one of the ways to achieve affordable health care is to have several of our major states lead the way in the federal government would then be called in to see that comprehensive reform  to affordable health care and unfortunately the given the state experience to date it seems unlikely that any one state will set the bases for the nation today's witnesses include experts and officials who have been at the forefront of state reform efforts and i believe we'll hear that it's very difficult for them to m uninsured and many are hampered by numerous issues state balanced budget requirements volatile financing the need for federal waivers from recess and other federal laws all of those  challenging states programs canada cheve universal health care just as i described one province at a time but that was four years ago and we face a different situation we have a larger and more diverse population health care costs have risen tremendously and special interests of growing ever more entrenched and committed to maintaining the status quo so while we made progress here  states have been trying health care reforms for the last four decades and we have relatively few successes in those that have tried and many states haven't even attempted it seems always be states that are unable to implement these reforms on their own for one reason or another but today we'll hear from a panel of experts that include state officials who study and aid state policymakers i look forward to hearing their testimony and we hope we can learn from their experience both the successes and failures as we begin to consider health care reform for our nation our my premise may still hold true that the states to lead the way and bring the federal government kicking and screaming to the table but there's an important instead of needing several states to achieve universal health care we simply need several key states who are trying to meet that goal and can show us the way that we can this through state and federal partnership achieve that goal i think today the will hear that there's a lack of commitment at the state level but the state health care reforms in recent months the subcommittees heard testimony on the many challenges facing our health care system each of those hearings has brought in the debate on health care reform and i believe highlighted the need to address this issue sooner rather than later today we'll hear directly from the states which are on the front lines of this battle many states including those testifying today have taken steps here their citizens have adequate access to the health care system and mr chairman i believe this could be one of the most important hearings we have this year because at the end of the day to make significant reforms in our health care system will need to work hand in hand with state governments in fact much of the work being done on the state at the state by the states on health care reminds me of welfare reform in the early one nine hundred ninety s and many on this committee will remember that before we enacted the one nine hundred ninety six welfare reform law states like wisconsin and michigan had already begun to make changes to their welfare programs instead of an acting overly broad national mandates we gave great the states greater resources and flexibility to craft programs that fit their own populations and i think the lessons we learned from that reform a decade ago can be applied to health care it's my opinion that states are the most appropriately situated to design health care plans that meet the needs of their citizens and congress should be looking at what works and what does not work in the states even more importantly we should be breaking down the barriers that are preventing states from trying to address their own difficulties and we'll hear today that many of the successes the states are only possible through waivers of existing law by c m s and h h s so who would have thought that the answer lies with eliminating unnecessary burdensome and unworkable federal mandates as we look at what the states are doing we must not overlook the single largest obstacle for guiding health insurance the discriminatory tax treatment for individuals who purchase health insurance on their own to spur the expansion of health coverage after world war two congress gave employers a huge tax benefit to offset the cost of providing health care to their employees this led to our current model today where you either get care through the government or an employer eighty five percent of all americans receive health care through their employer and this is left upwards depending on how you count it forty million americans uninsured or under insured i firmly believe we must address this in equity in the tax treatment with other reforms to adequately address the issue of health coverage  mr chairman this is an important issue i don't think this is necessarily a republican issue or a democrat issue and when we talk about health care shouldn't matter which party you're in we really must talk about an american solution and i believe we can work together to support the states and their efforts to craft innovative solutions but we must also be forward thinking and develop new solutions for the millions of americans that are demanding healthcare choices again thank you mr chairman for calling this hearing and with that i yield back hughes testimony suggests that he's going to give us an overview of the progress that states have made in the late ninety's mr weil was the state medicaid commission sure for the democratic d dr jack lew is familiar to many of us he made a terrible terrible mistake in his career path years ago when he left the great state of because we could have had the hearing there if he was still there he moved from hawaii unless they moved up to the great state of california and now is chief executive officer of the american college of cardiolog y i don't know just what jack is going to tell us about it but i'm sure he'll discuss why yes i think first state to mandate coverage for all residents and back in eighty six whenever that started and what's happened to that since i think we'll find that interesting mr hazel my or do i pronounce it correctly sir with the heritage foundation and he's worked was several states designing their health reform initiatives i think he'll talk to us about the themes that states have raised during his work and the challenges they face he's a strong proponent of consumer driven health care and is going to give us some alternatives to the plans that are on the books mistress riley is the director of maine governor's office of health of two thousand and three and advise us to how that's doing and whether or not our former colleague can run for reelection and the success of that plan or whether he should look too was cousins summarize i'm sure that the members will want to inquire and more depth as you complete your testimony please proceed thank you chairman stark ranking member camp distinguished members of the committee my name is alan while i'm the executive director of the national academy for state health policy nationally is a nonprofit nonpartisan organization that works with leaders in state health policy to identify emerging issues and addressed challenges in state health policy and practice this is an exciting time for states in our nation as the call for significant health care reforms grows louder states are considering and implementing innovative  promising strategies to reverse the trend of an increasing number of americans without health insurance yet given the barrier states face my over mark arching message to you today is that states cannot do this alone federal leadership is required in the absence of federal action a broad array of states in all regions of the country representing quite varied illogical perspectives is pursuing health reforms you will hear about some of these efforts from other witnesses but despite successes the state's ability to address our healthcare challenges is limited states are constrained for many reasons they lack authority to effect many of the health care activities within their borders about half of the typical state's residents are completely outside the reach of state authority because they are enrolled in medicare have coverage through an employer that self insurers or obtain services through various federal programs states face budgetary constraints due to balanced budget requirements and due to federal policy that requires that medicaid waivers be budget neutral with respect to federal costs expecting states to address the many vexing health policy issues on their own is unrealistic and constrains the number of states that can even make such an effort given these challenges it's not surprising that only three states in the last decade maine vermont and massachusetts have adopted comprehensive reforms and efforts in larger states such as california illinois and pennsylvania remain stalled now while state efforts make a real contribution federal leadership is needed to make substantial sustained progress in health reform federal leadership could take several forms including one that provides a substantial role for states to operate within a national framework indeed approaches that combine the resources stability and uniformity of federal of an involvement with the dynamism local involvement and creativity of states can foster excellent results the federal government can bring its clout as the largest purchaser and stable funding to weather economic ups and downs in standards that assure that all americans have meaningful access to needed services states can design the details of a plan to conform to local market and medical practice conditions develop models and enable us to learn what does and does not work and assure that program operations reflect local values federal waivers though helpful in some instances are no substitute for a clear federal commitment the federal leadership is required if we  to bring down unwarranted variation across the country in health care practice and costs a recent commonwealth fund report describes interstate variation in the use of and biopics to reduce the risk of infection during surgery variation across states in  share of the adult population without health insurance it has existed for decades and in recent studies they range from a high of thirty five percent in texas to a low of eleven percent in minnesota national requirements resources  benchmarks can all serve to close some of these gaps the importance of federal leadership is clearly demonstrated in the contrast between our recent experience covering adults and children for adults we have no national coverage strategy medicaid which is the nation's primary commitment to health care for the poor explicitly excludes non elderly adults unless they have a disability or dependent children for children we have a national strategy despite some limitations medicaid and s chip the percentage of uninsured children decreased in thirty two states the combination of a national priority with the resources to support it and state flexibility in the methods for achieving it can yield tremendous results in my job i have the opportunity to speak to many state officials their message is surprisingly consistent regardless of job title political affiliation or state they're doing what they can to address issues and problems that are bigger than the resources available to them they are eager for federal leadership they feel its absence but they're also nervous about a heavy handed or one size fits all approach a true federal solution to our healthcare problems require something like a joint venture cooperation between the federal government in the states that states have not seen lately delays in s chip reauthorization c m s is aug seventeenth letter the new medicaid citizenship and identity documentation burdens have all impeded state efforts to cover or more folks alternately in the absence of federal action states will lead and states will accomplish as much as they can given the constraints they face but piecemeal state action will never add up to what the nation needs a national response that honors the history of american federalism would include a series of national commitments to universal coverage improved access and quality and tempering cost growth that frame and support what states can do i thank you for the opportunity to appear before the committee today thank you very much this big good morning good morning i want to thank you chairman stark and ranking member can print finding they to testify before this hearing today on state health care reform i'm judy i'm the secretary of health and human services for the common law office massachusetts and i'm honored to be here today represent massachusetts governor deval patrick to tell you about the efforts to reform health care in massachusetts i want to start by telling a very brief story i've lived in the community that i currently live him for over a decade i've taken my clothes to the same dry cleaners for that period of time a few months ago the woman who is the color owner with her husband of this family business said oh dr bigby i saw you on t v doing a p s a on health insurance and i want to tell you how free form in massachusetts is the best thing that could have happened to us we never thought as a small business that we could afford to buy insurance for ourselves but we did i had my first check up to nineteen years because of this and i discovered that my blurred vision with student cataracts which i have had fixed and i can now see again and thank you for helping to implement this program that's the story of one person but we know that we have hundreds of thousands of people in massachusetts who are now covered because of health care reform from the beginning the strength of this effort in massachusetts was marked by a coalition of people that represent  representatives from the executive head and legislative branches of government providers insurers employers consumers advocates and community leaders and april of two thousand and six you all know that massachusetts an act to the health care reform bill that was designed to move the state to near universal coverage the components of this bill allowed us to do several things that are key to the success that we are seeing number one expansion of medicaid so that we could cover more people number two the creation of the commonwealth connector to do that up commonwealth care which is a state subsidized program for low income individuals who are not eligible for medicaid and also the connector developed affordable health insurance products for those with incomes over three hundred percent of federal poverty level who did not have access to employer sponsored insurance we also transfer form the uncompensated care pool which is a pool the state had developed more than twenty years ago to pay hospitals and health centers for care for those who were uninsured we also reform the insurance market to combine the non proven small group market and created the individual mandate which went into effect in july of two thousand and seven and  was in forest as of december thirty first two thousand and seven and we also defined what employer responsibility was through the fair share of cade wait a waiver from the centers for medicaid medicare and medicaid services is a critical component of massachusetts health care reform this partnership with the federal government allowed for expanded medicaid coverage including children with famil income to three hundred percent of the federal poverty level it also eliminated enrollment caps for other individuals so that they could be covered by medicaid including disabled working adults and individuals with  we currently are operating under a short term waiver extension while we finalize negotiations with c m s for renewal of our waiver and we look forward to being able to continue this historic effort enhance employer responsibility requires that all of employers with ten employees on more contribute a fair share towards covering their employees we've learned from this experience the defining what if here share is it's difficult to do as i said we have over three hundred forty thousand individuals who are now covered who are not covered in june of two thousand and six more than one hundred seventy thousand people or more old and they subsidize state program and a growth and number that was higher than we expected due to our under estimate of the number of uninsured in massachusetts but we do know that since an accident of health care reform we have decreased the number of uninsured in massachusetts by more than half and we have not seen a decrease in employer sponsored insurance we also know that people are getting access to care they're going for preventive care they are reporting that they have regular providers they also report that they're out of pocket medical expenses i have gone down we have also seen that the reform of the nonwhite market has created products with lower premiums and better coverage so we are in a good position to continue this experiment going forward what we need is the ability to continue to learn from this experiment and reply in our product and to gauge in our partnership with the federal government with much flexibility as possible thank you thompson thank you all for having having this this hearing today i mean i've been the c e o of the american college of cardiology for the past two years before that i was in california as the c e o of the california medical association prior to that i'd been a practicing physician for a long time in hawaii and i was a commission of health and white for eight years during a critical time when hawaii was developing and implementing its employer based access i wanted to talk a actually passed a law requiring every employed person to have coverage and and strong incentivizing their dependents to be covered as well along the richard nixon proposal hundred seventy four they thought it was going to become national law it went to all sorts of court challenges raised by employers and made the supreme court where the law was repealed actually on the basis of a violation of the recess today has coverage of all the defendants don't because the cost split between the employer and employee wasn't really fixed in the law and as the cost of gone up employees have been able to to afford to pay their their percentage of the dependent coverage so there's been some erosion there but why he has done something is very elegant basically in the private sector private coverage there's a great deal of portability it was really just requiring that there be a cost slip between the employer and the employee and that in the waiver that congress gave to hawaii the waiver froze the cost split at the percentage that at the time was the average cost of health insurance for employees and in the early hundred eighty s it was about three percent of wages or sour across the whole population that that constituted the cost of health care for the employee so the employer in the waiver that you granted the employer can't tax the employee more than one and a half percent of wage obviously that doesn't work today why would be afraid to come back and ask for you know revision of that labor for fear that the whole law would be repealed so the cost of to the employer over time has been fairly significant that the basic idea was to be a fifty fifty split with some subsidy for low income workers the state also developed a special program of state subsidies for people who are unemployed self employed part time employed  that program kind of ran out of steam when the state's budget issues came up later at one time while you had ninety six percent of its public covered almost ninety seven percent it's now back to ninety percent ninety six to ninety seven percent repeal that law successfully although it was only fifty point five percent vote very very close and then he attempted to try to create another system which i i work with him on it as you know that did not make it through the legislature i guess what i'd like to share with you is that state reforms are important or worthy of respect they do teaches what might works and what doesn't work but we need national reform or we'll see erosion of even the best state efforts over time we need national minimum requirements and policy second thing i'd like to share is that an employer mandate has really been kind of disparaged a lot lately is something that we're probably not going to use anymore there's been an erosion of coverage but employer coverage if we fix some of the problems that employer coverage  it still is the main source of coverage for most americans i don't think we ought to throw it out if we made employer coverage more portable if we think some of the fair insurance practices that would make it better if we expanded choice of coverage with coverage maybe through to regional or state purchasing cooperatives like the like the f d a g p then employer coverage for those who have it now would be stabilized in the future as we try to expand coverage for people in agriculture and food services  retail and small business that don't have coverage today i think the other point i would make is that the reforms in california the reforms in hawaii that i was privileged to participate in really didn't focus on quality of care improvement and on systematically improving quality patient safety any kind of federal action we need to incorporate that as well as electronic m r prescribing personal health records interoperability standards that would greatly facilitate  improvement in quality and we do see the ministry of cause and finally we have very perverse payments even obviously to medicare that don't really work quality or or patient safety and i would love to work with you here in congress to actually change those payment processes so that they do in fact incentivize quality and improvement the current system unchanged is going to be a financial trainwreck it's a it's going to be both an effort and economic and ethical imperative to change it states will continue to serve as critical laboratories but we need federal action and we need federal commitment a national policy to guarantee that everyone will have coverage in the future and we look forward to working with you to achieve that thank you thank you very much ms reilly how are things in the great state of maine they are fine chairman stark and i'm pleased to report that governable dutchy was reelected thank you very much for the opportunity to be here  camp and members of the committee us to speak a little bit about the lessons learned in the past five years and maybe the most important lesson following jacquelyn is that states have been at this work since one nine hundred seventy and each decade saw new kinds of reforms we in maine were pleased to start the fourth wave of state health reform in two thousand and three with the establishment of our dirigo health reform absent any sustainable new sources of revenue governable that he sought to achieve health reform by improving the efficiency of the health care system to achieve savings and reinvest them in health care access we learned early that clear goals are important covering the uninsured implies that we will find adequate financing to bring those now without coverage into the insured tent such an approach generally accept the status quo and how care is delivered in coverage provided the goal which was ours to assure every man woman and while has access to affordable quality care is different it seeks health security for all those without coverage those with inadequate coverage and those who fear rising costs will jeopardize their coverage numerous studies that you well know have documented that we in the united states pay for redundancy inefficiency variation and over supply our recent mckinsey global institute study concludes we spend four hundred seventy seven billion dollars more on health care than peer nations yet as you well know we don't cover everyone and we don't get better outcomes or health or quality for that investment when deer go began in two thousand and three main had the highest rate of uninsured in new england by two thousand and six every state in new england saw their uninsured rates rise only m saw that rate drop and dropped to the lowest in the region but our progress has been stalled lacking adequate finances and i think this will be the last time i say this given secretary big b s response because i'm certain massachusetts has now a paced us and congratulate them for that to guide manes reform we convened stakeholders in a health action team we found early that process may be as important as policy in this effort of health reform the legislature created a special joint commission on health reform with members from the health insurance an appropriations committee convened together the reform debate played out largely between two camps those who want to deregulation and market based solutions and those who wanted more investment to sustain comprehensive coverage to cover all the uninsured long ago she ations resulted in significant amendments to the original bill and found a middle ground that once strong bipartisan support both the health action team and the joint committee were dissolved once the bill was enacted in hindsight zero with oversight of the reform split among different legislative committees and no one single stakeholder group to provide guidance to the overall reform of that when was created that allowed the parties to return to their corners when the inevitable implementation challenges occurred and acting health reform we've found is tough few states has done it but implementing reform is tougher and i think whenever we think about what how to frame a federal response we have to think about the long term implementation to achieve progress all parties with strong leadership need to stick to it and work together to make mid course corrections rather than see each bump in the road as an opportunity to defeat reform as alan while pointed out medicaid is a critical component of any kind of reform and we based our our reform on it as well seek since the linking welfare and medicaid eligibility and imposing work requirements more low wage and part time workers receive medicaid because they can't receive a can't afford workplace coverage the premium assistant provisions within the medicaid program need serious reform that difficult to administer pay only for the employees share of premium and require a state match the dear go he pull all revenues including employer contributions from our small businesses who are covered and use those pooled state resources to match medicaid for eligible employees and their dependents c m s rejected our approach which will soon be tested in the courts there are several other ways that the federal government could take action complexity and redundancy are costs in the system streamlining and creating a single system and that does not necessarily mean a single payer would help the federal government should examine its considerable purchasing power to add standardizing reporting payment policy benefits eligibility and quality metrics secondly the states are to play a role in health care reform they need the capacity to work in a level playing field and arifin now prohibits that it prohibits much creative work and even the collection of key data from self enjoyed businesses and needs to be and i think it's particularly important we have jacqueline here for her from hawaii because it reminds us that state has been at this work for over thirty years the thirty years states have been the laboratories of democracy adopting insurance reforms before hipaa starting children's health programs the for states have done extraordinary work to lay the foundation for reform each state is operating relatively independently based on very different health systems coverage and costs and reflecting different state priorities that state the state very result the fragmentation and complexity across the country which drives costs over three decades of state health reform and the reams of studies and evaluations analyzing them suggest to me that it's time to get out of the laboratory and learn from the decades of state experimentation we cannot reform our health system piecemeal or even buy for the state state innovation in the spirit of federalism the national government must commit to a national policy and a clear roadmap that achieves affordable quality health care for all and finally answers the question thank you very much thank you thank you mr chairman ranking member camp and members of the committee for inviting me to testify today my name is ed in high school myer i am a senior research fellow at the center for health policy studies at the heritage foundation and i have to give you the cop out that my testimony is my own and the its foundation does not tak institution positions on these or other matters i come here having spent the last three years or more actually working with over eighteen different states throughout the country very diverse situations and i would like to share in my five minutes some observations and conclusions that i've reached over the past three years and i say literally diverse i can recall a week last september when on monday i was in anchorage and the following monday i was in tallahassee first of all to follow up on what some of the other panelists have said i am impressed by the diversity of states and that is in a number of areas the demographics their economies and importantly their delivery systems because remember health care delivery is always local also in the financing arrangements the way the insurance markets are regulated and the way they design and operate their public programs now and looking at this at the federal and state perspective my key observation is that the federal government controls a significant portion of the financing of health care in this country the tax treatment of health care is a key determinant of employer provided health insurance that is that the favorable tax treatment of course the federal government sets the rules for medicare and medicaid medicaid and  chip spending and medicare while it is a federal program has a significant impact at the local level because it is the disproportionate payer for hospital services so that is what the federal government controls the downsides of the federal government control is they have virtually no regulation and no experience in the area of insured private insurance markets nor do they directly regulate the providers the doctors the hospitals etc thus if you were to try to construct a national solution of some kind you would inevitably have to tackle those issues just think for a minute what agency should be tasked with regulating health insurance it's a very interesting question he never really come to the satisfactory solution at the federal level now on the state side the reverse is the case they have to work within federal constraints particularly on the financing side of things they do have considerable powers to alter their private insurance markets and to regulate providers so i see as the path forward states working creatively and i would emphasize creatively within the existing parameters of federal law and that is what i've been working with a number of states as i said doing the more i do this the more convinced i become that the path forward will be an evolutionary one not a revolutionary one i'm convinced of that because when i look at the politics and the interest groups and the variables in the equation in any given state they are enormous and then i try to imagine multiplying that by fifty and coming up with a solution that's acceptable to everyone and i have trouble seeing how we get there in one big bang what should the objective of health reform be in my written testimony i've gone on on some length on this i believe the objective is something should be something that we very rarely hear talked about in health care we hear talk about cost access occasionally quality maybe even benefit but the real missing word in my view is value are we getting our money's worth i think that we can all agree that both that a individual level and a societal level we are either paying too much for what we're getting  not getting what we should be for what we're paying and that is both in terms of our personal interaction with the system and also societal in other words we're spending all this money we have these uninsured so the question for me is how do we increase the value proposition in health care how do we get more for less how do we have health care work like other sectors of the economy such as electronics where next year's model has more features the same price or maybe even lower than last year's that should be the objective now the mechanism as i see it that will get us there is to focus more on making the system and the actors in the system the providers the insurers everybody else respond to the needs and demands of patients and consumers i the term consumer to mean somebody who's buying insurance but not at the moment seeking medical care what i think was significant about massachusetts and i wrote about this right after it was enacted is that they essentially tackled two things simultaneously a states that i've been working with are looking at doing one or the other or both the first key element was insurance market reforms to create and to work out the details of exactly what dr lewin pointed out which is to work within the context of employer provided insurance but create a mechanism whereby the coverage was actually chosen by the individual owned by the individual could be taken with them from job to job but at the same time didn't lose any of the protections of federal law or any of the tax benefits or other subsidies associated with that that is the first piece the second piece in the again this is what massachusetts embarked on only in part but other states are looking at going further is to restructure the existing public spending principally to shift from subsidizing providers for treating the uninsured to using those dollars to buy the uninsured coverage and i would submit mr chairman that anybody who 's interested in expanding coverage needs to look closely at that model because if you go about trying to expand coverage without making that financial shift then you're in effect paying twice for the same thing and you've got a tough road to h anybody who is concerned about value about quality about competition also needs to look at that because if you perpetuate a system that subsidizes providers for their existence particularly subsidizes certain providers versus others then you will never create the kind of competition where where patients go and insurers steer people to the people who offer the best results at the best price so i think from both the left and right there is a lot to learn from that  experiment finally let me conclude by saying that my bottom line in all of this is that we need to reform the incentives in the system in terms of how and private insurers operate in terms of how the delivery system delivers care to achieve better value to create incentives where the winner is the one that figures out how to provide more people with better at a lower cost once we do that the task of making sure that everyone without exception is able to participate in this system and that the disadvantaged are subsidized to buy into it becomes in my view a much easier task and is certainly doable thank you very much be happy to answer your question it's a it's it's an amazing and complex problem let me just try a couple of issues that i've been concerned about maybe we can  society this word mandate has caused great concern among parents they rush their children put wax in their ears and get them out of the room but the last time i look d the former governor of massachusetts i don't recall ever being accused of being a flaming liberal  both were able one way or another to use that word mandate and i suspect we have it in auto insurance and driver's licenses and income we have a lot of mandates  is there are there any of you who feel that we can achieve over a period of time universal coverage and  reasonable quality of care for all of our residents without using mandates whether it's requiring certain groups businesses to pay for example for all people to have a policy or have a provider if they can afford it is is there a major objection to amanda gengler well i think that you know we don't have anything to point to in this country chairman that would indicate universal voluntary anything we really don't have any universal voluntary programs out there so i think if we want everybody to be covered and we want everyone to pay their fair share and quoting the immortal and young we think that they can avoid coverage but also those who really need the coverage and can't afford it i think we need to have to try to make a policy that's that's either a mandate or some set incentive so strong that they're the equivalent of a mandate  i i i think that the individual mandate is a key part of the reform in massachusetts and we have a recent survey that demonstrates that the majority of people in massachusetts actually support the mandates and do you not think that it should be repealed i think the key is the mandate is for people who have access to affordable insurance and defining affordability and a mechanism for ascertaining affordability and having alternatives i think is key to implementing a mandate given given a plan that would reach your there are different mechanisms for getting to that point there's no one single mechanism and one can disagree as to how it's done i would simply make an observation if i could about what happened in massachusetts governor rom did not initially propose an insurance mandate what he said is that under the plan that he submitted to the legislature insurance would be made more affordable it would be create a mechanism where be easier for employers to at least offer the coverage since they wouldn't have to run their own plan they could simply bring people to the connector and let them choose so there was no reason to not offer the coverage and the insurance finally would be subsidized for those below three hundred percent of poverty in the position that he took in his initial proposal was ok folks you kind of run out of excuses if we do all these things for not having insurance so i'm not going to make you buy it but i'm going to say that you have to live with the consequences if you don't because if you don't buy it and then you go and get treated and then you don't pay your bill it's not the fault of the hospital it's your fault now the legislature in its wisdom turn that into a buy insurance or we'll find you mandate ok one can dad but i just signed no death penalty no definitely no it was fine and one can disagree as to the approach but i think follow softly they are the same thing the point i would make is that what happened in massachusetts is they tried to design their reforms to so that everyone participating individuals the providers the employers would see it as a good thing and want to participate and it was only at the end of that process did they then say well now do we need to make people buy it and the concern that i have is that if you start by saying we're going to make everybody buy it then you skip the necessary hard thinking about what do we have to do to make people want this without requiring them to buy it because that's going to make a difference as to how effective it is if people just want it regardless of you requiring them that any requirement is really to clean up the last two or three percent that's fine thank you mr  medicaid as opposed to if we set a national standard how does medicaid medicare how do we get those you know i will can you give me a couple of three areas in which you think federal action would be the most important mr chairman first and foremost there needs to be a national commitment to universal coverage without that the ability of states it's to feel confident in the resources in the in their ability to move forward i think everything else will suffer without that and of course once you talk about universality you do have to answer some important questions what does that mean what are the standards to give people confidence that they will have coverage we already have a lot of leadership from the federal government around  quality improvement but but we could use more the field the the i think the discussion about value is actually very much on the table now and the ability of the federal government to lead and work as the dominant purchaser with states as major purchasers in their domain provides a tremendous opportunity for forward progress and issues of cost  simply can't everyone says the incentives are wrong and then they go off and do their own thing to fix the incentives and the incentives continue to be fragmented and they continue to be wrong and if we're going to actually reach any agreement to try to align those incentives to improve the value in the system the different purchasers have to work together and within any given state the federal government and the state are right up there at the top i think there's a very potentially a very long list of areas for cooperation between the federal government in the states but as i say really what the country needs first and foremost is a commitment to universal coverage and then states within that framework i think could go a long way jack could you just expand a little bit on the issue of one with which i agree but beyond the idea that we've got one hundred sixty million people who now get insurance e hundred fifty nine of them right away and so i felt there's a political issue of just saying we're going to disband the coverage that this body people have are there are other reasons that you think we have to  don't have we need some some insurance reforms and as we mentioned before there there's the issue of choice of coverage that we need to expand so if we could add those features to employer coverage we'd strength and i think i would fear that were we to even send the message that we're moving away from employer coverage and we've seen erosion of employer coverage in many places california in particular what happens there is we were more likely to shift people to the public sector and in a way that we couldn't accommodate the absorption of the cost and then really handling that so if over time our our long term policy was individual coverage and we had a long ramp up period to it i would imagine we could find a way to get there and it would it could work but i think we'd be would be precipitous and dangerous to send that message now with with the vast majority of people covered there some employers are beginning now to take some actions as well to strengthen the health of their workers and recognizing that they've got another role in addition to being the administrators and the accountants if you will and i think there's a there's some hope out there that the employers could be encouraged to do some more activities you see what safeway is doing for example for its employees and other large corporations that are deciding to take some matters into their own hands and through voluntary approaches incentivizing he behaviors and rewarding those behaviors without penalize ing people who have for genetic reasons or other reasons  health problem that they can't the needs that needs attention so i think there's a lot going in the employer side right now that we should retain we want to focus on those sectors that don't provide employer based coverage retail  agriculture food services small businesses that's maybe where we could make the gains with individual coverage to start the process there and maybe that is a way to avoid a fight if you will with some entrenched sectors that would make it hard for us to make some progress so there's a reason that i think to approach those sectors with it with individual coverage but i think for the rest of the the marketplace we ought to try to protect employer coverage and improve it so we ask  really don't now have the ability or the data to determine quality in any kind of an empirical manner and unless and until we get outcomes research which will probably take us five or ten years of accumulating data the idea of you know what one of the internist was are they worth seventy bucks for a fifteen minute consultation or is another room with a hundred bucks i don't know if there's any any way and god's green earth that one can determine that without this database so we have to do a lot of work to build before we can start saying we're going to pay for quality i think that's absolutely right one of the features of massachusetts health care reform was the creation of the health care quality and cost council and also requirement at that council post cost and quality data for providers and massachusetts we are working very hard to get those data up on a consumer friendly website but the thing that we are struggling with is that we have very few measures of quality those individual measures of quality give us an overall measure of quality for an institution like the hospital or provider groups they are just that individual measures and they may not be that great we are finding that they don't distinguish care deficient lee across providers in massachusetts so you know we will post data that shows that everybody is due with ok and what do we do with that type of information as we have come together in the states all of our public purchases medicaid our state employee program the connector we're looking at our purchasing power to try to implement reforms in the way we pay for services to define dao you but we can agree on a few things but we understand that that doesn't necessarily represent an overall quality thank you thank you all very much wish you can well thank you mr chairman dr lewin individual consumer policy available and not erode the employer provided care that most americans five percent of americans have i believe there isn't that sort of the core of the insurance market reforms that i worked with with the then commissioner of insurance under mayor williams here in the district of columbia and the advantage was of course that when we tried to work out the details of how a sta regulating insurance would interact with federal law we just got in a cab and went and saw the department of labor department of treasury and that basic design was what was incorporated in the massachusetts reform we shared that with them at the time they were developing it and i sense you know in working with other states made refinements to it the analogy really is to what we did with four one k s in the pension area in other words instead of presuming that every small business could run a defined benefit pension plan where you work thirty years and then you get so much in the business has to invest it all create a system within the context of employer offering and all the advantages of that where people have an account and they invest in it and they take the money with them from job to job that's what the connector is designed to do that part has not entirely come on line they've only done that so far for the part time and temporary workers and for the individuals but they're working towards the discussions i've had with the connector leadership they're they're working towards a goal of this fall bringing online the ability of a business to simply go there and say this is my employer plan what is my employer plan consist of it consists of this menu of forty different options in the connector my insurance agent will sit there with you as a benefits counselor to figure out which you what's best for you and help you pick a plan now that has all the protections guaranteed issue it's header of federal law with respect to employer coverage it all qualifies as tax free but the individual owns the policy you can take them with them to the next job so that's essentially the  design and i see that that is sort of the first step in insurance market reform that a number of states are looking at massachusetts with a little further in also including their individual market in some other states that make take some time because some of the issues are a bit more contentious thank you and mr while you mentioned in the study you wrote coauthored that that one function would be for state government to provide a well functioning market and what are some of the things you envision in a in a well functioning market and how does that differ from what we currently have and what reforms might be included in that i think we can all agree that providing employees with more choice of plan would be a benefit to most of them whether it would really drive these broad reforms in the health care system is more uncertain but it is the case that most employees do not get a choice of plan most employers pick a single plan or a number of variance from the same carrier but there is an infrastructure there that the employer provides that needs to reside somewhere if it leaves the employer i know in my small business it may be a nonprofit business but we spend a lot of time helping our employees navigate their insurance products and we only have one of them imagine if there were one hundred of them to choose from someone still needs to play that role i think the real issue in regulating the market is a series of policy choices regarding pricing and availability there are many states in which the small group market and most states in which the individual market has fairly liberal rules with respect to the insurance industry practices regard rating up the policies of those who are older those who may have an illness those when you allow individuals to buy insurance products across state lines would i know i would not do that and the reason congressman i'd be a bigger pool for example for all the realtors that headers that are involved in some association the concern i think this is it's a very rich topic for discussion i certainly don't suggest my own views are the only you should hear but my sense of the problem with going across  lines is that there are pulling rules within each state and the moment i if i lived in massachusetts can buy my product from the unregulated state next door  then the pool that you've created to create an affordable system in massachusetts unravels as the low cost folks purchase across lines in a state that doesn't community rate and gives them a cheap product so all the consumer protection issues aside which i think are very large from a simple pooling perspective allowing purchase across state lines unravels any effort to create larger pools of  cross subsidy within a state and that means we will all purchase our own insurance our own prices that we will face will be those of the risk profile of ourselves older and sicker people will by definition pay more because younger and healthier people will find a state where they can buy a product that is priced at their low cost so i and i think that's a that's a dramatic policy choice for the nation as a whole to say that a state like massachusetts cannot create a single pool across which all residents of that state will will make a contribution i see my time's expired thank you all for being here thank you all for all the hard work you're doing and for your test this morning legislature gave the responsibility of giving meaning to terms like affordable minimal credible service reasonably comprehensive to a board rather than having the legislative body try to define all aspects of that at the federal level is that the best approach and perhaps you might have some thoughts as well on the the concept of a board modeled on the federal reserve former senator daschle has recommended yes i think that's a very good question i will say that i think the legislature realized that they could never come to agreement on what the definition of minimal represented the type of knowledgeable people that are there but also those who represent consumers and canap kate for them so i think that the concept of that type of board that has the authority to do that was an excellent thing and i think it could be done at the national level you have managed in massachusetts to do reduce the number of uninsured citizens significantly over a relatively short period of time at this point what do you think are the most important steps we need to take at the federal level to ensure that the job is complete and that you achieve universal coverage for all your citizens well i think that the components of health care reform that allowed this progress to occur are still what we would like to have in place many of those  components are there because we had a partnership with the federal government in our medicaid waiver i think that the ability to expand coverage to low income people was very important when we look at who has benefited the most from health care reform and where we've seen the highest increase in insured population it's among low income individuals and young m n who tended not to get insurance even if they could afford it i think that those principles of insuring people and using resources as has already been mentioned that had been going to institutions is very important for ensuring that we're covering individuals and that's very important in the long term we know that we have to do better at containing costs so that we c to stay in this and i think that the mechanism that we have for doing that will require just as much creativity as the things that we put together to ensure access so flexibility have and in fact or battling over this very day as we attempt to eliminate the incredible waste of unnecessary subsidies in the medicare program despite its defenders in the white house and some here unfortunately in congress as you look back over your experience i'm sure that any health care reform will encounter significant opposition but are there things in the cost containment area that you would would do differently or recommend that we approach it differently here at the federal level that that's a very tough question i think it is clearly when health care is a seventh of the economy it's one in six jobs in maine somebodies idea of cost containment is another person's salary so it's obviously very difficult i think it's absolute comfort honest to get the stakeholders around the table and to get a vested interest in cost containment we initially tried to do a global budget with our hospitals it was highly and fought viciously but that was replaced by voluntary hospital targets at their meeting we've created a main quality form to look at the national data and to eliminate the variation that exists pretty dramatically in our state and i think that that has been a fairly successful approach and we've  instituted medical loss ratios in a small group an individual market to do those kinds of protections but in the end i think it's it's that the notion of a global budget the notion of everybody coming together negotiating around the inefficiencies of the system to find ways to solve it to get the those inefficiencies out of the system and reinvest it makes lots of sense it's been a very challenging situation for us and i think in part because the financing was precedential so one of the problems i think we face as states is as long as as long as states of you does laboratory experiments and they're not policy then the reaction to people is to fight them not to fix them and i think alan's points quite right that we need a sustainable federal policy that says we're keeping our feet to the fire everybody has to work on this and get it right then i think we can get the right incentives around cost containment thank you very much and your efforts to try and move the state's health population ahead have run into any barriers in regard to arista have there been things you couldn't accomplish or have there been  have violated a risk and we had to get this arista exemption from congress the exemption is a frozen exemption it's the provisions of the whole are in there and how i was is fearful of ever coming back asking for any amendments so you know the cost split between the employer and employee was set for what the costs were then costs have gone way up and the employees cost remains one and a half percent of wage which is woefully low and it's unfair to the employers so that's a destabilize there when when we went back in to do a program for the unemployed unemployed and off employed part time employed the state health insurance program we had to make that we wanted to try to get everybody covered but we ran into a recent barriers with that and in california as we tried to proceed with s b two we also knew that when if a lot was going didn't make it through the the challenge of the public ballot initiative led by governor schwarzenegger we would have been challenged on the basis of a r s at some point in the future so yes i think every reform has to dance around a recess in order to try to get more people covered and i think converse any time we talk about mandates employer mandat requirements were always there's always a balancing act about when we're going to force employers into the self into a mode in away from the protections of state regulation and that's a balancing act at the state level a risk and it's live at its most narrow though is critically important to basic to chairman stocks concerned about quality and and data arista prevents us from acquiring self insured plans to contribute data to our all pay a data base so it's very hard to sort of move to a meaningful quality initiative across initiative without the ability to get that data from self into a companies and in in this to chew said in may we issued a report where we looked at the lawyers who had fifty or more employees on state subsidized health insurance and that total six hundred thirty six million dollars these are mostly part time workers who are temporary workers or people in the waiting period before the thompson a couple of things that i would add to the my colleagues here the data usage in particular but two areas i mean i'm not i mean yes a recent provides obstacles to certain things i'm not necessarily convinced that that's a bad requiring employers to buy and manage the insurance isn't necessarily a good thing but there are a couple of points one is this is an area i'm looking closer at it both federal law interests and also state law with respect to insurance is that the possible obstacles to plans offering subscribers rebates for successfully completing or participating in disease management i think the problem we see with a lot of the wellness stuff is that they don't feel that they can selectively say well ok he you know you have diabetes and you successfully if you participate in this program then we roared you at the end  for your success employers feel that they would fall under discrimination statutes in that case and so instead they say well here's a membership to a gym well that doesn't seem to produce much in the way of proving it so that is a bit of an obstacle in the states there's a corresponding obstacle that i'm looking into where those kinds of rebates under some state laws could be seen as an as an improper inducement to cover so that's an area the other area i would touch on is i think that  a large part of it i have a paper coming out on this shortly in fact i'll be at it when i get back is a large part of what has to be dealt with is the concept of how you risk adjust within the system and in effect  think that the easier way to do that is with a back end sort of claims pool where you put all the high risk claims in a pool and then redistribute the money across all the covered individual sever will this has been a terrific list of the impediments i would add only one which is there is growing interest in programs called premium assistance where you blend public dollars with employer dollars for those who have an offer of coverage at work and there are a lot of complications around those plans but one of the barriers a resupply poses is you cannot mandate the or to suppression or even the sharing of information by employers that might make it possible to determine whether that was a viable option guaranteed mechanism for high risk folks who could otherwise not get coverage to obtain coverage on the other hand we did i think did address cost at all premium was one hundred thirty five percent of average individual policy that really has been out of reach of most people which goes to the crux of my question if health reform continues to just deal with the financial intermediary range of issues we're missing the underlying cause of the whole problem that is costs are getting away from us we pay double per capita than any other country pays the world we're not getting an outcome that would reflect that additional investment indeed if you look at medicare data within our country you've got areas a higher cost are getting the worst for adults results a lower cost areas get the best results and we really need to get pretty darn serious about this because literally hundreds of billions of dollars of federal monies are going into these expensive areas not giving us best results so value medicine not meeting medicine on the cheap not meeting inferior medicine but med a value medicine this concept that i really think has to come to the fore of our health reform discussions  i'd like to go down the panel and just hear your thoughts about how we invent the notion of getting better value out of our care delivery system  continue on for a moment to give them our direction on the question as we look at value medicine and health reform maybe we have a look at more ways we build not just a response to insurance but state supported delivery systems and we've done a bit of this community health centers what is your view of the role that they are playing in terms of cost effectively getting broader access to some  care to people that otherwise don't have coverage school nurses is this a meaningful component of getting universal screening out to children where it might have tremendous preventive impact and cost savings that would result is there ways that medicare reimbursements can be rejiggered to provide greater incentive to integrate systems and elevate primary care as a principle component of medicare care delivery those issues i'm thinking about and i'd be very interesting panels responses thank you thank you at risk of taking away from secretary bigby i'd like to actually talk about some of the things going on in massachusetts because that provides an example i actually had the opportunity at another conference earlier last week to share the panel with a  woman who's the c e o of the hospital in concord massachusetts and some of the discussion was around this and some interesting things are happening in massachusetts as secretary big be noted in her example of the dry cleaner people are now with the coverage getting primary care they suddenly woken up and in the state and realize well we have a shortage of primary care providers which is something that us health policy people been talking about for years and years and now they're having to do something about it what's interesting is s is opening up minute clinics in massachusetts and what i found really interesting was when this woman who runs this hospital was discussing this on the panel she said you know my primary care providers don't have a problem with that in fact they like that because more and more people are getting the minor stuff seen to their time is available for the more complicated so contrary to what might think that there's a clash of interest actually no it's working out but what's happening is that the intermediaries are seeing that they now work for the patient not the employer and that's my second point and i use the illustration in massachusetts as well we call employers payers but payers and governments one is well care about three things in the system cost cost and cost so when the intermediary works for the payer the question is how do i control the cost well there are lots of ways to control costs in fact some of the easiest ones are ones that don't benefit the patient make it difficult for people to get care pay the docs and hospitals less the smoke's defective way to control costs don't pay now massachusetts is about to have a situation where an employer instead of having the insurance company work for them and their choice of insurer entirely based on well how low is your premium they're going to be able soon to give their employees the option of going to the connector and picking a plan if you go to the massachusetts connector in that scenario and you pick a plan and you look at the lowest cost plan and you ask why are they the lowest cost in the answer as well because when you get sick we make it difficult for you to get medical care and we only send you to the providers that take very low reimbursement i think you're likely to move on to somebody who's answer is well you know what we've taken all the data we already have and we figured out which providers give the best results with the best price and you can go to any provider but based on this tier and here's the data these are the ones you get a lower co pay for and these are the ones you get charged more  for thank you good to see you again i think the variation issue is particularly frustrating because when briggs work has been out there for twenty years and we've taken very little action on it in maine we've created them in quality form who focus is to look at variation work with the providers and because you can see a ten fold difference for the same person getting the same treatment and it means hospitals in every hospital in the country so the main quality from a work with providers to bring that variation down starting in a voluntary way and i think over time we'll have to connect prices with that the issue of community health centers and schools health centers and so forth is all very intriguing but i think what we can do tells us and most of the studies show is it is the fragmentation of our system that causes much of its cost so while those are extraordinarily important services how do they connect to gather and create a system of care so that we don't have redundant terribly terribly costly and i think we've not been as thoughtful about that as we ought to be and in fact when you think about federalism the federally qualified health centers and community health centers have a direct federal relation but none to the state so the state just like a self into a plan the state can't ask a federally qualified health center to do something specific as part of a plan and i think that's a question in federalism that ought to be looked at but i do think the big issue of the fragmentation of our system is a cost driver the federal government as a huge purchase of or of care medicare medicaid federal employee health benefit champus could set the same standards  ld set could determine prices could determine ranges of prices because what we know is we pay more and we have more in maine we decided to address the supply question we have a certificate of need program but added to that a capital investment fund that was a budget for new capital that said we'll have all the capital we need but not more because we recognize that supply in fact in this country drives demand and finally i think if we could look a little at medicare and medicaid one of the big cost concerns in the states is always the allegation that the public programs underpay and they do but i think this a middle ground how much to the public programs underpay and how much is surprising costs too high but the fact the notion of the ca shift is a problem in the system and we need better data to know we don't have comparable data state to state to state about what medicaid pays for or have a good system of looking at what medicare pays in a rural state like ours the wage index adjusted and so we are actually discriminated against in medicare and don't get even though we have to compete nationally but i think your question begs a bigger issue about what kind of federal reform we want it may well be that we need to think very differently it may well be that what we need as about the primary care crisis in america we're now talking about reinventing primary k s u something called an advanced medical home very good idea but it's become the new sort of silver bullet and i think maybe we should rethink maybe there ought to be a rethinking of our health care system where you have primary a publicly supported primary care preventive program that's mandatory for all americans and governmental we take our public health funds and we work with primary care physicians and then you insure just those things that are insurable events sickness but require insurance companies get to guaranteed issue to make sure everybody gets access to it may be time to really fundamentally think differently about how health care is provided thi chairman and thanks to our panelists and to dr lou and great to see you again this quick question it appears that the president today is prepared to veto the legislation that the congress passed both the house and the senate with overwhelming numbers to try to stave off a cut to medic doctor reimbursement rates which in many quarters of the country we're hearing are necessary in order for some of these physicians and providers to continue to provide medical services to medicare beneficiaries most of most of our seniors sixty five and over i'm wondering if you can tell me i know we're talking more globally more universally in terms of coverage for health care but what could be the impact of the president's veto well first of the president would veto and secondly if the if the veto were to stand on this cut or staving off the cut of ten percent to health care  providers sure well i think it could be significant i think that for primary care physicians and for rural physicians and inner city physicians who the viability issue is very very real and i mean i think you can't it's not like a starve the beast  philosophy just going to work here so i think that it's very damaging and it also has kept many of the health policy people in the physician community and in the month the health care professions together away from the topic of quality for seven years we just keep fighting the same repetitive battle we're treading water and going nowhere and i think that it's time to get over that i going back to mr pomeroy's questions about quality you know i think you know we leave putting on my cardiology at forty three percent of medicare costs are cardiovascular a lot of that is preventable if we don't work on preventing people in the pipeline from needing the services we're all going to we're going to bankrupt the system just on cardiovascular peril own but when you get to the care that's needed today we're not very efficiently spending our resources we really could do a much better job with the dollars we have at producing more health by using information the tools we have before us right today  to shine a light on who's doing a better job when when we last looked at all the hospitals in america and look you've heard our registries the cartney cardiovascular registries we have up across the country to say how much time and we have these registries in just about every large hospital today measuring outcomes in cardiovascular medicine we should we look at how much time it took from get from the emergency room when you're having a frank heart attack to getting the the blocked coronary artery unplugged we know that from the science that if you take longer than ninety minutes that the muscle tissue behind that that that blockage doesn't recover it becomes a scar putting you at risk for heart failure and an enormous cost in the future every every hospital in the country all the major center said we do this in less an hour but when we measured it we weren't doing it in an hour we're doing it two hours two and a half hours in one year just by giving people the information just about every hospital in america has gotten their time down under ninety minutes where it needs to be getting information to doctors and nurses and teams about how we're doing in hospitals is something we could do today and it would not only eliminate disparities it would it would get rid of variation and it would give people because nobody wants to be conspicuously you know spending more or doing less than what's appropriate and even at the individual care team or physician you can measure adherents to guidelines and performance measures and the standards we have today we need more of those but we can measure those today and and determine very accurately for every every care team and physician whether people are getting the best evidence based medicine that ought to be our goal we could get to that so inexpensively  that that i think that and the so the physician reform in the in the s g r doesn't do any of that really and there's been some movement on the let me let me ask dr bigby and miss reilly to respond because you have to run the state programs and if at the federal level we're sending down cuts to some of these providers you're saying we're going to possibly get out of the system at least for for medicare i imagine that throws your system's out of whack a bit as well yes somebody has already raised issue of cost of staying and it's something that we contend with every day you know i think that the issue of what medicare rates are for different providers is a very important one  there are things that medicare does not pay sufficiently there are things that they pay probably more than they should without a conversation about looking at that time namak and simply cutting rates across the board you just exacerbate a problem that already exist it's fairly well as the oldest statement nation we watch very carefully the work on medicare and quite concerned obviously when when medicare cuts somebody pays and that's cause shifted to premium payers and we're also a state of very small businesses who just can't afford to see their costs growth so we wish you good luck and i see my time has expired  president's veto on the medicare bill we will actually move all physicians under medicare to either scribing so thank you for oppositions and and actually all players help in getting that done and i will continue to do work on health i t i think the the discussion we've had about quality and measurement and fragmentation i think that you mention that all many of that many of those issues could be at least in part addressed by health i t and linking all of our providers in this country so for the comments what i want to address today is the the role of a market reforms in in reaching all americans being able to make sure that all americans do get access to universal coverage i think our chairman reflected  that because about fifty sixty percent of americans have employer based coverage where likely to keep that system in the going forward but as you number of you pointed out that there are major obstacles arisa being one but there are other market issues in both the individual marketplace in a small group market and and of course access to the larger employers because of the obstacles or if a are major issues and i'll raise just like you to really my question is whether you could really elaborate and so you've done this but even more on what what are some the essential mark reforms and the role we would play as a federal level so these mark reforms don't happen happen and individually in every state that the disparity between the states and what mandates the state level i did law i actually got a lot of mandates done on women's health meticulous because someone gets women at the table when the insurers decided what they wouldn't cover not so we did some of that you i have a bill to exclude to prohibit the use of these i'm a preexisting condition exclusions for children you know just the very fact that a parents may actually  insurance lapse and then they may sign up for insurance trying to do the responsible thing and they're told i'm sorry your child might be a diabetic but you hadn't and surance have to wait six months now my guess is that that child doesn't get help it's pretty bad for her child but the more likely get on compensated care help somewhere and probably the most expensive way possible i think is unconscionable that we've told in this country to whom insurance companies apply precinct conditions but they're waiting periods again in your employer can say i'm sorry i cover you but you have to wait six months to get coverage so much are you going to really be with us that long we have the employees who don't sign up for insurance and then because they forgot or because there was they were busy when they first were new employees and then they want to sign up and they employer says i'm sorry you didn't sign up in the first three months you have to wait for some change in status like you have to get divorced or married or something to make a change because again all the so many the rules are set up to ensure that our insurance companies don't cover people who are sick and i understand that they're going to be risk adverse but it has worked against even those who have access to insurance to not be able to get meaningful insurance coverage and so really the issue here of course i think for many of us is not just about getting all americans covered but to make sure they sign up for to mean something to them so if you could speak more specifically i raised several of the issues around marketed forms but my concern is that however we go in terms of national reform to do not look at these market issues for those who have access to insurance or don't and of  area to really look at the role of a risk but the role of the federal government in what is now a state regulated system of insurance health insurance that makes it completely again fragmented if you want to not just the lottery system but the insurance system so americans don't know that even when they're buying it when they get insurance there's going to cover the concern you know the health needs that they have so let's see if we can steal a couple minutes and have i think actually  we could start maybe the top or however once it is to really address some of these issues and it is a larger conversation going forward i know but i would appreciate your input as you note the the insurance regulation primarily that the state level and i think when the federal government steps in it should do so with some caution but it has done so in critical areas and i think it's appropriate to do so in those critical areas  i don't think anyone would benefit from a complete federal takeover of the entire system of regulation and as i responded to mr camper earlier i do worry about the crossing of state lines really i think the primary primary caution i would make is one congressman very similar to the point you made which is that the real federal issue is don't imagine that if federal policy shifts more people into state insurance markets particularly in village individual markets that you know what you'll get for that investment and less you have some federal standards with respect to what insurance is going to look like because the degree of variability around the country in those markets is so great a federal policy designed intentionally to move people into those markets will have very different consequences in different states just as a uniform tax credit at the national level would mean something very different in different states because if you have rating rules that are community rated then that credit will go an equal distance in providing coverage for everyone in the state but if you have a jew or health status rating as a uniform credit will be insufficient for other people it's just not that they're just one sentence with sorry which is that it's not that these issues can't be overcome it's simply that they should be attended to as you're considering the federal role but association health plans would be individuals that would so they would would they would be involved in nationwide plans not necessarily an individual policy but texas and california they're not here today except a little bit of california you know here i come from the efficient part of the medical delivery system in this country  washington oregon operate way below per person costs of any place the united states and it has struck me that the biggest problem we're going to have in this place is to if we take some way of getting everybody and we're going to bring everybody up to california or everybody up to new york or everybody up to boston now the average cost last year we spent two point one trillion dollars in this country on health care that's seven thousand dollars per person for the country how would you in massachusetts can you in maine take seven thousand bucks for everybody if you were guaranteed that amount of money could you deliver health care to your people one of the most expensive states which massachusetts is the most expensive and we are second i would love to take on the challenge but i'm very nervous about it in the same ways that maine unlike massachusetts which had significant medicaid money to fund it it's it's reforms vermont accepted a block grant like andy and we were unwilling to go there i think the worry we have when we move from an entitlement nature in medicaid programs and others is what we're moving away from universal coverage as we move away from entitlement so i would worry about a block grant approach in its capacity to meet everyone if it was but if we were talking about a reform that set a framework for national expectations and set a framework for the day to be if we designed a system are we going to go to an average for the country or are we going to go to we're going to keep recognizing these huge disparities we have today is i what you're saying we should let me be an outlier i'd love not to be an outlier i think th create the right incentives though to make sure that the the funding if it's kept comes at at the expense of efficient inefficiency and not at the expense of coverage so worry i have as you watch some of these reforms the question is always needs to be asked what is coverage because increasing it's is it real coverage if we give somebody just to be a bones plan i would argue let me let me good night another thing to chew on because i think this whole panel has talked and not one single word has been said about workforce not one single word about workforce as the driver of costs now i'm a i'm a physician so i know i got out of medical school five hundred dollars in debt but the kids coming out of the university of washington today are one hundred fifty thousand dollars in debt at a minimum which drives the way they practice medicine i would suggest that one of the things that's got to happen in this country is that state medical schools have to become free and require four years of service in under served areas within the state for you ever to get the kind of people that you need in the rural areas and the under served areas of the country i can't see how you're ever going to have people not want to have a residency and  or whatever if there are one hundred fifty thousand dollars in debt if they have been guaranteed a free education they could then be set out the someplace or in minnesota you could the same  in maine the same thing i don't i don't know how you're ever going to get the primary practitioners you need to do it i would argue that it isn't just state medical school who might my family the state of illinois educated me in the day i left for the day i graduated i left and never left anything on the table for the state of illinois now i think there's some social responsibility that has to go into state medical education that's why pick on state medical schools harvard can do what it wants or toughs or all the rest of schools new year all the new york schools can do whatever they want but the state schools should be producing they should be investing who state are investing in these doctors but they don't get the benefit of them maybe maybe the states and federal government together could could work on even a loan forgiveness program that would incentiv more and more people even primary care and some of those people would enjoy that primary care and stay in the primary care area where you have all those you know the issue of whether folks would wait until through their residency period you know cardiology it's it's almost eight years you know it's after medical school by the time most people are out and so that be a long way before they went to the rural area but i do think that the issue of workforce is very important but it's also in the context of the way we practice medicine today i'm a former primary care physician so i can say this if we think about twenty five years ago what we knew of out the management of chronic illness that many primary care physicians are caring for there wasn't really a lot that we could do for people in twenty five years that knowledge has grown exponentially and we have a much better understanding of the value of prevention of secondary prevention of intervention to avoid the complications of diabetes sent high blood pressure but we still pay people the same way to take care of those problems every fifteen minute visit and we don't support the teams that we now are important to help patients understand those illnesses so nurses health educators case managers so if we are going to attract people into primary care it's not about paying them more or obligating them if they come from a state school but actually supporting the type of practice that they want and that their patien a short story my mother in law had hypoglycemic experience in seventh growing minnesota now this is the boondocks let me tell you it is way far north the nearest medical facility of any size is fargo north dakota so they took her over to park rapids to the little hospital and they dealt with through there and they said you know we can handle you got to go to you of them or you got to go to mail and she went down there now they have figured out a complicated system to deal and she had a insulinoma on the tail of the pancreas so she was having serious problems had surgery and is back up in seventh growing today you know if you can do that state and do it for so much less th new york or boston or los angeles or these other places how do you deal how do we as congressman or do we just say oh well we just go the california way mr chairman if i could answer been anxious to answer mr mcdermott's question here because i've encountered this situation i did sort of touch on that when i talked about the increase in this is a primary care in massachusetts and the creation of minute clinics in c v s which are open in the evenings when people need them as opposed to doctor's office a couple of points one when you look at the emergency room data on who uses the what you find is medicaid patients are using the at twice the rates of the uninsured twice the rates of medicare patients and four times the rates of the privately insured so if you get as massachusetts is trying to do these folks out of the e d and into primary care well first of all you've got more money to pay people in primary care and so if you know you get what you pay for somebody says you have a demand there the other point that i wanted to make  directly addressing your question is i encountered this in louisiana where the hospital charity that they were using to train stations in dallas you was washed out and i had this conversation with dr all the way the chancellor of the ls you medical school and i went looking for a model and i found one and it exists and it is in utah and what utah did is they got a waiver from the federal gov in this when secretary leavitt was governor they got a waiver from the federal government to put their medicare g e m a money both the d m me in the eye and me also in other words both the direct medical education funding and the indirect into one pot in under the control of the state with their medicaid money and what they have privately and that allows them to have the dollars follow the didn't that enables the state to do a workforce plan and go online and find all of the stuff that's up and running where they say this is the mix of of providers we want for example we want more primary less orthopedi this is what we will fund and this is where we will fund so they get them out into those rural areas i use that as an example of the kind of tools that i stumble across and then share with other states so for example when i spoke with dr jones in the university of mississippi he was very keen on this idea of maybe as part of reform in mississippi you could use this as a tool to get more doctors in the delta doing primary care now from a congressional point of view your issue is that you in this committee are running a medicare payment system where it's structured so that the money goes to institutions because well these are the institutions that have always done it as opposed to saying no the money goes into a pot and the state can allocate those dollars  kind of residents it once and where it wants them so i would i would come back to you and say that's something for this committee to think about in the interim i'm going to be talking to these other states about what can you learn from how utah did it and maybe do it in your state with a you the short i interrupted you when you were trying to survey the panel and now that we everybody's had a chance at least what would you like to finish up on your probably has lower costs today even than the oregon minnesota i maybe not but i suspect you're a very low cost to what it is that because you can't leave so easily  the swim here i think a lot of things are higher very expensive but but health care is has benefited by virtue of having everyone having access to primary care there was a lower cost when you started down even then but also hawaii has benefited from from universal primary care access and a good safety net as well for even for people that didn't fit into the into the employer malled and that really made a big difference i mean why is data for example show that happened in the early one nine hundred eighty s when the employer mandate became activated i guess what i'm saying is prior to that time at that time were low costs then i mean well we were a low cost state for a number  of reasons but it wasn't because of genetic superiority or everybody surfing every day was having a had provided primary care to agricultural workers already for example and had done more in terms of building a safety net than a lot of states have done and i think that contributes i've produced a few articles in the past that show that getting that access to primary care for everybody something that most of the world has already learned reduces all sorts of later costs because you get people that idea which i thought was very interesting jim i'm sorry mr chairman thank you either thing i was struck listening to you was you all want to keep the employer based system in place and fiddle with it around the edges whatever whatever people are talking about i remember a guy named charlie wilson once said as general motors goes so goes the united states and general motors is their bonds that they are junk bonds and it is largely because of their health care costs and their pension costs and they are close and plants all over the place and they are looking for a way to be more competitive and they know they can't compete with toyota if they keep that stuff in house they are trying to get rid of it as is every airline in this country and i think that it seems to me you're hanging onto a sinking ship i'd like to hear your response to that because what do you see that seems to say i heard safeway somebody meant safeway's being a doing a good thing but what else do you see that makes you think that the work or the employer based system is going to survive well i guess my point there sara was that if we if we destabilize the employer based system without putting in place the the access to care solution with the mandate behind it so that many of those people who are currently covered by their employer end up uninsured we would really do our nation a great disservice so if we were to shift to an individual mandate approach or an individual coverage approach and have and have a mandate in place and then allowed a gradual attrition to a new system that my work quite well but but i think that the the concern i would have right now about moving too swiftly or sending a message to employers that you might as well you can let go of this this huge burden is that we end up with a lot of people who would would not elect voluntarily to to purchase their own coverage and we'd have many many more people in the emergency room and uninsured so i think we've got to be careful about destabilizing on the other i mean a lot of writers improve the employer coverage and put it on a level playing field with individual coverage so that the the individual could be could have portable benefits could have all the same advantages and then let people have an option and maybe even there some competition there exist in the market in the will that be a safety net enough to satisfy your concern it might be as long as you know i believe that if we had individual mandate in place across this country and then we want to look at  employer coverage then i think we be fine but i think if we do a voluntary coverage and then disincentive eyes employers that will have a lot of people who don't want to create more uninsured people or more people using the emergency room as their medical home so we need to develop a change in the employer policy for those currently covered in a careful way so as not to cast a lot of people out of uninsured congressman i i don't think there's great love and confidence in the long term future of employment based system it comes with some negative consequences first of all i think we would all agree with dr lewin that you have to have something else and the right now the something else don't look very good and the even if this ship is sinking there are a whole lot of people on it and it's sinking slowly enough that if you accelerate the rate of sinking the human consequences are quite dire  think that we also have a lot of differences around the roles that employers pay some employers are major innovators in the kind of motivation for integration realigning incentives investment in prevention and some ar e predicts particularly smaller ones don't have the resources don't have the tools to drive that kind of innovation and finally employers are a source of pooling of risk and imperfect one by a by all tests but again if the alternative is moving out with complete fragmentation of risk i think there are there are serious concerns there so i think what you're what you're hearing at least also speak for myself is a lot of anxiety about the unraveling of a system and frankly not a lot of faith in some very global hopeful optimistic and in my view unrealistic assumptions about where people would land if we didn't unravel that system and those are all reasons for caution but not reasons necessarily to say you know this is the best thing we would think of if we were starting from a blank piece of paper and i think we haven't had the policy discussion we haven't made as a country the decision about what kind of health care we're going to have so it's a tacit employer based system i do think we need to worry about it we need to have the discussion about whether we want to go forward with it and how particularly given two factors one is increasing the employers are constrained by the cost increases they're shifting more down to employees and we see a growing class of under insured people who don't really have coverage but they're paying for it and as the workplace changes and as more part time workers and more people not connected or who move through employment very much more rapidly than our generation did i think we do have to look very carefully and very quickly because our assumptions that that that employer base will stay the same clearly isn't correct finally though i think the kaiser family foundation and others have done some polling that suggest that like it or not the public is still committed to their employer based system and and very worried about what might replace it if you  what i said earlier that well i don't know if i'm understanding the panel none of you who would say that this is the end all and all to our answer to our problem but until we have a system that we can forward that the public will accept and the providers will participate in we better go cautiously about just tossing the employer based system overboard and somehow see if we can move carefully there and i wanted to ask one more a plan that we had some years back we talked about subsuming medicaid into medicare idea that we got to federal systems that often are different and disparate and leave the states with the long term care question because they get lobbied the most heavily from the old stirrers like me little kids and poor people lobby very well so every time there's a cut in state medicaid it comes out of the hide of the indigent and children in the nursing homes do pretty well thank you so believe that portion with the states and take  or how would that work in massachusetts so after big b well you know the idea of merging medicare and medicaid would allow us to address several problems that we would love to address but as many people on the panel have already pointed out medicare is a substantial player for a large percentage of the population and without being able to  supplemental add on is necessarily the most generous or complete program and it would seem to me that that would also be of something medicaid would do but if we got to kind of one of and i'm not sure there influence further reforms that have that are more than just covering people and giving individual access they would allow us to do some of the system three design that have been talked about it would innovating it would be a shame to lose it on the other hand i do think there's great value and you may not even have to take over the two programs but just have the same standards the same payment mechanism same requirements as a start because there is such fragmentation in those two programs and you could really ler that we could incentivize people to purchase health care or any sort of structure that can be created to do that yes i think that i think which you do is you follow essentially the prescription that they did in massachusetts in designing their reforms which is you find ways where you can make it easier for people to get and keep coverage so for example the connector in massachusetts enables people to go in there and get coverage single place it enables an employer to say look i don't have to go out negotiate with blue cross and blue shield or fallon i don't have to try to come up with a one size fits all plan for my employees and then the insurer won't give it to me unless i have eight out of ten i can just take my people down there and say here's the menu here's the money here's my agent to help you walk through the menu and figure out what's best for you to spend the money you get the insurance you want you take it with you from job to job and if you simply include on that and say well you know when the employer does that they pick one of the plan as the default start that everybody gets and then they have a choice of something else you're going to cover eighty ninety plus percent of people getting it and you don't have to necessarily require them to do it in the end yeah you'll have some residual questions especially if you bring in the individual market and i think it's a very simple rule i think the rules should be that if people b and keep coverage when they're healthy they should have as part of the deal a right to change coverage without penalties at certain times not in the time they want but it's certain times like an open season when they're older and sicker and so what they did in massachusetts is said look we're going to make it easier to get we're going to subsidize it for people who need help subsidize it and we're going to produce the incentives to bring the cost down thank you they can panel very much through the hearing before well we'll conclude the hearing and thank the panel i would like to announce to our guests that you can't go out the door is on that side of the room there's a problem out here in the hall or if you go out that way you have to take your shoes off you can't take any gels or liquids with you we have to exit out into this hallway if you will thank you very much