might help level the playing field for those who are taking on significant important jobs—and they are jobs. You can ask 

any one of them. They are probably more challenging than anybody 

sitting up here right now. Anything we can do to help level that 

playing field so that those people cannot be punished for doing 

their duties? 

Ms. CHA ́ VEZ. So, Senator Jones, I wish we could have another 

hearing just on this subject because the data is overwhelming. It 

is actually bigger than the pay gap. It is a wealth disparity issue. 

It impacts girls and women throughout their lifetime. 

I think from a federal policy level, it goes to how we educate 

women, how we ensure that employment rules and regulations are 

followed. But I also want to say that by reinforcing the aging sector, by looking at all the human services that impact seniors, you 

are actually going to impact women in a very terrific way. Interestingly enough, as we were looking at our data around the programs 

that we administer—for example, we run the National Institute of 

Senior Centers, and we looked at thousands of senior centers 

across the country and daily activities, and we found out that more 

than seventy-five percent of people who go to senior centers on a 

daily basis are women. We looked at our BenefitsCheckUp. It is a 

free, online system where you simply go on and put a few data entries about your Zip code, female/male, and we found that of the 

millions of people we serve, the majority of the people on the system are women. Either they are checking their benefits or they are 

caregiving their spouse or their children. 

So, again, I think that because aging disproportionately impacts 

women, anything we can do to reinforce these systems is incredible. 

I will say—perhaps the gentleman to my right could not say it, but 

I think any federal funding cuts to the Social Security Administration, for the Administration on Community Living, will have a disproportionate impact on women and children in families living with 

seniors across this country because, again, as I hear from my partners across the country that are running non profits, who are running state units on aging, their systems are overwhelmed and overburdened. And as we know, although we appreciate the federal 

laws that were put in place 50 years ago, they have not really been 

reformed in decades. 

So I welcome the opportunity to work with this Committee to figure out a way how we would leverage the experience that we have 

gained over these few decades, but also how we reinforce those connections between the federal, state, and local community organizations that are doing great work. 

AGING-G33-GPO with DISTILLER

19 

Senator JONES. All right. Well, thank you for that. 

Senator Collins, Madam Chairman, I would respectfully suggest 

that might be a pretty good topic for this Committee at some point 

in the future. So thank you so much for that. 

Dr. Ayati, just briefly in the time that I have got left, I understand and can relate to the challenges faced. Over the last year or 

so, I have faced many of those with my aging parents, and we are 

fortunate in Birmingham to have a fair amount of resources available, but it was still a challenge. But Alabama in particular also 

has a very rural population, and rural health care delivery in Alabama is challenged in and of itself, much less to the aging population. 

Do you have any suggestions of what we can do that might address the challenges specifically to our rural segments of this country? 

Dr. AYATI. Thank you so much. It is a great question. It actually 

is one of the biggest challenges that we always discuss, especially 

in our area. 

One of the models that has been suggested is that we actually 

utilize the resources that we have right now for rural areas. For 

example, we are having a lot of things in technology today. We can 

use telemedicine, which actually Medicare even approved for reimbursement for telemedicine for rural areas. But one of the suggestions is we expand geriatric consultation for these areas. We have 

wonderful primary care physicians that work in rural areas, but 

the problem is that the patients need a second opinion because 

they are frail, they have a lot of geriatric syndrome, but there is 

not any expert to help them. 

Definitely some sort of satellite program, telemedicine, virtual 

care, these kinds of models which, again, in a lot of areas they are 

using right now have been very helpful. And I think that the more 

we invest in that, we are able to have one physician that is taking 

care of the patient but always have a backup. One of the issues 

that we have here, which I think just goes more toward Government, is reimbursement for this model. The fees that we are currently paying for geriatric consultation in telemedicine does not 

make it satisfactory for the health care system to invest more 

money on it. If we have a better solution for that, definitely there 

is going to be a lot of encouragement for medical centers to expand 

this program, which is going to be very, very crucial. It is going to 

be a huge benefit for all the—because as you mentioned very well, 

many of the aging population, actually they live in rural areas in 

the United States. It is not only about Alabama. And that is why 

we can have this service and expertise for them to have the second 

opinion and, again, help them through that. 

Senator JONES. Well, great. Thank you. I also would like to mention—and I know my time is up—the telemedicine leads to another 

issue that we have in rural America, and that is access to 

broadband. So that is something we are going to be working on as 

well. 

Thank you, Madam Chairman. I appreciate the opportunity. 

The CHAIRMAN. Thank you very much, and that is a great leadin to my next question for Mr. Borland. 

AGING-G33-GPO with DISTILLER

20 

It is wonderful that the Social Security Administration has developed so many online tools that can help our seniors, but the fact 

is, in a state like mine, there are large sections of the state that 

do not have access to broadband services on the Internet. And 

there are also seniors who simply do not have computers in their 

homes and are not familiar with it. 

Finally, I would suggest that there are seniors who are much 

more comfortable with a face-to-face interaction than they are 

going down to their local library and trying to figure out how to 

access Social Security information online. 

We had an office closed in Rumford, Maine, which created real 

hardship for a lot of the people living in that community because 

the nearest Social Security office was in Lewiston. And in the winter that is quite a drive for seniors to have to make, and they were 

just uncomfortable. 

So what can you tell us about how Social Security is trying to 

reach rural seniors who may not have computers at all? Again, I 

think your online services are excellent, but they do not reach everybody. 

Mr. BORLAND. Thank you, Senator Collins, and you are right. We 

have to make sure that we have the services that we can deliver 

to all Americans, whether they live in urban areas or live in rural 

areas, whether they have Internet access, broadband access, or not. 

We have a commitment, a longstanding commitment to our field office structure. We have 1,200 offices around the country, including 

many in rural areas, small cities and towns across America. We 

have our 800 number. Certainly that is a lifeline for many people 

in rural America that have service delivery needs or have questions 

for Social Security. 

But we do not stop there. The part of the agency that I represent, we are responsible for outreach. We are responsible for communicating with the public. I think any of you who live in rural 

areas or have lived in rural areas know that weekly and monthly 

newspapers are a lifeline, that radio is a lifeline in rural communities. Our public affairs specialists work with local media. Many 

of our public affairs specialists have weekly radio shows where they 

talk about services and benefits; they talk about when to claim 

benefits. They talk about Medicare enrollment and the importance 

of enrolling in Medicare before you are 65. 

So we are using some of the more traditional means of communications to ensure that we reach rural America, but we are not 

stopping there. Also, you mentioned libraries. Not all seniors are 

comfortable using a computer at the library, but many are. That 

is why we have the SSA Express program where we partner with 

libraries to provide one-click access to our online information and 

services. 

The CHAIRMAN. Thank you. 

My next question is for both Dr. Ayati and for Ms. Cha ́vez. Doctor, I was so intrigued in your written testimony by your phrase 

that, ‘‘We live in an anti-aging society,’’ because I think this is a 

key issue in addressing isolation, in addressing how we treat our 

seniors, in keeping them engaged. And I would like both of you to 

address that issue. 

AGING-G33-GPO with DISTILLER

21 

What advice do you have for older Americans and their families 

so that we can counter this pervasive anti-aging feeling in our society that sometimes leads to our seniors being devalued or pushed 

aside? And, Doctor, I am going to start with you because you have 

lived in two different countries. You were trained in Iran, and you 

now live in the United States. So I would be interested if you see 

differences in those societies. But, in general, please comment, and 

then, Ms. Cha ́vez, I would like to hear from you, too. 

Dr. AYATI. Thank you, Chairman Collins. I am always asking 

this question for myself as a physician being in a Third World 

country and traditional society and then practicing here, why older 

adults in this countries, even there are—they do not have access 

to medical field. They do not have access to nutrition supplements, 

all vitamins that we have here, why they are physically and mentally doing better, but very interesting observation. These people, 

when they migrate to United States, they actually are going to get 

worse. They are starting to have depression or cognitive impairment. And I see it every day. Especially I practice in the State of 

California with a lot of immigrants actually living there, why this 

going to be changed? 

And, again, as you well mention, it is mentality. We are very obsessed about youth, and this culture is going from—from the beginning, I am always criticizing—or maybe I am doing as well, this 

is the wrong thing, that we teach our children that there is something wrong with aging, or aging is the microbe or the germ that 

we have to avoid that. 

When I go to every place shopping, I see the sign of anti-aging 

supplements. It makes me very nervous because I just tell my son, 

who is 4 years old, if I show it to him, that now your Dad is aging, 

it means something wrong with him. 

We should just the word of fighting with aging. I see a lot of time 

when they are trying to do public education, it says we have a seminar about fighting with aging. There is no fighting with aging. 

Fighting with aging, we are likely fighting with nature, with the 

solar system. We cannot fight with it. We need to adapt to aging. 

It is a process, starting from beginning of life. If you start this culture, which has changed the dialog in the community, in the society about aging, then we can accept the aging. That is why I have 

a very educated Ph.D. patient that, when he comes to me and asks 

me for depression treatment, he said, ‘‘Every time when I apply for 

a job, I have to dye my hair, and I do not reveal my age, because 

I have more experience and they are not going to pay me, and they 

actually’’—‘‘and they tell me that because I am aged, I am not innovative.’’ Who said aging people are not innovative? 

We actually have many studies that show as we age, our social 

skills improve, or why they are actually doing better, and we have 

many a study—not in United States, in Germany, BMW or Benz 

company, they actually had the study about older laborers versus 

younger laborers. The older laborers in the line of the production 

of the BMW, they actually do better, more productive, less mistakes. 

We need to change this dialog. When we change this dialog, older 

adult people do not feel frustrated, fear of aging. When we have 

this dialog change, then we can help this aging population to not 

AGING-G33-GPO with DISTILLER

22 

focus on negative things; stay on positive. And then we can have 

these things going to be changed. 

Just one comment. I have the same problem with my students 

and nurses to encourage them to work in aging field, because when 

we look at the media, the picture of the doctors or nurses, our heroes in the TV series, they are in scrubs, they have ten pagers, 

they are all body builders, and they are just—— 

[Laughter.] 

Dr. AYATI. This is the picture that my students see, and when 

I ask them to come work in nursing home, they say, ‘‘I do not like 

to come here. It just smells very bad. I have to take care of many 

old people there.’’ And the same with the young nurses. But this 

is not medicine. The people went into medicine because they have 

a passion to help these people. That is the philosophy of medicine. 

But we are changing. I think we need to definitely change for 

public education media, and then we will start from—I am sorry 

I have been a little bit over time. 

The CHAIRMAN. Thank you. 

Ms. Cha ́vez? 

Ms. CHA ́ VEZ. I enjoy sitting next to the doctor who is clearly passionate about this subject. It is wonderful. 

I have the same philosophy, actually. When I was running the 

state unit on aging in Arizona a few decades ago, people would look 

at me and they would say, ‘‘You are too young to be running a state 

agency on aging issues.’’ So I used to wear this button. It said: 

‘‘Aging: If it is not your issue, it will be.’’ 

[Laughter.] 

Ms. CHA ́ VEZ. Because for me it is a rite of passage, and in my 

culture as a Latina, seniors are the epicenter of our universe, so 

for me it is just something you do. But I would say three major 

things at NCOA we tell people to think about. 

The first is really think about your financial plan. For women, 

again, even more important. Start thinking about it now. Even for 

women and young men in college, start putting away for that 

longer retirement you are going to have, that bonus 20 or 30 years 

you are going to have at the end of life. Also, understand the benefits that are coming to you at that point in time, because there are 

ways of really leveraging those benefits. 

The second is engage in healthy behaviors. Doctors and scientists 

will tell you that the things you do in your 20’s and 30’s actually 

can have a great impact on what you will be able to do in your 60’s 

and 70’s. And if you look at my father, who is 89 years old and 

doing 200 push-ups a day, nobody can tell him that aging is a bad 

thing. It is a great thing. And so start doing great things now with 

your body, both mentally and physically. 

And, third, stay active and engaged in your community. Find a 

passion, something you are truly, truly excited about that gets you 

up every day. You know, having been in the field working on these 

issues for decades, I will tell you the number one reason seniors 

are able to get over a fall, or are able to get through chronic disease, is they have something other than disease that they are focused on every day. And so I encourage everybody to always think 

through, just as we say in our Aging Mastery Program, what are 

you grateful for? Because every day is a gift. And how are you 

AGING-G33-GPO with DISTILLER

23 

going to use that gift of time, not only wisely but for the better 

things in life? 

The CHAIRMAN. Thank you very much. 

Senator Casey, feel free to take some additional time, as I did. 

Senator CASEY. Madam Chair, thank you very much. 

I want to start with just something for the record. I would ask 

consent on two matters—two letters, I should say. The first letter 

was organized by the Medicare Rights Center. It is from more than 

75 national and state organizations urging Congress to pass the 

BENES Act. That is one. And the second is from former administrators of the Medicare program from both Democratic and Republican administrations who also support the bill. So I would ask consent, Madam Chair, to submit both letters to the record, one dated 

December 19, 2017, and the other dated August 22, 2016. 

The CHAIRMAN. Without objection. 

Senator CASEY. Thank you, Madam Chair. 

I also want to express support for two statements made here 

today, the first by our Chair with regard to the cuts the administration would propose or have proposed with regard to the so-called 

SHIPs program that allows us to have programs like the APPRISE 

program that Sharon has done such good work on. So, Madam 

Chair, I appreciate your saying that here today, and I certainly 

support that. 

And Senator Warren’s call for the Social Security Administration, 

we want to make sure that those kinds of cuts do not become the 

norm and do everything we can to prevent those cuts. 

I will go there with Mr. Borland. You have been asked a couple 

times today about the work that your team does, and we can, as 

you have, and we should cite efforts you have already undertaken 

and will continue to undertake, all of the outreach that you do, and 

we appreciate that. 

I hope, though, that when—maybe I will ask two questions. One 

is—I will make a statement and ask a question. The first is I hope 

if you think you need more resources, you or someone in your agency would tell us. I know that in every administration—I am not 

saying this just focused on this administration. Every administration instructs people sometimes not to say much, not to advocate 

for more resources. I do not know if that is the case here, and I 

do not want to make that charge. But I hope—I hope—that if you 

need more resources, you would come to the Congress and express 

that. 

I know what it is like to criticize agencies. I was for two terms 

Pennsylvania’s auditor general. I kicked the hell out of a lot of 

state agencies with tough investigations that really were critical of 

people and their work in the agencies. I did a lot of audits that 

criticized how state government agencies work. They never wanted 

to hear from me. 

But I also tried to couple that criticism and critique our investigation or audit with recommendations for how to improve, how to 

improve the work that you do, and sometimes that comes down to 

money. Sometimes you cannot fix a problem without the resources. 

You can be efficient, you can be effective and all that. I get that. 

I do not need anyone to tell me about that. But sometimes you 

need to ask for more dollars. I am not asking you to do that today. 

AGING-G33-GPO with DISTILLER

24 

I do not want to get you in trouble. But I hope that you would come 

to us, and not just to appropriators, but maybe especially to appropriators when you need more resources. 

So I guess, Mr. Borland, here is the question: How does the Social Security Administration make sure that people are prepared to 

sign up for Medicare? And if you want to reiterate some of what 

you have already said, I think it bears repeating. But maybe the 

more important question is: What initiatives or partnerships are 

underway right now at the Social Security Administration to 

strengthen the communications that you undertake and to prevent 

the misinformation that sometimes leads people to make decisions 

or fail to make a decision that can hurt them down the road? 

Mr. BORLAND. Thank you, Senator Casey. Let me talk first about 

some of the efforts that we are currently making. I have certainly 

talked and made a pitch for My Social Security Accounts. For 

Americans who do not have a My Social Security Account, they are 

missing out on an opportunity to learn an awful lot about the benefits that they may become entitled to in the future, including, yes, 

retirement benefits but obviously also survivor’s benefits for their 

family, disability benefits, but also Medicare. And as I mentioned 

earlier, we mail a Social Security Statement with an insert to everyone 60 years and older every year, until they claim Social Security benefits. 

In that insert very prominently displayed—the insert is entitled, 

‘‘Thinking of Retiring,’’ but very prominently displayed is a note, a 

reminder: ‘‘Make sure you sign up for Medicare three months before your 65th birthday.’’ That notice goes out at age 60, at age 61, 

at age 62. It is certainly a message that bears repeating, and we 

certainly repeat it. That is a primary way that we communicate to 

individuals who are not receiving Social Security benefits that they 

need to sign up for Medicare at 65. 

But I want, I think more importantly, to talk about some things 

that we are working on. Literally just three weeks ago, I sat down 

along with my counterparts from Social Security, from Policy, Communications, the folks that run our 800 number, across the table 

with the folks from CMS. We think there are great opportunities 

for strengthening the partnership between the agencies to prevent 

unnecessary hand-offs and to increasingly serve the public at the 

first point of contact. 

Senator CASEY. Well, I appreciate that. I know I am over time. 

I will just wrap up with this. The point that has been made here 

about even if you are making all of those efforts, there is a gap because of lack of broadband access and high-speed Internet, that is 

one of the many reasons why we have got to get to an infrastructure bill around here or something that would focus on broadband. 

Many people in the Senate, including Senator Gillibrand, who is 

here, have worked on these issues for years, but we have not gotten 

to the point where rural America has the kind of connectivity it deserves. Something on the order of thirty-nine percent of the people—not the places, the people—who live in rural America have no 

high-speed Internet. Thirty-nine percent of all the people living in 

rural America. So if there was ever a time to push for it, now is 

the time. 

Thanks very much. 

AGING-G33-GPO with DISTILLER

25 

The CHAIRMAN. Thank you. 

Senator Gillibrand, welcome. 

Senator GILLIBRAND. Thank you. I did not expect to—— 

The CHAIRMAN. If you would prefer that—— 

Senator GILLIBRAND. No, I am ready. I just did not want to bump 

her. I thought she had not gone yet. 

As the number of individuals eligible to claim Social Security 

benefits is rapidly rising, it is more important than ever that we 

ensure the Social Security Administration is fully funded and capable of providing the essential services older Americans need. SSA 

sites are being forced to close across my State of New York, making 

it inaccessible for seniors to get the benefits that they have earned 

and worked hard to pay into. 

Mr. Borland, can you tell us what steps SSA is taking to keep 

up with the growing demand for its services and how SSA will ensure that the quality of its services will not decline as it serves so 

many individuals? 

And, second, the Social Security Administration provides critical 

information to millions of individuals figuring out when to claim 

Social Security every year. Can you tell us a little bit about some 

of the issues surrounding claiming benefits that seem to confuse 

people the most and what topics it is most apparent people could 

use more information? 

Mr. BORLAND. Thank you, Senator. I would be happy to. Let me 

first talk about some of the areas where people have a lot of questions when they come into our offices. Probably the most important 

information that we provide folks is the basic fact that the longer 

you wait to claim benefits, the higher your benefits will be for the 

rest of your life. There is some confusion around early retirement 

age, full retirement age, and the impact of delayed retirement credits at age 70. 

But the basic message that we deliver to every person that asks 

us, whether it is over the Internet or via the 800 number or in a 

field office, is the longer you wait, the higher your benefit amount 

will be for the rest of your life. And that is a point of confusion. 

Others include that your benefits are based on your 35 highest 

years of earnings. Many people think that it may be your highest 

three or your highest five. It is your highest 35 years of earnings. 

Why is that important? Well, if you have 30 years of earnings or 

33 years of earnings, you are going to have zeroes instead of an 

earning amount in those years. It may encourage people to work 

a few more years, to fill in those zeroes and potentially boost their 

benefit amounts, again, for the rest of their life. 

Senator GILLIBRAND. Medicare beneficiaries rely on SHIP counselors for unbiased, one-on-one Medicare counseling. In New York 

we call the SHIP the Health Insurance Information Counseling and 

Assistance Program, or HIICAP. In 2007, SHIP counselors provided 

one-on-one counseling to nearly 130,000 individuals and held more 

than 3,000 educational presentations in enrollment events across 

New York. Many say that 1–800-Medicare is a sufficient source of 

information for beneficiaries, but I have heard from many New 

Yorkers that SHIP is essential for them to get access to benefits. 

AGING-G33-GPO with DISTILLER

26 

Ms. Cha ́vez, could you share with us the importance of SHIP 

counselors as a source of unbiased information beyond the 1–800 

number? 

Ms. CHA ́ VEZ. Thank you, Senator, for that question. Absolutely, 

we are a very big supporter of the SHIP program. We clearly know 

that it is going to take many different points of contact with the 

senior to ensure they really understand their benefits. We administer the Center for Benefits Access through a grant from the Federal Government, and so we physically put benefits counselors in 

the field to assist seniors. 

But we also know that there are other volunteers through other 

programs that we need to work with. So we are very glad on a 

daily basis to work with individuals like Mrs. Hill who are doing 

those community interventions and interviews and one-on-one discussions with seniors. And we also work very closely with other 

federal and state agencies to ensure that we are getting the latest, 

greatest information. 

One of the things that we have also gotten feedback on is because we run one of the largest online benefit access tools, which 

is free to the public, and we update that consistently to ensure that 

both the SHIP counselors and other benefits counselors across the 

country have access at their computer, not only to the federal benefits that those seniors may be eligible for but also at the state level, 

and sometimes even sort of municipality level. 

So, again, I think what you will see here today is that this ecosystem that we have built between federal partners, state agencies, 

volunteers such as the SHIP volunteers, and national nonprofits 

who are serving these seniors, this ecosystem is critical and would 

not be doing this great work without the support of Congress and 

the appropriations they provide. 

Senator GILLIBRAND. For the record, would you guys please submit an analysis of the impact of enrollment errors? Because I know 

that there is a percentage or a number of people who make mistakes enrolling, and almost 700,000 Americans paid Part B late enrollment penalties because it was late. Can you at least submit for 

the record so I can understand, when people make mistakes, how 

do we fix them? What is the burden? And what are your best recommendations on how to limit that? 

Thank you, Madam Chairwoman. 

The CHAIRMAN. Thank you very much. 

Senator Cortez Masto? 

Senator CORTEZ MASTO. Thank you, Madam Chair, and thank 

you for this second round because this is part of the discussion I 

wanted to get into. I echo my colleagues on the concerns with cuts 

to Social Security, and the reason why I wanted to go down this 

path—and I so appreciate, Ms. Cha ́vez, your comments on this. You 

know, I was fortunate enough to be raised by not only incredible 

parents but also grandparents and great-grandparents. Not only 

were they in our every day lives, I saw what happened to them as 

they aged. And I have a Mexican-American grandmother who 

worked her entire life as a sales clerk, and her retirement was Social Security. And I will tell you that pay gap had an impact on 

the type of retirement she had later on in life, and that is why I 

know, looking at the statistics, when it comes to Social Security 

AGING-G33-GPO with DISTILLER

27 

and the beneficiaries of that retirement or that the money they 

count on and they worked so hard for, are women and children like 

my grandmother. 

And so I do not support any cuts to Social Security, and, Mr. 

Borland, I appreciate the position that you are in, but I also know 

talking with some of your employees that live in my state and the 

interaction that I have seen in my state and the benefits of having 

those offices open and the interaction with state and local, which 

you are right, there is that interaction, and that working together 

there are so many beneficiaries of Social Security that are out 

there that are aging, that are going to need that interaction and 

those offices open. So I do not support cuts and will never support 

cuts to Social Security. There are ways that we can address this 

issue, but it does not start with harming all of those people out 

there that rely—that have worked so hard in their lives and they 

are relying on that type of retirement. So I thank you for that. 

The other thing, I appreciate the conversation today as well. I 

also have Italian-American grandparents, and, Doctor, I can tell 

you are a very good doctor. I have an Italian grandfather who loved 

to smoke cigars, play golf, and believe it or not, likes Christian 

Brothers brandy with orange juice, which I am not sure most people would. But as he aged and he got older, he became very familiar with his doctor, and he was always in the doctor’s office with 

an ache or pain or, ‘‘I cannot walk,’’ or, ‘‘I am dizzy.’’ And finally 

the doctor looked at him and said, ‘‘Lawrence, you are just getting 

old. I do not have a magic pill for you. This is about lifestyle. This 

is about healthiness, and this is about how you eat.’’ 

And so would you please—and we have not touched on this—I 

think part of this though, is this education that somehow not just 

nutritional food, but healthy food has an impact on your health. I 

think we need to learn at an early age, but at the same time, as 

you age, this has an impact on your health. And, Doctor, if you do 

not mind talking a little bit about that? 

Dr. AYATI. Thank you so much. I appreciate it. Before I started, 

whenever I talk about healthy lifestyle, I always admire Italian 

culture because they talk, and this is the best exercise for the 

brain. And that is why whenever I have an elderly person that 

complains about isolation, I say, ‘‘Live like Italians. Talk, talk, and 

talk. This is the best way to go.’’ 

[Laughter.] 

Dr. AYATI. It is a very, very important thing that you brought up. 

It is about nutrition. One thing about that, one of the biggest challenges we have for a lot of our patients, they are always looking 

for a magic formula. They say, ‘‘What are the best vitamins and 

supplements I can take?’’ The problem is that this is exactly part 

of the education that we should provide for them, that nutrition is 

part of exactly at the beginning, as Chairman Collins started, of 

the healthy lifestyle, which is eighty percent—or longevity depends 

on it, and only twenty percent on genetics. And nutrition should be 

a balanced diet. 

When we talk about balanced diet, a lot of people—again, we go 

back again to the conversation that I started, that we sometimes 

obsess about the diets. Sometimes the people recommend you have 

to take lots of fiber, you have to take lots of vegetables. I wrote 

AGING-G33-GPO with DISTILLER

28 

years ago in the San Francisco Chronicle, the local newspaper, that 

too much fiber actually can be harmful for the elderly. We should 

have only a balanced diet which has protein, carbohydrates, and 

fat. Even fat, fat can be helpful for the elderly, but only in moderation, not in exaggeration. 

That is why it is important for all the older people to know, first 

of all, they do not need to take extra supplements. If they eat just 

a healthy, balanced diet, that is going to be enough for them. Definitely more focus on healthy parts of the diet. But, again, one of 

the things is that we do not educate them, because in a majority 

of our health centers, we do not have educated nutritionists in senior care that they come and talk to them, review their diet. A lot 

of seniors are living on some of the programs that they actually deliver the food for them. 

But it is very interesting because one thing is only that they do 

not eat. The other thing is a social problem, lack of companionship. 

A majority of my patients, they have the program like Meals on 

Wheels, and when I do a house visit, I see all the foods in the refrigerator and nobody touched that because they do not have this 

feeling to eat. And there are a lot of other things related to nutrition, like good dental hygiene, and dental issues are one of the biggest problems. A lot of things happen for us because we prescribe 

too much medication, and they change the taste buds of the older 

adult people, and that is why they do not feel that they are eating 

food. 

One of my advice to senior centers is to make a good presentation for your food. Make them motivated and engaged that actually they are feeling that it is only not a piece of bread and a piece 

of meat. I mean, this art can make them to become motivated. But 

definitely nutrition is one of the biggest factors for healthy aging 

that we need to emphasize, and more public education. 

Senator CORTEZ MASTO. Thank you. Thank you very much. And, 

again, to the Chair and Ranking Member, thank you for this great 

panel and this great discussion today. I so appreciate it. 

The CHAIRMAN. Thank you very much. 

I want to thank all of our great witnesses for your testimony 

today and, more important, for your work that you are doing to assist older Americans who are navigating what can often be a confusing maze of information, to help our society recognize and value 

our seniors, and to assist older Americans in living healthier lives. 

Dr. Ayati, we really need you in Maine. 

[Laughter.] 

The CHAIRMAN. California has plenty of specialists. And we are 

the oldest state in the Nation by median age, and we have a real 

shortage of physicians who are trained in geriatrics. So I am serious about this. If you really, really want to make a difference, I am 

positive that I can get you a good job in the State of Maine. 

Dr. AYATI. I will prepare my resume today. 

[Laughter.] 

The CHAIRMAN. So it is a real problem. In states with aging populations, there are not people who have the kind of training that 

you have and that you discussed. And this problem is only going 

to become more severe as our population continues to age. When 

the fastest-growing cohort of our population are those 85 and older 

AGING-G33-GPO with DISTILLER

29 

and the second fastest-growing are those 100 and older, the future 

is staring at us. And I am really concerned about having the workforce that is trained and experts to help us adjust and ensure good, 

healthy lives for people as long as possible. 

When you think about how much our world has changed in the 

last 65 years since 1953, that is the year that color television first 

started appearing. Gas back then cost 20 cents a gallon. Nobody 

ever heard of iPhones or computers being widely available. In fact, 

when you were talking about the need for people to talk more faceto-face, this is a major obstacle to people having conversations. I 

could not live without it, but it is a major obstacle. And you cannot 

probably see from there, but my 92-year-old father in his World 

War II uniform is my screen saver on it. 

But we need to do so much more to adjust to the new reality that 

we are in, and that has been one of the purposes of this hearing 

today. So I thank you all so much for helping us to better understand the world that we are living in. And I also want to thank 

our staff for their hard work. 

Committee members will have until Friday, February 2nd, to 

submit additional questions for the record, so you may be getting 

some additional inquiries. 

And I would now turn to Senator Casey for any closing remarks 

that he would like to make. 

Senator CASEY. Chairman Collins, thank you. I want to thank 

you for this hearing and for the good work that led up to it by your 

staff and our staff as well. 

I want to thank our witnesses. I will pay special tribute to Sharon because she did such a good job and she is from Pennsylvania. 

We have a special place in our heart for Fayette County. I want 

you to know that. But I am grateful for all of that and especially 

because we are dealing with such a difficult issue when we talk 

about the many issues we had to confront today. People turning 65 

are facing a staggering number of decisions related to their health 

and financial security. These are complex decisions that can have 

lifelong consequences. It is our responsibility to provide people with 

information to make the best decision possible. Without information that is easy to access and understand, people are being punished for honest mistakes, and that is unacceptable. I think we can 

all agree on that. 

We have got a lot of work to do this year on these issues. I hope 

that we can pass the BENES Act. I will put another plug in for 

that. We are grateful for this opportunity, and I am looking forward to continuing to work on these issues. 

Thank you, Madam Chair. 

The CHAIRMAN. Thank you. 

Senator Cortez Masto, do you have anything? 

Senator CORTEZ MASTO. No. Thank you. 

The CHAIRMAN. Thank you. This hearing is now adjourned. 

[Whereupon, at 11:14 a.m., the Committee was adjourned.] 

AGING-G33-GPO with DISTILLER

AGING-G33-GPO with DISTILLER

(31) 

APPENDIX 

AGING-G33-GPO with DISTILLER

AGING-G33-GPO with DISTILLER

(33) 

Prepared Witness Statements 

AGING-G33-GPO with DISTILLER

34 

AGING-G33-GPO with DISTILLER


Insert offset folio 1 here 32636.001

SPECIAL COMMITTEE ON AGING 

UNITED STATES SENATE 

January 24, 2018 

STATEMENT FOR THE RECORD 

JIM BORLAND 

ACTING DEPUTY COMMISSIONER FOR COMMUNICATIONS 

SOCIAL SECURITY ADMINISTRATION 
35 

AGING-G33-GPO with DISTILLER


Insert offset folio 2 here 32636.002

Chairman Collins, Ranking Member Casey, and Members of the Special Committee: 

I am Jim Borland, Acting Deputy Commissioner for Communications at the Social 

Security Administration (SSA). Thank you for inviting me to discuss how SSA provides 

information to help workers and their family members decide when to claim Social 

Security retirement benefits, and when to enroll in Medicare. These decisions are 

important, and we are mindful of our responsibility to provide information to help our 

claimants make informed decisions that best fit their individual circumstances. 

Overview 

We administer the Old-Age, Survivors, and Disability Insurance (OASDI) program, 

commonly referred to as '"Social Security." Individuals earn coverage for Social Security 

retirement, survivors, and disability benefits by working and paying Social Security taxes 

on their earnings. Payroll tax revenues fund the Social Security program. We also 

administer the Supplemental Security Income (SSI) program, which provides monthly 

payments to people with limited income and resources who are aged, blind, or disabled. 

Adults and children under age 18 can receive payments based on disability or blindness. 

General tax revenues fund the SSI program. 

Few government agencies touch the lives of as many people as we do. Social Security 

pays monthly OASDI benefits to approximately 62 million individuals. During fiscal 

year (FY) 2017, we paid about $934 billion to Social Security beneficiaries. This 

included about: 

• $793 billion to an average of about 51 million retired workers, the spouses and 

children of retired workers, and the survivors of deceased workers a month; and 

• $I 41 billion to an average of more than 10 million disabled beneficiaries and their 

spouses and children a month. 1 

Medicare is a national health insurance program administered by the Centers for 

Medicare and Medicaid Services (CMS). It provides health insurance for people age 65 

and older, younger disabled workers, and individuals with end stage renal disease. SSA 

is responsible for enrolling people in Medicare. In FY 2017, we enrolled over five 

million people in Medicare. 

Helping Individuals Understand Social Security Retirement and Medicare 

Before individuals apply for and receive Social Security benefits, SSA has an important 

role to provide objective and clear information that individuals may use to plan for 

retirement and make informed decisions appropriate for their circumstances. We have a 

variety of ways to inform individuals about their claiming options before they decide to 

file for Social Security benefits or enroll in Medicare. These resources are critical 

'There were also on average more than 8 million SSI recipients per month in Fiscal Year 2017. 
36 

AGING-G33-GPO with DISTILLER


Insert offset folio 3 here 32636.003

because they allow individuals to consider the best age for them to start benefits based on 

their health, finances, and other personal circumstances. We provide this information 

using a variety of methods, including the Social Security Statement, our website and 

publications, outreach, and more. 

Social Security Statement 

The Social Security Statement (Statement) provides information on lifetime earnings as 

well as estimates of future benefits workers and their families may receive based on those 

earnings. Individuals may access their Statement at any time through a personal online 

my Social Security account. They also receive an annual reminder to check the most 

recent version of their Statements. Additionally, we currently mail Statements to 

individuals aged 60 and older who are not receiving Social Security benefits and do not 

have a my Social Security account.2 In FY 2017, 15.6 million my Social Security 

users accessed their Statements nearly 46 million times, and we mailed around 13.5 

million Statements. 

The Statement provides personalized information about an individual's potential 

retirement benefits, as well as a detailed record of the individual's earnings history. 

Individuals may use the Statement to verify their earnings history and to inform us if their 

earnings need to be corrected. For retirement benefits, the Statement lists the benefit 

amounts that an individual is estimated to receive at age 62, at full retirement age (FRA), 

and at age 70. The Statement describes additional factors an individual should consider 

before deciding when to apply for benefits. It includes information on how work affects 

benefits; how a worker's claiming decision affects survivors benefits; how to avoid a 

Medicare late-enrollment penalty; and information on average life expectancy. Since we 

launched my Social Security accounts in 2012, more than 34 million users have 

registered and more workers are signing up every day. In addition, my Social Security 

accounts consistently rank among the top I 0 in customer satisfaction for all Federal 

government websites. 

Over the next few years. we plan to enhance the online Statement to attract more workers 

to sign-up, review their personal information, and conduct business with us online. 

Publications and Online Tools 

We offer a wealth of other information to the public through our publications, website, 

and other online tools. More than 99 million people visited our website a total of more 

than 232 million times in calendar year 2017. Numerous publications, webpages, and 

Frequently Asked Questions explain the effect that earnings, the age at which benefits are 

claimed, and the receipt of a non-covered pension may have on Social Security benefits.3 

Our resources range from providing basic information about benefits, to delving into the 

details of bene tit calculations, factors to consider when filing for benefits, and more. 

'Individuals also may request a copy of their Statement at any time. 3 http://faq.ssa.gov/ 

2 
37 

AGING-G33-GPO with DISTILLER


Insert offset folio 4 here 32636.004

We offer a variety of online calculators. One of these, the Retirement Estimator, allows 

an individual to input a few pieces of personal information and receive an estimate of 

benefits that would be payable if he or she were to claim benefits at age 62, at FRA, at 

age 70, or at any age in between based upon his or her actual earnings information.4 

Based on surveys conducted by Foresee, the Retirement Estimator is one of the highest 

rated government sites in customer satisfaction. The Retirement Estimator lets 

individuals enter different future earnings information and expected stop work dates, to 

help decide the best time to retire. We also offer a Life Expectancy Calculator to aid 

people with their retirement planning. This calculator allows an individual to see average 

life expectancy based on individuals with his or her gender and date ofbirth.5 

We also offer substantial information when an individual completes the online 

application for retirement benefits. Throughout the online retirement application, we 

provide links that explain why we ask for particular information, and the importance of 

that information based on an individual's circumstances. For example, within the online 

application, when an individual indicates the date they want to start receiving benefits, 

we inform them that if benefits begin before FRA, their monthly benefits will be 

permanently reduced. We also provide links to detailed information explaining the 

effects of receiving benefits before and after FRA. Additionally, we provide a link to the 

Retirement Estimator, mentioned earlier, that allows claimants to see what their benefit 

amount would be at various ages. This level of information is important because the 

majority of retirement claims are filed online (in 2017, about 53 percent of retirement 

applications were filed online). 

Medicare Information 

CMS administers the Medicare program, but individuals enroll in Medicare by contacting 

SSA. Thus, SSA and CMS work in partnership and both agencies maintain and 

communicate information about how to enroll, what the enrollment options are, and who 

to contact for more information about enrollment. For example, our publication How to 

Applv Online fOr Medicare Only explains how an individual who is not ready to apply for 

Social Security benefits but does want to enroll in Medicare can do so quickly and 

efficiently 6 

Our publication entitled Retirement InfOrmation fOr Medicare Beneficiaries provides 

information that can help an individual who has already enrolled in Medicare decide 

when to apply for Social Security retirement benefits.7 

Our website includes helpful information about Medicare, including information about 

enrolling in Medicare at 65 and delaying retirement benefits until after FRA. Our 

4 https:/iwww.ssa.gov/retire/estimator.html 

5 https:/iwww.ssa.gov/OACT/populationilongevity.html 

6 https://v.'Ww.ssa.gov/pubs/EN-05-1 0531.pdf 7 https://www.ssa.gov/pubs/EN-05-l 0529.pdf 
38 

AGING-G33-GPO with DISTILLER


Insert offset folio 5 here 32636.005

website also links to the CMS flagship publication, Medicare and You, giving the public 

instant access to a wealth of information.8 

Direct Service to Customers 

Our employees are dedicated to providing customers with the information they need to 

make a well-informed decision about claiming Social Security benefits and enrolling in 

Medicare. They assist the public in a variety of ways, such as through face-to-face 

interaction in a field office, by telephone (including our national toll-free number, 1-800-

772-1213), in response to online applications, and by mail. 

Employees inform individuals ofthc benefits for which they and their family members 

may be eligible; provide monthly benefits amounts at early, full, and delayed retirement 

ages; and discuss other information the claimant may need to know about Social Security 

rules, requirements, and benefits. Employees also inform individuals about the Medicare 

program including information about premiums, deductibles, enrollment periods, the 

month coverage begins, penalties for declining Medicare Part B when first eligible, as 

well as the prescription drug plan (Medicare Part D), and where to find help with 

covering prescription drug costs. 

SSA employees provide detailed information about the Social Security and Medicare 

programs, and how the rules apply to each individual's situation. However, they do not 

attempt to persuade individuals regarding whether or when to file for benefits. This is 

because our employees are not in a position to know about or discuss the personal 

circumstances-such as financial resources, tax situation, health, and family longevitythat may be important in deciding which age is best for that person to claim benefits. 

Outreach 

Public outreach is an essential part of our strategy to educate more Americans on the 

retirement benefit options. We provide the public with critical information about our 

programs, benefits, and services. To this end, our field and regional offices are 

committed to connecting with the public at the local, grass-roots level. 

During fiscal year 2017, Social Security employees participated in more than 6,000 

events to help the American people better understand Social Security and Medicare 

benefits. With an estimated audience of more than 3.7 million people, these events 

ranged from small rural get-togethers in public libraries, senior centers, churches, and 

veterans' organizations to large gatherings like county and state fairs, senior expos, and 

employer group meetings. Whether the attendance is in the tens or the thousands, SSA 

employees are there to help Americans better understand their benefits. 

Among those events, pre-retirement seminars are particularly effective forums to discuss 

options for claiming Social Security and Medicare. Since 2004, we have helped the 

8 h ttps :1 /www .medicare. gov /medicare-and-you/different-f ormats/m-and-y -different-form ats.htm I 

4 
39 

AGING-G33-GPO with DISTILLER


Insert offset folio 6 here 32636.006

National Rural Electric Cooperative Association identify speakers for more than 400 such 

seminars throughout America's heartland. 

Examples from our regions further illustrate our efforts to ensure rural and remote 

populations have equal access to Social Security and Medicare information: 

Our Seattle Region is experimenting with existing technologies to conduct 

seminars in the remote and underserved communities in the State of 

Alaska. In our Philadelphia Region, we have worked closely with the 

Pennsylvania Department of Labor and Industry to ensure that remote 

counties like Erie, Crawford, and Franklin are served. Our preretirement 

seminars in these counties help residents understand their many Social 

Security options. Our Boston Region has worked with Maine's Area 

Agencies on Aging as well as the five federally recognized American 

Indian Tribes located in extremely remote areas of the state. 

In addition to our work in the regions, we also work closely with national organizations, 

advocacy groups, and other Federal agencies to maximize the reach of our public 

education and communication efforts. 

We continue to strengthen our partnership with CMS to improve our outreach for 

Americans nearing the Medicare eligibility age. Recently, we have: 

• Updated the Statement insert for older individuals to strengthen the message about 

when to apply for Medicare and to make the information more prominent; 

• Included additional language or made existing language about the late enrollment 

penalty and Medicare clearer in several publications; 

• Added additional frequently asked questions to address late enrollment fees, and 

signing up for Medicare when health insurance through current employment or 

when VA benefits are involved; and 

• Coordinated communications with Medicare beneficiaries about the issuance of 

new Medicare cards in 2018, including an alert to beware of scams targeting the 

elderly and disabled. 

Choosing When to Claim Retirement Benefits 

Choosing when to start receiving Social Security retirement benefits is an important 

decision that affects the amount that individuals receive for the rest of their lives. 

Workers can claim full (unreduced) retirement benefits at FRA- currently age 66 and 4 
40 

AGING-G33-GPO with DISTILLER


Insert offset folio 7 here 32636.007

months for people who turn 62 in 2018.9 Social Security also allows individuals to claim 

benefits as early as age 62 or to allow their benefit amount to grow up to age 70. 10 

Receiving Social Security benefits before FRA permanently reduces an individual's 

monthly retirement benefit- and the earlier benefits begin, the greater the reduction. 11 In 

2018, retirement benefits claimed at age 62 result in a reduction of up to 26.7 percent, 

compared to the benefit payable at FRA(66 and 4 months)Y 

On the other hand, individuals who delay claiming beyond FRA earn "delayed retirement 

credits" (DRCs) for every month they do not receive benefits after attaining FRA and 

prior to attaining age 70. For those born in 1943 and later, each month of delay increases 

the retirement benefit by two-thirds of one percent, or eight percent per year. For a 

person whose FRA is 66, delaying until 70 would result in a monthly benefit 32 percent 

higher than the amount that would be payable if claimed at FRA. 

For example, consider an individual eligible for a $1,000 monthly benefit who was born 

between 1943 and 1954. He or she would have an FRA of 66. As shown in the 

following chart, if he or she took benefits at age 62, the monthly amount would be 

permanently reduced by 25 percent to $750. On the other hand, if he or she delayed 

benefits until age 70, the monthly amount would be permanently increased by 32 percent 

(eight percent per year from age 66 to 70) to $1,320. Overall, delaying the start of 

benefits from age 62 to 70 would increase the monthly benefit by 76 percent (from $750 

to $1,320), or almost $7,000 a year. 

9 For persons born in years 1943 through 1954, full retirement age is 66. For people who tum 62 in 2018 

(born in 1956), full retirement age is 66 and 4 months, 2 months more than it was for those who turned 62 

last year. The retirement age will continue to increase by 2 months every year until it reaches age 67 for 

those who were born in 1960 or later. 10 Workers who are no longer covered under employer-sponsored health insurance and individuals with 

employers that have fewer than 20 employees must sign up for Medicare when eligible if they wish to 

avoid a penalty in the form of an increased premium for Medicare Part B coverage. Individuals who are 

still working or are covered by their or their spouse's employer's group health insurance plan, can postpone 

signing up for Medicare Part B without penalty until they are no longer covered by the group health 

insurance plan based on current employment, at which time they will have an eight-month Special 

Enrollment Period in which to sign up. In addition, there is a late enrollment penalty for not signing up for 

Medicare Part D during the Initial Enrollment Period. However, the penalty may be waived if an individual 

shows proof of creditable drug coverage. 11 The monthly benefit is reduced by 5/9 of one percent for each month up to 36 months before FRA and 

then 5/12 of l percent for each additional month before FRA. 12 For people born in I 960 or later, choosing to retire at 62 would reduce the benefit by up to 30 percent 

compared to the amount payable at FRA. 

6 
41 

AGING-G33-GPO with DISTILLER


Insert offset folio 8 here 32636.008

If receipt begins at age: !3 The monthly benefit would be: 14 

62 $750 

63 $800 

64 $867 

65 $933 

66 $1,000 

67 $1,080 

68 $1,160 

69 $1,240 

70 $1,320 

Retirement claiming decisions can also affect the amount of the benefit that the worker's 

spouse will receive if he or she outlives the worker. ln effect, the same adjustment that 

applies to the worker's retirement benefit will apply to survivor benefits paid to the 

worker's widow or widower for the rest of his or her life. 

Deciding when to claim retirement benefits can be complex, and a person should consider 

many factors when making his or her decision. In addition to the monthly benefit 

amount, individuals should consider their personal and family circumstances, including 

current and future financial resources and obligations, and anticipated health and 

longevity. 

Married couples have two lives to plan for throughout retirement. Married retirees must 

consider important information about Social Security protection for widowed spouses. A 

higher-earning partner who delays benefits will receive higher monthly benefits for his or 

her life. This delay may also result in higher survivor's benefits for a spouse if the 

spouse lives longer. 

13 See SSA Pub. No. 05-10147, "When to Start Receiving Retirement Benefits" (January 2017), available 

at https:l/www.ssa.gov/pubs/EN-05-1 0 147.pdf. 14 These monthly benefit amounts do not account for any benefit increase that may be due to earnings after 

age 61, nor do they include cost-ot~living adjustment (COLA) increases. 

7 
42 

AGING-G33-GPO with DISTILLER


Insert offset folio 9 here 32636.009

Enrolling in Medicare 

We strive to make it as easy as possible for people to get information about how to enroll 

in Medicare and to complete the enrollment process. It is important that people know 

their enrollment options in order to avoid delays in the effective date of coverage or 

increases in their premiums. One of our goals is to help people who are approaching age 

65 know that, even though full retirement age is increasing, Medicare eligibility still 

begins (in most cases) at age 65. Accordingly, for people who are age 55 or older, we 

include with the Statement a document titled "Thinking of retiring?", which features a 

prominent message advising the person to sign up for Medicare at age 65 even if he or 

she does not plan to receive monthly Social Security benefits at that time. 

Current Social Security retirement beneficiaries receive an enrollment package from 

CMS about 3 months before they turn 65. It tells them that they will be enrolled in Part 

A. It also tells them they will be automatically enrolled in Part B unless they inform us 

they do not want the coverage (except in Puerto Rico where, by law, residents must optin if they want Part B coverage). Disability beneficiaries who have been receiving 

benefits for 24 months are also automatically enrolled in Medicare and receive the same 

enrollment package. 

Individuals who are not receiving Social Security benefits must take action to enroll in 

Medicare. They can do so in person, by phone, or online during one of the following 

enrollment periods: 

• Initial Enrollment Period -the month the individual turns 65, the three months 

before, and the three months after; 

• General Enrollment Period -January I to March 31 of every year; or 

• Special Enrollment Period - Individuals who continue to work past age 65 or who 

have a spouse that works and who have employment-based health insurance may 

have a special enrollment period (SEP). The SEP allows the individual to file 

during the eight-month period that begins after the employment-based health 

insurance ends, without having to pay a penalty in the form of increased 

premiums. 

Many individuals can enroll in Medicare online, even if they do not want to claim their 

Social Security benefits. Individuals can use our online Medicare application if they: 

are at least 64 years and 9 months old; 

want to sign up for Medicare but do not currently have any Medicare coverage; 

do not want to staii receiving Social Security benefits; and 

8 
43 

AGING-G33-GPO with DISTILLER


Insert offset folio 10 here 32636.010

are not currently receiving Social Security retirement, disability or survivors 

benefits. 

Conclusion 

When Congress passed the Social Security Act in 1935, it did so to provide seniors with 

benefits based on their earnings to sustain them throughout their retirement. This 

continues to be one of the program's core purposes. Currently, program rules allow 

individuals to claim their retirement benefits and receive different monthly benefit 

amounts at any time between the ages of 62 and 70, offering individuals flexibility to 

make decisions based on their individual circumstances. Accordingly, we understand the 

importance of providing useful information to the public about their choices for 

retirement. Through interaction with agency employees, the Statement, my Social 

Security accounts, other online tools, our publications, and our outreach efforts, we 

provide valuable ways for individuals to learn about how claiming decisions may affect 

their benefits. 

Similarly, when Congress passed Medicare in 1965, it charged the Social Security 

Administration with the responsibility to enroll people in the program. We take that 

responsibility very seriously, and we strive to ensure that we, in partnership with the 

Centers for Medicare and Medicaid Services, provide accurate, useful information that 

helps ensure people know when and how to contact us to enroll in Medicare, especially 

when they arc not yet receiving Social Security benefits. 

Thank you again for inviting me here today. I would be glad to answer any questions. 

9 
44 

AGING-G33-GPO with DISTILLER


Insert offset folio 11 here 32636.011

Testimony of 

Anna Maria Chavez 

Submitted to the 

Special Committee on Aging 

U.S. Senate 

on 

Turning 65: Navigating Critical Decisions to Age Well 

January 24, 2018 

National Council on Aging 

25118th Street, Suite 500 

Arlington, VA 22202 
45 

AGING-G33-GPO with DISTILLER


Insert offset folio 12 here 32636.012

Chairwoman Collins, Ranking Member Casey, and members of the Committee, I appreciate the 

opportunity to speak with you today on behalf of the National Council on Aging (NCOA) about the 

critical decisions that older adults face as they turn 65. 

life after age 65 has changed dramatically in the last 30 years. Where retirement once meant spending 

several years of leisure buoyed by the financial security of a pension, today's older Americans have both 

the gift and challenge of planning for a bonus 20 to 30 years of life. 

According to the Social Security Administration, a man reaching age 65 today can expect to live, on 

average, until age 84 and a woman until age 86. What's more, one out of every four 65-year-olds today 

will live past age 90, and one in 10 will live past age 95. 1 

Few Americans are prepared for the challenges and opportunities of this increased longevity. Traditional 

defined benefit retirement plans have mostly disappeared, and Americans' individual savings for 

retirement have not caught up. According to a 2017 BlackRock survey, the average pre-retirement baby 

boomer- defined as 55-64 years old- has only $127,000 in savings-' Yet the Elder Economic Security 

Standard'" Index calculates that people over age 65 with a mortgage need a minimum of $31,000 per 

year just to afford the basic necessities like housing, food, health care, and transportation. 3 In Maine, 

York County has the highest Elder Index at $31,080. In Pennsylvania, the highest is Chester County at 

$37,404. 

In addition to higher daily costs, living longer means increased chronic disease and rising health care 

costs. The National Center for Health Statistics reports that more than 85% of Americans aged 65 and 

over are coping with at least one chronic health condition, and 56% are coping with two or more' 

Chronic conditions which include asthma, diabetes, heart disease, and arthritis, among othersaccount for 85% of the nation's $2.7 trillion annual health care expenditures, according to the U.S. 

Centers for Disease Control. 5 

1 Social Security Administration, h\tps://www,isa.govffilanners/lifeexpectancy.html 2 BlackRock, https:/lwww.blockrock.com/invcsting/insights/itw''stor-puls&fr~tb·ement 

3 University of Massachusetts Boston, https://scholarworks.umb.eQ\!Ldemographyofaging/13/ 4 U.S. Centers for Disease Control, National Center for Health Statistics, 

https://www.cdc.gov/nchs/health policy/adult chronic conditions.htm 5 U.S. Centers for Disease Control, )lt_1JlJ>)i~""-'<v".£>KE.Q.v.i<;hr.9nl£9J5gil5.<:1.9.v.l:'ni~\!i.Ll!J!d!Ox.htm 

2 
46 

AGING-G33-GPO with DISTILLER


Insert offset folio 13 here 32636.013

Today's women, in particular, face unique hurdles past age 65. They begin retirement with a challenge 

that has followed many throughout their lives- the pay gap. Lower pay means less money saved. 

Women who chose to leave the workforce to be a parent or caregiver have fewer Social Security 

benefits built up. Overall, women receive nearly $4,000 a year less in Social Security benefits than men. 6 

Women of color face an even deeper disparity. Over 70% of elderly Hispanic women and more than 64% 

of elderly African American women are economically vulnerable, according to the Economic Policy 

Institute. 7 

While this situation may sound dire, the good news is that there are proven, cost-effective ways to help 

Americans successfully navigate life after 65. Many of them are small steps that can have a huge impact 

on quality of life. 

Since 1950, NCOA has been working to empower older adults with the information and resources they 

need to take these steps. With the help of thousands of partners across the country, NCOA has 

developed innovative programs that help older adults remain healthy, economically secure, and 

independent in their communities. 

At NCOA, we envision a just and caring society in which each of us, as we age, lives with dignity, 

purpose, and security. To achieve that vision, we are focused on improving two essential pillars of life 

past age 65 health and economic security. 

At every age, good health ensures independence, security, and productivity. Unfortunately, millions of 

older Americans struggle every day with health challenges such as chronic disease, falls, and behavioral 

health issues- all of which can severely impact quality of life. 

6 Social Security Administration, https://www.ssa.gov/news/press/factsheets/ss-customer/women-ret.pdf 7 Economic Policy Institute, .b.w.:.LL!X\l!.w"ePJ.&cgfRublice.l.illllLIToJ:lQmic.:"'i~£Urity-elder!Y:?meri~?m:li.~~L 

3 
47 

AGING-G33-GPO with DISTILLER


Insert offset folio 14 here 32636.014

Chronic Disease 

Older adults are disproportionally affected by chronic conditions, such as diabetes, arthritis, and heart 

disease. The National Center for Health Statistics reports that more than 85% of Americans aged 65 and 

over are coping with at least one chronic health condition, and 56% are coping with two or more. 8 

Chronic conditions are costly to individuals' lives and to the health care system. They can limit a person's 

ability to perform daily activities, cause them to lose their independence, and result in the need for 

institutional care, in-home caregivers, or other long-term services and supports. They are also the 

leading causes of death among older adults in the U.S.' Chronic diseases account for 93% of Medicare 

spending, yet less than 1% of U.S. health care dollars is spent on prevention to improve overall health. 10 

Healthy behaviors can improve health and reduce spending. There is strong evidence that patients with 

chronic illnesses have better outcomes and lower costs when behavior changes are implemented, and 

these changes can be made only when patients have the confidence in their ability (self-efficacy) to 

effect change. Community-based aging services organizations and the public health community have an 

important role to play in improving healthy behaviors by promoting self-management and addressing 

the social determinants of health. 

Chronic diseases can be managed to improve quality of life and reduce costs. Chronic Disease SelfManagement Education (COSME), created and tested by researchers at Stanford University, includes 

cost-effective, evidence-based programs that have been proven to help people better manage their 

chronic conditions. The Chronic Disease Self-Management Program (CDSMP), for example, is a six-week, 

interactive, small-group workshop- also available online- that helps participants deal with fatigue, 

pain, frustration, or isolation; maintain strength, flexibility, and endurance; manage and adhere to 

medications; communicate with family, friends, and health professionals; and eat healthy. 

The results show improved health outcomes and lower costs. CDSMP participants in randomized studies 

have reported improved health status in six indicators: fatigue, shortness of breath, depression, pain, 

stress, and sleep problems; improved health-related quality of life, unhealthy physical days, and 

unhealthy mental days; and improved communication with doctors, medication compliance, and health 

8 U.S. Centers for Disease Control, https://www.cdc.gov/nchs/datil/hus/husl6.pdf#020 9 U.S. Centers for Disease Control, https://www.cdc.gov/nchs/data/hus/hus16.pdf#020 10 U.S. Department of Health and Human Services, bJ!p_}_Lww)Y,_~.hll'2YLilsJL1.<a!Jiy/2011/1QLtf.Ql.11Q.1Z!l.JJ.ITD.[ 

4 
48 

AGING-G33-GPO with DISTILLER


Insert offset folio 15 here 32636.015

literacy. Moreover, cost savings among participants included $714 per person in emergency room visits 

and hospital utilization. Based on the data, the nation could save $6.6 billion by bringing COSMP to just 

10% of Americans with one or more chronic disease. 

There is also an online version of the program for people who cannot attend an in-person workshop. 

Recent research by NCOA, Stanford University, Anthem, and HealthCore, funded by Bristol-Meyers 

Squibb Foundation, showed that the online version improves diabetes outcomes, improves depressive 

symptom and medication adherence, and helps people increase exercise by 43 minutes per week. 

NCOA serves as the National Resource Center for COSME. With funding from the U.S. Administration on 

Aging, NCOA supports the expansion and sustainability of evidence-based health promotion and disease 

prevention programs to bring them to more older adults both in the community and online through 

collaboration with national, state, and community partners. 

As recently as eight years ago, the federal investment in COSME was $16 million annually. Current 

funding has dropped to $8 million, made available through an annual allocation from the Prevention and 

Public Health Fund (PPHF). NCOA is extremely concerned about the implications of proposed cuts, the 

looming sequester, and threats to the PPHF on COSME funding. The Senate Appropriations Committee 

has proposed level funding COSME for FY18, but both the Administration and the House Appropriations 

Committee have proposed a $3 million cut. It is critical that funding for COSME at least be protected, 

and in the event that a deal is reached to raise the Budget Control Act (BCA) caps, the investment should 

be restored to $16 million to improve access to those in need. 

Congress should move beyond appropriated programs to provide more sustainable funding for these 

proven interventions. NCOA supports the development of a Medicare demonstration program to test 

Integrated Self-Care Management, in which primary care and community service providers collaborate 

and integrate support to help older adults and their caregivers reach personal goals for healthy aging. 

The initiative would have two overarching goals: (1) improving health and quality of life outcomes for 

older people who have multiple chronic conditions and (2) reducing preventable hospitalizations, 

readmissions, and emergency room visits in order to lower per capita health care expenses for the 

target population. 

In addition, Preventive Health Services authorized by Title 111-D of the Older Americans Act (OAA) 

provide formula grants to support evidence-based health promotion and disease prevention. Annual 

5 
49 

AGING-G33-GPO with DISTILLER


Insert offset folio 16 here 32636.016

funding to provide formula grants to the 50 states, the District of Columbia, and five territories has 

remained at $19.8 million in recent years. An investment of at least the $20.8 million authorization for 

FY18 approved in the 2016 bipartisan OAA reauthorization would help the aging network disseminate 

these proven programs that empower older adults to adopt healthy behaviors, improve their health 

status, and reduce their use of hospital services and emergency room visits. 

On an individual level, healthy behaviors are the name of the game when it comes to preventing and 

managing chronic disease as you age. Older adults with chronic disease can stay healthier if they: 

Exercise regularly. Physical activity boosts physical and mental health. A mixture of aerobic, 

strength and balancing building, and stretching movements are best for older adults. 

Quit smoking. 

Drink in moderation. For most older adults, moderation is defined as no more than one drink 

per day. 

Sleep well. Getting at least seven hours of deep sleep each night is crucial for older adults. 

Eat a healthy diet. Older adults should focus on foods that are high in nutrients and limit 

consumption of alcohol, caffeine, artificial sweeteners, and highly processed foods. 

Manage stress levels. It's important for seniors to reach out to family and friends during rough 

spells and consider regular meditation. 

Talk to their doctor. Older adults who have experienced any of the warning signs of depression 

or other behavioral health issues should talk to their doctor about treatment options. 

Falls Prevention 

Falls are another pervasive and significant health concern for older adults. Like chronic conditions, falls 

can severely impact a person's quality of life and health care costs. 

One in four older adults falls each year. Every 11 seconds, an older adult is treated in the emergency 

room for a fall, and every 19 minutes, an older adult dies from a fall. Fear of falling can lead older adults 

6 
50 

AGING-G33-GPO with DISTILLER


Insert offset folio 17 here 32636.017

to limit their activities, which can result in more falls, further physical decline, depression, and social 

isolation. 11 

Falls are the leading cause of fatal and nonfatal injuries among older adults, causing hip fractures, head 

trauma, and death." Today, the nation spends $31 billion a year in Medicare costs13 treating older 

adults for the effects of falls and, if falls rates are not reduced, direct treatment costs are projected to 

reach $67.7 billion by 2020. 

The good news is that falls are not a normal part of aging, and they are preventable. Just as with chronic 

conditions, there are proven, cost-effective programs and education that can help older adults prevent a 

fall. These programs which include A Matter of Balance and Stepping On- have been shown to reduce 

the incidence of falls by as much as 55% and produce a return on investment of as much as 509%. 

NCOA leads both the National Falls Prevention Resource Center, funded by the U.S. Administration on 

Aging, and the Falls Free® Initiative, a national coalition of groups working together to bring proven 

education and prevention to their communities. The goal is to increase public awareness about the risks 

of falls and how to prevent them; support and stimulate the implementation, dissemination, and 

sustainability of evidence-based falls prevention programs; and serve as the national clearinghouse of 

tools, best practices, and information. Every September on the first day of Fall, NCOA sponsors Falls 

Prevention Awareness Day to spotlight this critical health issue and solutions. Thank you to Senator 

Collins for sponsoring the Senate Proclamation declaring September 22, 2017 as Falls Prevention 

Awareness Day. 

Since enactment of the bipartisan Safety of Seniors Act of 2008, an annual appropriation of 

approximately $2 million has been provided to the u.s. Centers for Disease Control {CDC) National 

Center for Injury Prevention and Control for falls prevention research and dissemination of best 

practices to the public health sector. Starting in FY14, the PPHF made possible new funding to the U.S. 

Administration for Community Living {ACL), with an annual allocation of $5 million to support grants for 

evidence-based community falls prevention programs. 

11 U.S. Centers for Disease Control, htlps://www.cdc.gov/homeandrecreationaisafety/falls/adultfalls.html 

12 Bergen, G et al. Falls and Fall Injuries Among Adults Aged ~65 Years - United States, 2014. Morbidity and 

Mortality Weekly Report. September 23, 2016 I 65(37);993-998. 13 U.S. Centers for Disease Control, biJPs~LLwww.q;!s.ggyfhomfuJ_QQifJffi!l.L<m.<!l?Ilfet'ILfgj]s/fallco_eLhn1Jl 

7 
51 

AGING-G33-GPO with DISTILLER


Insert offset folio 18 here 32636.018

The nation can no longer afford to spend over $31 billion annually to treat the results of falls when 

evidence-based programs have been designed to prevent them. As with CDSME, NCOA is extremely 

concerned about the threats to falls prevention funding with proposed appropriations cuts, threats to 

the PPHF, and the looming sequester. The Administration proposed eliminating falls prevention funding 

at CDC but level-funding the ACL investment for FY18, while the Senate and House Appropriations 

Committees protected funding for both. Sufficient federal investments are needed to make these 

important, cost-effective programs available to more older Americans at risk, and increases should be 

considered if the BCA caps are raised. 

On the individual level, NCOA promotes 6 Steps to Prevent a Fall 14• They include: 

1. Find a good balance and exercise program. Look to build balance, strength, and flexibility. 

2. Talk to a health care provider. Ask for falls risk assessment. The CDC has developed an 

assessment guide for health care professionals to use for this purpose. Older adults need to feel 

comfortable speaking with their health care providers about their falls history and if they have a 

fear of falling. 

3. Have medications regularly reviewed by a doctor or pharmacist. Medication side effects and 

drug interactions increase the risk of falling. 

4. Get vision and hearing checked annually. Your eyes and ears are key to keeping you on your 

feet. 

5. Keep the home safe. Remove tripping hazards, increase lighting, make stairs safe, and install 

grab bars in key areas. 

6. Talk to family members. Enlist their support in taking simple steps to stay safe. Falls are not just 

a seniors' issue. 

14 National Council on Aging, https: I /www.ncoa.org/healthy-aging/falls-prevention/preventing-falls-tips-for-olderad L~!t~::9I19.:f-1!(~,gty_~J9~~.~g_!J.!!~9l-gf:Y.9.UC:.b..S9l!_h.:2:?J£.P_,~:!Q.:PEY.~J.:.§I_:fEllL 

8 
52 

AGING-G33-GPO with DISTILLER


Insert offset folio 19 here 32636.019

Behavioral Health & Social Connections 

Good health is not only physical, but also mental. One in four older adults experiences depression, 

anxiety, risk for suicide, or substance abuse. 15 Older adults also have been significantly affected by the 

opioid epidemic with increased use of opioids due in part to experiencing painful chronic conditions, 

such as arthritis, back pain, and fibromyalgia. 

Behavioral health problems can complicate the treatment of other medical conditions, reduce quality of 

life, increase use of health care services, and lead to premature death. In 2014, nearly 11,000 people 

aged 60 and over died by suicide. Men aged 85 and over have a suicide rate that is about four times 

higher than the rate for all ages. Excessive alcohol use accounts for more than 23,000 deaths among 

older Americans each year. These problems are not a normal part of aging and can be treated. However, 

66% of older adults are not receiving the care they need. 16 

Social isolation and loneliness can exacerbate both physical and mental health concerns among older 

Americans. One in six older adults lives in social and/or geographical isolation. 17 In addition to living 

alone, isolated seniors face physical, cultural, and geographical barriers that prevent them from 

receiving important services and supports from family members, friends, and private and governmental 

agencies. 

Social isolation refers to an objective state of having minimal contact with other people, while loneliness 

refers to a subjective state of negative feelings associated with perceived social isolation. The effects can 

be just as significant as physical health problems. Older adults without adequate social interaction are 

twice as likely to die prematurely. 18 Their mortality risk is comparable to that of smoking 15 cigarettes a 

day or drinking 6 alcoholic beverages a day'9 and is twice as dangerous as obesity. 20 

Several factors contribute to older adults becoming isolated and lonely. Widowhood affects older 

women who are more likely to outlive their spouses. Older people's social networks often get smaller 

when children move away and aging relatives and friends die. For some, retirement decreases self15 U.S. Centers for Disease Control, https://www.cdc.gov/aging/pdf/mental health.pdf 16 U.S. Centers for Disease Control, https://www.cdc.gov/aging/pdf/rnental health.pdf 17 National Council on Aging, https:/!www.ncoa.org/wp-content/uploads/crossing-new-frontiers.pdf 18 PLOS Medicine, http://journals. plos.org/plosrnedicine/<Jrticlc ?idol0.1371!iournal.prned .1000316 19 SAGE Journals, http://journais.sogcpub.com/doi/full/10.1177 /1745691614S68352 20 American Psychological Association, bttg.J/.l<Y.IY.\!0.~Ll~."Qf£Lilr.'!:L~L!!Jg;2Lf;;l~l;;t>L?ilELQS.LL®fJ.Ycclle,,_il5ill\ 

9 
53 

AGING-G33-GPO with DISTILLER


Insert offset folio 20 here 32636.020

worth and reduces engagement due to lack of work-related connections. Approximately one in three 

people aged 60 or older indicate that they feel lonely some of the time or often. 21 

Research also has shown a clear biological link between loneliness and depression. 22 Depression can 

impair an older adult's ability to function and enjoy life, and it contributes to poor health outcomes and 

high health care costs. Compared to their peers, older adults with depression often need greater 

assistance with self-care and daily living activities and often recover more slowly from physical 

disorders. Without appropriate treatment, symptoms of depression can lead to such negative 

consequences as substance misuse disorders, further isolation, suicide, and death. 23 

In the community, senior centers serve as a beacon for older adults seeking support and social 

connections. Almost 10,000 senior centers serve more than 1 million older adults every day. Senior 

centers serve as a gateway to the nation's aging network- connecting older adults to vital community 

services that can help them stay healthy and independent, as well as fun and friendships. 

Senior centers offer a wide variety of programs and services, including meal and nutrition programs, 

information and assistance, health and wellness programs, transportation services, public benefits 

counseling, employment and volunteer opportunities, and social and educational programs. Research 

shows that older adults who participate in senior center programs can learn to manage and delay the 

onset of chronic disease and experience measurable improvements in their physical, social, spiritual, 

emotional, mental, and economic well-being. 

Socialization is an important benefit of senior center participation. Survey data from program 

participants aged 60 and over at multipurpose senior centers found that more than half (56%) report the 

people they associate with at the senior center sites are usually the only people they spend time with 

and interact with during the day. The great majority (90%) view personal contacts made with people at 

the senior center as important to them. 24 

21 Wilson C & Moulton B (2010). Loneliness among older adults: A national survey of adults 45+. Prepared by 

Knowledge Networks and Insight Policy Research, Washington DC: AARP. 22 Matthews GA, Niel EH et at (2016). Dorsal raphe dopamine neurons represent the experience of social isolation. 

Cell: 164, 617-631. 23 Substance Abuse and Mental Health Services Administration (2013). Older Americans Issue Brief Series, Issue 

Brief #6: Depression and Anxiety in Older Adults. 24 Turner KW (2004). Senior citizens centers: What they offer, who participates, and what they gain. Journal of 

Gerontological Social Work, 43:37. 

10 
54 

AGING-G33-GPO with DISTILLER


Insert offset folio 21 here 32636.021

NCOA runs the National Institute of Senior Centers (NISC), the nation's only organization dedicated to 

improving senior centers. NISC supports a national network of over 3,000 senior center professionals, 

and promotes cutting-edge research, promising practices, professional development, and advocacy. 

NISC also offers the nation's only National Senior Center Accreditation Program", which provides official 

recognition that a senior center meets nine national standards of senior center operations. 

The Older Americans Act defines a multipurpose senior center as "a community facility for the 

organization and provision of a broad spectrum of services, which shall include provision of health 

(including mental health), social, nutritional, and educational services and the provision of facilities for 

recreational activities for older individuals." To effectively engage and address the needs of the aging 

population, it is crucial that their expertise be fully tapped to leverage resources and partnerships to 

achieve the goals of the OAA in communities across the nation. 

In the 2016 OAA reauthorization, NCOA's proposals resulted in the addition of language to support the 

modernization of senior centers, with the identification of best practices and provision of technical 

assistance to facilitate the dissemination of these strategies. As NCOA begins to envision a bold 

reauthorization for 2020, we intend to build upon this language. 

ECONOMIC SECURITY 

Along with health, economic security is integral to enabling people over age 65 to live their best lives. 

Today, over 25 million Americans aged 60 and over are economically insecure- living at or below 250% 

of the federal poverty level (FPL), or $29,425 per year for a single person. More accurate measures of 

economic well-being- including the Elder Economic Security Standard'M Index managed by NCOA and 

the Gerontology Institute at the University of Massachusetts Boston- show that half of older adults 

living alone struggle to meet their monthly expenses. 26 

Even for those who can afford daily expenses, rising debt is taking a toll. Today, 61% of senior 

households have some form of debt, and almost 34% of senior households owe money on a mortgage, 

home equity line of credit, or both. NCOA research shows that 48% (67% of low-income adults) worry 

25 National Council on Aging, https:/!www.ncoa.org/national-institute-of-senior-centers/standards-accreditation/ 

26 N a tiona! Council on Aging/ btt25..JL~~~~Y.JJ~~-mi:.9Xg}Jtf"JJll9JJ.!!£:-.?.~f_t.J.,!Jly/Jngll.g:'l~lillJl£&ill1l~lllf-~QgL:-l.n.Q~-~ 

11 
55 

AGING-G33-GPO with DISTILLER


Insert offset folio 22 here 32636.022

they won't have sufficient finances as they age, and 23% (44% of low-income adults) struggle to pay 

their bills each month27 

Older women of color are disproportionately economically insecure. More than 70% of elderly Hispanic 

women and 63.5% of elderly African American women are economically vulnerable. 28 The number of 

older adults who are struggling is likely to grow given that the 65 and older population is the fastest 

growing age group in the country. 

Despite these sobering statistics, there are concrete ways to support older adults who are struggling 

economically. NCOA is focused on improving access to benefits, supporting optimal Medicare choices, 

and employment. 

Benefits Access 

Connecting low-income older adults to money-saving programs as soon as they are eligible can have a 

profoundly positive impact on both economic well-being and health- by improving access to 

affordable health care, medicine, and nutritious foods. But many older adults are unaware of these 

programs or how to apply for them. 

Senior participation rates in the core set of safety net programs is low. These core benefits include 

Medicare Savings Programs (MSPs), the Medicare Part DExtra Help/low-Income Subsidy (LIS), 

Supplemental Nutrition Assistance Program (SNAP), Medicaid, and Low Income Home Energy Assistance 

Program (LIHEAP). Only 42% of eligible seniors are enrolled in SNAP, 29 and current estimates suggest 

that of eligible non-institutionalized Medicare beneficiaries aged 65 and older, only 54.6% and 48.3% are 

enrolled in LIS and MSP, respectively. 30 

NCOA estimates that low-income seniors are eligible for and not receiving more than $20.5 billion in 

aggregate annual benefits. Why? A nationally representative survey of 1,000 low-income older adults 

conducted on behalf of NCOA points to lack of awareness, assuming the application process is a lot of 

27 National Council on Aging, https://www.ncoa.org/economic-security/money-management/deQ!Lsenior-debtfill;ill 

28 Economic Policy Institute, https:/J.www.epi.org/Q1Lblication/ecooomic~~~s:~_urity-elder!y+americans-risk/ 

29 U.S. Department of Agriculture Food and Nutrition Services, tJllJl..iJ/www.fns.usda.gov/snao/trends-usda12 
56 

AGING-G33-GPO with DISTILLER


Insert offset folio 23 here 32636.023

paperwork, not knowing where to begin to apply, and falsely believing that other people need more 

help than they do. 31 

NCOA is the nation's leader in connecting seniors with the benefit programs for which they are eligible. 

With support from the Medicare Improvements for Patients and Providers Act (MIPPA) funding, NCOA's 

Center for Benefits Access helps community-based organizations find and enroll seniors and younger 

adults with disabilities with limited means into benefits programs, so they can remain healthy, secure, 

and independent. Currently, NCOA funds 69 Benefit Enrollment Centers in 36 states that help lowincome older adults enroll in core benefit programs. 

Funding for this important Medicare outreach and enrollment work must be extended. The goal is not to 

expand Medicare eligibility, but merely to assist those who already qualify under current law. Outreach 

and enrollment efforts have led to important, proven results. MIPPA resources enabled state agency 

partners and community-based organizations to: 

Help increase the number of low-income Medicare beneficiaries enrolled in the Medicare 

Savings Programs from 6.4 million in 2008 to 10.5 million in 2016. 

Provide individual assistance to 2.5 million beneficiaries in need. 

Since 2001, NCOA also has offered BenefitsCheckUp®, the nation's most comprehensive free, online tool 

to screen seniors with limited income for benefits. It includes more than 2,500 public and private 

benefits programs from aliSO states and the District of Columbia. As of today, over 6.4 million people 

have discovered eligibility for $23.3 billion in benefits on the site. 

Moreover, NCOA's Senior Hunger Initiative works to combat senior hunger by enrolling eligible older 

adults into SNAP. The initiative combines technical assistance to local community organizations with 

online help and advocacy to make it easier for eligible older adults to access SNAP to pay for healthy 

food. 

Medicare 

Understanding the A, B, C, and Ds of Medicare is an overwhelming, isolating experience if older adults 

go without help. Yet making sub-optimal choices when enrolling in Medicare can mean years of 

13 
57 

AGING-G33-GPO with DISTILLER


Insert offset folio 24 here 32636.024

overpaying for coverage and even long-term penalties for late enrollment. For people coming from 

Medicaid or who get subsidies on Health Insurance Marketplace, turning 65 can sometimes be a "cliff" 

where they fall off benefits and have to start paying costly Medicare premiums. 

The basic rules underpinning the Part B enrollment system were developed more than SO years ago, 

when Medicare was first established. Knowing whether and when to enroll in Part B requires that a 

person understand when to sign up during time-limited windows, how their other insurance will work 

with Medicare, and what penalties may result if enrollment is delayed. The consequences of missteps 

can be significant and include higher out-of-pocket costs, significant gaps in coverage, and lifetime 

penalties. In 2014, 750,000 people with Medicare were paying a Part B Late Enrollment Penalty (LEP) 

with the average LEP amounting to nearly a 30% increase in a beneficiary's monthly premium. 32 1n 

addition to this considerable penalty, many retirees and people with disabilities face large out-of-pocket 

health care costs, gaps in coverage, and barriers to care continuity because of honest enrollment 

mistakes. 

The bicameral, bipartisan BENES Act (S. 1909, H.R. 2575), introduced by Ranking Committee Member 

Senator Casey in the Senate, aims to prevent these costly mistakes by modernizing, simplifying, and 

improving the Medicare Part B enrollment process. It fills long-standing gaps in notice and education for 

those approaching Medicare eligibility and aligns and simplifies enrollment periods, bringing Part B rules 

in line with Medicare Advantage and Part D rules. 

Medicare State Health Insurance Assistance Programs (SHIPs) are also vital federally funded resources 

that help seniors navigate this complexity. SHIPs provide local, in-depth, insurance counseling and 

assistance to Medicare beneficiaries, their families, and caregivers. This encompasses a broad range of 

areas, including coverage options, fraud and abuse issues, billing problems, appeal rights, and 

enrollment in low-income protection programs. This scale of support cannot be replicated by agents and 

brokers. 

SHIPs receive funding under ACL for 54 grantees (all states, Puerto Rico, Guam, DC, and the U.S. Virgin 

Islands), overseeing a network of more than 3,300 local SHIPs and over 15,000 counselors, 57% of whom 

are highly trained volunteers who donate almost 2 million hours of assistance. Several states that 

estimate savings to beneficiaries resulting from SHIP assistance reported achieving significant savings in 

32 Congressional Research Service, httg_~:f/liiU2rJSLsgpLcJ0l.misc/R49.0~:SJLctf 

14 
58 

AGING-G33-GPO with DISTILLER


Insert offset folio 25 here 32636.025

2015, including $110 million in Massachusetts, $56 million in Michigan, and $53 million in North 

Carolina. 

Over the past two years, more than 7 million people with Medicare received help from SHIPs, and 

individualized assistance provided by SHIPs almost tripled over the past 10 years. It is critical that, at a 

minimum, SHIP funding be maintained to meet rapidly growing needs. SHIPs offer increasingly critical 

services that cannot be supplied by 1-800 MEDICARE, online or written materials, or other outreach 

activities. In fact, approximately one-third of all partner referrals to SHIP originate from Medicare 

Advantage and Part D prescription drug plans, local and state agencies, the U.S. Centers for Medicare 

and Medicaid Services (CMS), the Social5ecurity Administration, and members of Congress and their 

staff. 

If the federal investment in SHIPs had simply kept pace with inflation and the increasing number of 

Medicare beneficiaries since FY 2011, FY18 funding would be at least $67 million. However, FY17 

appropriations for SHIP were cut by $5 million to $47.1 million, and the Administration and the House 

Appropriations Committee have proposed eliminating all funding in FY18. We applaud the Senate 

Appropriations Committee for yet again rejecting proposed FY18 cuts in aging services and calling for 

level-funding SHIP. If a BCA deal provides additional FY18 resources, we urge that SHIP at least be 

restored to its FY16 level of $52.1 million. 

Too many Medicare beneficiaries still do not understand or have access to effective tools for comparing 

and choosing among increasingly complex plan options and do not shop around when they should. Our 

vision is that millions of informed, engaged Medicare beneficiaries will make optimal decisions about 

public and private insurance, providers, and treatments. In response to these concerns, NCOA has 

launched an Improving Medicare Markets Initiative, with an expert Advisory Group of diverse 

stakeholders that has been meeting and collaborating since 2014. The group has provided extensive 

comments to CMS on improving tools to make informed choices, and will soon be issuing a report, along 

with others, on improving the Medicare Plan Finder. 

NCOA offers an additional tool to help individuals navigate Medicare. My Medicare Matters"' is a free, 

educational website that helps visitors choose the best Medicare plan for their needs and make the 

most of their benefits. Since launch in 2015, it has cost-effectively brought Medicare education 

materials to millions of Americans. 

15 
59 

AGING-G33-GPO with DISTILLER


Insert offset folio 26 here 32636.026

EMPLOYMENT 

Millions of older Americans continue to work past age 65 out of financial need or a desire to stay 

active. The Senior Community Service Employment Program (SCSEP) is the nation's oldest program to 

help low-income, unemployed individuals aged 55 and over find work. It provides nearly 70,000 older 

adults with part-time jobs at community service organizations. Participants build skills and selfconfidence, while earning a modest income. For most, their SCSEP experience leads to permanent 

employment. 

SCSEP is unique in that it's the only U.S. Department of labor program that does not overlap with any 

other similar programs, and it is specifically targeted to senior workforce development. The value of the 

community service provided is estimated around $820 million yearly- which is more than double the 

program's yearly appropriation. NCOA is one of 19 national SCSEP sponsors, running programs in 

California, Georgia, Kentucky, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Tennessee, 

Virginia, West Virginia, and Puerto Rico. 

Federal investment in SCSEP is critical, but threatened. Final FY17 funding was cut by $34.4 million, to 

$400 million. The Senate Appropriations Committee has proposed level funding for FY18, but the 

Administration has proposed eliminating all funding and the House Appropriations Committee has 

proposed cutting the program by $100 million, or 25%. This investment in low-income older workers 

must be protected, and if raising the BCA caps provides additional resources, funding should not only be 

restored to the FY161evel, but at a minimum, increased to the $454.5 million level authorized for FY18 

in the bipartisan 2016 OAA reauthorization. 

CONCLUSION 

Recognizing that Americans need support to navigate both health and economic security after age 65, 

NCOA has developed its own innovative approach called the Aging Mastery Program® (AMP). The 10-

class in-person workshop and new at-home Aging Mastery® Starter Kit are a fun, engaging way to 

empower older adults to make their own personal pathway for aging well. 

The program incorporates evidence-informed materials, expert speakers, group discussion, actionable 

goals, and small rewards to give participants the skills and tools to achieve measurable improvements. 

Topics covered include nutrition and fitness, sleep, relationships, economic health, civic engagement, 

16 
60 

AGING-G33-GPO with DISTILLER


Insert offset folio 27 here 32636.027

advance care planning, and more. The program encourages mastery- developing sustainable behaviors 

across many dimensions that lead to improved health, stronger economic security, enhanced well-being, 

and increased societal participation. 

To date, more than 10,000 older adults have graduated from AMP, and results have shown that 

participants significantly increased their social connectedness, physical activity levels, use of advanced 

planning, and participation in evidence-based programs. The new in-home Starter Kit will bring the 

benefits of AMP to older adults who are socially isolated, live in rural communities, or cannot easily 

attend community-based classes. NCOA is optimistic that the Aging Mastery Program® will grow rapidly 

across the United States as community organizations, Medicare Advantage plans, and employers 

recognize its value and benefits. 

After serving older adults for more than 67 years, NCOA knows that aging is not something you just let 

happen to you. Like your career decisions, your education decisions, your relationship decisions- aging 

well means making informed, deliberate choices. 

As a society, we're not doing enough to help people prepare for and navigate their third stage of life. 

We don't teach them how their bodies are going to change as they age or how to manage their savings 

so it will last an extra 20 to 30 years. We teach young people how to become adults- but we don't 

teach older people how to age well. At NCOA, we offer tools and solutions to help people make smart 

choices to age on their terms. 

We can't stop the inevitable. You, me, your parents. We're all aging. But that doesn't mean we have to 

be afraid of it- or pretend it's not happening. Instead, we can face it head on. And we can be prepared. 

17 
61 

AGING-G33-GPO with DISTILLER


Insert offset folio 28 here 32636.028

Statement of Dr. Mehrdad Ayati, M.D. 

Dr. Mehrdad Ayati, M.D., is an Adjunct Assistant Professor of Medicine at Stanford University School 

of Medicine where he teaches and trains medical students, residents, fellows, and nurses in 

Geriatrics. Dr. Ayati is board certified in family and geriatric medicine. He joined the Stanford 

University School of Medicine in 2011 as a member of its faculty, where he taught and practiced 

Internal Medicine and Geriatrics prior to starting a private geriatric practice in 2016. Doctor Ayati is 

a member of the Ethnogeriatrics Committee of the American Geriatrics Society and serves as a Faculty 

Advisor for the Center on Longevity at Stanford University. He is a member of the Health Care 

Advisory Committee of Northern California and Nevada Chapter of the Alzheimer's Association and 

is the Geriatric Consultant on Aging Research Projects at SRI (Stanford Research Institute) 

International. He founded the Bay Area Senior Care Society. He has served as the Medical Director 

and Medical Advisor of multiple skilled nursing facilities in the San Francisco Bay Area in California. 

Dr. Ayati is the Founder of the Geriatric Concierge Center in Menlo Park, California, where he 

currently practices, and is co-author of the book Paths ta Healthy Aging. 

Before the 

U.S. Senate Special Committee on Aging 

Turning 65: Navigating Critical Decisions to Age Well 

January 24, 2018 
62 

Executive Summary 

Dear Madam Chair, Ranking Member, and distinguished members of the U.S. 

Senate Special Committee on Aging. Thank you for inviting and giving me the opportunity to discuss critical challenges regarding the aging population in the U.S. 

My name is Dr. Mehrdad Ayati. I am a board-certified Geriatrician and an educator. 

I am also board certified in Family Medicine. I am presenting myself as a physician 

who has treated and managed, and continues to treat and manage, thousands of 

senior Americans. 

I would like to start with some statistics. Today, the number of Americans ages 

65 and older is approximately 49 million. This number is estimated to grow to 98 

million by 2060. Currently, there are about 7,000 geriatricians in practice in the 

United States, yet according to the Alliance for Aging Research, we should instead 

have 20,000 geriatricians—nearly three times our current number—just to accommodate the needs we have right now. By 2030, this group estimates that our country will need about 37,000 of these specialists. 

Since 2011, approximately 10,000 Americans have been enrolling in Medicare 

every day. This aging population is faced with multiple challenges on the path to 

healthy aging. I would like to outline eight of these challenges briefly and suggest 

some directions for overcoming them. 

There is a Lack of Experts in the Field of Geriatric Medicine and Gerontology 

Unfortunately, our health care and education systems have not been designed to 

train enough senior care providers such as doctors, nurses, physician assistants, 

pharmacists, social workers, dementia experts, and physical and occupational therapist who can specifically manage seniors. As we age, our physiology changes. For 

example, absorption of drugs through our digestive system can be altered. Our liver 

function decreases, and it becomes harder for our body to metabolize and eliminate 

drugs. Changes in our circulatory and nervous systems affect our reactions to drugs. 

Therefore, we might need lower or higher doses of medications compared to other 

age groups. Additionally, there are medications that while working perfectly well for 

younger adults, should not be prescribed for the geriatric population. Therefore, it 

is crucial for the elderly to be managed by healthcare providers who have been educated and trained in this field. In the U.S., 80% of those 65 and older have at least 

one chronic condition (more than 3 out of 4) and 50% have two chronic conditions. 

Forty percent of the seniors take at least five medications, not taking into account 

over-the-counter supplements and herbal remedies. They see many different specialists and are prescribed a number of different medications through each. This situation can result in polypharmacy or over-medication, and even Drug Cascade Syndrome, where an undesirable side effect is misinterpreted as a medical condition 

and results in a new prescription. That is the reason why 4.5 million Americans 

visit the emergency rooms and physician offices each year. Adverse drug events account for a large number of hospital stays and deaths among the elderly. Therefore, 

there is a critical need for training more senior care providers. 

There is a Dearth of Scientific and Research-backed Medical Information Regarding 

Healthy Aging 

Despite the fact that we live in an era of advanced technology, with massive 

amounts of information on the subject of aging at our fingertips, the validity of 

much of such information is highly questionable. Our seniors are bombarded with 

contradictory claims, literature that is overly technical and hard to understand, recommendations that are impossible to follow, and often marketing-oriented myths 

about how to take care of themselves. They lack simple, straight forward, easy to 

follow information about aging on topics such as nutrition, mental and physical 

health, frailty, medications, finding the right physician, and end of life decisions. 

For example, misleading marketing campaigns at every corner are enticing our seniors to take drastic measures such as taking unregulated vitamins and supplements 

or undergo harmful diets to live longer and healthier. This is regardless of the fact 

that scientific data collected over many years indicate that such over-the-counter 

supplements and drastic diets are not contributing to better health and could even 

be detrimental to our health. Consequently, there is a critical need for reliable information, valid guidelines, and effective strategies so that senior can avoid or more 

effectively manage chronic diseases and have a better quality of life. 

Very few clinical research and trials are designed for or even include older people, 

which consume majority of the pharmaceuticals currently available in the market. 

As such, the safety of most medications in the elder population is not well researched. 

There is also a lack of academic and scientific research on the subject of aging. 

There is also an urgent need for the development of innovative tools to help the elAGING-G33-GPO with DISTILLER

63 

derly stay in the comfort of their homes as long as possible and avoid spending time 

in nursing homes. 

The Elderly are Becoming more Racially and Ethnically Diverse 

In 2010, more than one in eight U.S. adults 65 and older were foreign born, a 

share that is expected to continue to grow. The U.S. elderly immigrant population 

rose from 2.7 million in 1990 to 4.6 million in 2010, a 70% increase in 20 years. 

It is estimated that the number of U.S. immigrants 65 and older will quadruple to 

more than 16 million by 2050. This increase is due to the aging of the long-term 

foreign-born population and the recent migration of older adults as part of family 

reunification and refugee admissions. In 2014, about 15% of people age 65 and older 

lived in a home where a language other than English was spoken. Currently, we 

lack the resources to address the challenges of this growing ethnic and racial 

groups. These challenges include language barriers, cultural differences, religious 

and belief differences, physiological factors such as genetic backgrounds, and financial inequalities. 

We Live in an Anti-Aging Society 

We are a youth-oriented society that is not properly focused on aging and the 

older generation. As people grow older, they need more attention, care, support, 

companionship, and love. We need to raise awareness about the needs of the elderly 

as well as the hardships they face and to promote the respect, gratitude and appreciation they deserve. All too often, older adults are forced out of the workforce and 

replaced by cheaper and unskilled labor. They may then retire to the solitude of 

their homes, where they can become isolated and lonely, and as a consequence, develop depression and cognitive impairment. Later, they may be institutionalized and 

set aside by the society they built and the children they raised. They can even be 

mistreated, cheated and taken advantage of. 

We Need More Infrastructure and Resources 

Our seniors face a lack of appropriate resources in the areas of transportation, 

affordable housing, senior centers, organized and affordable social activities, and 

qualified healthcare centers. These problems are magnified for those suffering from 

dementia. Currently five million Americans suffer from this condition, and in the 

next 15 years this number is expected to triple. However, we lack the dementia 

units as well as the professionally trained staff to provide care for this population. 

Seniors are Experiencing Financial Difficulties 

A large number of seniors are living in poverty. The recent global economic crisis 

of 2008, the collapse of the housing market and the astronomically high cost of 

healthcare in the U.S. are among the many factors contributing to the growth of 

debt among the elderly. Some of them are forced to forgo retirement and seek very 

low paying jobs, which they may still have a very hard time finding due to age discrimination. Often, they are faced with a hard choice between paying their mortgage, buying the many medications they can’t survive without, or purchasing food. 

Too often, they become not only financially but also physical dependent on their 

children, which are known as the ‘‘sandwich generation’’ when they care for parents 

while at the same time raising their own children. 

We Expect Quick Fixes 

We live in a modern society where more is considered better. This kind of mentality tells us that for every single problem, there should exist a quick fix—even if 

there is no logic behind it. ‘‘Modern medicine’’ dictates that health issues should be 

resolved with either medications or interventions. But in reality, the statistics do 

not support this. The Congressional Budget Office in 2015 estimated that 5% of the 

nation’s gross domestic product, $700 billion per year, goes to tests and procedures 

that do not improve health outcomes. Therefore, modern medicine, with its emphasis on attempted solutions rather than prevention, does not necessarily make 

happier and healthier citizens. 

Medicare Expenditures Are Not Aligned With Needs 

As the Medicare system is set up today, it does not pay for the medically necessary services, which can have tremendous impact toward a better physical and 

mental quality of life for adults. For instance, if an older adult needs more physical 

therapy to help with mobility or needs a necessary piece of equipment to have a 

better quality of life, it will be denied by Medicare. However, if the same person 

wants to undergo an expensive diagnostic test, the test will be quickly authorized. 

Unfortunately, as we discussed, many of these diagnostic tests do not change the 

quality of life for the elderly. Sometimes they do not even improve the management 

AGING-G33-GPO with DISTILLER

64 

of the disease. I see on a daily basis that Medicare would fully pay for diagnosing 

and treating my patient’s cancer, even if it would extend their life for just a few 

weeks. However, Medicare would not pay a penny if the same patient needed help 

at home, nor would it pay if he/she required counseling to overcome anxiety and depression. I had a patient a few years back with advanced dementia in a nursing 

home. He also had advanced colon cancer. He could not eat, was in severe distress 

and could not recognize anyone. His life expectancy was less than 2 months. On one 

of his visits to the ER, his family members were instructed to consult with a cardiologist. The cardiologist advised them to get a pacemaker for him. They put a patient with advanced dementia and cancer under general anesthesia to give him a 

pacemaker. And Medicare paid for it. He died less than a month later. 

Solutions 

Expansion of Geriatric Education 

A large number of the teaching physicians in the U.S. medical schools don’t have 

the appropriate expertise or background in the field of Geriatrics. As a result, medical students, residents, fellows, and practicing physicians who currently treat the 

elderly lack the basic knowledge in the field of geriatrics. Therefore, too often the 

elderly are misdiagnosed and mismanaged. In contrast, in Great Britain, every medical school has a department of geriatrics, as do one-half of Japanese medical 

schools. Of the 145 U.S. medical schools, only 11 have geriatric departments (7.6%). 

Plus, the geriatric curriculum at over three-quarters of the U.S. medical schools is 

an elective, not a required field of study. As a consequence, many older Americans 

will not get the most knowledgeable care they need when they most desperately 

need it. In fact, it’s already too late for a solution that involves training enough certified geriatricians. The experts admit this and offer an alternative solution. This 

solution hinges on creating enough geriatric educators to ensure that every new 

physician, of which there are over 16,000 per year, will have been sufficiently 

trained in geriatrics in medical school to know the differences between medical care 

for non-geriatric patients and medicine for the oldest of us. Another recommendation is that all primary care physicians and specialists should have mandatory 

training in the field of geriatrics as part of their CME (Continuing Medical Education). This rule should also be mandatory for nursing, advanced nursing and physician assistant practice education. 

Earlier this year, the American Geriatric Society endorsed the Geriatrics Workforce and Caregiver Enhancement Act (H.R. 3713), a bipartisan proposal for programs addressing the shortage of health professionals equipped to care for the elderly. Introduced by Reps. Jan Schakowsky (D–IL), Doris Matsui (D–CA), and David 

McKinley (R–WV), the bill draws on considerable insights from the Eldercare Workforce Alliance (EWA), a collaborative comprised of more than 30 member organizations co-convened by the AGS and now reflecting the diverse expertise of millions 

of professionals who support health in aging for older Americans. The proposed legislation would codify into law and authorize funding for the Geriatrics Workforce 

Enhancement Program (GWEP). The GWEP is the only federal program designed 

to increase the number of health professionals with the skills and training to care 

for older adults. 

Launched in 2015 by the Health Resources and Services Administration (HRSA) 

with forty-four 3-year grants provided to awardees in 29 states, the GWEP is helping geriatrics experts develop innovative local solutions. When approved, H.R. 3713 

will authorize GWEP funding of more than $45 million annually through 2023, allowing current and future GWEP awardees to educate and engage with family caregivers, promote interdisciplinary team-based care, and improve the quality of care 

delivered to older adults. I hope this bill will be finalized soon, as this can be a big 

victory for our vulnerable older adults, allowing them to receive better care for their 

future. But this is only a beginning and we need more funding in the future. 

Medicare Reimbursement Model 

With the passage of the Affordable Care Act, the reimbursement basis is slowly 

shifting from a Fee for Service (FFS) structure to one which puts emphasis on improving performance and outcomes. However, the level of reimbursement is still not 

adequate. Geriatric counseling and geriatric assessments require time. Keep in 

mind that there is a shortage of geriatricians and there is a large population of geriatric patients with multiple chronic conditions on many medications. As such, the 

amount of time spent per patient needs to be long enough to be effective. However, 

at the current low reimbursement levels, geriatric professionals need to see many 

patients in a short timeframe to survive financially. Geriatrics is one of the lowestpaying specialties, and experts say this low pay and factors such as the high cost 

of living and office overheads as well as the long work hours are driving new physiAGING-G33-GPO with DISTILLER

65 

cians away from the field. Increasing reimbursement fees for geriatric consultations 

would undoubtedly create more attraction for medical centers and doctors’ offices to 

expand their geriatric care and hire more geriatric care providers. It would also 

allow the care providers to spend an effective amount of time with each patient to 

provide all the necessary assessments, management and education. 

Expand Geriatric Consultation 

One efficient way of properly taking advantage of the currently low number of 

geriatricians in the field is to use geriatricians as consultants rather than primary 

care providers for the elderly. To accomplish this, all healthcare providers could 

send their elderly patients for a geriatric consult at least once or twice a year. This 

would allow geriatric professionals to evaluate patients and their list of medications 

and make the proper recommendations to their primary care physicians and other 

specialists. It should also be made mandatory for primary care physicians to consult 

with a board certified geriatrician or a gero-psychiatrist for their patients suffering 

from dementia. Of course, a proper reimbursement method is necessary for this 

model to survive. 

Medicare Annual Wellness Visits 

Medicare has a comprehensive and well detailed annual wellness visit structure. 

Unfortunately, many physicians do not follow the well-established CMS annual 

wellness instructions. The majority of discussion time between patients and the physicians is spent on management of high blood pressure, high cholesterol, refill of 

medications, and/or vaccinations. Although these are relevant topics which need to 

be well addressed, this annual wellness visit should in addition include a thorough 

geriatric assessment and evaluation. This includes screening for depression, discussing nutrition, and screening for memory loss. It should also include discussing 

goals of care and life preferences. Primary care physicians should consult geriatricians during these CMS annual wellness visits to properly assess their older patients. 

Coordination of Care 

Bringing together a team of health care providers, with a geriatrician at the center, and working closely with the senior patients, family caregivers, primary care 

physicians, specialists, case managers, and other care professionals is of essence to 

ensure healthy aging. This team can coordinate individual needs, synchronize the 

variety of short-term and long-term medical services, improve health care access 

and outcomes, support and improve communication resulting in improved individual 

well-being and health outcomes. 

Physical Health of our Older Adults 

Frailty is defined as a progressive deterioration of multiple body systems resulting 

in physical and functional decline. It is characterized as a drop in the body’s energy 

production and utilization as well as a deterioration of its repair systems. It can 

occur at any age but is much more prevalent in the elderly. As we grow older, we 

eventually lose about 40% of our muscle tissue. Unfortunately, as we discussed, our 

seniors lack the basic infrastructure to stay healthy and fit. For example, there is 

a lack of senior-friendly exercise centers in this country. Such centers should have 

suitable equipment designed for seniors and have certified trainers who can help 

them stay physically strong, and to prevent, slow, or reverse the development of 

frailty. Seniors also need transportation systems to reach such physical and social 

centers. 

We also need more effective, continuous adult education in medical centers, physician offices, media, and public programs about the importance of exercise for older 

adults. It is essential that providers be honest with their patients and explain to 

them that medications and procedures alone are insufficient: they must be accompanied by regular physical activity in order to maintain their mental and physical 

well-being. 

Mental Health of our Older Adults 

Mental health is the most important aspect of healthy aging. As we discussed, 

people in this group are highly susceptible to becoming lonely and isolated and to 

suffer from depression and/or anxiety. Unfortunately, this will lead them toward increased cognitive impairment and disability over time. Data is showing that loneliness in the elderly is associated with the use of psychotropic drugs. Further, seniors 

who feel lonely and isolated are more likely to report having poor physical and mental health, as indicated in a 2009 study using data from the National Social Life, 

Health, and Aging Project. It is therefore essential to expand senior day center programs providing intellectual stimulation, extend adult educational programs, and 

AGING-G33-GPO with DISTILLER

66 

increase community support for the seniors. There is also a strong need for social 

engagement and interaction centers for the elderly. We should also develop mechanisms to help our older adults to engage in voluntary programs in their community. 

Another important factor is the lack of professional geriatric counselors or therapists who can treat depression and anxiety in this population. Medicare does not 

currently provide funding to support geriatric counseling or psychotherapy. Consequently, depressed seniors are only to receive pharmacological treatment options. 

Furthermore, with the increase of ethnic and racial groups in the U.S., there is a 

crucial need for therapists with different cultural and language backgrounds. 

Nutrition 

Proper diet and nutrition are essential factors for health. Unfortunately, many of 

our seniors are looking for the best supplement that could act as a magic solution 

for better health. Sadly, this unfounded belief in the power of supplements has become a practice model in our society and is gradually replacing the healthy diet for 

this population. 

As we age, we lose bone mass, muscle, and water content while increasing fat content. Other physiological factors such as losing taste buds and sense of smell, dental 

issues, lack of companionship, medical and psychological illness, and stress also result in weight loss. Many medications also cause loss of appetite and weight loss. 

Medical and social education for this group should put emphasis on proper hydration, maintaining a balanced diet, practicing mindful eating, avoiding fad diets, and 

not relying on over-the-counter supplements and herbal remedies. Social support 

programs providing meals for older adults are crucial. Eating meals in senior centers can help not only nutrition but also help to avoid loneliness in this group. 

Polypharmacy and Drug Cascade Syndrome 

As discussed before, prescribing for older patients offers unique challenges. A periodic evaluation of the drug regimen that a patient is taking is an essential component of the medical care of an older person. Such a review may indicate the need 

for changes to prescribed drug therapy. These changes may include discontinuation 

of a treatment prescribed for an indication that no longer exists, substitution of a 

required treatment with a potentially safer agent, reduction in the dosage of a drug 

that the patient still needs to take, or an increase in dose or even addition of a new 

medication. An interdisciplinary geriatric team will be the best group to help our 

older adults avoid the negative impacts of polypharmacy. It is essential that all 

medical centers follow Beers criteria. These are guidelines for healthcare professionals to help improve the safety of prescribing medications for older adults. 

Physicians who have not been trained enough in the geriatric field should avoid 

prescribing psychotropic medications for dementia-related behavioral disturbances. 

These medications have very serious side effects such as confusion, disorientation, 

hallucinations, seizures and delirium, and memory loss. In the elderly, they can result in falls and death. 

Through medical and social media, it is essential to educate the seniors and their 

care givers to have a current list of their illnesses and their medications, including 

the dosage, and to share that list with all their physicians and pharmacists. Patients and their caregivers are often unaware of the reasons why some of their 

medications have been prescribed. Patients should question their physicians thoroughly about each of the medications prescribed for them. They should ask what 

side effects to look out for. 

They should also ask their physicians to ensure that any new medications do not 

interact with or inactivate their existing medications. The public should also be 

aware that over-the-counter medications, vitamins, antioxidants, supplements and 

herbal remedies are not necessarily safe to use and can interact with their existing 

medications. 

Conclusion 

A joint effort involving better public education, widespread training of caregivers 

in the field of geriatrics, and changing Medicare and government regulations is required to ensure that the growing wave of seniors live healthier and happier lives. 

I would like to thank the Senate Special Committee on Aging for giving me the 

opportunity to discuss healthy aging and the challenges currently faced by the aging 

population in the U.S. as well as offering solutions. 

AGING-G33-GPO with DISTILLER

67 

AGING-G33-GPO with DISTILLER


Insert offset folio 29 here 32636.029

REFERENCES 

https:/ /www.agingresearch.org/newsletters/view/180 

American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics 

Society 2015 updated Beers Criteria for potentially inappropriate medication use in 

older adults. JAm Geriatr Soc. 2015; 63:2227-2246. 

Hines LE, Murphy JE. Potentially harmful drug-drug interactions in the elderly: a review. 

Am J Geriatr Pharmacother. 2011; 9:364-377 

• Azarani A, Ayati M, Paths to Healthy Aging. Amazon 2015 

• U.S. Census Bureau, Series P95/01-1. Washington, DC: US Government Printing Office; 

2001 

Geriatric Review Syllabus, AGS, Edition 8 

• http://healthcare-economist.com/2008/11/07 /us-spends-700-billion-on-unnecessarymedical-tests/ 

https :/I changi ngagi ng. org/hea lth-well ness/many-geriatrics-few-geriatricians 

https:/ /www.americangeriatrics.org/publications-tools/current-ags-newsletter 

Healthcare Changes and Affordable Care Act, A physician call to action. Springer 2015 

Hazzard's Geriatric Medicine and Gerontology, Seventh Edition, editors, Jeffrey B. 

Halter, Joseph G. Ouslander, Stephanie Studenski, Kevin P. High, Sanjay Asthana, Mark 

A. Supiano, Christine Ritchie; editor emeritus and senior advisor, William R. Hazzard; 

senior editorial assistant, Nancy F. Woolard, AccessMedicine2017 

Fabbri E, AnY, Schrack JA, et al. Energy metabolism and the burden of multi morbidity in 

older adults: results from the Baltimore longitudinal Study of Aging. J Gerontol A Bioi Sci 

Med Sci. 2015;70(11):1297-1303. 

American Geriatrics Society Choosing Wisely Workgroup. Things healthcare providers 

and patients should question. JAm Geriatr Soc. 2014; 62:950-960. 

http:/ /open.lib.umn.edu/socialproblems/chapter/6-5-problems-facing-older-americans2/ 

http:/ /www.prb.org/Publications/Reports/2013/us-elderly-immigrants.aspx 
68 

Prepared Statement of Sharon Hill, Apprise Volunteer, State Health 

Insurance Assistance Program, Vanderbilt, Pennsylvania 

Chairman Collins, Ranking Member Casey, and Members of the Committee, 

thank you for inviting me to testify today. It is an honor to be here. 

My name is Sharon Hill. I am 63 years old and a resident of Vanderbilt, Pennsylvania. I have two sons and six grandchildren, with a seventh due any day. My 

granddaughter, August, has joined me here today. I am a volunteer with the Pennsylvania APPRISE program. Nationally, APPRISE is also known as the State 

Health Insurance Assistance Program or SHIP. 

In addition to volunteering with the APPRISE program, I work cleaning my 

church. I also care for my 89-year-old father and help care for my 92-year-old neighbor, who is blind. I have a disability and rely on the support of state and federal 

programs to remain active and engaged in my community. 

I have been an APPRISE volunteer for 4 years. I initially saw an ad in our local 

senior newspaper, called the Senior Times News, asking for volunteers to help people with Medicare issues. At that time, I was on Medicare due to a disability and 

had recently been left with $67,000 in medical bills after a cancer diagnosis. I also 

recalled the difficult decisions my parents had to make about their Medicare coverage. Both events were behind my interest in volunteering for the APPRISE Program. 

To be an APPRISE volunteer I had to attend many training sessions. At these 

sessions, I learned about the different parts of Medicare, including Medicare Part 

A, Part B, Part C, Part D as well as Medigap. I also learned about programs that 

can help low-income seniors and people with disabilities, like Medicare Extra Help, 

and even Pennsylvania-specific programs that help individuals who have high medical expenses. I was trained on how to use the computer system and enter information into Medicare Plan Finder. Each year we receive a refresher training to provide 

volunteers with updated information. 

The more I learned, the more I realized I did not know. People have a lot to consider when signing up for Medicare, and the decisions can be daunting. I wish I 

would have known about these resources sooner, because had I known that programs like this existed, I do not think I would have faced the hardship that I described. 

It is because of my own experiences that I am passionate about the APPRISE program. APPRISE is the only place that older adults can go, in person, to get unbiased 

information to help with their Medicare decisions. As a volunteer, I give speeches 

at local senior centers and provide in-person counseling sessions. Each counseling 

session is 60 to 90 minutes long, and during Medicare open enrollment season, we 

are very busy. 

Sometimes people come in with specific questions about their coverage and other 

times we are starting with the basics. It is common for people to make Medicare 

coverage decisions based on the well-intended advice of friends, family, or others. 

What I have learned during my time as an APPRISE volunteer is that people do 

not have all the information they need to make the best decisions for their health 

care or financial needs. 

Making a bad decision when signing up for Medicare can have unintended, lifelong consequences. When I see people with gaps in coverage or seniors paying lifelong penalties, it is often because of misinformation. Knowledge is important in 

helping beneficiaries maximize their benefits and avoid the pitfalls of life-long penalties. 

Thankfully, as an APPRISE counselor, I am trained to help those that are having 

trouble with their Medicare due to misinformation. We can liaison with organizations to appeal a decision or screen people for programs that help cover the cost of 

their medication. APPRISE counselors not only provide information, they help beneficiaries navigate a complex system and serve as advocates. We also find that once 

people come to APPRISE for help, they come back each year to be sure their coverage is right for them. 

People’s lives are changing and they need to be educated or they will fall through 

the cracks. It is because of this that I tell everyone I meet about the program. APPRISE counselors do not make Medicare decisions for beneficiaries, we instead provide them with information to make the best choices for themselves. 

Again, thank you for the invitation to testify before the Committee. I look forward 

to answering your questions. 

AGING-G33-GPO with DISTILLER

(69) 

Additional Statements for the Record 

AGING-G33-GPO with DISTILLER

70 

AGING-G33-GPO with DISTILLER


Insert offset folio 30 here 32636.030

Medicare Rights Center Support Letter for the BENES Act 

December 19,2017 

The Honorable Mitch McConnell 

Majority Leader, U.S. Senate 

Washington, DC 20510 

The Honorable Paul Ryan 

Speaker, U.S. House of Representatives 

Washington, DC 20515 

The Honorable Chuck Schumer 

Minority Leader, U.S. Senate 

Washington. DC 20510 

The Honorable Nancy Pelosi 

Minority Leader, U.S. House of Representatives 

Washington, DC 20515 

Dear Majority Leader McConnell. Minority Leader Schumer, Speaker Ryan, and Minority Leader Pelosi: 

The undersigned organizations share a commitment to advancing the health and economic security of older 

adults, people with disabilities. and their families. Together, we represent the 57+ million Americans who rely 

on Medicare. We need your commitment to pass the bipartisan Beneficiary Enrollment Notification and 

Eligibility Simplitication (BENES) Act (S. 1909; HR 2575) by the year's end. This bi-partisan, bi-cameral 

legislation is urgently needed to improve Medicare Part B enrollment, and to modernize the now-outdated 1965 

law to align with changes in the Social Security and Medicare Advantage laws. The legislation has widespread 

support trom everyone from MA Plans to beneficiary advocacy groups, and needs your support now. 

The basic rules underpinning the Pmt B enrollment system were developed more than 50 years ago, when 

Medicare was first established. The BENES Act offers long-overdue solutions to modernize and simplify Part B 

enrollment. Through bipartisan, low-cost reforms, the BENES Act shields people with Medicare trom steep 

premium penalties and tills needless gaps in coverage. 

Knowing whether and when to enroll in Part B requires that a person understand when to sign up during timelimited windows, how their other insurance will work with Medicare, and what penalties may result if 

enrollment is delayed. The consequences of missteps can be significant and include higher out-of-pocket costs, 

significant gaps in coverage, and lifetime penalties. 

In 2014, 750,000 people with Medicare were paying a Part B Late Enrollment Penalty (LEP) with the average 

LEP amounting to nearly a 30% increase in a beneficiary's monthly premium.' In addition to this considerable 

penalty, many retirees and people with disabilities face large out-of-pocket health care costs, gaps in coverage, 

and barriers to care continuity because of honest enrollment mistakes. 

The BENES Act significantly alleviates these challenges. It fills long-standing gaps in notice and education for 

those approaching Medicare eligibility and aligns and simplifies enrollment periods, bringing Part B rules in line 

with Medicare Advantage and Part D rules. Together, these changes will help prevent costly enrollment slipups 

among the 10,000 people becoming Medicare eligible each day. For these reasons, we strongly support the 

BENES Act and we believe it should be a priority for Congress. 

Far too many people with Medicare are irreversibly harmed due to a cumbersome and contusing Part B 

enrollment system. The BENES Act presents an important opportunity for members of Congress to advance 

1 P Davis, ''Mcd1care Part B Premiums." (Congressional Research Serv1ce· August 2010), available at ht!Jlilllils org/sgp/crsimts<:/R40082 ruif 
71 

AGING-G33-GPO with DISTILLER


Insert offset folio 31 here 32636.031

commonsense, bipartisan, low-cost reforms that are in the best interest of the many millions of Americans who 

will soon come to rely on Medicare. Thank you. 

Sincerely, 

ACCSES 

Aetna 

AgeOptions 

Aging Life Care Association 

Alliance for Aging Research 

Alliance for Retired Americans 

AMDA- The Society for Post-Acute and Long-Term Care Medicine 

American Association on Health and Disability 

American College of Clinical Pharmacy (ACCP) 

American Federation of Government Employees (AFGE) 

American Foundation for the Blind 

American Geriatrics Society 

American Society on Aging 

Association of University Centers on Disabilities (AUCD) 

Austim Society of America 

B'nai B'rith International 

Better Medicare Alliance 

Blue Shield of California 

BlueCross BlueShicld Association 

Brain Injury Association of America 

California Health Advocates 

Center for Independence of the Disabled 

Center for Medicare Advocacy, Inc. 

Community Catalyst 

Compassion & Choices 

Dialysis Patient Citizens 

Disability Rights Education and Defense Fund (DREDF) 

Disabled In Action of Metro NY 

Empire Justice Center 

Epilepsy Foundation 

Families USA 

Family & Children Association, Senior Services HIICAP 

Gerontological Society of America 

International Association for Indigenous Aging 

International Union, United Automobile, Aerospace & Agricultural Implement Workers of America 

The Jewish Federations of North America 

Justice in Aging 

Lakeshore Foundation 

LeadingAge 

Lutheran Services in America 

2 
72 

AGING-G33-GPO with DISTILLER


Insert offset folio 32 here 32636.032

MAXIM US 

Medicare Rights Center 

Metro New York Health Care for All 

National Academy of Elder Law Attorneys (NAELA) 

National Active and Retired Federal Employees Association (NARFE) 

National Adult Day Services Association (NADSA) 

National Adult Protective Services Association (NAPSA) 

National Association for Home Care & Hospice (NAHC) 

National Association of Area Agencies on Aging (n4a) 

National Association of Health Underwriters (NAHU) 

National Association of Nutrition and Aging Services Programs (NAN ASP) 

National Association of Social Workers (NASW) 

National Association of State Head Injury Administrators 

National Association of State Long-Term Care Ombudsman Programs (NASOP) 

National Coalition on Health Care (NCHC) 

National Committee to Preserve Social Security and Medicare 

National Consumer Voice for Quality Long-Term Care 

National Consumers League 

National Council on Aging (NCOA) 

National Partnership for Women & Families 

New York Legal Assistance Group 

New Yorkers for Accessible Health Coverage 

Partnership to Improve Patient Care (PIPC) 

Patient Advocate Foundation 

Service Employees International Union (SEIU) 

Smart Policy Works (formerly Health & Disability Advocates) 

Social Security Works 

Southern Tier Independence Center (STIC) 

The Arc of the United States 

The National Multiple Sclerosis Society 

Third Way 

UA W Retiree Medical Benefits Trust 

United Jewish Organizations of Williamsburg 

Women's Institute for a Secure Retirement (WISER) 

CC: The Honorable Orrin Hatch, Chairman, Senate Committee on Finance 

The Honorable Ron Wyden, Ranking Member, Senate Committee on Finance 

The Honorable Greg Walden, Chairman, House Committee on Energy & Commerce 

The Honorable Frank Pallone, Ranking Member, House Committee on Energy & Commerce 

The Honorable Kevin Brady, Chairman, House Committee on Ways & Means 

The Honorable Richard Neal, Ranking Member, House Committee on Ways & Means 
73 

AGING-G33-GPO with DISTILLER


Insert offset folio 33 here 32636.033

Centers for Medicare & Medicaid Services Support Letter for the BENES Act 

August 22,2016 

The Honorable Orrin Hatch 

Chairman, Committee on Finance 

U.S. Senate 

Washington, DC 20510 

The Honorable Kevin Brady 

Chairman, Committee on Ways & Means 

U.S. House of Representatives 

Washington, DC 20515 

The Honorable Fred Upton 

Chairman, Committee on Energy & Commerce 

U.S. House of Representatives 

Washington, DC 20515 

The Honorable Ron Wyden 

Ranking Member, Committee on Finance 

U.S. Senate 

Washington, DC 20510 

The Honorable Sander Levin 

Ranking Member, Committee on Ways & Means 

U.S. House of Representatives 

Washington, DC 20515 

The Honorable Frank Pallone 

Ranking Member, Committee on Energy & Commerce 

U.S. House of Representatives 

Washington, DC 20515 

Dear Chairman Hatch, Ranking Member Wyden, Chainnan Brady, Ranking Member Levin, Chairman Upton, and 

Ranking Member Pallone: 

As former Administrators of the Centers for Medicare & Medicaid ServicesiHealth Care Financing Administration, 

Republicans and Democrats. we frequently disagree among ourselves about any number of issues. But we all agree on 

the importance of treating Medicare beneficiaries fairly, efficiently, and as helpfully as possible. Thafs why we have 

come together in support of the bipartisan Beneficiary Enrollment Notification and Eligibility Simplification (BENES) 

Act (S. 3236 and H.R. 5772). 

Many of the problems addressed by the BENES Act did not exist when most of us were in the government. but the 

decoupling of eligibility ages for Medicare and full Social Security benefits, revisions to Medicare Secondary Payor law, 

and the growing number of Americans working past the age of65 have, together, substantia11y complicated the decision 

making process for eligible individuals and couples in deciding when and how to enroll in Medicare. 

Signing up for Part B is not a straightforward task, particularly for the increasing share of Americans who are working 

longer and delaying retirement. For these individuals, knowing when and whether to enroll in Part B requires 

understanding complex and varied rules. Enrollment missteps are a common occurrence and often lead to a lifetime of 

higher Part B premiums. In 2014, 750,000 people with Medicare were paying a Part B Late Enrollment Penalty (LEP) 

and the average LEP amounted to nearly a 30 percent increase in a beneficiary's monthly premium. 1 Gaps in coverage, 

higher health care costs, and limited access to needed care are also consequences experienced by those who make honest 

enrollment mistakes. 

To prevent costly enrollment errors among people new to Medicare, the BENES Act provides enhanced notice and 

education for those approaching Medicare eligibility, aligns and simplifies Part B enrollment periods, and updates 

existing mechanisms for those seeking reprieve from Part B premium penalties and coverage delays. We encourage you 

to support the BENES Act. 

Thank you. 

' P Da> IS, '·MediCare Part B Premmms." (Congresswnal Research Serv1cc· August 2016). <wadable at: https"//\W."W fas org!sgo/crs/misc!R400~ 
74 

AGING-G33-GPO with DISTILLER


Insert offset folio 34 here 32636.034

Sincerely, 

Leonard D. Schaeffer 

Administrator 

Health Care Financing Administration 

1978-1980 

William L. Roper, MD, MPH 

Administrator 

Health Care Financing Administration 

1986-1989 

Gail R. Wilensky, Ph. D. 

Administrator 

Health Care Financing Administration 

1990-1992 

Bruce C. Vladeck, Ph. D. 

Administrator 

Health Care Financing Administration 

1993-1997 

Nancy-Ann DeParle 

Administrator 

Health Care Financing Administration 

1997-2000 

Tom Scully 

Administrator 

Centers for Medicare & Medicaid Services 

2001 -2004 

Mark McClellan, MD, Ph. D. 

Administrator 

Centers for Medicare & Medicaid Services 

2004-2006 

Donald M. Berwick, MD 

Administrator 

Centers for Medicare & Medicaid Services 

2010-2011 

CC: The Honorable Mitch McConnell, Majority Leader, U.S. Senate 

The Honorable Harry Reid, Minority Leader, U.S. Senate 

The Honorable Paul Ryan, Speaker, U.S. House of Representatives 

The Honorable Nancy Pelosi, Minority Leader, U.S. House of Representatives 

2 
75 

AGING-G33-GPO with DISTILLER


Insert offset folio 35 here 32636.035

MEDICARE 

ALLIANCE 

STATEMENT FOR THE RECORD 

Submitted to the Special Committee on Aging 

United States Senate 

Hearing On 

Turning 65: Navigating Critical Decisions to Age Well 

January 24, 2018 

Better Medicare Alliance 

1090 Vermont Avenue, N.W. 

Suite 1250 

Washington, DC 20005 

http:/ /betterrnedicarealliance.org 
76 

AGING-G33-GPO with DISTILLER


Insert offset folio 36 here 32636.036

Better Medicare Alliance (BMA) is a broad alliance of more than 100 

organizations, including doctors and other professional health care providers, 

health systems, aging service agencies, business groups, retiree organizations, 

health plans as well as beneficiaries. Collectively, we support and advocate for 

Medicare Advantage and the innovative, quality care it delivers. BMA works to 

ensure the Medicare Advantage program is stable, accessible, high quality, 

cost effective, and financially viable through the ongoing support of 

policymakers. We achieve these goals through information, research, 

education, commentary on policy, and advocacy. 

We applaud the Committee for its hearing to discuss the important decisions 

older Americans must make as they approach age 65. Turning age 65 is a 

considerable milestone and momentous occasion for Americans, a point at 

which they generally have the opportunity to enroll in Medicare in a timely 

manner. 

In the US, over 48 million Americans are age 65 or older, a number that is 

increasing rapidly. This population is projected to nearly double by 2050 

making them the fastest growing group in the US, dominated by the Baby 

Boomers (born from 1946 to 1964), who are reaching retirement and Medicare 

eligibility. Thus, efforts to support older adults age successfully with optimal 

health outcomes, access to quality care, financial stability, and tools to make 

decisions independently have become a priority. 

Approximately 10,000 Americans turn 65 and become eligible for Medicare 

each day and understanding the decision points and coverage options of 

Medicare can be an overwhelming, isolating experience if older adults and 

people with disabilities do not have timely, accurate, accessible and 

understandable information about their important health coverage choices. 
77 

AGING-G33-GPO with DISTILLER


Insert offset folio 37 here 32636.037

This trigger of age 65 and the years leading up to it presents a number of key 

considerations for which older Americans must plan; including the ability to 

manage health care expenses through suitable and adequate health coverage; 

the ability to determine health needs and understand treatment options; and 

the ability to make sound health care decisions given available financial 

resources. 

Medicare Advantage - also known as Medicare Part C - is an option within 

Medicare that provides the same benefits and services as Traditional Fee-forService Medicare, under a managed care model. Offered and administered by 

private health insurance providers, Medicare Advantage is the preferred 

choice of health coverage for 20 million seniors - one in three Medicare 

beneficiaries - in large part because of the affordability, value, high-quality 

care and additional benefits these plans provide. 

Medicare Advantage's framework focuses on preventive care -which means 

fewer hospitalizations and incentivizes innovation and value-based care 

models. Plan offerings often include additional cost-effective services and 

coverage that seniors highly value like prescription drugs, vision, hearing, 

dental, disease management, fall prevention programs, nurse help hotlines, 

nutrition support, and wellness care. Surveys indicate that 92 percent of 

beneficiaries are satisfied with the quality of care they receive, their health 

insurance plans, and their benefits. 

Medicare Advantage protects seniors' financial health, too. Unlike Traditional 

Fee-for-Service Medicare, Medicare Advantage caps out of pocket costs -

helping protect seniors and disabled beneficiaries from potential catastrophic 

health care expenses that could threaten their financial security. 
78 

AGING-G33-GPO with DISTILLER


Insert offset folio 38 here 32636.038

Choices for Medicare Coverage 

BMA has engaged in considerable work over the past year with more than 

300,000 beneficiaries to gauge beneficiary understanding of their health 

insurance coverage options upon turning 65, and to improve public 

educational materials so that they can make the most suitable choices for 

their near- and longer-term health care needs. 

Currently, there are over 100,000 Medicare Advantage beneficiaries who have 

signed up to be BMA Advocates. Our beneficiaries are racially, socioeconomically, and geographically diverse with beneficiaries represented in 

both rural and urban areas across the country. In addition to the beneficiaries 

in our email database, BMA also has 300,000 followers on Facebook and we 

see about 1,000 posts from advocates every week. 

We also have a task force of BMA Ambassadors who are our most engaged 

Medicare Advantage advocates. There are 483 beneficiaries who have joined 

this task force who we interact with daily. 

We engage our beneficiaries in a number of ways including: educating them 

on Medicare Advantage, conducting surveys, collecting stories, and posting 

other advocacy activities on our website including sending letters to the 

editor and contacting representatives in Congress. BMA advocates have made 

over 10,000 calls to Congressional offices and wrote personal letters to CMS 

and their Members of Congress on Medicare Advantage, joined telephone 

town halls, signed petitions and joined BMA on Capitol Hill. 

The Medicare program has complicated rules about how other health 

insurance interacts with, or "coordinates" with Medicare coverage. This 

includes health insurance that someone has because of current, active 
79 

AGING-G33-GPO with DISTILLER


Insert offset folio 39 here 32636.039

employment. In certain circumstances, individuals can stay on their employerbased health coverage and forego enrolling in Medicare Part B without 

penalty, until they retire. Unfortunately, people are often unaware of these 

complicated rules or get mis-information about how they work. As a result, 

they may have to pay premium penalties and may face many months, or 

longer, without access to Part B coverage. 

That is why BMA is pleased that Ranking Member Casey has led the 

introduction of and Chairman Collins has cosponsored the bipartisan BENES 

Act (S. 1909 I H.R. 2575), legislation aimed at simplifying and modernizing the 

Medicare Part B enrollment process. We urge Congress to take up and swiftly 

and pass the BENES Act in order to help older Americans avoid inadvertently 

incurring fees and penalties for late enrollment. 

Part A and Part B Is Not the Only Choice 

Most Americans believe that simply enrolling in Medicare Part A and Part B 

(Fee-for-Service) Medicare completes their decision-making process. And 

while this is an important step for timely enrollment and planning health 

insurance coverage options, it is by no means the completion of the process. 

A recurring theme in BMA's beneficiary engagement and work with 

policymakers is the importance of explaining to beneficiaries in addition to 

Medicare Part A and Part B enrollment they have a choice in how they receive 

their Medicare coverage. Omission of Medicare Advantage or failure to 

accurately explain the option of Medicare Advantage is an issue that 

policymakers and public educational materials should resolve. 
80 

AGING-G33-GPO with DISTILLER


Insert offset folio 40 here 32636.040

In fact, research conducted in 2017 by Morning Consult on BMA's behalf, a 

national survey of 2,000 adults over age 65 found that many seniors do not 

know there are other important choices to make, nor do they understand the 

different options they have. Specifically, the survey found that: 

• 43% of adults 65+ are not familiar with Medicare Advantage. 

• 59% of adults 65+ are not confident that they know the difference 

between Medigap and Medicare Advantage. 

• Only 2% of adults 65+ use the Medicare Plan Finder tool to research 

Medicare enrollment options. 

• Only 50% of adults 65+ said that the option of Medicare Advantage was 

made clear to them. 

• 41% experience confusion in finding the best type of Medicare 

Advantage plan for their needs. 

BMA believes that in order for beneficiaries to make the best choice for 

themselves as they enroll in Medicare. they deserve easily accessible, clearly 

understandable information on the choices available to them. 

There is a notable lack of information in the material that the Social Security 

Administration (SSA) sends to would-be beneficiaries in advance of their 

turning age 65. In SSA's letter sent to near-65 year old soon to be 

beneficiaries the basic steps for enrollment in Medicare Part A and Part B is 

clear. However, there is no mention of the choice between Fee-for-Service 

Medicare and the option of Medicare Part C (Medicare Advantage). BMA 

believes this should be remedied. 

BMA was pleased that the Centers for Medicare & Medicaid Services (CMS) 

undertook a number of positive changes to the "Medicare & You 2018" 
81 

AGING-G33-GPO with DISTILLER


Insert offset folio 41 here 32636.041

Handbook to better communicate the availability, as well as the differences 

and benefits, of the option of Medicare Advantage. 

We welcomed the opportunity to propose changes to the Handbook and the 

Welcome to Medicare package when CMS called for public input in 2017. Our 

feedback included suggestions to add more charts, tables, and illustrations to 

clarify information on coverage options, provide more information on the outof-pocket spending limit in Medicare Advantage, update language and 

placement to better explain Medicare Advantage, and additional information 

on specialized care and benefits available under Medicare Advantage. We 

appreciate that a number of these improvements were adopted in the 2018 

Handbook, and we look forward to working further with CMS and other 

stakeholders to build on these changes to clarify the choices for beneficiaries. 

SMA also provided recommendations to CMS Planfinder and is working in 

corporation with other stakeholders engaged in this process. 

Experience has shown that older adults learn and process information on 

health coverage differently than younger adults. In addition to one's personal 

health literacy, presentation of enrollment options, reading level of written 

materials, formatting, and source of information all influence older adults' 

understanding of their Medicare coverage options. Improving readability and 

comprehensibility of the information sent to beneficiaries - especially those 

who may have low health literacy - are all essential. 

BMA Convening on Medicare Beneficiary Understanding of Choices 

In December 2017, SMA brought together a group of approximately 50 

thought leaders, including beneficiary advocates, researchers, health plans, 

practitioners, community partners and policymakers, to discuss how to 
82 

AGING-G33-GPO with DISTILLER


Insert offset folio 42 here 32636.042

improve consumers' understanding of Medicare coverage options, particularly 

Medicare Advantage. The meeting discussion focused on three topic areas: (1) 

assessing the Medicare population's educational needs; (2) discussing 

currently available educational resources on Medicare coverage options and 

educational gaps; and (3) developing recommendations for improving 

education and decision-making tools for Medicare beneficiaries. Overall, 

stakeholders agreed that educational materials must be improved to engage 

and assist Medicare beneficiaries in making optimal coverage decisions. 

BMA would welcome sharing with the Committee a copy of the final report 

from our Convening, but we wish to highlight for the Committee three key takeaways: 

• Overall, there was broad stakeholder consensus at the convening that 

improving outreach, education, and decision-making tools for Medicare 

beneficiaries must be a priority for the Administration, policymakers, 

and advocates. 

• Stakeholders agree that CMS should be conducting additional outreach 

to beneficiaries on choosing Medicare coverage, particularly the choice 

of Medicare Advantage. 

• Recommended changes described in the report include readily doable 

action, as well as those that require public investment. 

BMA also commends the Committees attention to the valuable role that 

Medicare State Health Insurance Assistance Program (SHIP) counselors play 

in helping older Americans navigate their health insurance coverage options. 

SHIPs provide local, in-depth, insurance counseling and assistance to 

Medicare beneficiaries, their families and caregivers. This encompasses a 

broad range of areas. including coverage options. fraud and abuse issues. 

billing problems, appeal rights, and enrollment in low-income protection 
83 

Æ 

AGING-G33-GPO with DISTILLER


Insert offset folio 43 here 32636.043