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US Senate Committee on Finance, Subcommittee on Health Care


Testimony submitted by Assisted Living Federation of America (

Sen. Rockefeller and committee members,
My name is Richard Grimes, the President and CEO of the Assisted Living Federation of America ( Thank you for giving me the opportunity to submit testimony on the role of long term care in health reform and thank you for highlighting the need to include long term care in the health reform debate.

I would encourage you and the committee members to take the broadest possible view of long term care. It was not so long ago, in our own childhoods, when the only real option for long term care was a skilled nursing home. In the past 25 years, much has changed. The private assisted living industry has exploded in popularity in the United States and is now the fastest growing long term option in the nation.

The nature of aging has changed in the United States and it will continue to evolve as the baby boomers move through their senior years. When lawmakers sitting in your seats passed the Social Security Act, the average life span in this country barely reached 60 years of age. Now 60 is the new 40 and seniors are living into their 80’s, 90’s and beyond. The number of Americans living beyond the century mark is at a record high and promises to only grow with time.

I was struck that all of your expert witnesses at the hearing agreed that home and community based care , which includes assisted living, is far more desirable than institutionalization. Even though most public long-term care funds go to institutions, a consensus in favor of  other options has clearly emerged among both consumers and government officials. Not only is home and community based care far less expensive than hospital or skilled nursing care but every study shows that disabled and senior consumers and their families prefer it. No senior asks to go into a nursing home or hospital. Circumstances sometimes make it unavoidable but in many instances, the needs of the individual can be met in a less rigid setting.

None of your witnesses spoke specifically about assisted living.  I would like to offer some thoughts as to why assisted living provides a desirable and more cost effective model for long term care in the future.

Assisted living is the resident-centered alternative to institutional care. More than one million seniors call assisted living communities home at tens of thousands of communities located in every state.  Our residents are frail seniors who need some assistance with activities of daily living and can no longer (or choose not to) live in their family home—but do not need round the clock nursing care. Our typical resident is an 85 year old widow. She takes eight to 10 different drugs each day, almost as many medications as a nursing home resident, but her medications enable her to manage chronic health conditions . She usually lives in her own room or apartment.  The community provides her meals and a variety of social and recreational activities from card games to movies to book clubs. A van takes her to her doctor’s office, to local entertainment events, and to the local mall for shopping trips. She lives surrounded by caring staff and friends and maintains control over her own life, deciding when to go to bed, when to get up, when to bathe and when to eat. In other words, she has independence and choice.

Assisted living is a philosophy of care that embraces choice, independence and the opportunity for seniors to live enriching lives with dignity, respect and privacy.

We are convinced that assisted living is popular because of the bedrock principle of choice. Assisted living supports the resident’s decision on how and where a person should live. Many of you are grappling with the challenge of caring for aging parents and grandparents. Senator Rockefeller’s moving description of caring for his own mother who suffered from Alzheimer’s disease in her final days is an experience many Americans share. I , too, am one of the 74 million baby boomers with aging parents who need care.

The decision for someone to leave the family home where children were raised and she spent many happy years is never an easy one. But when a loved one realizes it simply is not safe to live alone, nor does she want the responsibility of living in her own home, assisted living is a terrific option. Many seniors grow isolated and depressed living alone as their spouses and peers die. In assisted living, we see men and women truly gain a new lease on life.  Consumer surveys, including those conducted by state regulatory agencies repeatedly show an astonishing satisfaction rate of more than 90 percent.

The issue for most seniors and their families is finding quality care that is affordable  The assisted living alternative is available everywhere in the United States. Because it is resident-centered and affordable, it has grown to become the consumer preference. Assisted living costs about half as much as skilled nursing home care. Medicaid saves between 50 and 66 percent for each resident cared for in an assisted living community instead of a nursing home. (More than 40 states have sought or obtained waivers to use Medicaid funds for assisted living for qualified residents. This population amounts to less than 10 percent of  the residents in private assisted living communities.) Any form of long term care is labor intensive. A tiny fraction of Americans purchase long term care insurance now and with the recent stock market decline, many have seen their savings dwindle or disappear.

To us, the public policy challenge you face as you consider long-term care needs is helping Americans save for retirement and afford the type of housing and care they need and want as they age. ALFA strongly supports the Community Living Assistance Services and Supports (CLASS) Act which would create a nationwide public insurance program to help pay for Americans with significant functional needs. The CLASS act keeps control in the hands of the individual and guarantees choice in long term care options.

The growth of assisted living shows that the long term care industry is no longer monolithic and nursing homes are not the only option.   All of you know that an institutional bias in government programs lingers against home and community based settings. That is because Medicaid and Medicare, the twin safety net programs for the poor and aging, were created by Congress long before the private assisted living industry existed in the United States.  Indeed, when the prescription drug benefit was added to the Medicare program, it inadvertently charged a co-payment for low incomer seniors who live in assisted living communities, so called dual eligible recipients of both Medicare and Medicaid. We are pleased that lawmakers are trying to correct that inequity this year.

There is a risk to over-medicalizing the federal government’s approach to aging. Aging is not a disease even though the US Census Bureau tells us a majority of seniors suffer from two or more chronic health conditions. Yet millions of seniors live busy and happy lives for decades with chronic diabetes, heart disease, arthritis and other serious illnesses because of modern drugs. Just a generation ago, that would have been unthinkable.

We are fortunate to live in a time when the average lifespan is steadily growing longer and the quality of life for older Americans is improving. As you grapple with health care reform, we urge you to make certain your plans give maximum flexibility and choice to aging Americans.

ALFA and its members welcome the opportunity to provide more information to the committee as it considers this challenging topic. We are grateful for the chance to submit this testimony and look forward to working with committee members.

The Assisted Living Federation of American is the largest national association serving companies operating professionally managed assisted living communities for seniors. ALFA is the voice for senior living and advocates for informed choice, quality care and accessibility for all Americans needing assistance with long term care. For more information go to