our standard procedure and we're sure short video and good deals with the issues many americans who are uninsured and under insured are facing  we know that there's a lot of discussion in the campaign and in the press and everyplace else about the health care reform and it's been some years since the last the largest that system wide reform and the failure to be able to come to a conclusion with it in this election year candidates all on all sides are talking about health care with different approaches and philosophies and but i think each candidate recognizes that there have to be some changes in the system of delivery of medical care the number of uninsured is increasing middle class americans having trouble paying their premiums paying their cost sharing they just announced the other day they're going to charge us more for expensive drugs and we all know i think that the medical care delivery system is need of change and before we rush into solutions i think we should develop an understanding of where we are what is the problem can we identify the problem trying to fix hopefully mr camp and i can come to some kind of agreement on that we may not agree on what the fix ought to be but hopefully we don't have to argue about what the problem is and that's the purpose of today's hearing i'd like to defer on mentioning our first witness for a moment but after we do hear from our first witness we'll hear from a panel of witnesses who will describe the instability of health coverage and the availability  after this second i'm going to recognize mr camp will then go off the record and view a ten or twelve minute clip that comes out as of a sixty minute program in coming months and years ahead of the stick if thank you mr chairman and i want to thank our witnesses for being here today as well the laws and regulations governing the us health system can prevent from between twenty five and to forty five million americans from having health insurance and that's wrong every american should have access to quality health care for we can solve the problem we need to ask why so many americans lack health insurance one of the most immediate causes has to be the skyrocketing costs of health care and health insurance since two thousand employer based insurance premiums have increased by about one hundred percent and that's four times the rate of inflation the spiraling costs are driving increasing numbers of employers to drop health insurance coverage for their employees at the same time overregulated state insurance markets are failing to provide affordable health insurance for many american families we also need to identify who is uninsured approximately two thirds of the uninsured are in families with incomes below two hundred percent of poverty or about forty thousand dollars a year in the current difficult economic times it shouldn't come as a surprise that these individuals do not have the resources to purchase private health insurance that does not mean however that they cannot have private health insurance every uninsured person in this country shares one common characteristic they receive no assistance under the federal tax code to help them purchase health insurance at the same time that costs for health insurance are soaring our tax code firmat it really discriminates against the uninsured if we were to simply equalize tax subsidies that we provide millions that we provide no ians of more millions more americans would be able to get health insurance the generosity of the american taxpayer should not only go to those with employer purchase health insurance it should apply to individuals small businesses and large corporations like to do that we must make sure those americans who already have insurance keep it and we must help those who don't have coverage get it i want to thank mr star for calling this hearing to give us all the opportunity to examine this issue i hope that in exploring this issue we can begin we can begin to identify solutions to reducing the number of uninsured without further burdening existing entitlement and his ability to work with people from both sides of the aisle to find solutions he brought some of minnesota's most innovative and successful ideas to washington dave served on the two senate committees with health policy the finance committee labor committee and also chaired finance health subcommittee senator byrd left his mark on every major piece of healthcare legislation through the one nine hundred eighty s into the ninety's he also authored a prescription for change a book on health care reform through consumer choice since his retirement i know firsthand senator dearmer is not slowed down one iota in addition to teaching graduate level courses in health policy and i understand his graduate students from st thomas university are here today with him he formed the national institute on health policy a joint effort between the university of st thomas and the university of minnesota senator durenberger also started the medical technology leadership forum and also serves on the medicare payment advisory commission of course most significant to me personally senator dave durenberger has been a close friend mentor confident for thirty years we would be here all day if i listed all of dave gerber's credentials but let me just say i have deeply appreciated your expertise david in your friendship over the years and this subcommittee certainly looks forward to your testimony when we appreciate your collaboration on what i believe is one of america's most pressing problems thank you again for being here and thank you to all the witnesses and yield back mr chairman thank you thank you and it is i'd like to join you it's my pleasure to welcome dave here we've worked together since nine hundred eighty five on issues dealing with medicare and other issues of camp members the committee but especially jim ramstad the other gyms that he's been a very close for a long period of time and it was i had mixed feelings when jim announce he was retiring as many of you had to on the one hand i was happy for him on the other hand i was unhappy for the rest of you because of the contribution that he has made to good not just good health policy but a good policy in so many ways each of us is reflective in a way of the people that we represent the places we were raised we were educated and so forth and jim did this better than most people and as i see some of the people that i know here like mr camp and his part of michigan and mr kind in his part of wisconsin we have much more alike than we have and we differ and that certainly is true of health policy as well because it was an honor for me to sir minnesota for three terms in the senate was always a challenge i must say to go to conference here at the end asked to testify or do i do so in the spirit that for most of those years characterize our relationships and our effort to make national health policy and particularly to improve the health system in this country by changing the financing incentives for providers in the medicare program one of the things you learn fairly early on in this process that we don't have a national health system and mr camp alluded to i think it is government but what we do have because we know this from our personal experiences in the communities we represent we have a series of systems and the work at dartmouth for example explains that to us quite clearly but my job is not the talked about the health of the more the specific challenge of the uninsured but i was asked to reflect on my experience in doing health policy the first let me say not since the presidential campaign of one thousand nine hundred two have americans been as concerned about their financial well being as they are this year most americans know they can't afford the rapid rise of health insurance premiums especially when it is currently accompanied by the escalation in the cost of so many other of their basic needs so it's just a it's a big challenge but it isn't just health policy and you know this better than i public opinion polls reflect this strong support for proposals to guarantee access for all the health and medical services for all americans through some system of health insurance but clearly the same poll will tell you that there is no consensus on how to do it as both of you pointed out the debate as it always has been is between universal coverage and the cost containment and it's also between social insurance systems and private insurance for example senator clinton advocates a universal coverage path that can utilize a form of what we might call medicare light for persons under sixty five sen obama same party advocates using the model of the federal employee health benefits plan and senator mccain advocates cost containment through greater tax subsidies for private major medical insurance interestingly each advocates similar cost containment measures through realigning financial incentives to produce better quality outcomes effectiveness and efficiency from the delivery system and similar battles as we know only too well are being waged ad the state level in part coverage in part quality and value and so is always been unfortunately critics of the democratic proposal to characterize them as socialized medicine and critics of the republican proposal criticize them as doing nothing to meet the issue of affordability which is driving up the numbers of uninsured and under insured and that will probably get us nowhere and policymakers we have all as policy makers we've always followed a two path course the universal coverage it is most obvious in the medicare program where we have been making most national health insurance policies since i became active in helpless the reform in the early one nine hundred seventy s we have used both social insurance and private insurance in our financing policy changes aiming ourselves at expanding access coverage and cost containment the test for how for high value health insurance is how well it does for people when they are sick seriously injured or chronically ill it's the problem of the eighty twenty problem twenty percent of the people present us with eighty plus percent of the cost challenge and so the real test of choosing an insurance course universal coverage is how well does the plan do in that regard how many benefits a plan has or how little people use a deductible is not the measure the value test for both social insurance and private insurance is how well each does to consistently pay for quality for outcomes for effectiveness and for efficiency and that has been our challenge in that since i started doing this sort of thing how do you move both social and private insurance in that direction for example the federal employee health benefit plan has always been a model for consumer choice of private health plans and the impact of that choice was important in creating health insurance competition community by community using federal employees and retirees to accomplish that my first health legislation proposal was the consumer choice health plan of one nine hundred seventy nine and some of the were born probably in the purpose of it was to require similar choices they have ph b p in the private employment in exchange for the employer tax subsidy so medicare always used private insurance first in his benefit design and hugely successful in areas of the country where they were tried and where medical practice in relations with community and state based health insurance guaranteed their success for example in our part of the of the country which always brags about being a low cost area we were the hike one of the high cost areas we were in the upper court tile in the head of one county paul area and in north dakota and places like that and within two and a half years of this experiment with private h m o we went to the bottom court trial and unfortunately we're still there principally because we didn't share the savings we in the medicare program did not share the savings but the people that made that possible who are the physicians the hospitals and the local hills and the local health plans who did it as well the rest of the country chose to follow the path of hospital the r g s which we instituted at the same time but on another vehicle by one hundred eighty nine of necessity we adopted the pay for prefer the prospect of payment system to physician payment and created a lots of other problems none of which i endorse that you repeat the mistake we made of course was not in leaving more of the financial savings for changing the over use of medical services with the care professionals and the hospitals and the plans that were responsible for doing the mistakes the medical industry made was to take these community based examples  cooperation national and to take the local managed care organization the tional as well for example united health group and our own community became the largest health insurer in the country through merger and acquisition of lots of local h all over america likewise wellpoint became the largest insurer in the country through the conversion of lots of local state local and state blues plans the for profits and their merger an acquisition this new private insurance phenomenon national private insurance phenomenon for a while was very successful in driving down health care costs and their premiums and profits made them all street darling but by the end of the one nine hundred ninety s the same plans were  national industry playing by either state rules or no rules in the employer self insured market because of eartha when congress in one thousand nine hundred seven authorized private plans to do what markets are supposed to do determine through price competition for basic benefits what's the real cost of a basic set of benefit medical services in a community by community the industry refused to play the managed care industry slowly but surely adopted itself to the realities of consumer demand for freedom of choice access innovation and expectations and this is obviously unfortunate and they did that particularly in areas in which physician groups and hospitals had the power to make sure that sort of thing happen so in effect we've lost some of the benefit and the potential that exists in private insurance and that's the point i'd like to make not that it's wrong it's very right it's been our course from the beginning and the question is how do we design it and what is the policy goal we're trying to achieve at the medicare payment advisory commission on which i served until last we completed my six years we simply predation on medicare is less effective in achieving performance improvement than private insurance then how do we structure the value proposition in the relationship between medicare and private health insurance paying financial bonuses the medicare advantage insurance plans for simply adding service benefits to the medicare program is probably something you could do as a congress but it's not the right thing to do without clear evidence that those services have value added over existing insured services which takes us to issues around comparative effectiveness which i won't dwell on because you've heard plenty of that so let me conclude by saying there are many reasons that universal coverage is important many of them relate to the vastly improved economics of reducing or eliminate cross subsidies from paying to nonpaying services in hospitals especially i have not lived long enough with the consequences of our national failures to secure financial access to needed health care services for all americans that i believe a commitment of the next president to those goal is important to my vote i do not believe it is possible in a federal system for each of the fifty states to accomplish this goal on their own their fiscal capacity their populations are just too disparate this is a matter of income security policy for the nation of which we are all citizens we have no income security policy and we have a bunch of aging entitlement programs in this camp this out with a bunch of aging entitlement programs which are bending and sometimes breaking under the weight of population health and ageing and the cost of medical technology and providers it would be an appropriate challenge for this committee the ways and full committee to take the lead in going beyond reforming programs that were  thirty's for the thirty's and the sixty's for the sixty's and developing an income security policy in this country and a good place to start would be but as we recommended in the pepper commission get long term care out of the welfare program and convert it into a combination social and private insurance program and that would make your challenges a lot more simple i have no reason to believe that is republicans or democrats we have much disagreement about the need to agree quickly on how to do the work of data gathering measuring performance motivating better outcomes and rewarding the first great performers in the business an informed consumer in as many communities as possible and i am also pleased to have been afforded this opportunity much as expected the beach of you in an area that is too complex to be understood by anyone of you but challenging circumstances always bring out the best and i hope that i may continue to sir whatever you may continue to take interest you may take in health coverage and reform thank you  sen dave thank you very much as you know you and i have a great difference in this problem of the underpayment of the minnesota north dakota wisconsin area  representing a district that is drastically in your opinion overpaid i've always said swell let's just cut the payments to california down to the level that we're paying in minnesota and think of all the money we'll save i'm not sure sure that that's the most popular approach to this solution in your part of that country and it would be very popular in mine but it occurs to me that that's one way to do it  i just want to ask one question and that is one of the issues that we're going to be faced with that i'm not sure any of us as yet have an answer in the reimbursement program for physician services is what we do about you and i'm sure that in redesigning that system as i think we all agree it must be redesigned we have to deal with that issue and my question is when you come back and help us with it well i'd be glad to and i'm i'm going to connect the two just very very briefly the disparities exist in payment across the country but it's largely because there are disparities in performance and whether you look at mr camp's district or you look at my district or you look at lacrosse wisconsin and by the way congressman kind there's a doctor from gunderson out here in the m b a classes with all but if you look in our in our district and you compare measurable quality outcomes performance for the dollars that are spent in your district in his district in my district and so forth it's a bargain for the rest of the country but it's also a model for the rest of the country to be followed and unless we can we you can design a payment system that begins to reward high performance in some way appropriately we're go continue to have these problems and the key to that is physician payment reform and we talked about accountable care organizations we talk about bundling we talk about a variety of approaches and i would be happy to come back and be helpful  thank you mr chairman and thank you senator during burger you're welcome a number of good points i appreciate your outlining really didn't serve as background on medicare that it always has had a private insurance component to it tell me what do you think of some of the proposals that are have been introduced either in the senate or the house that are attempting to use the tax code either tax credit or tax deduction or a combination thereof to really create an individual insurance market tell me if you think and also what you might think about the question of mandates if you have time and i'll again try to be brief but number one we just had the benefit yesterday of having both ron wyden and bob bennett speak i sort of like fresh from one model of some of the ideas  that are out there first with regard to the tax subsidy the proposal for the tax subsidy they have this increase everybody's pay ten thousand dollars and make them pay with the money that his lap like the  president bush's proposal has been needed for the thirty five years that i've been involved in this and it's a question of getting from here to there that is always a challenge so i think on the appropriateness of the tax subsidy for individuals that is so much better than any other approach that has been taken the challenge i think in this concept that somehow we can blame the universal coverage of the democrats with the market ideas the republicans gets us around to do we have real markets and how quickly will we have real markets you'll not have markets start with something simple like insurance you'll not have real markets  insurance until you have national rules by which all health plans have to pay play the idea that we should just stay with fifty state regulation and you can go shopping around the country for a good deal just will not work it will protect consumers but the idea of having a set of national rules by which both national and state plan can truly compete is really a great idea and that's been presented as value based benefits and presented as a guaranteed after that the issue becomes the same with regard to doctors and hospitals and we talked about that in terms of what's quality what's good outcome how do you measure it how do you get consensus and a lot of progress is being made on that but again unlike the secretary's ideas and value exchanges and things that focusing on local communities and finding out who are the people that are already ahead of the of the curve is is critically important when you get the market working you've got all the information you need people are informed and they're getting their information from reliable sources they've curb their own expectations about having this on the moon the stars and everything else then the only way a national system works most effectively is through everyone having an ownership that insurance and whether it's a long term care i mean long term care insurance as we've analyzed many times is basically it's the port of services for elderly people and if we were able to sell disability insurance to everybody in this country when they were young you know you wouldn't have to worry about needing long term care insurance because people can use it at various times the same thing applies to health insurance and just quickly before my time what do you think of the individual mandate some proposals think that's essential others don't i don't again it depends on if you have to tie it together with the insurance reform before you even in my book for you even before you even consider it you also have to tie it together with some other reforms i think in the end at some point you're going to i would not start with an individual mandate whether it's at the state level or the or the federal level there are other ways i think to explore the problem that's created by free the free loaders or the whatever the economists call it the free the free somebody or others on the on the system all right thank you very much you're welcome mr dog would you like where thank you very much for your testimony does any other country provide us a model of any aspect of what we should be striving for here or is our predicament so unique that we have to strike out on our own you know they're there the models basically the policy models have been tried in one form or another all over and we've had some discussion about what are the what's the appropriate policy model to get from from here to there one of the challenges that you face as a subcommittee and the larger ways and means committee is there's already by most people do something a lot of money in the system and a lot of it is being spent on tax subsidies that are not doing i mean they're benefiting wealthy people rather than low income people how are you might consider those long term care going into a welfare system rather than being in its uninsurable of amps and we ought to be having insurance so there's no there's there's all kinds of money out there the inside build up on on tax subsidized savings and things like that so there's plenty of money in the system but there's no policy to guide you as a committee there's no policy to guide you to get from here to there which is why i made the argument about income security thinking about it as income security policy and i i don't long time ago i think of the twenty fifth anniversary of medicare something i made the statement that medicare and medicaid are not health plan programs there are income security programs they're not health programs and if you think about that long enough the reality is we've got this whole series of programs built for various purposes at various times that are not working today for the benefit of the people that need them the most and that's that is an enormous challenge for you to follow but in terms of the cost reduction the cost containment and so forth the examples i've tried to give you take medicare advantage because i just heard this yesterday from abby block who runs the medicare advantage program at c m s she didn't know there was going to be somebody in the audience from lacrosse wisconsin so she says the difference in the value to a medicare beneficiary in dade county florida in the amount of money that you are spending on her services in miami florida versus lacrosse wisconsin and this is what i heard from her you'll have to check it is two hundred forty eight percent more money being spent on this beneficiary in dade county for no reason other than well you will  part of the policy design in the practice design i certainly agree with you that you know these tax credits by their very nature are very blunt instruments and they're they're very costly for what they produce they're not the most efficient way sometimes of getting  health coverage where we need it and i certainly concur in your comments about how costly some of them are for what they produce do you believe that it's possible for some type of government insurance program to coexist  with private insurance to address this problem it does now and to the advantage of it to the potential advantage of polls and this is not in my view this is america i mean we're a pluralistic society and we ought to build on that and that's why i made the point that we've always followed two paths and the question is have you set the goals correctly i mean is the goal to be paying for the sick the severely you know the really injured i mean is that the purpose of insurance and also is part of the purpose of insurance to facilitate the rewards for quality and outcomes and efficiency and things like that so if you set the policy goals right there might be some circumstances some populations for which social insurance works much better and others for which private insurance works better thank you so much thank you  pleasure i'd like to focus for a moment and ask you about health care disparities today the congressional black caucus is hosting their annual health care disparity conference at a hotel here in washington c and i had to choose between which i could attend a so i decided to be here with you and i wondered that in the work that you've done around health care have you had any focused in on health disparities as it involved the delivery of in majority and if so what your experience has been and what your recommendation would be to this committee as we walk down the road of trying to repair the health care delivery system in this country thank you very much for the for the question and i'll just give you two brief reactions there are communities in this country where because of state efforts to provide universal coverage mine  one you've heard about massachusetts you can see a group of states in this country that have gone the extra mile to finance as for as close to one hundred percent of their population as you possibly can and so in varying ways we do rely have relied traditionally on the states to provide the initiative for finance financing access for people who are disadvantaged by income by education  for whatever reason and so those states are on most charts of health and access and so forth are going to be ahead of states that have taken different courses and have not chosen either through the way they practice health care or the way they organize their systems or the way they finance them to accomplish it so one of the one of the ways in which you can consider over time and getting to to broader access to the financial to the  insurance side of this of course is to think instead of thinking about the medicaid program in the traditional way is to think about it in terms of income related subsidies for either private insurance or for some other form of access and the transition to getting from here to there would involve taking long term care out of that that particular thing the second but the second and maybe more important comment to make is the nature of what's going on in this country right now and you're having a hearing on cultural and other disparities economic and other disparities today that same discussion that's taking place in every community in this country and the link that organized medicine broke between public health and medicine eighty years ago something like that is now being reattached in many of our communities i can point to in texas for example i can point to parkland hospital in dallas and some of the leadership there to involve the communities when the legislature is unwilling to provide the financing of access the leadership at that very public very challenge hospital is out in the community reaching out to gang leaders and other leaders to try to bring the community into the delivery system one of the values of not for profit hospitals on the community benefit tax exemption is to think more about what are they contributing to bringing in the access not just through insurance but access to services is happening in many communities around this country and it's a really wonderful thing that is that it's it's happening and i'm not sure that there's anything other than paying attention to this phenomenon that we reconnect public health personal responsibility and you know the the the insurance programs for medical care services and fostering that in some appropriate way thank you i'll just put on the record not a question about how do we increase the availability of health care delivery personnel never seen being one of the huge things that one of the areas professions that we're in such deep need for and what idea that you don't have time to give me in today but i would be interested in what you might think how we might achieve address that issue well in twenty second they're going to tell us start financing the students and stop answering the institutions that educate them i mean the old i mean you look at where all the medicare money is going for example it's going to large academic medical centers and they're overpaying for indirect medical education benefits and so forth and my sort of conservative side says i'd rather finance the consumer him piss in this education game than the continue to finance the establishment pointed out that minnesota does a lot of things right when it comes to health care delivery and we all know that we were we were recently ranked as the healthiest state in the nation we have the lowest rate of uninsured we have a long history of delivering high quality fish and care and low cost yet as you pointed out as we all know on this subcommittee every federal program seems to punish minnesota for doing the right thing we get low medicare fee for service and medicare advantage reimbursement because of our history of low cost i don't know how many times i've copied your illustration in comparing dade county we have been county and my district we can't use s chip funds to cover children because we were we were already covering kids through minnesota care before s chip was ever created our state high risk pool for the uninsured will get slow federal funding because our state has done a good job of covering the uninsured how in your judgment can federal incentives be realigned so we are actually paying for quality and value instead of inefficiency and utilization as you put it well thank you for the question and thank you for the self aware of and one of the i mean the the short answer is we tried it already i mean we tried using the what was then called the h m o and managed care to do our work for us basically to identify all of the poor quality areas that were just costing us a lot of money and they performed well they continue to perform well the virginia mason clinic for example and in seattle is one of the leaders in this country on offici forth so it isn't really i guess up to this it's not possible i'd say for the for the committee or the subcommittee to start designating you know who do you like and who do not like you almost need an intermediate intermediary to do that for you and that's why i make an argument for changing the rules and changing the goals in the requirements for both public and private if you're going to pay extra money for private insurance to go out there and find the most effective places the spend money  same thing for traditional medicare and able the doctors and the hospitals to be rewarded for their efficiency their outcomes and their quality as well well first of all i should thank you for being less parochial than i get rid of i mean there's not enough money in the system or in the federal treasury for that matter to equalize things through the a p c formal i mean we really need a new new system don't you agree and that's that's the but the design of that system will probably vary from one place to the other i mean your task is to reward either the this is where med pac was going you know with bundling pay finding accountable care organizations that's where some of the people in the professions are going with the concept of medical home we submit we had a regional medical home application under the six forty six demonstration program we had the entire region from montana the wisconsin the the medical group at the university of wisconsin was part of it was six doctor group out in western south dakota part of it just to demonstrate if we have the authority has demonstrated from c m s to demonstrate that paying for quality saves money but there's briony of those ways that can be chosen some of which most of which are going to relate to position and those criteria much more important than geographic criteria some of suggested moving to a regional system but wouldn't we still say have some of those same geographic inequities you have the same problems chairman other than to acknowledge a senator for all his work and to thank him for taking the time to be here very much appreciate it and with that mr chairman i will you back and say that i hope we are able to move forward with some of the ideas that the senator has articulated and more importantly just recognize that more and more people are saying it's time to do something so thank you for your testimony thanks for being here they're very welcome to thank you mr chairman just for the record you again and i'm appreciate the effort you've made to and reaching out with so many of the providers in my own congressional district to have this type of conversation ongoing and i couldn't agree with you more but there's going to be tremendous savings had within the medicare system of we can get to an outcome or performance based type of reimbursement system but that of course will follow the huge investment in h i t which will be important stablish ing the standards and inner operability and everything that's taking place right now i don't know if you've had an opportunity to pick up shannon brownlee's book overtreated at all if you've read that many people have and your basic thesis is that there's a huge disparity obviously and utilization and that's backed up with the dartmouth atlas study every every year  and if we look at how over utilization is taking place from region to region there could be tremendous cost savings one of the point that she made i had a chance to talk to her a little bit more about that is that crucial six months and life care and the tremendous spending that goes on there and her point was if we get back to listening to the patient a little more closely because again there's vast differences in utilization and what type of hospital stays recommended or tests that are ordered in those final months or weeks of life there could be tremendous cost savings there not through major reform with health care treatment but just by listening to the patient she says invariably patients don't want to be in the i c u unit for weeks and weeks and weeks and having multiple tests ordered multiple drugs administered and that generally patients are more conservative than a typical provider and they just like pain management and have a chance to be at home in those final days of life and if we get back to that listening to the patients it could be not only greater satisfaction with the patient in the family but also tremendous change in the health care system one of the bills i've been working on through a period of years model closely what you were advocating when you're still serving in the senate is trying to set up a national purchasing pool and of course we've had the ongoing debate about associated health plans and federal preemption of state mandates but i also agree with you that we do need a set of national rules national standards my question to you is how do we get there what would the process look like one of things i've been toying with in the legislation would be a small business and family farm health act modeled after the federal employee purchasing pool concept because when you look at the forty seven million uninsured most of the working americans even small businesses run farms who just can't afford to provide any health care coverage but part of the key to this is six success obviously is getting away from the fifty different rules and mandates that are established from state to state which would make it more easier for he plans to come in then and be able to compete in the national pool one of the ideas i had is forming this commission perhaps represented strongly by the various state health insurance commissioners to see if they can reach some type of agreement on what minimal standards should look like and therefore have a national template i don't know if you have any thoughts and i'm sure you health care to informed patient choice informed patient choice means there is an obligation on the doctor to access all of a level information that relates to that patient's condition to provide that to the patient and then have the patient make the choice and take the responsibility for that choice on the second point jeff bingaman from new mexico and i i think it was nine hundred ninety two introduced the health insurance nobody brings it out anymore except folks who want to talk about association health plan which is a very different approach so i'd recommend to you to look at that legislate the health insurance purchasing cooperative because it's basically a local way in which to do  large group purchasing and it serves the individual and the small group market as well just to stop you there oakley in fact we've got some pilot programs taking place in wisconsin right now targeting family farmers throughout the state as a health insurance cooperative enrolling them to pool together it's been tremendously popular and there's a backlog of a waiting list of help right now and mail just decided to participate in like six or seven plans right now participating in this this pilot program e mail just decided to participate as well here senator let me just ask one thing seems to me that the companies that provide insurance for their employees do it with the pretax dollars and yet individuals or small companies that can't provide insurance have to buy with after tax dollars this committee has an opportunity to fix that now under what your thoughts are on that i think we ought to fix that and there one thirty years i've been asking the same question asking and we haven't got the boyd of changing it but those are two good i think in my opinion those are two good ways to change it but one of the things i don't agree with and some of the proposal is getting rid of the employer i think the employer is a vital part of the purchase and a lot of other things that whole effort to go to help the health management and helping people become more productive productive person and so forth is really being driven by the employer  involvement in the health care system so i would not endorse you know everybody walks around with no contribution from their employer it's too expensive to get any kind of coverage unless you can keep those people involved and i think i think you're on target thank you senator you're welcome that's all i gotta say that i do want to pick up with ron and that on the end the life i mean i do think you know we have this if you look at health care you get five presidents have tried universal care truman johnson nixon carter and clinton and we're over five but we've universalized care for segments of the population medicare medicaid veterans s chip was an attempt at that and you're always torn between trying to do the system and get it right because i agree with you i want to associate myself with what your comment is there's a lot of money in the system we spend two trillion dollars on three hundred million people and have life expectancy at seventy three the e which is similar population spends a trillion dollars less and has life expectancy is seventy five if you're doing this smartly just say we ain't getting our bang for the buck at that's one measurement and i'm always torn between just doing the whole thing hoping for hope that the six times the magic number or then taking steps here that you've outlined one is the end of life we do spend a preponderance of dollars on the last six months six months of life to something dave and i are working on which is getting people earlier in life that is early retirees fifty five sixty five participating in a chronic illness management before they get into medicare and they get reduced co pays for every illness or year they spend in a whether it's you know smoking diabetes heart blood cetera so you get you wore the right type of behavior and so i suppose that's one option to look at the other thing is to invest in the i can get to those national standards you talked about and then allowing people to compete once that kind of floor and boundaries were set up based on what you've seen in the history of reform where it succeeded where it hasn't where would you buy i mean what would guidance be given the next congress in the next president's go for the whole thing or try to make significant reforms kind of early retiree buy act which was a step in the direction of making some sense out of the medicare program and he says now it's got to be a commission for long term care and everything else and out of that came the employer mandate it did not come the answer to your question already there was a we came with the solution we did not the republicans voted against it but but i am a person and the democrats voted including people for mr chairman and out of it came the employer mandate which was you know it was it was a solution or an answer but it wasn't the answer to your question and so we've always had this kind of debate between cost containment and  so forth so my and my belief about twenty nine is the importance of the president and i make a difference whether it's republican democrat or which which democrat it is critical that the president begin by giving all americans  view of what is possible in a country as rich as ours as very desires but the entrepreneurship that we see in health care medicine and all that so i think with a vision like that people like you all can accomplish a lot more th because with no vision the the the status quo you know the old business of what one person the income of somebody else has cost them that or the reverse of that so i think leadership right now is the biggest factor in getting to the to the all this other stuff we can agree on some combination and we're looking more locally and accountable care organizations and palliative there there's a lot of things we can talk about but unless the people are on that the difference between the ninety the now these are the household income where we saw six thousand dollar rise in the ninety's and eleven i dollar drop in median household income all related to health care health care in fact americans got a right raise in the last six years the problem is it all went to the health insurance industry when you get health care costs for family for going from six thousand to twelve thousand median incomes dropping by eleven thousand just simple they got a raise it just went to them health care system it didn't go to their bottom line to meet other needs that's absolutely right and unless we do something about this which is going to end up when you just can't double it again thank you you're welcome again dave thank you very much we'll take you up we'll go off the record for about ten or twelve minutes and observe a video and perhaps what we're doing that the second panel would like to come on up and i think you'll be able to see the video from director of policy for the american cancer society each of you have submitted testimony which will without objection appear in the record in its entirety and will ask you  summarize or expand upon your testimony in the manner that you are comfortable will start with dr rowland thank you mr chairman and members of the subcommittee i'm pleased to be here today and will try to put some of the numbers to go with the very human experience you just saw in the video health insurance coverage can provide a valuable lever to help gain access to primary and preventive health care services as well as peace of mind and financial security for many facing serious health care problems yet our latest statistics show that nearly forty seven million americans were without health insurance coverage in factors age income workplace and state of residence for those over age sixty five and those with permanent disability medicare provides health insurance protection slightly more than half of all americans receive employer based coverage and about five percent purchase coverage through the non group or individual market together medicaid and s chip play a critical role for the low income population covering twenty nine million children and twenty four million non elderly adults and people with disabilities this leaves however one in six americans sixty percent of our population uninsured the forty seven million uninsured americans including nine million children primarily coming from low wage working families eighty percent of the uninsured are from families with a full or part time worker and two thirds have incomes below two hundred percent of poverty or roughly forty thousand for family of four most of the workplace work in places where health insurance is not offered through their job and the rising cost of health insurance premiums now over twelve thousand for a family means that if coverage is offered the employee share of the premium is becoming more and more an affordable for working families take for example one of the families participating in our study on family budgets sam is uninsured and has just gotten a job in a home improvement store his wife carmen is at home with their three children once he becomes eligible for employer sponsored coverage he will be required to pay four hundred dollars per month and his insurer a share of the insurance premium which is a quarter of his sixteen hundred dollar monthly take home pay today nearly ninety percent of the family's spending already goes to basic necessities leaving little room in their budget roughly one hundred  fifty dollars a month for additional spending that could be used for health care or to pay deductibles and cochere ing for the health plan yet having health insurance matters it affects how and when people use the health system and ultimately their health and financial well being the uninsured are much more likely to postpone or forego care due to cost than those with coverage and when they seek care they are often billed full charged and left to pay what they can sometimes accumulating large medical debts that can lead to bankruptcy leaving forty seven million americans without health coverage if it's not only the uninsured but also puts a growing burden on our health care system and additional strain on the economy in two thousand and six it is estimated this sudden twenty two thousand americans died prematurely as a consequence of being uninsured and the lost productivity of the uninsured had an annual economic cost of between one hundred and two hundred billion as the availability affordability and scope of insurance decrease both insured and uninsured americans are now dealing with budget consuming medical bills and  two thousand and four some forty five million americans were in families that had a high financial burden for health care spending more than ten percent of disposable family income on health care services and insurance premiums this financial burden provides a measure of under insurance individuals that high risk for these levels of financial burden include those fifty five to sixty four who are not yet eligible for medicare those in  poor health and especially those with diabetes stroke heart disease and other chronic illnesses it is clear that for many health insurance alone is no longer a guarantee of financial protection from the cost of health care and financial stress when illness strikes health insurance is an important source of financial security for families when illness strikes and helps to promote access to health care services they can often stave off more serious illness as congress moves forward to address the growing uninsured population and the impact of rising health care costs on america's families promoting improved access to affordable health care and adequate health coverage for all americans will be an important but challenging objective i appreciate the opportunity to testify before you today and will welcome your questions at the conclusion of the panel thank you thank you chairman stark representative camp and the members of the subcommittee on health for inviting me to testify in the health consequences for americans who lack insurance and on the persistent problem of racial and ethnic disparities in the u s health care system these topics are  vital importance to our nation my name is john and i'm a professor of medicine and health care policy at harvard medical school over the past sixteen years i have studied the adverse effects americans experience when they lack health insurance as well as racial and ethnic disparities in health care from two thousand to two thousand and four i served on the institute of medicine committee on the consequences of an insurance i'm also a practicing physician at brigham and women's hospital in boston where i've seen firsthand how patients lives are affected when they lose their insurance uninsured americans are much more likely than insured americans to avoid seeing a doctor because of the cost among those in poor health fifty to seventy percent of uninsured adults go without needed medical care compared with only about twenty percent of insured adults and poor health uninsured adults are less likely to receive high quality primary care and important preventive services such as cholesterol testing and mammograms as a result they are often unaware of their major health risks such as high blood pressure high cholesterol and those with curable cancers such as breast cancer colon cancer or diagnose it a more severe stage of disease because of their unstable and sporadic medical care uninsured adults have a much greater of dying at younger ages than insured adults the institute of medicine has estimated that eighteen thousand americans died prematurely in two thousand because they lacked health insurance sadly many of these premature deaths occur among people with conditions that are readily treatable including high blood pressure hiv infection and breast cancer the instability of insurance coverage in the it states has especially harsh effects for adults who are uninsured or radically insured between ages fifty five and sixty four about four million adults in this age group were uninsured in two thousand and six for those who have lost their coverage finding insurance in the individual market is often prohibitively expensive if not impossible when they have preexisting medical conditions as a physician i see that people who receive good medical care in their fifties and early sixties live longer and healthier lives however recent research by our group and others has shown that the health of uninsured adults declines more rapidly in middle age than the health of insured adults these declines in health are associated with a forty percent greater risk of death for uninsured adults this risk is concentrated among uninsured adults with high blood pressure diabetes or heart disease precisely the conditions for which we know good medical care makes a difference but the evidence on this topic is not all grim if uninsured adults survive to age sixty five medicare improves their access to physicians medical tests and effective treatments in our most recent research we have found that differences in health between uninsured and insured adults with cardiovascular disease or diabetes at age sixty five are reduced by half after five years of medicare coverage or research also shows that after these uninsured adults gain medicare coverage they experience fewer heart attacks less heart failure and less severe chest pain the status quo masks hidden costs to the medicare program when millions of uninsured adults enroll in medicare uninsured adults particularly those with chronic medical conditions have fewer visits to physicians and fewer hospitalizations than insured adults and similar health before age sixty five after becoming eligible for medicare uninsured adults have a rapid increase in physician visits and hospitalizations that persists for at least seven years after age sixty five their care in the medicare program is thus more costly because they reach age sixty five in worse health and have more immediate and expensive medical needs than if they had been in toured and well treated in their fifty's and sixty's if all adults in this age group had insurance coverage the costs of covering them could be offset by better health and potential savings for the medicare program the instability of insurance coverage in the us also is also an important factor contributing to racial and ethnic disparities in health care and health outcomes rates of coverage vary widely across racial and ethnic groups in the united states with the highest rates of an insurance among african americans american indians and hispanic americans without consistent insurance coverage many minority many americans receive fewer preventive services and less effective treatment for many medical conditions in the latest national health care disparities report three key themes have emerged since two thousand and one first overall disparities in health care quality and access are not getting smaller second some progress is being made but many of the biggest gaps in quality and access have not been reduced and third the problem of persistent on insurance is a major barrier to reducing disparities in conclusion as you consider the instability of health coverage in the united states the financial challenge of achieving universal coverage may appear daunting but the human and economic consequences of the status quo are substantial to put it bluntly uninsured americans live sicker and die quicker because they receive too little medical care that often comes too late to prevent avoidable complications and death thank you for inviting me to speak with you today about this important problem for our nation that you a chairman members of the subcommittee my name is michael o'grady and i'm a senior fellow at the national opinion research center at the university of chicago previously i was the assistant secretary for planning an evaluation at the department of health and human services i have also served on the professional staff of the senate finance committee the joint economic committee and the congressional research service in all those roles i've studied the problem of the uninsured for cyclists an important point i urge you to keep in mind is that the uninsured are not one single population consider the following more than half of the uninsured who are of working age are full time workers it is not only the unemployed who lack insurance second those who work in small firms are far less likely to have coverage than those in the larger firms third the uninsured are found at all income levels but most notably the poor and the near poor for the uninsured are found at all ages except for seniors because of medicare youth eighteen to twenty four are the least likely to be insured and sometimes by their own choice hispanics are the least likely to have insurance followed by blacks asians and then whites about twenty percent or ten million people of the uninsured living in the united states are not u s citizens other than being uninsured these individuals often have very little else in common design in evaluating proposals to expand health insurance coverage is remarkably complex it is made even more difficult in the event that budget constraints require tough choices about who will be assisted in what way i offer two suggestions first consider coverage options along several key policy dimensions second consider the mix of coverage tools for providing coverage to this very diverse population the first dimension i recommend is the desire for coverage it can be broken down into at least three groups first people who are desperate for coverage such as the chronically ill and are willing to pay almost any price if it was only available second those who see coverage but are priced out of the market they just can't afford it and third people who do not seek coverage even if it is available and affordable traditional definitions of universal coverage provide coverage to everyone regardless of an individual's desire to be covered for example the single healthy young adult who isn't interested in health coverage at it at him at this linton life on the other hand those following a phased approach might rank some groups of the uninsured as a higher priority than others for example they may be more concerned about an uninsured fifty five year old diabetic with complications than a young healthy recent college graduates the second dimension i'd suggest is time without coverage of the data on coverage indicates that the longer a person is  insured the longer the potential gap in needed services in this example higher priority might be given to those uninsured for the longest period of time for example more than two years the third dimension is citizenship status there may be neither the political consensus nor the budget to extend coverage to all the people living in the united states a likely scenario might have coverage first office to citizens before coverage would be considered for non citizens either legally or illegally illegally in the country this chart provides a visual way to think about the interactions among the three policy dimensions i've just outlined people falling into the highest priority on all three dimensions are assigned the highest overall priority of one while policymakers may differ on the assignment of priorities or on the dimensions they wish to consider this provides a common framework on which to base decisions in addition to those policy dimensions different policy tools may be needed to meet the needs of these very different sub pop elations for small business with moderate income employees the successful solution might include access to both purchasing pools so they have the same options as larger firms and improve tax advantage to help them offset the cost of coverage for the an uninsured without employment based coverage it could be more affordable if you could be made more affordable if they had access to the same tax advantages as the employer based as employer based coverage for immigrants legal or illegal so that some that same combination of incentives would probably not meet be as nearly as effective also especially for the illegal immigrants it would seem unlikely that expanded government programs would prove effective asking illegal immigrants to interact with govern that in tag and eligibility officials is unlikely to generate much trust or compliance this the population need to better service through a clinic approach which ensures care if not coverage and is closer to the model of care found in many of their home countries policymakers will need to carefully consider the circumstances of the sub population involved to judge which type of design will be the most successful the systematic examination of the composition of the uninsured a prioritization of those who receive insurance assistant and review with the mix of tools available to help the uninsured gain access to health care will prove useful in shaping a scientifically sound and viable policy for the future thank acronym ram was formed in one nine hundred eighty five as a tax exempt five hundred one c three publicly supported organization headquartered in knoxville tennessee its intent was to provide airborne medical and veterinary relief with whom i had lived for many years in a remote area of the upper amazon however observations that are u s based in the heart of the appalachians revealed a substantial need for ram free services here at home the need is massive and it touches all regions of america both rural and urban it's not limited to the homeless unemployed and on and showed it affects the working class and those who have insurance health care in america has become a privilege of the wealthy and well insured more than fifteen percent america's population are uninsured and there are millions more who have insurance inadequate to meet the needs of a catastrophic medical event well visits to the dentist or i don't have the ram experience in hundreds of thousands of cases moves huge numbers of americans cannot afford routine dental care and simply legs their teeth rammed data show that all volunteer dentists extract an overwhelming number of teeth that are beyond repair people as people tell us they face thousands of dollars of dental work and when we look in their mouths we see cases as bad as any discovered among the amazonian tribal groups the state of vision care among those who visit ran clinics is no better they can't afford an eye exam and if they had one can't afford the prescription glasses no wonder hundreds sometimes a thousand people lined up throughout the night before a ram free clinic in an effort to get their teeth fixed and obtain a free pair of glasses from us services for children under the age of eighteen usually are covered by state programs but access can be difficult topping the list of reasons as government reimbursements are too low and paperwork too cumbersome to make it worthwhile once people transition into adult hood they are on their own for dental and vision care unless they are able to pay large insurance premiums i received a call last sunday from a thirty eight year old working mother of four in kentucky all five of the family have serious dental problems she has insurance through her employer but it has a fifty dollars deductible and when the plan pays she has to cover an unavoidable twenty percent co payment her seventeen year old needs his wisdom teeth extracted but the plan does not cover the seven hundred dollars for the anesthesia the mother needs her own teeth extracted so she can get dentures and the family cat needs to be spayed i told her to come to the ram clinic at lincoln memorial university at the end of may and we would fix everybody's teeth and iran volunteer vet would spayed a cat all free why does the united states the richest country on our planet have a health care system number thirty seven out of one hundred ninety countries by the world health organization we have the most advanced technology accessible only to those who can afford it america's poor and the not so poor who have some type of insurance are suffering debilitating pain and health risk from disease teeth and a handicap with vision problems that are correctable but not affordable when britain was at war in one nine hundred forty one the government realized they needed a national health care system and in one nine hundred forty four gave the ministry of health in r and bevan a mandate to develop it i'm not advocating that the united states follow britain france canada germany or any other developed country which has some form of national health care system however i am convinced that the ram experience with the hundreds of thousands of patients we have seen that america does need to provide free care for the millions who cannot afford it and free dental and vision care for the  be included in closing i would like to stress that a great impediment to providing free care in this country is that willing volunteer health care providers holding licenses in one state are not allowed to provide free care in another tenn change concurrent resolution number sixty nine was introduced to congress in one nine hundred ninety seven to encourage national adoption of the tennessee model to our knowledge it never got out of committee if practitioners were allowed to cross state lines to provide free care for those in need and had protection from frivolous malpractise suits the system of free care that rahm has developed and proven throughout all these years could be replicated throughout america i'd like to thank the committee for inviting me today and thank you c b s sixty minutes so dramatically focusing on this national problem is sister advocacy organization the american cancer society cancer action network are working together to elevate the issue of access to care and its impact on cancer patients and their families i would like to begin my discussion of inadequate health insurance by sharing during story with you during a fifty seven year old former medical office receptionist was diagnosed with stage four breast cancer in the fall of two thousand thought the cancer spread to her spinal column liver lungs and left femur  retired new york city policeman and she has health insurance through his retirement plan her plan limited or to thirty outpatient visits a year a number during quickly exceeded our plan had other restrictions as well including a limit that initially prevented her from getting a stent for her chemotherapy she was ultimately led to have the procedure for the stand but only after a delay she also learned of some of these restrictions from her plan only after she had exceeded them as a result and been more than one hundred thousand dollars to the hospital for various treatments these significant restrictions resulted in delays in treatment and great emotional stress that further jeopardized her health as defined by this is society adequate health insurance insurers timely access to the full range of evidence based health care services necessary to maintain health avoid disease overcome acute illness and live with a chronic condition the services include the complete continuum of evidence based cancer care for preventing treatment and support needs including clinical trials doraine is one of sixteen thousand people of called the american cancer society because she had problems with her private health insurance the primary problems we have identified among those with that inadequate health insurance include annual or lifetime dollar limits or restrictions on necessary services like terrain experienced no or limited coverage within the plan for out of network specialists limiting the patients ability to access quality cancer care no or limited coverage within the plan for prescription drugs but the biggest single issue we see is related to call sharing nearly two thirds have trouble meeting deductibles paying their co insurance first for prescription drugs and treatment and covering costs necessary  necessary services not covered by their plan let me illustrate the car sharing problem with martha story martha a sixty three year old retired woman was diagnosed with stage one breast cancer and of amber two thousand and seven martha's cancer treatment included surgery followed by radiation martha has health insurance but the policy is inadequate for example the insurance paid one thousand dollars of a ten thousand dollars hospital bill for her surgery her accumulated deductibles and co pays for various medical services have left her with twenty eight thousand dollars in medical debt and the hospital is threatening her with a collection agency co pays and deductibles may be may be reasonable for routine care but when a person has a serious medical condition like cancer the accumulat expenses can become very significant today martha struggling with keeping her head above water financially some of the most disheartening kinds of stories we hear from people of had to interrupt their treatment because of inadequate coverage we logged nearly nine hundred such cases last year please think about this for a minute these are people who have stopped treatment for a deadly disease because they cannot afford to pay for additional necessary care for them a decision to delay treatment is often a life or death decision but if they proceed they risk breaking them cells and their families financially more formal study support our experience for example nearly one in three cancer patients who are insured have out of pocket causes costs that exceed ten percent of their family income more than one in nine cancer patients with insurance have out of out of pocket health costs that exceed twenty percent of their family income twenty percent of cancer patients with insurance used all or most of their savings when dealing with their financial cost of cancer and ten percent of medical bankruptcies are from people have had a cancer diagnosis the probable under insurance is very difficult to measure but we know the problem is very real for many cancer patients and they should be a concern to everyone because cancer can touches all slightly less than one in two men will have cancer in their lifetime and slightly more than three and one in three women will although i have focused on the issue of adequate adequacy of insurance the american cancer society is also greatly concerned about the the problems of the on a chart which the other witnesses this morning have addressed we believe in the science in the knowledge exist to provide quality care for all americans but we must work together to restructure our coverage and delivery systems to achieve that goal you're hearing today is a valuable contribution to that discussion you to all of the witnesses who are here today mr finn and i'd like to pick up where you left off i'm a huge proponent of preventive care and an area where i see the huge problem is the the barriers that seniors face in regard to getting just preventive care in the form of cancer screenings and in and such and it seems to me at that when someone's a senior in many instances their disposable income numbers are going down and right now sadly at the same time that the cost for food and gasoline and energy and everything else is going up i'm concerned that co payments and co insurance payments are having an impact a negative impact and provide a barrier to these preventive services and and that's having an impact on things like cancer screening which cost us more money  in the long run to anything you want to add to that an article recently in the new england journal of medicine that looked at the issue of co pays and preventive services among the medicare population and they found that even a small co pay as little as ten or ten dollars resulting in about an eight percent decline in the number of women who sought mammograms so that it does suggest that there's an enormous price sensitivity among the elderly to these kinds of services and then we pay for it at the other end want to become exactly and here for ten dollars we  on the other end of the spectrum on the other age of the end of the age spectrum the issue of preventive care for children when i was in the state legislature i had success with legislation that required all providers to provide health care for kids preventive health care for kids from birth to eighteen years of age one loophole in that legislation was the arista loophole and it's my feeling that that is in fact a true loophole and i know we can save a lot of money and a lot of lives and a lot of anguish if we can catch problems early and kids and it is everything from keeping kids out of the hospital and a hospitalization for kids is more expensive than adults and it's longer than adults and and then also if we can deal with these things when they're preventable rather than when they are acute we're we're building a more healthy medicare population in the future should we close that a risk of a loophole  it's clear that investing in the health of children is a very worthwhile endeavor and anything we can do in a cost effective manner to achieve that goal it is very important the you know we studied this issue in the institute of medicine and the consequences  insurance and the importance of consistent coverage for children as well as their parents and i think it was clear that the evidence is that children are more likely to get the care they need when they have coverage and it's consistent across different plans and particularly also when their parents are covered if the parents use that health system more effectively for their children and we get long term benefits from that so yes and then lastly mr brock thank you for being here and thank you for all the work that you're doing that's pretty fascinating ten percent of the doctors practice in rural areas and i'm told about twenty five percent of the patients are in rural areas so it's a real  disparity and representing one of those rural areas i hear all the time about the trouble that we get to attract physicians to our areas and keep physicians in our areas and when we share the same health care problems as  under served areas be them real urban or otherwise and how much of the of the lack of access to health care in rural areas can be attributed to the lack of providers well people but the paperwork requirements and the reimbursement rates fortunately are not attractive enough for many of the providers to be willing to accept the patients in downtown urban area the number of patients that are going to show up for our services are about the same as a small turn out they're going to be five or six hundred patients turn out at a large  event there are going to be several thousand that turn up and it doesn't matter whether they're living in urban area or rural area and the biggest problem really in providing this kind of care for these people is that the we have found over many many years now that the local physicians dentists and eye doctors really don't want to deliver the care to these people in their hometown very same doctors are very very willing to travel hundreds of miles with us perhaps to south dakota to provide the care but they're really not interested in providing the care in their in their own home districts and for that reason we are strongly hoping that the rules were changed so that doctors can cross state lines from all over the country and alleviate this very very serious problem percent are non citizens what percentage of the total uninsured population are eligible for medicaid and other programs but are not enrolled i don't have that figure right off the top of my head but i can certainly get it for you though it is one that is under some considerable kind of discussion of figuring out what the right figure is and part of it has to do with the interactions between these eligibility questions so if some of these kids given immigration laws would not be eligible as is true for the legal immigrants that you're not eligible in the first five years for either medicaid or s chip exactly who's eligible or not is certainly somewhat of a bone of contention although more of the nation's best experts and this if you could submit that in writing that answer i'd appreciate that what percentage of the uninsured let coverage for just a short period of time say less than three months or less than six months where we tend to see this pattern again i'll get back to it the exact figure but what we see is we see there's points in your life where you are more vulnerable and some of these vulnerabilities we worry about more than others so you do i gave the example in the oral testimony about the kid who leads college and before they start that first summer  job that first real job and get coverage that is certainly their uninsured we would certainly prefer to have them insured but we don't really worry about them quite as much as we do about the chronically ill and these people have been uninsured for years so it is this idea of where i've tried to introduce this idea of thinking about how you might treat this problem because the likelihood of having enough money and political consensus to do everything for everybody might just not be there in reality you know and can you tell us what percentage of the uninsured elect not to purchase health insurance even if it's offered to them there are a certain ways we sort of back into that question if there is not good data what we do know and you'll see in the written testimony is we see we know that the that the offering rates especially among once you're over about five hundred or a thousand employees in a firm that almost all those firms offer but you still see perhaps ten percent in both those categories as being uninsured now we know they're offered we don't know exactly whether they are like i said what we tend jokingly call the young immortals who sort of as long as they don't fall off their motorcycle they really don't see much need for insurance or is it that category or is it someone who is in a position where  coverage is being offered but whatever that their share their premium their share the cautionary going on makes it on affordable for them and splitting those two kind of groups is i don't know anyone who's done it  do there's been a lot of debate around the question of an individual mandate to buy in health insurance do you have any opinion on whether there should be a mandate and what would be the pros and cons of imposing a requirement  buy insurance even if they feel they don't need it yeah an individual mandate is is is a tough issue in terms of you have these situations in the last generation of these sort of proposals we heard an awful lot about employer mandates and in some today we hear about matching employer and individual the individual mandate does get to the point where we talked about before my my young immortals and the idea of should you be in a position where you are in effect forced them to have coverage now that's much of the discussion that's gone on on the campaign trail between mrs clinton and mr obama mr obama sort of wondering once you're out of children once you're at a certain age you want to make it as affordable as possible to actually want to take that extra step to mandate it is true  term that the senator was searching for before is free rider so when these folks fall off their motorcycle and all the sudden need health care system they are going as bad debt on the rest of us there's no doubt about it i noticed in the tape we saw that  well let me just say there are twenty three federally qualified health centers in tennessee and from what i understand they have a list of services that are required including the emergency medical and dental services among a list of other services can you tell me why individuals would not be able to be also attending the federally qualified health centers that have a mand to see anyone who comes in right they do have a mandate they certainly serve the uninsured they serve the under insured medicaid population and even if you just because a low cal regular insurance people all the evaluations i've seen is they score very high on what they do they have brought up before about health information technology they have one of the best systems in the country right now whether it's poor outreach or just a nod of allowing them to know but i know of no structural failings of our public health system in this country that those serious needs are there demanding the extraordinary effort you put under you've undertaken one of the issues that i noted from the sixty minutes clip is the difference between providing a one stop for periodic kind of service a like eyeglasses or dental care versus the need for continuing treatment continuing care like the young woman with who had had cervical cancer is there any way through your program that you can provide someone a primary health care home for that type of continuing care or what what happens to the the person who requires the periodic checkup whether it's for  cervical cancer or for maintaining their blood pressure or their cholesterol or whatever on a repeat visit basis well i think that question is admirably demonstrated at a clinic that we do every year in wise county virginia and wise county virginia for two and a half days people come at the rate of twelve hundred people a day and they can fifteen hours for the service now we provide all of the services that you just mentioned not only do we have about one hundred dentists there and dozens and dozens of doctors but we also have cardiologists and we have cancer experts we do mammograms and we do pap smears the whole gamut the interesting thing is again this goes back to the fact that so few of these state and federal programs address the dentistry and the vision care so here you have twelve hundred people who arrive at one of our clinics and wait many many hours and when they get in the door they want to see the dentist so bad because they teeth are just in agony and they want to pair of eyeglasses because they can't see to read the paper or they can't qualify to get a job and we are constantly with the hundreds of other practitioners that we've got they're saying save your place in line you need to come down here and you need to have a diabetic checkup you need to have a checkup for high blood pressure and so on and so forth and it is it is extremely difficult to get those people motivated to do that so if some of these programs were addressing an enabling people to get their teeth fixed there was a media problems then we would find it easier to get them to see the other specialties that they need when you look at the cross section of the thousands of people that we see it's largely self induced problems they're all  very difficult to get him to take advantage of the rest of it thank you dr roland dr you touched on this issue but really the lack of insurance is a matter of life and death and i've seen one recent study in the state of texas which is notable for having more uninsured children proportionately than any other state in the nation tragically that about seven working age texans die each day because of a lack of health insurance i suppose if the death certificate amended to show the true cause of death along with the physical cause as being a a societal disability that we would see lack of health insurance on the desart on a pretty regular basis it would be up perhaps as high as desk from diabetes could use comment again on what you see as the life and death cost of the failings of this congress in this administration to see that there is access to health insurance for more of our citizens well clearly we see from all of the research that when you don't have health insurance you make decisions that are contrary to your health so as we saw in the film so graphically people to lay care and as a result of delaying care they come in at a later stage diagnosis where treatment options are fewer and where the outcomes therefore mean that on their desks or to fix it they may die from the cancer but the cancer could have been treated if it caught an earlier stage and doctoring it's work has really helped to really magnify the impact of lack of insurance by looking at specific conditions so i let him come in and it just i would just add that we all know that insurance of effective insurance coverage is the gateway to the health care system for  most people in our country and when people lack that they don't have the good primary and specialty care that we know makes a difference and in many ways we just defer the costs you know effective primary care can be very cost effective preventive care screening tests care of chronic disease like high blood pressure and diabetes and if we don't take measures to provide coverage and provide access to care for people at those early stages of disease then we end up with more costly complications of heart attacks kidney failure advanced cancer would you like to thank mr chairman for any first three over there you know i believe one way to increase access to health care for more americans in this country is to decrease the cost and if there's one thing america has proven it's competition is the best way to drive down the cost and health care is no different there's two initiatives i think are critical in achieving this goal he uninsured and almost half have end comes below fifty thousand dollars concerning age ps estimates indicate that at least sixty percent of the working uninsured work for small businesses i think we can have a conversation about the end insured in his country without talking about a way to allow small businesses to pool their resources in order to provide health insurance for their employees would what clearly we know that when you look at the problems facing our health care system rising costs and the increases that we've seen in premiums over the last two years have taken a real toll on both employers ability to offer coverage as well as  employee's ability to pay their share of those premiums however i think one of the things that's important when you look at the low income uninsured population two thirds of the uninsured come from families with incomes below forty thousand dollars a here is how much they can afford for the premium how much she would subsidize that premium and also how much they're able to pay out of pocket and one of the concerns we have from some of the research we've done is looking at the assets the fine liquid assets of individuals at these lower income levels we see that they are relatively few savings and as a result if they have a health care policy that requires a fairly high deductible they may not have the resources to be able to pay those co payments and deductibles which in the end could end up having them behave more in their interaction with the health system like an uninsured person then like someone with health insurance coverage so i think one really needs to look at the availability of income and the availability of assets to be able to meet geishas as one assesses the adequacy of health insurance coverage and work that the department of health and human services has done looking at financial burden assesses many families especially those with higher deductible plans as ending up spending much more of a share of their income on health insurance coverage than people with more comprehensive plans especially those offered now through the employer sector yes there are a couple of things you thought of two very good one thing is to keep in mind is that making this more affordable is essential at the same time it is that value proposition has been discussed earlier about we have the baby boom retiring we have these other pressures that are coming so it's it's more spending smarter not more not and how we're going to control that and how we're going to determine whether really getting most of us don't mind spending more if we think we're really getting that breakthrough drug or that breakthrough device that's going to really make a difference we mind spending more for something that seems wasteful and is just nicer cars for physicians that sort of thing so when the chief actuary came in i assume a week or two ago and showed you those in medicare those same trends exist for employers trying to offer coverage medicaid they just don't have the trustees report that you get every year so all that money being absorbed there is more money being taken off the table for the uninsured and so the notion of how you ease up on that cost pressure to give yourself enough leeway to start to think about expansion and do it in a fiscally responsible way is is vital there was a piece done a few years ago by a researcher at the university of san diego that looked at those small firms and in years when premiums were going up very fast they either had to drop their coverage or for the firms that were looking to add coverage  not an a ten percent premium increase here in the slower years that's when people either held their own in terms of offering coverage or were able to expand so it's very important h s a's fill a niche a very important in terms of affordability because by changing the structure of the health benefit moving into the more serious more catastrophic things they definitely lower the premium now i have one personally i've had a probe of three years now i like it very much it works and i have a chronic illness and it works because it means also that account i can go to whatever provider i want to whether they're in the network or not or participating with my plan or not so it works very well on the affordability but certainly it is putting financial pressures on folks for that upfront cost there is no denying that it's again none of these particular solutions that people put for me or anyone else or anyone else you'll hear from are going to be totally pain free there's also you're go to help on affordability but you'll heard on cautionary note on the beneficiary but back to your first notion about bringing down this overall growth in spending you know that's the key that's where you can have a cost less for both the employer and the worker for insurance thing from the statistic that we came up with last saturday certainly missed two hundred fifty people showed up at a rural area in tennessee and one hundred twenty four of them were prepared to answer the following questions it turned out the seventy three percent of them were unemployed eighteen percent were employed part time and ten percent were employed full time of the full time employees employed only eighteen percent had any kind of insurance of those employed part time fifty eight percent of them had insurance and of the unemployed of which there was seventy three percent of them were unemployed forty give me just a quick sense of what your your understanding of what your senses of an individual mandate opposed to require that individuals purchase insurance in order to obtain access to health care that rather than require an employer rather than do it through a system like medicare which is government financed that we put the burden of painting the insurance on the individual and by requiring everyone in the country to have insurance then we will end up having that universal coverage that we need insurance so that presents us with a very difficult problem the question give us a get a very quick sense because i know my time is limited what are some of the comments you hear from some of the caregivers the doctors that dentists the other providers that volunteered to be part of these clinics that you set up what's what's their sense they obviously go back to their paint job later on where they're providing health care but what's their sense of where we have to go where a solution something needs to be needs to be fixed and again going back to we really need to allow these doctors and dentists who are willing to provide the service to cross state lines and provide free care anywhere in the country as long as they can prove that they are a doctor in good standing and the tennessee volunteer health care services act it's as simple as this doctor shows up even without any notice hey i heard you're holding a clinic i'm from here's my license i'm not under any judicial review signed that statement roll your sleeves up and go to work let me let me ask my question is more i imagine the doctor from iowa who goes to tennessee can only do that once in a while and my question goes more to the point of what do they see as a longer term solution to this crisis that causes hundreds if not thousands of people to show up on a weekend to try to receive the care you offer well i think i think that they would like to see some brock does inspiring and demoralizing at the same time inspiring because you have people who are willing to volunteer the good samaritans who go out there with professionals who provide this care demoralizing  because hundreds and thousands of people have to rely on a weekend opportunity to get it taken care of in all the studies that have been done and all the work that we've had come before us for presentation i still don't see that the american public is anymore angry and prepared to take us to a place where we then as policymakers feel that we  could provide that type of coverage that gets the university ality that i think most of us would like to see for the american public and so i guess my question to you is do you see any further movement in the eyes of the america public that's so much the policy makers but the american public in and having the outrage to make take having their policymakers move in a universal direction you know as we do our work in public opinion we asked the public about the uninsured and about their access to care and one of the startling things from our research is that people say well the uninsured get the care they need they just may get it a little later and i think we still have a real burden of educating the public on the fact and i think things like the sixty minute documentary is very important about the fact that if you're uninsured you make different choices and you may not get the care you need and as john and others work shows the consequences on your health and on our society's health are really monumental but i think it really is a lack of understanding about we think that we have the best medical care system in the world and that it anyone really gets sick they can show up at an emergency room and they can get the care they need and we know they don't even show up often at the emergency room and the consequences of not getting preventive and primary care are overwhelming thank you i appreciate your testimony all of you and i look forward to having you back i think the public is actually saying to policy providers like us and legislators that they do want and need health care i think the dilemma is that the united states has been sold for a lock of the focus on preventive that we had to be a country that focuses on acute chronic care versus preventive care that's my little piece of it but i want to focus for a moment if i can with  to get over there this afternoon but i see that in your report and i don't recall that you have enough time in your five minutes to really delve into what we need to focus in around this there were seven things that i just said in front of me not last long if you go back to that again for me and if you had to prioritize the one through seven factors all around health care disparities would you give them to the seven steps in which we can lose voltage and people not get the care and the quality of health outcomes that we're looking for it clearly insurance coverage is an important part of the health care disparities we see for different racial and ethnic groups and social economic groups in this country and so that's one of the most important factors we have a safety net in many areas safety net providers are doing very important effective work but it leaves too many people outside the boundaries of our health care system are not coming in until they're their illnesses are too far advanced we also know that healthcare providers that serve predominately minority communities of low income communities  tend to be less well supported less access to appropriate specialty care if primary care is available it's not consistently available to all in the community so i think we also need to organizations hospitals health care centers medical community centers medical groups that care for disproportionate share of minority patients and make sure that they're well supported that their staff are highly qualified that they have the the services that are needed in the relationships within their communities and i think one of the points that was touched on in the first panel discussion was the need for communities and states to understand that the presence of health care disparities in their and develop their own local and state plans we're seeing some problems promising evidence about this work in chicago trying to address racial disparities between african american women and white women in breast cancer mortality where community health centers breast cancer survivors community leaders leaders of the major medical centers are coming together and really working on access to mammography access to effective treatment and then the quality of care that people get so i think those are the some of the highest priority areas and i think it's very important at a national level through tools like the national health care disparities report to pay close attention to the text to what progress or lack of progress we have on this front and then also to use data and resources to support local communities in addressing the health care needs where they're well understood i remember that as a kid in the public school systems there were at least a school nurse and a dentist that fell through at least every once in a while and i can't understand why for folks at every level hopefully begin a process of working with young people with the vision of what prevented really means because that is what's ultimately going to be the concept i don't have time to allow the rest a few to respond to that particular issue but i think it's something we need to think about how do we marry at education and in education about preventive care within the system mr bach on applaud you for the work you're doing and i think i will be in knoxville on friday and depending on my schedule i may try to catch up with you if i get a number or an address if you like to see thank you mr chairman thank you  uninsured would you like to it's roughly twenty percent of our uninsured population are children and when we look at uninsured children we think that about two thirds of those children are actually eligible today for either the medicaid or the s chip program but have not been enrolled partially because they may be unaware of their eligibility or their family may not have taken them in and about half a million children who are uninsured have an immigration status that prohibits them from being eligible for either medicaid or ass chip but incomes below the three hundred percent of poverty thank you further  i don't know of other countries that deny coverage to people who happen not to be citizens but what how big of part of our problem is that what currently about twenty two percent of our forty seven million uninsured are non citizens however the majority of them are legal and not illegal and and we estimate that about ten million people therefore out of the forty seven million are non citizens many of them waiting for eligibility for citizenship and about four million are from the illegal immigration population and therefore currently at least with about eight million who have some form of insurance even though they are  there and in fact most of the growth we see in our uninsured population comes from the citizen growth so that it's about eighty percent of the growth each year since the number of illegals the still small in comparison to the total population iranians points out that if i think if i remember correctly if you're i find money insured before i mature into medicare for the next seven years sixty five to seventy two map to be more expensive than those who had a continuum of medical care which one presumes means they were insured then there's the issue of the local emergency room i'd like to think although i'm not positive that we don't let people bleed to death on the streets so they end up in an emergency room they're the stabilized at the treated somebody pays for that either those of us who are paying for insurance pay through higher premiums or the local community pay so it's through taxes to subsidize care then the issue benefit caps and other words whether it's the people who sell these association plans that are generally don't meet decent standards in terms of providing care that is covered by most insurance commissioners or other reasons can we get i think commonwealth did a study that deals with the social costs what productivity is kind that their workers may be absent more than others kids are there many studies in the any of you i'd appreciate the answer seriously it's kind of hard for us to quantify to me how much more do we spend on medicare can we find out because of the uninsured who mature into medicare is there a number out there that would be available to us without extensive  research i'd have to say at this point there's not a definitive number but it's something that we're actively working on and working with medicare data to try and understand that better from some of the work that i discussed earlier we found that people in their late fift early sixty's were uninsured fifteen to twenty percent lower levels of services in the presence of heart disease and diabetes so a group clearly that should be in care and where we know health care makes a difference and then almost immediately after they turn sixty five we see sort of a flipping of that and the people who are uninsured use about fifteen percent more services after they enter the medicare program so we're now actually moving forward to trying to understand exactly what services some of them may be fairly expensive like people needing coronary bypass surgery others aspects may be fairly basic like senior primary care physician for diabetes care and our issue that we're pursuing is to what extent might those you suggest are not insurable as in so far as i know the american dental society is not very anxious to see dental insurance made available by any kind of mandate and that's so without their help by natural ever happening speaking of mandates which is an issue that was brought up  i'd be remiss if i didn't suggest that governor romney and governor schwarzenegger who i not ever seen in any of our progressive caucuses or any other liberal groups both suggested mandates is part of their state plans and i don't think they're political disadvantage i think they both felt as i feel that there was no way they were go universal coverage without somehow quote mandating it i just don't think that whether it's the the youngsters who think they're invincible will buy it if they're not told to but at some point i think mandates if we if we would like to see universal coverage i don't know how we're going to avoid that my commentary on that  appreciate should find in the work the american cancer society does try and save us from ourselves and what what happens to somebody diagnosed nobody you're a male and when you get prostate cancer if you're uninsured go to the emergency room prostate cancer generally doesn't present itself except for maybe an urgency to go to the bathroom that you can't says why but other than that what happens to that person what happens to the woman who says oh i've got a love but i don't know whether that's breast cancer or not and they virtually don't have access to a systematic protocol what do they do while you're correct mr chairman these people in those situations typically show up at the emergency room at that point they probably have an advanced stage cancer it's obviously becomes much more expensive to treat at that point that cost is being borne more widely by society because they're uninsured they get treated though i mean to fish up to they get surgery or radiology or chemo which one could be a long  procedure it depends on the state of the condition actually and where they happen to go into the emergency room i think it varies considerably by that the facility and where they are and what kind of charity is available but the fact is we know that some recent research that was done by some of my colleagues in society shows that the for for those who are uninsured they they tend to be diagnosed much later and there are much less likely to survive they have less to find ways to provide care like public clinics but with all your persecutory and intellectual curiosity you blew it the stark solution for these people who are truly uninsured be they citizens with documents or people without documentation how you could have missed the chance that i've suggested for every uninsured americans who under the constitution all they have to do is walk out of this room step out there on the corner and kick a cop you'll end up in jail where the constitution will require us to provide you with the medical care you deserve and so i've always suggest you don't have medical care anyplace else go ahead a cop you'll get all the medical care they probably need a little extra when you're done but please add that to your testimony because you really haven't done the job that i think they your position requires that i have a correct i let us take the the state of massachusetts i have here as a result of the sixty minutes piece i request from the campaign for a better tomorrow in massachusetts saying to us we are proposing a convoy of three hundred southeastern massachusetts residents from our school bus to treatment by remote area medical in tennessee does this mean then that one of the richest states in the union is going to be send patients to us that one of the poorest