thirty two hundred america's affordable health choices act of two thousand and nine on july thirty one the committee ordered thirty two hundred reported over the course of the five day mark up on th coverage to all americans and appreciate all the hard work that committee members and their staff have devoted to this effort at the conclusion of the july thirty one mark there were still a number of democratic and republican  august we did report that bill but at the end of that markup members had a number of amendments and my members had a handful and we both agreed that we would have a  supplemental markup even though we are going to report the bill had that happen in the twenty five years i've been in congress i would assume that maybe you and mr markey who've been here longer than me have had that happen in any event we're here today not marking up a bill not introducing a new bill but considering the motion from mr dingell to instruct you to instruct the rules committee to add whatever we decide to add to the comprehensive bill that's unusual but we're going to work with it you and i also had an agreement on what could and couldn't be offered and we're going to honor that we had seven amendments  that were pending i think we're going to offer two of them we have two other amendments that we would wish to offer and had we known then what we know now we would have had them pending but we didn't have the  and so we're going to encourage a adequate amount of time to debate and then see what the will of the committee is and whether they should be should be offered or not but we're going to operate in good this market which is the last time we're going to have a committee consideration before the bill goes to the rules committee is that when the president said in august i mean two weeks ago to the country and to the congress in joint session and what he felt he could said there are hundreds of millions of americans who already have health insurance through your job if you want to keep it we believe that we've got a provision the rogers amendment that does that and then when the president think all of us listened carefully to the president's address to the joint session of congress on health care and i think many countries agreed with what he said unfortunately a lot of the claims that the president made regarding the health care bill which he thought was included in this legislation h r thirty two hundred is not in fact most of his claims were not particularly the one that's dealing with illegal immigration the president said quote the reforms that he is proposing would not mr chairman when h r thirty two hundred passed out of this committee on the last day of july moved into the arena of public opinion for the last fifty four days i like many of you have held town hall meetings and it is clear to  me that opinion of the american public has rejected the judge much of the majority of the committee that voted to pass h r thirty two hundred today we will revisit a bill that has been rejected not only by many of the american public trying to become jurassic park and recreate thirty two hundred which has become extinct it is clear to me that no amount of our reconstructive surgery in the form of amendments that were drafted or the yes gentleman from kentucky thank you mr chairman each one of us on this committee has been sent to washington to be advocates for our constituents and during august when all of us went home ask to the rules committee and then the thirty two hundred i would ask the chairman to send thirty two hundred back to this committee and give us an opportunity to reopen that bill to reflect the changes that the constituents of our district was when president obama spoke he said that he would he would not favor taking money from medicare h r thirty two hundred takes money from medicare he said he would not increase the debt thirty two hundred increases the debt he said he wanted medical malpractise reform this bill does not have it so i the chair i'm going to allow mr rogers bring thirty two hundred back and allow us to do this again committee adjourned its markup on h r thirty two hundred the american people want health care reform i have been fighting for health care reform since i got here in one thousand nine hundred five but the american people have made it clear they do not want the heavy hand of government one thousand and twenty six pages of it in h r thirty two hundred they do not want the command of the government telling every insurance company in america what it must charge precisely  after bureaucracy to micromanage the industry not what a public plan they do not want the individual mandate but mr chairman there is bast agreement on things that we do agree upon on a bipartisan fashion every republican and every democrat in this congress lives and they're asking for us to be pragmatic and i before i left i had a good conversation with one of my colleagues because we're conservatives together and he didn't like the public option so we sat down had a very good conversation and manner gentleman from oklahoma thank you mr chairman i agree with a lot of my colleagues i along with many of them got to speak to thousands of my constituents over the break and i found bipartisan dislike for this measure and one of the things i heard a lot about was how it affects small businesses which are the backbone of our economy this bill imposes an eight hundred eighteen billion dollars tax on small business they don't like that i don't think that's a good recipe right now an economic slow times that we're in to do something like that and neither do the people in my district we need to get another thing we need to get all the stakeholders at the table i don't think we've got them i spoke to a lot of physicians for example and they said the american medical association endorses the physicians were on board i can tell you they were in the first congressional district oklahoma not only were they not involved i heard only seventeen physicians in america are members of the american medical association and the ones that were members of it quit in droves in my district also i think that it's very important to get everyone pay hospitals all the people together and move incrementally as we go forward to reform our health care system which we all agree happen we need to reduce cost in health care we need to make sure that all people of preexisting conditions can get coverage but we don't need to do this with a one point five trillion dollar government takeover health care system that sets up tremendous bureaucracy and puts all kinds of stuff between the patient doctor relationship tell me as time has expired i do it incrementally move more slowly thank you mr chairman mr murphy chairman like many meetings as well thousands attended and i heard from thousands and thousands more with mails e mails phone calls and they made their message loud and clear fix health care but not this way millions said scrap much of this bill and do something else while millions of americans can't all be wrong many are without insurance we need to fix that medicaid and medicare are seriously flawed they're old we must fix the will rogers once said when you find yourself in  hole we are still digging but not with a shovel with a whole army of back today we're going to be voting on amendments to increase spending even more how do you make health care affordable by adding more mandates more bureaucracy more inefficiency more barriers and more the like many of my colleagues heard from my constituents and i had hoped we would listen to america during the august recess and would come back to this congress and hit the reset button or at least the pause button but instead we're both hitting the fast forward on once again i think the general disappointment with this bill is that we are trying to do too much address the issue of bipartisanship this bill has never been bipartisan right from the start but do feel compelled now that some of my colleagues on the republican side seek to bring up the larger bill again i just want to say i had i had town meetings and during the august break as they often do of course i heard from a lot of my constituents but there was no question in my mind that my constituents overwhelmingly support h r thirty two hundred and believe strongly in what we're trying to accomplish in the bill and that is to establish affordability continues to be a problem as health care costs and plays continue to go up so nothing has changed other than it's gotten worse and more and more americans have no insurance and more and more americans are faced with higher  and we create choice which hasn't been available for america many americans in the past gentleman's time has expired thank you mr chairman two weeks ago president obama addressed a joint session of congress the president is now given your forty different speeches on health care while the president claims to bipartisanship and while he has invited members of congress to discuss the bill line by line let it be noted for the record that a number of us have taken him up on his offer  things that make our medical care the best in the world more than forty of us have co sponsored h r thirty four hundred a bill that fixes the parts of our health care system that are broken without destroying the things that work our bill addresses that we lower health care costs for families by republicans in a row make opening statements while the democrats decided we wanted to get on to the amendments before before but viewers or those in the audience listen to the republican comments suddenly realize in august that there was a problem and they're back here to do something about it we've been trying for years to get the republicans engaged and the president has given us leadership committee has already done its work on the health insurance reform bill as have the other committees in the house that has jurisdiction but we had additional amendments and if  committee since to the rules committee in the chairman's motion would have equal standing with the bill that was reported is that these are these are recommendations for request the rules committee that h r thirty two hundred be returned to this committee for further deliberations so that we would not have to go through this process asking permission to make additional changes to the bill that has already been sent to the rules committee is that something that is within the power of this committee to request will this committee report of a bill and that it would go to rules committee as a bill but that doesn't guarantee that bill will be taken up on the house floor without some changes to reconcile that bill with the other bills on the same subject of the other two committees that have jurisdiction mr chairman of the inquiry i think you may be misunderstood my question my question was before the rules committee acts to reconcile the various versions of thirty two hundred could this committee request that the rules committee send the version that we submitted to them back to this committee for further consideration we've reported the and now we're seeking to read the report additional amendments that we would recommend to the rules committee to add to that bill as it goes to the house floor without being disrespectful could i ask counsel if they have an opinion as to my inquiry you stated again yes i'm simply asking does this committee have the ability to request of the rules committee that the version of h r thirty two hundred that was sent from this committee be returned to this committee for further deliberations on due process within this committe committee could do a motion to recall the bill because the bill that we reported has not yet officially been considered by the rules committee and that if the committee affirmatively voted to recall the bill we would bring the bill back for consideration in reopen it before the rules committee act that was if i remember correctly he called it a motion to recall the bill and he said that does happen not very often but it does that that's not what not objecting mr chairman the point i tried to make was that this does not have the full strength of the bill that it is a request of the committee at the chairman's request to include these amendments that it doesn't have equal standing to the bill that was report and you agreed with that but it is a legal procedure it does have standing it does have merit we are not objecting to the chairman's decision when the clerk report the  how does this motion of mr dingell affect those other two bills does it also apply to those other two bills that's the first question well i have no impact on those two bills is that correct from bill and will not be voted on the house floor as amendments but be part of your understanding that could be put on the house floor as amendments but any amendments on the house floor will be up to the whatever's permitted on the house floor will be up to the rule but the real good presented on the floor it's up to the rules committee they can handle it in a lot of different ways it's no longer what we are making to the rules committee recommendations it has a standing in similar to the bill report is out because the bill reported out when we had two other committees similar bills were bills to be reconciled by the rules committee think of this i concur i concur with your views on this is not about me what do you think about you know i concur with your view i got it the substitute amendment evon of the democratic amendments described in the motion by mr dingell this amendment was developed after the minority indicated they would seek to have numerous amendments in the  motion considered individually the amendments in the nature of the amendments in the substitute are those that the minority indicated they would support and which they would not seek individual consideration disease and amendment i represent a marquis authorizing the commissioner to use data on enrollee demographics inpatient and outpatient diagnosis and other such information as the secretary may determine is necessary in creating risk adjustment mechanisms for the exchange and a map mentioned by representative murphy requiring the secretary to attempt to attract ten percent of eligible providers to act as bundling  on two thousand and nine may continue operations with a waiver of geographic integrity rules and an amendment by representative clarifying the means by which individuals can submit information to the qualified health benefits plan including mail telephone electronically and in person a substitute amended also includes language by representative boyer which the minority and majority have reached agreement that permits nature of the substitute to the dingell motion to instruct the chairman to report to the rules committee the following amendments as agreed upon we we do support the christianson amendment to get maine's amendment the green amendment the committee if there is not a jurisdictional issue strongly encourage these amendments to be made a part of whatever the base text is that goes to the to the floor because this does have the full faith and credit of the entire committee behind behind it and i think for presidential purposes while i don't think we'll do this very often we do want members to know that if we use this procedure in the future their good work will not just be something that for show that it does have the full authority of the committee and the chairman to be included in whatever if anything goes to the floor that we support as a basis i certainly accept the gentleman's and going through this list you know certainly i support the boy or amendment which is the last one in here but the rest of them i'm having a little trouble understanding is there any reason why the authors of these amendments just couldn't g if the members of each of the amendments want to speak on it they are certainly eligible to be recognized for that purpose these are amendments that have been offered by our colleagues that are non controversial  and i respect the ranking members and you know obviously that's why we want that one in the budget neutrality is just something that if someone might just give us a little bit of what the medicare advantage senior have syllabi is all about  gentleman yield i'd be glad to i would like to point out to my good friend from florida that the democrats offered sixty amendments we have always accepted seven that's a good point we have we have operated in good faith with members in the staff we've insisted that the minority commitments that were made in order could be made in order in voted on and most of the minority amendments are not going to be voted because the members are chosen not to do so i think we're only going to offer two but on the se definition and one of the requirements is that they must have for at least one year prior to january want two thousand and thirteen and have been under a demonstration project established by the secretary which means that they would have already been in place as of january this year do you know how many plans that definition i do not know how many but we can find that information out and get it to you happy to do that my concern is that by limiting it to those who were on a demonstration and that obviously it does not include many others that maybe are doing exactly the same thing but just were not i demonstrate project stablished by the secretary my concern is that if it's if it's a good idea then why not extend it to everybody who meets the other definitions here well i think there's certainly the potential over time to expand off of the demonstration project that has been in place before the goal here was to make sure that we preserved this particular approach so that it didn't go by the boards and didn't expire which is what this is designed to do because the demonstration so far has been pretty successful in terms of aligning the service area with in effect the boundaries of a continuing care retirement community where you can explore particular management of care approaches that both deliver high quality care and achieve efficiencies with respect to cost so that was the first objective gentleman is trying to do my concern is that we may be on daily restricting those to meet the same criteria but we're simply not on a demonstration project if the gentleman has access to that information as to who would a to underscore zero zero one communications with commissioner that i mean we talked about the town meetings in august and one of the biggest concerns that i heard of my privacy you know people's concerns when they deal with the health insurance that they want to maintain their privacy so i just want to ask the  gentleman what the purpose of this is because i would be very concerned that you know for example if you come into my office and you want us to inquire of social security or anything you have to fill out a privacy form and people you know were very concerned that when we're office and a constituent request is now open to the public and i would be very concerned that that would inhibit people from even asking us to look into something and i'm only talking about members of congress now because they would be afraid that all their personal information now would be available to the public so i just i would have to oppose that i was going to ask the terry why what he seeks to accomplish with this because i think it really hinder our ability to function with  commissioner was so many powers outside of congress that i worry about the vulnerability of that position to outside pressure to rule one way or another or provide waivers senate that they'd be open to political influences from an outside group or from members of congress and i think those type of contacts should be recorded well my only concern to take back and i'll be brief  i mean we have free of information act ways of inquiring along the lines of what the gentleman is seeking it seems to me i would have to oppose it because i think that it would make it very difficult for me to operate as a member with my constituents that every time you know we made an inquiry they would be they would be concerned that you know their personal health matters would be open  organizations and individuals not just members of congress regarding any individual's or rolled in exchange plan now that seems to me undermine fraud and abuse activities by requiring all communications including with whistleblowers to be made public those with knowledge of illegal activities will be reluctant to come forward secondly it will create a great deal of paperwork unparalleled  subsidies are applied for or renewed commission will need to report on millions of contacts and communicate from individuals who have questions about their subsidies and thirdly you raised it so well there are privacy concerns for every individual involved it's highly inappropriate for congress to legislate that communications between people and their government be made public particularly when the commissioner which is the person who's going to be making the decision whether it's was blowers well now you've got an obligation to record if there's been a matter of fraud brought to the commissioner and we can gentlemen we don't require the oil companies to be disclosed when they go into the department of interior or their lead we don't require maybe we should maybe they ought to be more transparen offense mr waxman but we don't have jurisdiction over the interior and we're talking about a political entity with a great deal of power and therefore the transparency is absolutely needed you don't have to give out  this in block amendment alone amendment that authorizes the secretary to establish infant mortality pilot programs authorized the secretary to award grants to community based collaborative care networks that assist low income patient populations and access to health care services and in participating management stupak amendment that clarifies that manufactures need not pay authorizing the secretary to ward grants to certain communities to help develop integrated health care delivery systems baldwin amendment that provides for technical assistance to states to improve coordination between medicare and medicaid or dual eligibles and new quality measures for reporting related reporting relating to care for dual eligibles butterfield requires a report by the secretary on the need and cost of providing oral health care as part of the essential benefits package deal makes minor and technical changes to the position payment sunshine visions reported by the committee cast or provides grants for employer wellness programs sarbanes dingle school health clinics funded under the new grant program of twenty five eleven of the committee reported bill federally qualified for purposes of medicaid murphy establishes a novice on women's health within the office of the secretary and within the director's office act do not preempt state laws relating to disclose your payments to physicians waxman provides program integrity in the three board three forty deprogram their procedures for improving compliance by covered entities and manufacturers with program requirements alone not advised standards for qualified health benefits plans including a public option to provide for rules regarding training programs to prepare students for careers in health sciences and the raw nondiscrimination amendment provides that the act will not supersede state laws prohibiting health benefit plans or insurers from discriminating regarding participation reimbursement or related requirements against a health care provider acting with the scope within the with the scope of its license or certification under nature some of them do have controversy but they didn't appear to be so controversial that they could not be considered in blogs there are two in particular that i want to bring the committee's attention in the chairman's attention to one that i'm very supportive of and i think all the minority are supportive of is this our brain amendment on school based health clinics this amendment would would give a school based health clinics the right to  receive grants and be considered as a qualified federal health center for purposes of medicaid there are a number of school clinics in my district in terran county under the john peter smith public hospital program working with a number of the independent school districts and that that amendment is something that i think we could all agree should be supported there are two amendments to deal with drug pricing under section three forty  this to pack them in which prevents medicaid managed care organizations from double dipping so to speak that would mean to get the discount on the drug under the three forty and then get a rebate receive the discounted drug price under three forty it's my understanding that it's your intent to prevent hospitals that receive those discounted prices from getting more drugs than they have a legitimate need for but it's my understanding that the language in this amendment as currently crafted does not have that limitation to limit the amount of clarify our intent here in cases where there may be a drug shortage we're not saying that three forty to magically go to the front of the line but we are saying that manufacturers cannot send them to the back of the is that you and i both share the policy of limiting the purchase of these drugs to the apps the absolute so in a government public option plan which is the preferred measure to do this by the majority now we've learned from the embarrassingly low rates of the federal government already pays doctors under medicare and medicaid that this leads to problems of the primary problem that occurs subsidization for many from the private sector to the public sector which requires the public sector to the private sector to actually subsidize  the public sector and many doctors actually refuse to see medicare medicaid patients altogether ironically the one means by which doctors might be able to afford those on the public plan is explicitly denied in this legislation  would be to allow billing i have a letter here from the from the american medical association as you know they did support the bill they support this amendment and i'm quoting dr michael the executive vice president of the a m a adoption of this amendment would be an important step forward for patients and physicians adequate payment would incentive positions and other providers to participate in the public plan thereby ensuring insert the record into the into the letter into the record now in order to ensure that americans choosing or being forced onto a government plan will be able to see their doctor of their choice this amendment would allow doctors within reason to build their patien for the difference between what the service actually cost and what the government is willing to pay for it this is essential to ensuring that americans can access the services that they need from the doctors that they want and it will prevent the cross subsidi on phenomena from further harming insurance in the private sector and if he wishes time i'll be happy to yield to my friend from georgia member deal i thank the gentleman  believe that the amendment is very straightforward and does ensure that we will have further continue participation by physicians in the program and also that we do not continue to shift the cost of a government provide balance billing protections for patients who receive services from in network providers including mr burgess his home state of texas and there are a number of states who also provide balance billing protections for when patients get services out of network to the why do they do this because providers shouldn't be charging patients more than the rates that they agreed to when they agreed to participate in the plan's network it leaves consumers exposed to extra financial risk at a time when many are having trouble affording the premiums co payments and co insurance that they're already responsible for we keep talking about the issue of affordability and this goes directly to it this amendment in my opinion is essentially an attack on  patients as well as their families as well as the public plan private plans routinely write into their contracts that the physician may not charge one of the plans enrollees anything beyond the agreed upon amount it's an essential protection for enrollees to stay in network to know that their co pay will be what it says on the insurance card and this amendment would prohibit the public plan from pursuing the same commonsense protections so essentially would put the public plan on a severely on level playing field compared to  competitors everyone keeps saying that if we're going to have a public plan which i support should be a level playing field and i think we all agree with that even if we don't agree there should be a public plan we all agree that it should be on a level playing field and i think this changes that dramatically the public plan should have the ability to guarantee the patients don't pay more than the negotiated rate just as private plans can so i would oppose that i think it goes directly to affordability and it  it directly contrary to the idea that that the public option should have a level playing field yield to the chairman if you have an insurance plan and it has certain providers that you go to in network often insurance companies regularly insurance companies say that those providers can only charge that amount to go and add more to the patients bill what this amendment would do is that if one of the insurance companies is a public insurance company they would not be able to limit their doctors from going to the patients and asking for additional money in other who opt out of medicare it would prohibit the public plan from imposing any protection from beneficiaries from unpredictable or excessive charges providers private plans can require you stay in network and this would have meant as a member it would prohibit the public plan from pursuing those same common sense protections no read no providers going to be required to participate in the public plan that was something we worked  for the very beginning provider doesn't have to people in the public plan but we shouldn't prevent a public insurance plan from providing protection to the insured for additional charges the same way we do the same way we do to limit medicare balance building the same way private insurance limits balance billing when they have a preferred disregard that as part of the debate on this amendment back and i think general feeling back mr chairman the president the united states talking to us two weeks ago today said if you like your doctor nothing in this plan will require you to change your doctor all we are trying to do with this amendment is try to ensure that the president is good for his word because as mr shimkus points up there will be a tendency to drive out the private sector by this public option and if you like your doctor but all you've got the public option and the doctor can't afford to keep his doors open because of what the public option is reimbursing lost your doctor and we heard testimony to that effect right here in this committee a pediatrician  who came in testified to our committee and said in rural alabama my pediatric practice is now seventy percent medicaid public option and i'm having to borrow from my retirement plan to keep my doors open we are not reimbursing that pediatrician the cost of delivering the care her thirty percent private pay can offset the cost of the subsidy of the seventy percent that she's required to take in water seventy percent medicaid population as a consequence as soon as her retirement fund is exhausted which i suspect  fairly soon she will be out of business those patients will lose their doctor even though they like their doctor let me be absolutely clear i do not support the public option i do not support thirty two hundred but i am trying to preserve and protect the mad this is reduces adverse symptoms and improves quality of life when combined with education and monitoring often patients who must rely upon home oxygen services are elderly and have cerebral co morbid conditions such as dementia congestive heart failure and authorize some patients may be too ill to leave their homes while others rely on oxygen services to continue performing daily life activities patients physicians therapist and others in the home oxygen community agree that suppliers of home oxygen services do more than deliver oxygen equipment they assist patients by providing important subclinical services such as education training maintenance and ongoing monitoring the current structure of the home oxygen therapy benefit inappropriately focuses on the equipment provided rather than on the needs of beneficiaries and the necessary services provided to them not only with the new oxygen payment structure in my mehmet mirror that applied to other medicare providers but it also it would also address many of the concerns historically raised about the benefit by requiring specific covered services and data collection through c survey over the course of august i continue to work with various stakeholders including both patient and provider groups to make additional improvements to my mema which would better meet the needs of patients and provide much needed reform of the medicare home oxygen benefit specifically my members would focus on the needs of the patient by mandating a minimum set of services tied to patient needs and link patient need to reimbursement and a strong set of patient protections provide for greater cost transparency and link payment to patients eliminate the flawed thirty six month rental cap in a manner that is designed to be budget neutral based on the current medicare payments for home oxygen strengthen the medicare program integrity by and hansing the tools that medicare would have to combat rot and abuse most importantly my memet is designed to be budget neutral i would like to ask for a commitment from the chairman to try and address any outstanding issues  s i would ask you work with me to get a meeting with those so we can determine exactly how they're going about scoring this and how maybe we can resolve that issue because it's time for us to address home oxygen therapy in a much different way than we have in the past it's much different than a lever in a wheelchair a walker or a bad someone's home and it should be treated differently and that's what we're trying to do in this legislation but certainly as you well know i'd like to  ross i support your effort here doctor our oxygen people back home and understand the impact that it has on the patients i would like to just raise the issue on all durable medical goods taking this opportunity you provide us days they may be barred for a year to sell durable medical goods when they've done everything in the process and i would just encourage our committee do you work with the center so we can get those durable medical good provider certified in a timely manner so they don't lose their across this country and with your commitment i'll withdraw the amendment gentleman withdraws the amendment do you have an amendment mister mr chairman we have an agreement with you and mr green on is one of the amendments that was not on the list on either side at the end of the market but it is an amendment that you and i both agreed if we could get an agreement could be offered today and i want to thank you for your leadership and your willingness to have this considered i want to thank congressman green for negotiation and i want to thank dr burgess for his long work on this issue this is an idea that whether you're for the pending bill underlying bill that's already been reported or you support an alternative plan like we can all across has got the least transparency of almost anything that is there are a lot of reasons for that but what it means is when people decide what kind of health their plan to choose what kind of provider to go to what type of facility to to to to enter they have very little hard information on which to base that decision and this amendment if agreed to b committee and is put into the base text on the rules committee and if that passes and goes to the senate and becomes law begin to make that possible to get real transparency so that whether you believe in a market based system where consumers make the choices more and more regulatory system where regulators need information to determine what type of plans and procedures to do utilize  this amendment starts that process it's a good amendment and again mr green and mr waxman and mr burgess and myself have worked across party lines on it i think most of the mentioned between yourself mr green mr burgess of myself it's an issue that mr green is worked on for a very long time has been a champion of it because we ought to have transparency people ought to know  what what the charges are going to be if they go to a hospital they need to know what the out of pocket costs are going to be required for them to pay before they get a service from any health care provider we work closely with stand for quality a coalition of consumers unions business groups hospitals and other providers to develop a better process for quality measures fourteen forty one through fourteen forty five  have all members respond to the call the r offer an amendment which we have agreed will be debated for no more than an hour and it will then be withdrawn and then we will be available to other members who may wish to offer amendments and withdraw them we will have i'm informed by the minority a request for a roll call vote when all amendments have been disposed of i don't expect well i don't expect any further votes on any amendments that we have will be the vote on the final passage of the rogers amendment when we get to it will be debated five members will be recognized for five minutes during that period of time going back and forth so i would a call on mr space and then we'll go to mr rogers but i want members to know that the rogers and i'm not prepared at this point to place that burden on the taxpayer however i believe it's important to notice the point of this amendment under this bill we make significant cuts to medicare reimbursement rates to skilled nursing facilities while will especially feel these cuts taking the fifth largest of any state and those cuts are recommended by med pac and are part of a difficult process of tightening our belts at the federal level and at the same time we're seeing these medicare cuts we're also seeing medicaid reimbursements skilled facilities across the country being cut as states struggle with meeting medicaid obligations many providers are feeling the wrath of difficult economic times and while we must also recognize this legislation is not creating any new paying customers for nursing homes we have to ask the question of where this leaves us and those skilled nursing facilities that provide such vital services to our senior population  the nursing homes in my district are looking at this bill simply as a list of cuts with their margins continuing to shrink i fear what the impact of this bill may may be the larger issue to me is a medicaid system in need of serious review with struggling to meet their commitments at the same time the federal government takes on increasingly increasingly larger burdens i believe it's time we take a serious look at this system which is under immen strain and with that mr chairman the gentleman yield to me i want to express a great deal of concern about the problem that you would seek to address when we have skilled nursing facilities they get some reimbursement under medicare which is being proposed for reductions for their for their services and then we have for the most part nursing homes getting patients that are covered under medicare and medicaid reimburses at such a low level that the nursing homes find it very difficult to meet their costs at one time we had a lot named after former senator boren and the board and that required that the homes under medicaid be reimbursed to cover their costs and that was struck over the objection of a number of us who were at the here at the time it was it was deleted from the law in order to give the states the ability to go even less the cost of the nursing homes to give the medicaid population that are privately insured or their private patient hospitals do it all the time doctors do it all the time but nursing homes for the most part if they have almost all of their patient population  medicare and medicaid well they're facing the situation where every state is reducing the reimbursement rate because of the downturn in the economy and the shortfall in their revenues so at the time that the nursing facilities are getting reduced under medicaid by the state we're also talking about medicare reductions which may well very much be justified for medicare reimbursement but it leaves the skilled nursing facilities without the ability to shift the costs and do get paid adequately so i think we need to address as you point out the concern that medicaid is not provide the reimburse the levels that are necessary for many providers specially nursing homes but all almost all providers  to be able to see the medicaid patients and to feel that their services will be acknowledged in adequately funded i sympathise with this amendment i know it would cost an enormous amount of money and we are not ready to put that kind of money into this area at the moment but i do what express sympathy with what you're trying to do mr chairman the gentleman from space can i just  of course i just want to associate myself with the chairman's remarks in general but i've distinctly remember the night when you were so upset about the possible repeal of the bourne a memo because of your concerns about what might happen and  know how hard pressed you were to try to make sure that we retained it so i totally agree and i think this i know we can deal with it now but it needs to be addressed to move them from ohio   that crisis i would at this time withdraw the amendment gentlemen withdraws his amendment mr rogers you have an amendment that you wish to offer without objection the clerk will report the amendment then mr rogers you recognize the start of the debate for five thank you mr chairman i really don't wish to withdraw the amendment and i would certainly ask that with your careful consideration that we could actually have a vote on this amendment if you'd be so inclined to do that i know there is an arrangement i would certainly well let the gentleman before you even start your debate this is an amendment that is not germane this is an amendment that does not fit into the category of the amendments under consideration because it wasn't on file this is an amendment that i've been presented president presented to me as an amendment that the republicans basically want to use to debate the health care reform bill and under that they will consider the amendment and have the debate but this amendment is not going to be put to a vote because it is not germane it is not an amendment vote because of any person of the rules do not allow a vote on this and that it would be out of order it's a rule that you could waive or certainly if you wanted to do that you have what you have done that earlier on today but my understand we want to be helpful and as you said that was before the start of my time i would present him as recognized for five and thank you mr chairman you know there's a great quote that i i just love from ben franklin and i've heard it used a lot in a lot of different debates but he said that those who would sacrifice liberty for a little safety and security deserve neither liberty nor security and it was interesting that in the recent months you heard that tied to the quartering soldiers or d process or civil liberties and that's really not where he got started is this was before the constitution was written before the revolutionary war he was the finance chairman in pennsylvania on the state legislature and there was a group of very wealthy people from the western side of the state who came to that committee and said we think the people of philadelphia should pay for the first time ever a direct tax to the state to help us in the problem that we have in the western side of the state good idea he said and what he was trying to say is and his whole argument is that is not fair you cannot punish those people in the areas of philadelphia who are working hard and playing by the rules to pay for the few on the other side of the state for something that they should take responsibility for it was interesting because that is an ember that lived and burned pretty bright in the whole debate of who we are as the american people in the most difficult times we've had in this country we never abandon the thought that we should it's ok to punish those who are working and doing the right thing and playing by the rules and take something away from them to give it to somebody else who may or may not do that we have agreed that a safety net is a good idea so you think about the great depression over thirty percent unemployment for years the poverty level the united states was staggering but we didn't give up we didn't say you know what too hard the federal government should do it for us we didn't do that world war two and they were rationing sugar rubber tires we didn't give up and that spirit that ember of fairness on behalf of the american people has what has led to the greatest nation on the face of a because it's individuals responsibility it's people getting up every day and think i can do this better faster quicker the speed of business i can take care of my family let the government take care of something else so now we get to this point in four years and years this debate has come up the federal government has to step in and run your health care the federal government has to step up and run your health care and for years and years once the american people get a chance to look at it they say no way in heck it's not going to happen that's what you saw in august that same number that ben franklin talked about it's the same one and what they found when they read the bill what there was fifty four boards and commissions and programs to run their health care that they had to go into a government plan might affect the present your plan if you like it and if you talk to americans they found that pretty offensive the words of the federal government if you like your dentures we're going to let you keep it if you like your children we're going to let you keep it in the good of us they didn't have the right to tell us they could keep something that we so here's what we did we went through into a line by line  president's challenge just to bring us something one version of it and it's a step it's a combination of all the work that we we can control those things passionately that we can make an impact on health care for the better we can control costs we can improve access we can do all those things without the federal government stepping in and controlling two hundred seventy million people worth of health care they could even get seven hundred fifty thousand transactions right on cash for clunkers we're still fighting about it and we're going to take millions and millions of the most personal transactions you do every day in your life and turn it over the federal government that's what this bill does it's in the bill so what we did and i'm going to quickly go through just a few of these quote from the president's speech to congress for those americans who can't get insurance today because we have preexisting medical conditions we will immediately offer low cost coverage that will protect you against financial ruin a good idea mr president that's why we have had a bill that expands  state high risk pools that accept all patients and prohibits plans from imposing coverage gap federal government you don't have to be involved between me and my doctor problem solved as one big group the president ited states customers will have a greater leverage to bargain with insurance companies for better prices and quality coverage president great idea that's why for the work of members on this committee there's an association of small business plans that a law business is not because the federal government tells your chance to answer these questions in a way that millions of americans covered on health care and doesn't involve the federal government all the time in your doctor gentleman's time is expired is recognized for five i could i ask you to yield to me could i ask you to yield to me your time thank you mr chairman i just wanted to respond to mr rogers because you know you talked about liberty and i respect i think everyone here on both sides of the aisle believes in liberty and our founding fathers and what they stood for but my concern is that as time goes on we realize that the federal government has to step in when certain things are just not accomplished in the marketplace we set up medicare because seniors could not find health insurance we set up medicaid because poor people were not covered and were not able to access health care and there are times when the federal government has to step in because of the fact that you know the marketplace is simply not providing people with options and that's what this is all about today i mean we know that the number of uninsured continue to increase and so our answer is let's set up a health exchange program provide affordability through subsidies competition with a public option with the private sector creating a large if you will almost like a group plan and  you know i don't like government intervention anymore than anybody else but the bottom line is that right now the marketplace isn't working for those people who don't have insurance and increasingly it's not working for people in the individual market of the small group market and that's why we're setting it's up i think that there needs to be a recognition of the fact that the are times when the federal government has to step in not because we will love a huge bureaucracy not because we think that the federal government preclude unless there was some sort of unanimous consent agreement but if there were to be a vote i think this is an amendment that if we studied it members on both sides could support i just want to go through  wishes to have health insurance in america should have it should have the ability to get it mr rogers amendment accomplishes it does it differently it doesn't do it employer mandate individual thousand citizens who all had a very intense concern about their health care very involved in what we're doing up here very few of them have to admit mr chairman some of them wanted a government run government option but not very many if you took a vote i would say would have been well over ninety to perfect the private sector and maybe five to ten percent that wanted to or thirty two hundred talk about another thing that the president said in his bill that if you have your health insurance and you want to keep it you're the pending bill has specific cuts of over one hundred thirty billion dollars to medicare specific mr rogers does away with mr rogers amendment doesn't have those  thank you mr chairman i appreciate the ranking member walking through what's been proposed but the first question i have is has this  legislation of mr rogers has it been scored it hasn't it is not been scored all right well let me just say it's roger's come lately ok and i respect the maker of the motion  but there has not been a bill presented by our friends on the other side of the aisle relative to reforming the health care system with just a second to second let me get my stuff in and then if i have time i'll be glad to yield number two i really think that you're on the wrong side of history here because what you're saying is let's leave this to the insurers let's leave this to the insurers now there are all kinds of ideas about how to get to where we want to land in terms of cost savings a universal system and then bringing the cost down and holding them down families federal government state governments businesses no one can sustain these costs the cost increases any more but you are paid and repeat let's just stick with the insurers let's just stick with the insurers look where we are i mean talk about who's going to come between the doctor in the patient constituents that's really what this effort is about and with all due respect to the maker of the of the amendment in the motion is i think you're really on the wrong side of history  we can debate a public option i think you mischaracterize public option we've added five percent to medicare in this thing and no one is forced into it it's going to stand or fail based you are offering that is actually going to in the private sector the private sector to bring about the changes that need to be made i don't know a lot of talk about trigger ma because it doesn't cure what is what the illnesses with the with the private insurance sector today and and the costs that are associated with  it i wish you'd brought in something that was that was scored so we can see what your idea cost and and then compare and contrast but it isn't it's offered as an amendment i think that mr barton wanted  official committee reported hasn't been scored and with regard to the insurance companies the rogers amendment includes the rescission language which we opted in the last congress to prevent things that happen like happened t rogers suggest is an idea where everybody as my good friend from california just said everybody needs to have coverage regardless of preexisting conditions we shouldn't leave this debate without that happening no matter what happens dozen speakers that were broadly representative of the health care and research community every one of them talked about talked about medical liability reform they talked about more transparen president says as one big group customers will have greater leverage to bargain with insurance company for better prices and quality control coverage he was talking about creating associations cooperatives small businesses in this country individual membership association what about the realtors all the realtors get together have a cooperative for health insurance what about the quantum what about the chamber or even large large churches why not allow them this opportunity was simply the this bill you have real to go after it and if we don't eight percent will bankrupt us because eight percent of a bigger pool when you add more people into the government plan means a lot more fraud and a lot more of that gets flushed down the tubes that's in there we also stop the five hundred billion dollars in the medicare cuts that you all of proposed and thirty two hundred it's wrong we don't have to do it so there's great innovation in here as we went through and listen to the president provided him with bills but by the way these aren't bills that i just wrote last night these are all bills that have been here that have not been allowed to be a part of this debate so we put them all together addressed every one of the president's concerns and said here you go gentleman's time has expired mr  engel thank you mr chairman i would like to just very briefly talk a little bit about the health care debate you know we talk a lot about the town hall meetings and people yelling and people screaming there's been so much misinformation out there far as i'm concerned mostly from  republicans for using this for political purposes to scare people into saying they're going to lose what coverage they have and everything is going to be terrible the insurance companies they have put out misinformation they like the system just the way it is and they compete with themselves they decide what to do i have spoken with with so many people from my district and outside of my district that have been denied coverage by the insurance companies they go to an appeal process and who is sitting there appealing them the same insurance companies that denied them the right of for insurance and for medical help in the first place so i think that that thirty two hundred is tempting to correct all of that  i really think we need a robust public option and i hope the democratic leadership will put a robust public option tied to medicare out on the floor so we can we can vote on it it keeps premiums down because the insurance companies will have to compete with the public option which will be low if expect to to medicare and also it saves money i don't understand my friends on the other side who call themselves fiscal conservatives and they reject the public option the public option has been scored to save anywhere from seventy billion to one hundred twenty billion in the bill so if you're a fiscal conservative you should be for the public option if you want rates to to be kept low to help our constituents you should unclear thirty two hundred closes the donut hole for seniors to medicare beneficiaries and the raja's a substitute continues the donut hole created in the original drug bill just thirty two hundred is a long term fix to the physician payment problems in medicare and the republicans substitute is a twenty one percent fee cut for medicare physicians in two thousand and ten and these cuts threaten a physician participation and access to care and finally if you look at insurance regulation our bill h r thirty two hundred office protection from preexisting condition exclusions premium ratings on health status inadequate insurance coverage the republican substitute is the continued exposure to health underwriting arbitrary claims in niles and discrimination against sick in rowley's our bill limits on out of pocket exposure to medical cost of public and substitute continues unlimited exposure to medical costs for all our bill has a genuine competition competition on price and quality of health insurance republican substitute is simply a race to the bottom where states with the least protective laws set the rules for all plans nationally and finally h r thirty two hundred is a continuation of the strong role in regulating insurance within the state the republican substitute is not so i'm with the chairman i think it's so important that we reject this and so important that we go to the floor with a strong bill with a row the public option thank you for yelling and i will i will try to make it into a couple of questions i would like to ask mr rogers or someone from the side proposing this substitute bill  i'm very interested in the comments that many of my constituents have been bringing to my attention really over the years but focused in the last few weeks as we've met with them on this on this legislation they're concerned about their insurance policies they like the policy they have but they're very concerned about changing jobs and getting a new health insurance policy and being denied for a preexisting condition they're also  terrified but the stories that their friends and loved ones have told them about being diagnosed with a very bad condition and then being told by their insurance company that they're being dropped what is your bill do to address the real life  and that is one of many reasons why i oppose it i worked with mike rogers for years on the intelligence committee and i think we are good friends and i was struck by his opening comments about security and liberty my view are reinforcing values and if we want to achieve what the constitution requires which is the protection of life liberty and the pursuit of happiness we need a robust public role and a robust private role and that is what i think  voted against one of the amendments offered by one or two although i understand and respect mr dingell strong concerns about safety i personally support drug importation and the employee that you have to go through the federal exchange number one and number two the rescission bill which is a bipartisan bill in here to make sure that that doesn't happen and reclaiming my time i have a very different conception of thirty two hundred  you know i'm sure mr dingell would attest that we heard the same arguments when medicare was proposed thank goodness passed because now we have a program that serves so well people over sixty five years  of persons with disabilities and while i personally believe that expanding medicare for all americans would be the most effective way to go that isn't what we're doing here and i would say for medical care for those who are illegally in our country this committee had the opportunity to require verification of citizenship and thereby verify eligibility and unfortunately it was rejected the posture of this bill that will come before the rules committee from the energy and commerce committee and on fortunately from the other two committees of jurisdiction will have no requirement for verification of citizenship this is the last opportunity with the adoption of the language that is in this bill to require verification of your citizenship just as we require verification for social security and for medicare it is one of those universally accepted positions which this bill totally ignores it is interesting that in h r thirty two hundred we spend four pages saying how we're going to verify income eligibility and not a single sentence as to how we're going to verify citizenship eligibility the language that i have inserted in this bill mr rogers will clarify that issue it will give this committee the chance to say to the full house that we support the position of verification of citizenship it appears to be something the president has at least some lip service to but it is certainly something that the american public is going to pay attention to this committee deserves to reflect that interest medicare part d i just want to remind people that c b l scores h r thirty two hundred as they increase of twenty percent of premiums in medicare so not only are you going to try to close don't don't know but you're going to increase prescription drug coverage cost the seniors and my colleague from chicago is left i have great respect for we're just very different on this h r thirty two hundred creates a public option which as many of us believe and it's been stated that in ten to fifteen years there will only be one option and that will be the government option and then we move to a one payer system and one pair system only controls costs through rationing care that's why we are adamantly opposed to the public option plan it will never compete equally with the private sector so i along with the vast majority of my constituents want to reform the current system and that's the great thing of what my colleague mike rogers has done what he has done is taken the president's own words and married them with legislation not recently written this is legislation that has been proposed for numerous congresses i held up two pieces of three pieces of legislation two or which are included in the  amendment purchasing insurance across state lines to make it a competitive market larger pool and medical liability which is a huge cost for the medical liability insurance or defensive practice payments both addressed by the president not addressed by thirty two hundred i want to commend the chairman emeritus who said we should vote on this we should vote on  this and i would agree with chairman emeritus that this amendment should be voted on so we really know where people stand on these proposals that will help us bring us closer to what the president chairman it is tragic that we are now actually finally debating health care in this committee and most of my democrat colleagues have left i am particularly saddened that now that we're getting down to the merits of this debate caps has left because of i thank the ranking member in the chairman and i do support the rogers amendment and i commend the gentleman for pulling together lots of good legislation that the republicans have brought forward putting  also we have additional time that will be required to debate this amendment and why don't i do another five minutes on the democratic side and then ministers the medicare program which provides coverage for forty million seniors across the country government provides disaster relief for communities when their hard hit government is an in instrument of the people that the people use when they perceive that they need to protect themselves and through this government is going to insist for example that the health insurance industry abandon these practices which have taken advantage of people were so many years government is going to provide a public option so that people have an alternative and the public about as far from a government takeover as you can possibly be but it's an escape valve for people who feel like they've been a prisoner of the private health insurance industry that's the relief the government acting as an instrument of the people now my understanding with respect to what we're going to do people have preexisting conditions under the republicans bill will be solved by creating a permanent high risk pool creating a permanent high risk pool as the solution to that problem is a concession to the fact that the same broken health care system in place we should not be trying to design something that says let's leave it broken and just create better ways of picking up the pieces of people's lives by having some high risk pool that goes on forever what we should be trying to do which is what the democratic bill does is try to fix the underlying design of the program by reining in these private health insurance companies in the practices that they have engineered for many years so that this problem doesn't happen in the experience we all had town hall meetings as well and we heard dozens hundreds thousands of stories like this one woman in my district single mother has a very sick child losing her job and she knows what's going to happen when she goes out in the job market not to be able to find another job because a potential employer is going to look at her and her sick child and understand that that's going to cost them more money than they can bare in the new insurance cost gentleman who lost his job because he had gall bladder cancer because of his illness now taking almost every dime unemployment checks in order to pay for his cancer treatment what kind of freedom is that for that woman for that gentleman what kind of liberty is that the fact is mr starr i think very appropriately laid out for us that whether it's the public option whether it's a federally regulated insurance exchange government intervention into a very broken marketplace ad liberty adds freedom the shackles of badly run private market can be just as onerous as those placed on individuals by government i think that this approach on the republican side failure government has to step in people have jobs that meant when people worked all their lives retired they didn't have a job and they didn't have health insurance so government created medicare have now a failure of the private health system to cover everybody because if you're sick they don't want to cover you with an individual policy and not only that if you can't afford a  gingrey for two minutes mr chairman thank you and i want to point out of my colleagues that the rajah's amendment to the motion is just that mr rogers did not suggest that this was a comprehensive wonder what do they really want to answer that question is not where every american is going to be helped they don't really want to correct preexisting conditions they want to put people into a pool of high risk pool and then have them get insurance but much higher amount what about these people  pool that a higher amount of what about the people who have to go out and buy insurance and they can't afford it because the insurance companies want to put them in the higher risk area i think what we have to do is have real reform and i think the president has been pretty clear what he wants and we try to be pretty close to following what he has recommended to us his idea as he said in his campaign and he said from the very beginning of this year let's reform the health care system so we can hold down the cost of this or not to be able to keep a medicare program if the cost are going up as rapidly as possible and we're going into more and more deficit spending let's reform medicare cause but by holding our health care cause overall let's get everybody covered let's help those who can't afford it be able to buy a policy let's make sure that if they're discriminated against because of a medical condition that stop and wait to get everybody covered that's what that's what spreads the risk out it won't take that i would encourage the chairman based on what you just said and i'll stipulate to roger's amendment is not in order under the agreement that you and i have there are parts of it that are not germane to our committee so there are numerous improvement that still doesn't get us to vote on the republican side of the aisle that every republican on this committee will vote for the rogers amendment today if you allow there to be of course you will of course you'll vote for all the time to exclude people from coverage i have to tell you we just have huge differences and you think you're representing the president but i meant that you're not representing the president and i'm ready to vote for the president's bill but if he talks about aren't in here are in matter fact there's a twenty percent increase in their prescription drug premiums twenty percent there are real problems with it and here's the fundamental difference my friend said that liberty that government gives you and makes you happy i don't know what constitutional document you read that allows that to happen all of the rights of the constitution by the people of the united states and here's the difference the difference the president said thirty million people don't have health care thirty million that was his number to force two hundred seventy million people into some government structured system of providing health care that's what you're doing you're going to punish the very people who helped make america great health care and say you're the bad guys we're going to tax you well mr rogers amendment but he said he would withdraw and i'm supporting before i do that i would ask the chairman then on one last occasion and i'm i'm sure there are some agreement and there's some parliamentary procedure there's some rule but two hundred seventy million americans are waiting for the answer medical the national medical association many many more organizations including over one hundred patient advocacy organizations many of which represent individuals with disabilities and is supported by many members of th committee is also important i think in the package recommended an independent public private institute and president obama himself in his platform has said that he wanted an independent institute as well the provisions that are included you understand what you're trying to do you're trying to do a lot of number of very important things we need to make sure this is done right i want to pledge to work with you and and make sure that we adequately address the needs of population  i don't know how we got into this process and it was an amendment that was made a couple weeks i think before we got to the end of july we're prepared to discuss and debate it i helped work i thought that we want to make some changes to work out some changes on this amendment but we don't have the ability under the procedure for today to have second degree amendments we have to get your venomous consent that would mean involving a lot of different and for clarification i do not receive federal employees health benefit package and there are constituents think that we have some special program let's give them the same opportunity we have a number of federal programs including federal employees  fifteen seconds that i'm just very much opposed to the brac process and the way that the brac process operates because i think it takes away the jurisdiction of congress and i think that it is an extreme measure i think that gentleman's purposes can be achieved without switching the responsibility if you will of the congress in taking away our jurisdiction and essentially giving it to an independent commission i don't think that's the way to go and i just want to stress that gentleman withdraws his amendment as read and gentleness recognized for five minutes you mr chairman and we've been talking about the broad implications of health care reform oftentimes we forget about some of those key frontline providers who do the tasks that are critical to patients in need all across the country and yet rarely receive a lot of discussion during this health care debate this amendment deals with the essential contributions that are made by home health service you don't have lawyers and providers and making sure that they are properly reimbursed we know that home health services are used by over three point four million medicare beneficiaries annually most home health agencies in iowa rely primarily on medicare and medicaid funding to cover operating expenses they are not only a high quality but cost effective alternative to nursing home care for many people and bring significant savings to medicare by repeat reducing repeat hospitalizations today less is spent on home health then in one thousand nine hundred seven overall and on a per patient basis at the same time the quality of care has been improving through the use of better focused therapy and modern technology my med address is a concern that home health cuts proposed in the health care bill would cause access problems throughout the country meanwhile overall financial circumstances are even worse because of low medicaid payments and the virtually non existent commercial insurance payments in the home health industry if home health agencies close down with these cuts both patients and the medicare budget will suffer greatly particularly in rural states like iowa these cuts are more severe because hospital based providers often are not available in the rural counties  then they would have to make difficult decisions on whether to continue to offer a home health services at all my member targets abuses noted by the g a o and med pac and cuts payments to many high profit sectors while avoiding a payment rate for others providing time to adjust to reduce payments rather than a drastic set of reductions immediately the amendment also allows a med pac recommendation by moving a payment model toward a more we formed instead of simply rate reforms are needed to address the very wide variations in the cost of care that reflect the wide variations in population density and service delivery environments the need for home care is growing as our nation's population ages particularly for those with chronic illnesses and multiple chronic illnesses we know that home health care provides an efficient and high quality solution accessed in home health care keeps people in their community where mobility restricted family and friends can remain an important support network for that reason i ask for your consideration of this amendment but i'm also prepared to withdraw  recognize mr us now passing a health care reform that lowers cost and improves quality of care and makes access available to this so many while passing health insurance reform today i'm offering an amendment that i will hesitantly withdraw which i feel improves the quality of care for medicare beneficiaries with hearing loss and balance disorders approximately thirty one million americans experience some degree of hearing loss and that number is expected to increase to seventy eight million but by tw in addition hearing impairment is one of the most common conditions affecting older adults with approximately thirty three percent of americans aged sixty and over and forty to fifty percent of those aged seventy five and older with hearing loss currently medicare requires that beneficiaries with hearing loss or balance disorders obtain a physician referral before seeing an audiologist this amendment will allow medicare beneficiaries the option of going directly to a qualified  just as they are allowed access to a range of non physician practitioners including podiatrist optometrist clinical psychologist and physician assistants furthermore this amendment would give consumers choice without diminishing the important role of medical doctors are expanding the scope of practice audiology in addition to providing comparable coverage of many private health plans this amendment would also bring medicare in line with the policies of other federal health programs such as the federal employee health benefits program and department of veterans affairs in fact the veterans administration cost issue that has been raised by the cvo however i have many questions on how c b l arrived at their projections therefore i asked the chairman for his supporting commitment in working with me to answer such questions also asked the chairman for a support and revisiting this important legislation in the future so that we can work towards improving access to hearing care for medicare beneficiaries the gentlemen were willing to work with you on it my understanding is that you're going to withdraw it and will certainly work with you on it has a gentleman withdrawn his amendment appreciate the chairman's commitment to work with us on the c b s scoring issues as well as how we can advance means committee chairman are committed to ensuring that the veterans will have met their obligations for health insurance under the tax code and not be subject to the two point five percent tax consequence two questions  yes i agree that a smooth transition is important and i commit to working with chairman rangle to see what we can do in reference such individuals returned from active duty as a part of what the secretary of the treasury considers when developing did the minimus rule and forth mr waxman i understand your concerns about the amendment that i'd offer during the markup to protect employers of guard and reservists and i agree with you that the guard reserv notable employer penalties for not providing health insurance to their employees can you please explain the intent of h r thirty two hundred on the obligation of employers to offer or provide health insurance to their employees individuals and families are dealing with vote pending and so mr weener will now discuss his amendment and and we will not come to a vote on it then we'll return after the votes on the house floor reasons there is a conflict of interest inherent in that relationship one that doesn't protect necessarily pay more tax there is an exception that was written into the so called stark rules for in house ancillary services that would reimburse because that small gap has now turned into a giant pensive loophole through which billions of dollars each year dr that's not me saying that the blue cross blue shield recently said that thirty  all imaging procedures that are done by non radiologists are unnecessary meaning doctors who have an image machine in their office are using it thirty percent more than they should medicare spending on image performances by self reproach physicians have risen dramatically is one from fifty eight percent in two thousand to sixty four percent according to g a o american college of radiology estimates the cost of my necessary imaging resulting from self referrals is about sixteen billion dollars a year washington post recently did a story where they looked at one practice in the iowa illinois border where they found that your ologist in that practice did thirty five scans in october forty one in november fifty five in december of two thousand and five and then it went up seven hundred percent the month that they purchased their own their own scanner that they had to go ahead and pay for it's intuitive that if you believe that this conflict of interest it's intuitive that is being abused and the evidence bears it out the evidence bears out something else dangerous the amount of radiology the amount of radiation that is being pumped into people by these are necessary and expensive exams are calling real health problems a study was done that show in that one percent of all cancers are just radiation from medical imaging that is completely on the server the brayley we know amendment would ban the reimbursement for yield two minutes to the gentleman from iowa before you yield to him just one of four members that there's three three of the half minutes left on the vote on the house floor so we'll have a transcript of mr brayley's comments if you're not here to hear them directly mr brayley thank you mr chairman i'm the primary focus of this amendment is on two very important priorities reducing cost and improving patient safety every medical economists will tell you that the problem of overutilization is a big driver of health care costs and that nowhere is that area more important than diagnostic imaging services and one of the things that we're trying to do with this amendment is to try to focus sharply on the contributing factors and address them in a way that is meaningful and i think my colleagues as laid out some of those important priorities but one of the things that he didn't mention is that the serious issue of patient safety is often over overlooked because said we bought expensive machines we've got to pay them off now i understand i feel bad about that maybe we can structure this in some way to allow them to and i don't want to you know i know people have bills to pay but that can't be what animates this debate too much of the waste that we have in the system are people saying i need to do these things that are inefficient because i need to pay my bills i think that that is not the way we should make decisions and if we fail to pass as a man c m s has the right and they should require a doctor that orders a test report know that reauthorizing the title seven health workforce programs including primary care workforce training dental work force training workforce diversity and student loan repayment have been for a long time a concern of this committee i just want to thank the congressman the for raising this issue and for working with me on the provisions reflected in the bill as you know we've targeted our focus on primary care and nursing workforce to ensure that we're able to facilitate access to the primary care services that all americans need the recent salmonella and h one n one outbreaks demonstrated how strategic investments in the public health workforce are necessary to ensure we're well equipped for public health emergencies and the bill also take steps to make certain the health workforce is prepared to serve america's health needs in the twenty first century of course there are other areas in title seven that i and many members of interested in addressing and know we need to make sure that many of these programs are improved and where appropriate reauthorize and move to strike the last word general is recognized for five minutes i thank the chairman and i would like to engage in a colloquy chairman waxman thank you very much i want to thank you for your tireless work on health care reform and i know that we nation's largest insurers for information on their current laws and that information will be forthcoming to help inform the congress and the public about this important issue access to prescription drugs at the low prices offered under the three forty program in our bill i'm not offering it in committee today but i do hope to see this amendment in your legislation as it moves to the house floor this amendment would simply add  hospitals access to prescription drugs at the low prices offered under three forty program this amendment would reduce costs for these expensive treatments for the benefit of the uninsured patients treated by these facilities it's consistent with the overall goal of the three forty program which is to enable safety health care providers to purchase prescription drugs at significantly reduced prices thank you chairman waxman i hope i can count on your support while i do an inquiry about pending business on the floor tomorrow that is jurisdiction of this committee if not could be sure i have just been informed that there is going to be a special session of the rules committee t see in which it will be recommended by the speaker that a special rule be passed that allows a bill to come to the floor tomorrow dealing with the medicare part d premium which under current law is scheduled to rise i believe by two point nine percent or something like that or a magnitude that i am also told that this is an issue that would be within the jurisdiction of this committee if we were going according to regular order so i would inquire of the chair what the chair knows about this and what if any impact this committee has had on that and why we didn't have a hearing in  a markup of this bill my understanding mr barton is that it's an emergency matter because the premium actually goes up at the beginning of the siskel year which would be next wednesday or thursday and so that if we don't act on it on an emergency basis tomorrow that premium would go into effect so that's that's the reason for acting on an emergency basis tomorrow why couldn't we have held a hearing on this and mark the bill up in the month that we've been back since the august or the three weeks i mean isn't it a little demeaning to the committee that this thing comes up  apparently no absolutely no input from anybody on either side of this committee i think i think the problem stems from the co op in other words we were not aware until the actual information came out about you know what the cola would be and since i guess there was no increase in the cola you know this has an impact on senior citizens ability to pay part b premiums so if there's no cola increase now we realize that should not be any part of the premium increase that's that's you know information that was not available of the minority has we have sympathy for the issue i mean but my constituents knew about this in august town hall meetings i mean i was asked about it by my medicare constituents it's just stunning to me mr chairman that time and time again this committee is treated as cavalierly in the process is treated cavalierly as it is there is absolutely no reason mr chairman we couldn't have had a hearing in your subcommittee mr waxman chosen full committee and we to have to deal with it because we i don't want to have a negative impact on our or our constituents so i don't know that there's anything else to say other than that we feel we have to proceed now because we are up against that october first