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LIVING WITHOUT HEALTH

INSURANCE: WHY EVERY

AMERICAN NEEDS COVERAGE

HEARING

BEFORE THE

SUBCOMMITTEE ON HEALTH

OF THE

COMMITTEE ON ENERGY AND

COMMERCE

HOUSE OF REPRESENTATIVES

ONE HUNDRED TENTH CONGRESS

FIRST SESSION

APRIL 25, 2007

Serial No. 110–34

(

Printed for the use of the Committee on Energy and Commerce

energycommerce.house.gov
COMMITTEE ON ENERGY AND COMMERCE

JOHN D. DINGELL, Michigan, Chairman

HENRY A. WAXMAN, California

EDWARD J. MARKEY, Massachusetts

RICK BOUCHER, Virginia

EDOLPHUS TOWNS, New York

FRANK PALLONE, JR., New Jersey

BART GORDON, Tennessee

BOBBY L. RUSH, Illinois

ANNA G. ESHOO, California

BART STUPAK, Michigan

ELIOT L. ENGEL, New York

ALBERT R. WYNN, Maryland

GENE GREEN, Texas

DIANA DEGETTE, Colorado

Vice Chairman

LOIS CAPPS, California

MIKE DOYLE, Pennsylvania

JANE HARMAN, California

TOM ALLEN, Maine

JAN SCHAKOWSKY, Illinois

HILDA L. SOLIS, California

CHARLES A. GONZALEZ, Texas

JAY INSLEE, Washington

TAMMY BALDWIN, Wisconsin

MIKE ROSS, Arkansas

DARLENE HOOLEY, Oregon

ANTHONY D. WEINER, New York

JIM MATHESON, Utah

G.K. BUTTERFIELD, North Carolina

CHARLIE MELANCON, Louisiana

JOHN BARROW, Georgia

BARON P. HILL, Indiana

JOE BARTON, Texas

Ranking Member

RALPH M. HALL, Texas

J. DENNIS HASTERT, Illinois

FRED UPTON, Michigan

CLIFF STEARNS, Florida

NATHAN DEAL, Georgia

ED WHITFIELD, Kentucky

BARBARA CUBIN, Wyoming

JOHN SHIMKUS, Illinois

HEATHER WILSON, New Mexico

JOHN B. SHADEGG, Arizona

CHARLES W. ‘‘CHIP’’ PICKERING,

Mississippi

VITO FOSSELLA, New York

STEVE BUYER, Indiana

GEORGE RADANOVICH, California

JOSEPH R. PITTS, Pennsylvania

MARY BONO, California

GREG WALDEN, Oregon

LEE TERRY, Nebraska

MIKE FERGUSON, New Jersey

MIKE ROGERS, Michigan

SUE WILKINS MYRICK, North Carolina

JOHN SULLIVAN, Oklahoma

TIM MURPHY, Pennsylvania

MICHAEL C. BURGESS, Texas

MARSHA BLACKBURN, Tennessee

PROFESSIONAL STAFF

DENNIS B. FITZGIBBONS, Chief of Staff

GREGG A. ROTHSCHILD, Chief Counsel

SHARON E. DAVIS, Chief Clerk

BUD ALBRIGHT, Minority Staff Director

(II)
(III)

SUBCOMMITTEE ON HEALTH

FRANK PALLONE, JR., New Jersey, Chairman

HENRY A. WAXMAN, California

EDOLPHUS TOWNS, New York

BART GORDON, Tennessee

ANNA G. ESHOO, California

GENE GREEN, Texas

Vice Chairman

DIANA DEGETTE, Colorado

LOIS CAPPS, California

TOM ALLEN, Maine

TAMMY BALDWIN, Wisconsin

ELIOT L. ENGEL, New York

JAN SCHAKOWSKY, Illinois

HILDA L. SOLIS, California

MIKE ROSS, Arkansas

DARLENE HOOLEY, Oregon

ANTHONY D. WEINER, New York

JIM MATHESON, Utah

JOHN D. DINGELL, Michigan (ex officio)

NATHAN DEAL, Georgia,

Ranking Member

RALPH M. HALL, Texas

BARBARA CUBIN, Wyoming

HEATHER WILSON, New Mexico

JOHN B. SHADEGG, Arizona

STEVE BUYER, Indiana

JOSEPH R. PITTS, Pennsylvania

MIKE FERGUSON, New Jersey

MIKE ROGERS, Michigan

SUE WILKINS MYRICK, North Carolina

JOHN SULLIVAN, Oklahoma

TIM MURPHY, Pennsylvania

MICHAEL C. BURGESS, Texas

MARSHA BLACKBURN, Tennessee

JOE BARTON, Texas (ex officio)

PROFESSIONAL STAFF

BRIDGETT E. TAYLOR, Chief Health Finance Policy Advisor

ROBERT CLARK, Policy Coordinator

RYAN LONG, Minority Chief Counsel for Health

CHRISTINE HOULIHAN, Legislative Clerk

(V)

C O N T E N T S

Page

Hon. Frank Pallone, Jr, a Representative in Congress from the State of

New Jersey, opening statement .......................................................................... 1

Hon. Nathan Deal, a Representative in Congress from the State of Georgia,

opening statement ................................................................................................ 3

Hon. Gene Green, a Representative in Congress from the State of Texas,

opening statement ................................................................................................ 4

Hon. John B. Shadegg, a Representative in Congress from the State of Arizona, opening statement ...................................................................................... 5

Hon. Diana DeGette, a Representative in Congress from the State of Colorado, opening statement ...................................................................................... 7

Hon. Michael C. Burgess, a Representative in Congress from the State of

Texas, opening statement .................................................................................... 8

Hon. John D. Dingell, a Representative in Congress from the State of Michigan, opening statement ....................................................................................... 9

Hon. Heather Wilson, a Representative in Congress from the State of New

Mexico, opening statement .................................................................................. 10

Hon. Lois Capps, a Representative in Congress from the State of California,

opening statement ................................................................................................ 11

Hon. Marsha Blackburn, a Representative in Congress from the State of

Tennessee, opening statement ............................................................................ 12

Hon. Tom Allen, a Representative in Congress from the State of Maine,

opening statement ................................................................................................ 13

Hon. Joe Barton, a Representative in Congress from the State of Texas,

prepared statement .............................................................................................. 14

Hon. Anna G. Eshoo, a Representative in Congress from the State of California, opening statement ........................................................................................ 15

Prepared statement .......................................................................................... 16

Hon. Tammy Baldwin, a Representative in Congress from the State of Wisconsin, prepared statement ................................................................................. 17

Hon. Hilda L. Solis, a Representative in Congress from the State of California, prepared statement ...................................................................................... 18

WITNESSES

Hon. Thomas A. Daschle, distinguished senior fellow, Center for American

Progress ................................................................................................................ 19

Prepared statement .......................................................................................... 21

Answer to submitted question ......................................................................... 130

Michael K. Smith, secretary, Agency of Administration, State of Vermont ....... 23

Prepared statement .......................................................................................... 24

Answer to submitted question ......................................................................... 130

Gerald W. McEntee, international president, American Federation of State,

County, and Municipal Employees ..................................................................... 25

Prepared statement .......................................................................................... 27

Grace-Marie Turner, president, Galen Institute ................................................... 30

Prepared statement .......................................................................................... 31

Answer to submitted question ......................................................................... 129

Gary Rotzler, Utica, NY, on behalf of the National Cancer Society .................... 36

Prepared statement .......................................................................................... 37

Tony Montville, president and chief executive officer, Healthtek Solutions,

Incorporated .......................................................................................................... 39

Prepared statement .......................................................................................... 41

Susan Colburn, vice president, benefits, AT&T Services, Incorporated .............. 45

Prepared statement .......................................................................................... 48

Heyward D. Wiggins III, PICO National Network ............................................... 66
Page

VI

Heyward D. Wiggins III, PICO National Network—Continued

Prepared statement .......................................................................................... 67

Robert E. Moffitt, director, Center for Health Policy Studies, the Heritage

Foundation ............................................................................................................ 69

Prepared statement .......................................................................................... 71

David L. Knowlton, president and chief executive officer, New Jersey Health

Care Quality Institute ......................................................................................... 74

Prepared statement .......................................................................................... 76

Joseph R. Antos, Wilson H. Taylor scholar in health care and retirement

policy, American Enterprise Institute ................................................................ 79

Prepared statement .......................................................................................... 82

Jeanne M. Lambrew, associate professor, the George Washington University

School of Public Health and Health Services .................................................... 94

Prepared statement .......................................................................................... 95

Answer to submitted question ......................................................................... 130

SUBMITTED MATERIAL

‘‘Battery-Powered Health Insurance? Stability in Coverage of the Uninsured,’’

Pamela Farley Short and Deborah R. Graefe, Data Watch, November/December 2003, submitted by Mr. Moffitt .............................................................. 106

Daniel E. Smith and Wendy K.D. Selig, American Cancer Society, submitted

statement .............................................................................................................. 118

Sister Carol Keeham, DC, president and chief executive officer, the Catholic

Health Association of the United States, submitted statement ....................... 119

John Graham IV, president and chief executive officer, ASAE, Washington,

DC, submitted statement .................................................................................... 122

William B. Spencer, vice president, government affairs, Associated Builders

and Contractors, Incorporated, submitted statement ....................................... 125

Joseph M. Stanton, vice president, government affairs, National Association

of Home Builders, submitted statement ............................................................ 127
(1)

LIVING WITHOUT HEALTH INSURANCE: WHY

EVERY AMERICAN NEEDS COVERAGE

WEDNESDAY, APRIL 25, 2007

HOUSE OF REPRESENTATIVES, SUBCOMMITTEE ON HEALTH, COMMITTEE ON ENERGY AND COMMERCE, Washington, DC.

The subcommittee met, pursuant to call, at 10:08 a.m., in room

2123 of the Rayburn House Office Building, Hon. Frank Pallone,

Jr. (chairman) presiding.

Members present: Representatives Eshoo, Green, DeGette,

Capps, Allen, Schakowsky, Dingell, Deal, Wilson, Shadegg, Pitts,

Rogers, Burgess, Blackburn, and Barton.

Staff present: Amy Hall, Christie Houlihan, Purvee Kempf,

Bridgett Taylor, and Robert Clark.

OPENING STATEMENT OF HON. FRANK PALLONE JR., A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW JERSEY

Mr. PALLONE. I will call this hearing to order.

Today we have a hearing on ‘‘Living without Health Insurance:

Why Every American Needs Coverage.’’

This week, as many of you may know, is Cover the Uninsured

Week, and as part of our efforts to highlight the growing number

of Americans who go without health coverage, we are holding a

hearing today on the issue. The statistics, I must say, are truly

frightening. There are nearly 47 million Americans who go without

health coverage for an entire year, and that is more than the populations of Connecticut, Maine, Massachusetts, New Hampshire,

New Jersey, New York, Rhode Island and Vermont combined. Millions more experience periodic gaps in coverage over the course of

a year, and even more are considered to be underinsured.

The question is, who are these 47 million people? They really are

no different than you or I. They are hardworking American families. They go to work every day. They pay their taxes and they play

by the rules yet because of rapidly rising health care costs, insurance coverage is out of reach for many of them. As a parent and

a husband, it is hard for me to imagine the uncertainty these families must face from day to day hoping and praying that their health

holds out, and I don’t think any American family should have to

live this way.

Now, what has led to this growing problem? First and foremost,

increasing health care costs have weakened employer-sponsored insurance, which has traditionally been a reliable source of health
2

coverage for a majority of Americans. As a result, more and more

employers have been forced to shift costs to their workers, who are

in no better position to bear this grave financial burden. Alternatively, employers have begun to offer policies with less-adequate

coverage, or stopped offering health insurance benefits altogether.

Since 2000, the total number of Americans with employer-sponsored coverage has fallen dramatically. According to the Kaiser

Family Foundation, since 2000 the total number of Americans with

employer-sponsored coverage has declined from 66 percent in 2000

to 61 percent in 2004.

If it were not for our safety net system consisting of Medicaid

and SCHIP, the erosion of employer-sponsored insurance would

have had a much greater impact on the number of uninsured

Americans, and this is especially true for low-income children. But

thanks to these public health insurance programs, our Nation’s

children have largely been able to access the medical care they

need to grow up healthy. In recent years, however, the number of

uninsured children has also begun to increase, and that is why as

a first step to addressing the problem of the uninsured, we must

take every effort to strengthen our public programs which provide

health coverage to those who would otherwise be unable to access

care. Reauthorization of the Children’s Health Insurance Program,

or SCHIP, will be our first step on a path to provide every American with access to meaningful health care coverage, and it is my

hope that today’s hearing will reemphasize the need for a strong

and comprehensive SCHIP program.

I know, however, that not everyone necessarily agrees with me.

For instance, the President and many of my Republican friends in

Congress have proposed to reduce payments to States that cover

children above 200 percent of the Federal poverty line. Similarly,

there are proposals that would further cut Medicaid spending,

which provides health care services to millions more low-income

families, and this would undoubtedly result in the loss of health

care coverage for our most vulnerable citizens. It strikes me as

both illogical and even immoral for anyone to suggest that we move

in a direction that would actually increase the number of Americans without health coverage.

But strengthening our public programs is only part of the solution. We must also look at private insurance markets and how to

increase access, adequacy and affordability. Unfortunately, I do not

believe that the administration’s proposal to tax the health care

benefits of hardworking Americans would achieve any of these

goals. Instead, the President’s plan would take a bad situation and

make it substantially worse by taxing Americans who have worked

hard to secure good health insurance coverage in order to subsidize

less generous policies in the volatile non-group market.

Now, we certainly have to look for more creative ideas. The

States, as you know, have been making strides and they have been

experimenting with new policies on how to achieve universal health

coverage. From Massachusetts to California to my home State of

New Jersey, States have been taking it upon themselves to develop

new ways to provide their citizens with the means to afford and access health coverage. While I am eager to learn more about what

is going on in the States, and we will today, their efforts do not
3

mean that the Federal Government has been absolved of its duty

to address the situation also.

In the end, I am not telling you anything new here. We have had

a growing problem with the uninsured for quite some time now in

large part due to what I view as the failures of President Bush and

some Republican policies designed to address this issue, but I think

there is now a bipartisan momentum building behind efforts to

tackle this problem, and I am looking forward to hearing from our

witnesses today and learning from them on how we might achieve

this goal.

I now recognize our ranking member, Mr. Deal, for 5 minutes for

the purposes of making an opening statement.

OPENING STATEMENT OF HON. NATHAN DEAL, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF GEORGIA

Mr. DEAL. Thank you, Mr. Chairman.

I think we all agree that one of the biggest problems facing our

health care delivery system is the growing number of uninsured

and underinsured Americans. In almost every year since 1989, the

number of uninsured has increased. Continued growth of this population is not only unsustainable, it is unacceptable. I believe that

members on either side of the aisle here would not dispute that we

must address the problem in this committee of the uninsured.

However, the composition of the uninsured in this country highlights the reality that the simple expansion of public programs and

provision of government-dictated health care will not properly and

efficiently solve the problem of the uninsured.

According to a recent study, nearly a quarter of the uninsured

population was eligible for public coverage but were simply not enrolled. Additionally, approximately 8.8 million, or another 20 percent of the uninsured could probably afford coverage but remained

uninsured. These statistics indicate this problem goes beyond eligibility or affordability and reforms focused only on the expansion of

eligibility criteria will fall short of providing coverage for every

American.

In the meantime, proposals which expand Government programs

like Medicaid or Medicare to cover the uninsured will exacerbate

existing struggles with these programs. The financial burden on

State and Federal budgets will increase dramatically and it is

shortsighted to assume the sustainability of our current programs

will be improved by the expansion of eligibility to even greater populations, especially when the Medicare trustees reminded us on

Monday of the rapid growth of Medicare spending, estimating that

the Medicare Part A trust fund will be exhausted in 12 short years.

To me, the growing number of uninsured stems from a broken

health care system of soaring costs and limited efficiency. If we

truly want to address the complex problem of the uninsured, we

must consider broad reform of the health care industry in this

country. As a guiding principle, I believe we must reduce the cost

and increase the overall quality of our health care delivery system.

The high cost of insurance has led to a downward spiral as the uninsured population only makes coverage expensive and in turn

making it more difficult for the uninsured to buy coverage. This is

why I am convinced that we must focus on lowering health care
4

costs which would not only help cover the uninsured but make our

existing programs more sustainable.

There is a long list of reforms which could help transform our

health care delivery system and in turn provide coverage for the

uninsured, improving health information technology and the creation of an electronic system to track medical records will sharply

reduce the number of medical errors and help eliminate inefficiencies and waste in the system, thereby lowering costs. State insurance mandates drive up the cost of purchasing health insurance

and should be addressed. Moreover, we should consider allowing

patients to purchase insurance from other States to find the plans

that best fit their needs. Cost growth could be addressed by medical liability reform, which would address the issue of wasteful practice of defensive medicine and the astronomical cost of medical malpractice insurance.

This list is by no means complete but it indicates the type of

broader reforms which would begin to heal our health care system.

I would hope that the growing uninsured population would focus

our attention on broad-based reforms which address many of the

underlying problems in our health care system and allow patients,

not the Government, to control the system.

I yield back my time, Mr. Chairman.

Mr. PALLONE. Thank you, Mr. Deal, and we will continue with

opening statements. Next is our vice chair, Mr. Green.

OPENING STATEMENT OF HON. GENE GREEN, A

REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS

Mr. GREEN. Thank you, Mr. Chairman, and following our ranking member, I have to admit, I come from the State of Texas and

we have some of the harshest medical liability laws in the country

and yet we also have some of the highest percentage of uninsured

in the country, so I don’t know if it is a combination of us needing

to do more with malpractice legislation on the national level because the States typically are taking care of it, but we still a lot

of uninsured, I think the highest percentage in the country.

Mr. Chairman, I appreciate the hearing on the important health

issue. We couldn’t ask for a better hearing topic for this week as

we recognize ‘‘Cover the Uninsured Week’’ and examine ways to

improve health insurance coverage levels across the country. More

than 46 million Americans live without health insurance despite

the fact that this country spends more money on health care as a

percentage of GDP than most industrialized nations. Poll after poll

indicates that Americans view health insurance, health care, and

access to health insurance as a top priority as well as it should be

since everyone ends up paying for the uninsured one way or the

other. With less access to care, the uninsured are less likely to seek

preventative care and only get care once their health problems

reach emergency proportions. In fact, nearly 50 percent of the uninsured have postponed seeking health care because they can’t afford

it. Only 15 percent of individuals with health insurance have postponed care for this reason. The difference can literally be life or

death.

Unfortunately, the state of health insurance in Texas is worse

than almost anywhere else in the country. Twenty-four percent of
5

our Texans are uninsured compared to 16 percent for all Americans. Despite programs like Medicaid and SCHIP, the situation for

Texas children is not much better with 21 percent of all Texas children currently living without health insurance as compared to 11

percent nationwide. Everyone can agree that something must be

done to stem the tide of the uninsured yet it is important that we

put in place policies that not only increase the number of Americans with health insurance but also ensure they have a quality of

comprehensive insurance.

Make no mistake about it though, health savings accounts and

association health plans are not the magic answer. The success of

insurance plan health insurance is that you spread the risk. However, both the HSA and the AHP models would separate out the

healthy and the wealthy, leaving sicker and poor Americans to fend

for themselves in an individual health insurance market that already is out of reach for most low-income Americans. It is not the

way to ensure Americans are healthy and productive members of

our society.

We do need assistance for small businesses who want to offer

health insurance to their employees yet find themselves doing their

best to meet payroll and monthly expenses. Again, Texas is a

small-business State yet only 28 percent of our Texas small businesses with less than 50 employees offer insurance. I am glad to

hear that our colleague from Maine will be introducing the Small

Business Health Plans Act to create small-business health employer plan that offers small-business employees adequate coverage

and benefits, and without question, the SCHIP reauthorization offers us our best opportunity this year for increasing the level of

health insurance coverage in this country. With two-thirds of the

uninsured children in the country eligible for SCHIP that are not

enrolled, we should do all we can to expand the program and dismantle many of the bureaucratic hurdles that are barriers that

serve to suppress the enrollment in this important program. I look

forward to working with the chairman and our committee to ensure

that all low-income children have access to coverage under SCHIP

as we move through the reauthorization process.

I want to thank our witnesses, today, Mr. Chairman. We have

a great panel, a number of panels, and particularly the first panel,

and with that I will yield back my time.

Mr. PALLONE. Thank you, Mr. Green.

I recognize the gentleman from Arizona, Mr. Shadegg.

OPENING STATEMENT OF HON. JOHN B. SHADEGG, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF ARIZONA

Mr. SHADEGG. Thank you, Mr. Chairman, and thank you for

holding this hearing.

I worked on health care reform my entire tenure in the United

States Congress. Indeed, I dropped my first bill to address the

issue of the uninsured in 1998, just 2 years after entering this

body. I believe this is a serious problem confronting our Nation but

I believe it is one that is deeply misunderstood. I think indeed it

can be broken down into a simple matrix. Do we put patients in

charge of their health care or do we leave third parties in charge

of their health care? The last 50 years, we as a Nation have pur-
6

sued a policy that said we are not going to empower patients, we

are going to empower third parties, namely employers, and so the

decisions about health care made for virtually all Americans today

are not made by the patients themselves, we decided we cannot

trust them to make health care decisions. We have put the power

to make the decisions about their health care in the hands of some

third party. Who is that third party under the current scheme?

That third party under the current scheme is a corporate manager,

someone who does not consume the service, someone who largely

does not know the individual to whom the service is being rendered, someone who markets and takes products and bids from insurance companies, from doctors and from hospitals without even

knowing who they are going to provide the service to, and now we

are shocked that that system doesn’t work.

In 1998, I introduced the Patients’ Health Care Choice Act, now

called the Patients Health Care Reform Act, to put patients back

in charge of health care, and we certainly can do that and it is time

that we should do that. We trust Americans to make their own decisions about their auto insurance, about their homeowner’s insurance, about their life insurance, about thousands of decisions in

their lives. We give them choices in every grocery store of hundreds

of products to pick from but when it comes to health insurance, we

tell them you are not bright enough to make this decision, that

right now your employer will make those decisions for you, and

some in this room will advocate we should have the Government

make that decision. If you want to know what is wrong with socialized medicine, which is what is being advocated as the next step,

you don’t have to go to England, you don’t have to go to Canada

to see the failures of either of those programs, go to Walter Reed.

You will discover a campus of people enrolled in a Government

health care program and the Government couldn’t even keep track

of them with them living on the campus. Those soldiers did not

have choice in health care. They could not pick their doctor, they

could not pick the facility where they were treated. They were

trapped and they were lost and Government failed them. I understand that those who advocate socialized medicine believe it is a

better answer and are sincere but I suggest they are sincerely

wrong.

What we can do is empower patients to make their own choice.

How do you do that? The bill I introduced would give every single

American a tax credit to buy health insurance. We decided as a Nation long ago that no one should go without basic health care in

this country and yet we don’t provide them the mechanisms to do

that. My bill not only gives a tax credit to every American to buy

health insurance and to make their own choices, it is a refundable

bill. That is to say, for every American and the 44 million we are

now currently worried about who are uninsured, it would actually

give them cash to go buy a health insurance policy that meets their

needs. This is not a complicated debate. It is a simple debate. Do

we want to move from one third-party payer, corporate America

that is not making the right decisions and is wasting lots of money

and running up the cost, to another third-party payer, the Government, or do we want to empower patients to make choices for

themselves and allow them to keep any money they save and in-
7

vest it and the tax save mechanism to pay for future health care

bills?

Mr. Chairman, I am glad you are holding this hearing. I hope

that we will bring some rationality to this debate.

Mr. PALLONE. Thank you.

Next is the gentle woman from Colorado, Ms. DeGette.

OPENING STATEMENT OF HON. DIANA DEGETTE, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF COLORADO

Ms. DEGETTE. Thank you very much, Mr. Chairman. I am

pleased we are having this hearing during the ‘‘Cover the Uninsured Week.’’

Throughout the world, United States health care is considered to

be the best. We have the most advanced medical technology, the

most highly trained medical professionals and institutes and centers dedicated to finding cures for countless diseases. But at the

same time, as you mentioned, Mr. Chairman, the United States

has about 47 million uninsured including 9 million children. Each

day throughout our country, emergency departments are overwhelmed as they serve both those with critical needs and those

who simply have no place else to turn for basic medical care. In the

wealthiest country in the world, we have children who are unable

to get the basic care they need to grow up to be productive and

healthy. This is simply not acceptable.

In addition to the medical problems resulting from the large

number of uninsured, our country also faces financial challenges.

Our inability to create a sustainable health care model in this

country is dramatically impeding our ability to compete in the global marketplace. Over $1,700 of every car built by General Motors

goes to providing health insurance to employees, retirees and their

dependents, and just today it was announced that Toyota, who

pays a fraction of the cost of GM, just took over as the No. 1 car

manufacturer in the world. If we are going to continue to be an economic leader, we have to have a health care system that doesn’t

hamstring our businesses, particularly our small employers. We

really need to have real health care reform.

To that end, I think that the first step towards covering the uninsured is to provide health care access for all children. The fact

of the matter is, children by and large are the easiest and cheapest

people to provide adequate health care for. Unlike older Americans,

who have a number of health conditions, most children only need

well-child visits and basic dental care to deal with common maladies. However, if those minor problems like an ear infection go untreated, they can develop into something much more serious and

result in a hospital stay or worse. When we work on reauthorizing

SCHIP, I think we have to meet three goals. Number one, we have

to have sufficient resources so all children can be enrolled. Second,

we need to have outreach to allow the States to enroll the 6 million

kids who are eligible for SCHIP but not enrolled. And finally, we

need to make sure that it is appropriately designed for all of the

kids who are eligible. If we achieve these goals, Mr. Chairman,

children will go to their doctor for an ear infection, not to the emergency room with pneumonia.
8

I look forward to working with you on reauthorization of this important bill and all of the health care challenges we have facing us

in this committee.

Thank you.

Mr. PALLONE. Thank you.

Dr. Burgess, 3 minutes.

OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A

REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS

Mr. BURGESS. Thank you, Mr. Chairman, and I will try to go

fast.

Once again, we are having a hearing where I am a little mystified. We don’t have an insurance company or a doctor on the

panel but I do appreciate the panelists who are here today. We

seem to be preoccupied with the details of health insurance rather

than the access to care. Mr. Green is quite right. There are a large

number of uninsured in Texas but I also know that many of the

uninsured get top-notch care. They did certainly during my residency at Parkland Hospital and during my over two decades in private practice, sometimes as frequently as every other night. Never

less frequent than once a week I would provide care to unassigned

patients who came to my hospital.

A little history. During World War II, the country imposed wage

and price controls in order to deal with shortages and prevent inflation. Companies began offering health insurance in order to recruit employees and the courts ruled that health insurance did not

have to be taxable. The economic boom following the war led to

widespread adoption of this practice and we became entrenched

with a system that is largely employer-based. By not taxing health

insurance as income, the Federal Government has encouraged it, in

fact subsidized it. Europe’s monolithic system grew out of the battlefields where they were largely vanquished or even victorious,

their economies were in tatters. In order to avert a humanitarian

crisis, a monolithic system needed to be stood up quickly in order

to provide care in that environment.

But a lot has changed since the 1940’s. According to the Bureau

of Labor Statistics, the average American holds 10 jobs between

ages 18 and 40. While employer-based health care has provided excellent care for the majority of Americans for many years, it doesn’t

travel well. It does not provide the health security that Americans

need and want in an increasingly mobile society. For those who

suggest more Government regulation, even to the point of a singlepayer system, this is troubling. One of our witnesses today will talk

about the problems that he has had. It seems that in 1993 the

State of New York imposed community rating and guaranteedissue laws on the individual market. Insurance prices jumped between 20 and 60 percent. How in the world was that individual

supposed to find health insurance when the Government, in a misguided attempt, had driven prices up like that? Chairman Pallone

would describe that as immoral. The President has proposed that

we give people who are trying to buy health insurance on their own

the same tax advantage. It is actually a relatively small change.

The average family pays insurance worth about $11,000 per year.

By making private health insurance affordable and easily avail-
9

able, we can create a system that is flexible and personalized in

ways that a government-run system never could be.

The American health system in general has no shortage of critics

home and abroad but it is the American system that stands at the

forefront of innovation and new technology, precisely the types of

system-wide changes that are going to be necessary to efficiently

and effectively provide care for America’s seniors in the future.

Tyler Cohen, writing in the New York Times last October, ‘‘When

it comes to medical innovation, the United States is the world leader. In the past 10 years, 12 Nobel Prizes in medicine have gone to

American-born scientists working in the United States, three to foreign-born scientists working in the United States, and just seven

have gone to researchers out of the country.’’ He goes on to point

out that five of the six most important medical innovations in the

past 25 years have been developed within and because of the American system. The fact is, the United States is not Europe. American

patients are accustomed to wide choices when it comes to hospitals,

physicians and pharmaceuticals. Because our experience is unique

and different from other countries, the difference should be acknowledged and embraced when reforming either the public or private health insurance programs.

I certainly look forward to hearing from our witnesses today and

I yield back the balance of my time, Mr. Chairman.

Mr. PALLONE. Thank you.

I now recognize the chairman of our full committee, Mr. Dingell.

OPENING STATEMENT OF HON. JOHN D. DINGELL, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF MICHIGAN

Chairman DINGELL. Thank you, Mr. Chairman. I commend you,

Mr. Chairman, for holding this hearing and thank you for the good

work that you are doing here on behalf of the people. Mr. Chairman, we have before us a great opportunity, an opportunity to

move forward with legislation to address concerns that every American has.

I want to express my thanks to all of the witnesses for joining

us today. We have a distinguished panel of witnesses as we observe

the annual week of the uninsured, some 46 or 47 million of them.

Unfortunately, during the past decade this conversation has not

prodded the Congress to act on even incremental solutions but beyond that, as a Nation it seems we haven’t come to a consensus on

the need for universal coverage in this country, something which

curiously not only American labor but American business and ordinary American citizens seem to understand is desperately needed.

I want to express my personal thanks to our former colleague

and dear friend, Mr. Daschle, for being here this morning. He is

a valuable leader on all kinds of important issues and we are grateful to him for not only his presence but for what he does, and I

want to express my personal welcome and gratitude to my dear

friend, Mr. Gerald McEntee, for being here this morning. He has

been a great leader for not only labor but for all Americans and not

only in health care but in all kinds of important concerns.

Eighty percent of Americans who are not covered by health insurance come from working families. It is interesting to note that
10

a prodigious erosion of employer-sponsored coverage threatens

more coverage of Americans every day. Total annual health insurance programs now exceed the annual salary for a full-time minimum-wage worker. Medical debt is the cause of more than 50 percent of bankruptcy each year in this country, and worst of all,

18,000 annual debts are attributable to the lack of health insurance and failure to provide adequate access to care. We live in a

country that spends $1.9 trillion a year on health care. This is 16

percent of our American gross domestic product. We have some of

the best medical institutions, finest doctors and the best practices

in the world but we rank 22d in average life expectancy and 25th

in infant mortality. To be uninsured means getting fewer and less

appropriate medical services, to not get treatment when needed

and to not be able to have access to preventive care at a time when

it could save lives or make lives much better for the people, and

it means huge risks for people, especially children. It means health

care providers do not have a reliable source of reimbursement for

their services and those who treat high numbers of uncompensatedcare patients are at risk of closing, leaving communities with a

threadbare safety net to care for these uninsured people. The uninsured weaken a productive workforce and cost those with employersponsored health insurance an average of $922 more each year.

My dear old dad introduced legislation that would provide national universal health insurance to all Americans during his years

in Congress, and I have kept the commitment to the uninsured, introducing H.R. 15 each Congress as well. In addition, today I will

be reintroducing the Medicare for All Act with my good friend, Senator Kennedy. This bill brings the promise of a quality, affordable

health insurance program to all Americans.

This year I note is the 10th anniversary of the State Children’s

Health Insurance Program. It is also the end of that program unless we in the Congress authorize the Act again. Before us are two

important tasks that will ensure that health care is adequate and

available to all Americans. It is time for action, and I look forward

to today’s hearing on this important subject, and I look forward to

seeing to it that your leadership on this matter, Mr. Chairman,

moves us forward towards a desperately important national goal.

Thank you.

Mr. PALLONE. Thank you, Chairman Dingell.

I next recognize the gentleman from Pennsylvania, Mr. Pitts.

Mr. PITTS. Mr. Chairman, I waive.

Mr. PALLONE. And then we go to the gentle woman from New

Mexico, Mrs. Wilson.

OPENING STATEMENT OF HON. HEATHER WILSON, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW MEXICO

Mrs. WILSON. Thank you, Mr. Chairman. I appreciate your holding this hearing and I thank the witnesses who come here today.

New Mexico faces a huge challenge with respect to the uninsured, and in New Mexico 21 percent of our population and 18 percent of our children are uninsured, making us rank 49th in the

country. Only Texas has more uninsured citizens than New Mexico

does. A lack of insurance no doubt has an impact on the lives of
11

the uninsured, and I am sure several of our witnesses today are

going to testify to that fact, that there is a delay in access to care,

that health outcomes are worse and generally those who do not

have insurance are not in as good of health as those who do have

insurance.

But there are also impacts on our health care system. In New

Mexico, the fact that we have so many folks who are uninsured

puts a burden on the health care system for others. One of the

things that we have the most difficult time with in New Mexico is

attracting and keeping health professionals in the State, particularly oncologists and neurologists and trauma surgeons. Part of it

is that we come from a rural State but there is also clearly the opportunity to make more elsewhere where the rates of insurance are

higher. The uninsured have higher rates of using emergency rooms,

of uncompensated care, of driving up costs in the health care system elsewhere for those who do have insurance and hence making

health insurance less affordable for those who still have it.

I believe very strongly that we have to start with the children

and reauthorize the SCHIP program this year. That will give us an

opportunity to relook at this program, how well it has worked, because in States like New Mexico, frankly, it has not worked very

well. New Mexico, with a very high rate of uninsured children, has

year after year had to turn money back to the Federal Government

because this program was not set up in a way that New Mexico can

take advantage of it. We need to fix that so that States that do

have a high percentage of children who are uninsured have the

flexibility to use those Federal funds.

We have a report coming out just this week in New Mexico that

is going to make some recommendations to our State government

on an approach to covering the uninsured and in many cases States

have taken the lead and been the laboratories for innovation and

ideas. I don’t believe that we will have a single point Federal solution for health insurance and for the uninsured, nor should we. I

think one of the strengths of our system in America is that we have

a variety of options. We can all agree that covering the uninsured

and access to effective care is a priority. We may have disagreements on how best to accomplish that goal.

I have supported a variety of things: tax credits for the uninsured, association health plans, health savings accounts, the

SCHIP program and a strong supporter of Medicaid, but we need

to make sure that these funding mechanisms also put the priority

on improving the health of the people who depend upon it, and too

often we have a system that pays for episodes of illness rather than

focusing on improving the health status of low-income Americans

who depend upon it. I look forward to hearing new ideas today,

sharing those ideas and bringing those ideas to reality.

Thank you, Mr. Chairman.

Mr. PALLONE. Thank you.

Next is Mrs. Capps.

OPENING STATEMENT OF HON. LOIS CAPPS, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF CALIFORNIA

Mrs. CAPPS. Yes, this is Cover the Uninsured Week and I thank

you, Chairman Pallone, for holding this very important hearing.
12

As we are going to hear over and over again today, the 46 million

Americans that are currently uninsured is resonating across this

Nation. My constituents understand that this Nation pays more for

health care than any other nation in the world and yet its outcomes are among the least of the developed nations. This translates

into their lives personally, and taxpayers have the right to be asking why this happened. We know the lack of access to affordable

health coverage means delaying or even avoiding important medical care.

As a nurse I have a responsibility to provide the best possible

care I can to my patients. As a Member of Congress, I translate

this into a responsibility to find ways for all of my constituents and

really all Americans to access the best possible care. This administration has ignored our Nation’s uninsured. Instead of supporting

initiatives that would expand coverage, we find the White House

promoting risky health savings accounts and association health

plans. These would pave the way to diminish, not improve, health

coverage for Americans. Congress must act now to expand access

to health coverage. We must do it in a way that promotes primary

and preventive health care. I am proud to be a cosponsor of the

Health Partnership Through Creative Federalism Act introduced

by our colleague, Tammy Baldwin. Unfortunately, our country has

dug itself in a hole so deep that I am afraid there isn’t one simple

solution to the puzzle of covering the uninsured. However, it has

been encouraging to watch as individual States begin to take their

own initiatives to improve health coverage for their residents and

I think we need to be creative just as the bill proposes because

there are multiple ways in which the Federal Government can

partner with States to devise programs that are best fitted for different populations.

As a Federal representative, I pledge myself to improving health

access for all citizens but I think it is important for us to look more

closely at the models being talked about and even implemented in

different States. In California, State Senator Sheila Kuehl has introduced a bill to provide coverage for all of our State’s residents

through a State health insurance plan. What I especially like about

it is that it relies upon regional directors who can tailor this program to meet local population’s needs. So again, I think it is really

so important that we continue this conversation here and really

take the proactive steps to encourage engagement by Congress with

the State and local governments to improve health care access for

all.

I look forward to the testimony of our witnesses, and I yield back

the balance of my time.

Mr. PALLONE. Thank you.

The gentle woman from Tennessee.

OPENING STATEMENT OF HON. MARSHA BLACKBURN, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF TENNESSEE

Mrs. BLACKBURN. Thank you, Mr. Chairman. I appreciate that

and I appreciate our witnesses taking the time to be here and to

talk about the uninsured and what we can do about the situation,

and I hope we are going to, Mr. Chairman, look at things from both
13

the private sector and the public sector and the solutions that are

out there because one of the things that we have learned is that

there is a right way and a wrong way to go about approaching this

issue.

Now, in my home State of Tennessee, we have a program called

Tenn Care, and I think everybody knows right now and has

learned through the past many years, the past decade, this came

about because they needed a place to test Hillary Clinton’s health

care, so a deal was struck. It came to Tennessee. Well, let me tell

you something. Tenn Care at this point in time is over 30 percent

of the State’s budget. It is making it very difficult for the State to

have ends meet. They have had to go in under a Democrat Governor now and restructure the program because guess what? They

cannot afford it. So when I grew up in my little hometown, there

was a used car dealer. He had a sign up at this dealership that

said ‘‘We tote the note.’’ When I was a kid, I used to ask my dad

what does that sign, ‘‘we tote the note’’ mean, and my dad said

somebody has to help you pay for this. Well, that same lesson applies to health care when we look at health care and health care

programs. Somebody is going to pay, so I hope, Mr. Chairman, that

today we will talk a little bit about how we make the system fair,

how do we make it fair for American taxpayers, how do we make

it fair for the uninsured. I would also like for us to talk about how

we encourage people to make health care a personal priority and

see them take the responsibility that is necessary when they have

access to a program to be a good steward of that opportunity. That

has been one of our big problems in Tennessee, is making certain

that everyone that has that wonderful opportunity was a good

steward of that opportunity, and how do we make certain that this

is affordable for all of our citizens because our goals should be preserving access to affordable health care. In Tennessee, that is my

goal. I hope that we as a nation will say how do we work together

to make certain that everyone has access to affordable health care.

Thank you, and I yield the balance of my time.

Mr. PALLONE. Thank you.

The gentleman from Maine, Mr. Allen.

OPENING STATEMENT OF HON. TOM ALLEN, A

REPRESENTATIVE IN CONGRESS FROM THE STATE OF MAINE

Mr. ALLEN. Mr. Chairman, thank you for convening this hearing

today on the growing number of the uninsured in America.

The erosion of employer-sponsored health care is contributing to

the growing ranks of the uninsured. Employer-sponsored health insurance provides coverage for 160 million Americans including

nearly three of every five of the non-elderly. However, the percentage of firms offering health benefits to their employees has fallen

significantly from 69 percent to 60 percent just in the last 5 years.

Small businesses in particular are struggling to provide health insurance for their workers. According to a recent Kaiser Family

Foundation survey, the smallest firms are the least likely to offer

health insurance. Only 48 percent of firms with 3 to 9 workers offer

coverage compared to 73 percent of firms with 10 to 24 workers

and 87 percent of firms with 25 to 49 workers. In stark contrast,

over 90 percent of firms with 50 or more employees offer health in-
14

surance coverage. Small businesses have higher administrative

costs, fewer people over whom to spread the risk of catastrophic

costs, and they lack the purchasing power of large firms to negotiate with insurers. Because health care coverage is especially costly for small businesses, their employees make up a large proportion

of the Nation’s uninsured individuals.

Tomorrow I am introducing my Small Business Health Plans

Act, which would establish a health benefits program for businesses with up to 50 employees. Under the bill, small businesses,

their workers and the self-employed would be provided a choice of

at least two health plans that are comparable to the insurance coverage currently available to Federal employees. Premium assistance would be available for smaller businesses and lower-wage

workers. Insurance companies would be eligible for Federal reinsurance coverage up to 75 percent of costs for catastrophic cases.

My bill would improve the integrity of the health insurance market

and protect individuals and families facing unexpected medical expenses. It would lower costs and improve quality by encouraging

integration of health information technology tools, better management of chronic illness, a focus on disease prevention, and reliance

on evidence-based medicine. These policies would provide guaranteed quality coverage at affordable rates to small businesses and

their workers without preempting State requirements. I invite my

colleagues to join me in cosponsoring this legislation.

I do want to welcome Senator Daschle and all the panelists

today. I look forward to hearing your testimony, and I yield back

the balance of my time.

Mr. PALLONE. Thank you.

Next is the ranking member of the full committee, Mr. Barton.

Mr. BARTON. Mr. Chairman, I will submit my opening statement

for the record and reserve my time for questions. I want to welcome the panel but also especially the former majority leader, who

I think was in the House before he went to the Senate. So it is good

to have you back and I appreciate the many courtesies that you

have extended to me when you were the majority leader in the

United States Senate. It is good to have you in the House.

[The prepared statement of Mr. Barton follows:]

PREPARED STATEMENT OF HON. JOE BARTON, A REPRESENTATIVE IN CONGRESS FROM

THE STATE OF TEXAS

Thank you Mr. Chairman,

I commend you for holding this hearing on the important topic of the uninsured.

I know there have been several proposals to help address this issue including the

President’s recent proposal. The President has proposed a standard deduction for

health insurance as a reform of the Tax Code to make private health insurance

more affordable and to level the playing field so those who buy health insurance

on their own get the same tax advantage as those who get health insurance through

their jobs. For those who still can’t afford coverage, the President’s Affordable

Choices Initiative will help eligible States assist their low-income and hard-to-insure

citizens in purchasing private health insurance. I’m sorry to read in the news that

the Democratic majority already has declared these proposals dead on arrival without even conducting a hearing.

Many of us think it is important to look to ideas that go beyond bureaucracy and

employ consumer choice, competition, and accountability for value. Socialized medicine is notoriously bad at determining the right price for services. Socialized medicine doesn’t innovate and it doesn’t explain itself to either patients or payers. Those

types of Government systems lead to mediocrity in health care and create a burden
15

on private sector systems. Not every disease requires another program run by a centralized bureaucracy with pricing by politics.

Our two big programs—Medicare and Medicaid—have enormous budget problems.

They’ve dominated the health discussions in Washington for decades, and it’s a good

bet that people will be still sitting in these hearing rooms, still trying to get it right

long after all of us are gone.

We also need to realize that every Government increases the cost of health care

and along with it, the cost of insurance. Each new, confusing regulatory regime that

politicians in Washington load on the backs of employers, workers, insurers and doctors is one more reason for companies to throw up their hands and stop providing

health insurance.

As we continue to look at the uninsured, it is obvious to most people that the

right solution will give people the ability to choose what’s right for them in the everchanging landscape of medical treatments and preventive services. Will 80-year-olds

opt for pregnancy coverage? Only if the Government is involved.

If we can’t get it right, Federal policy will continue to stifle innovation, reduce

private sector coverage, and reduce the incentives for quality care while increasing

costs and the bureaucracy.

On Monday, the Medicare Board of Trustees released their annual report on the

financial status of the program. The overarching theme is that entitlement spending

is still growing so fast that it is outrunning growth in the U.S. economy. The good

news in the Medicare report is the cost estimates for the Part D program continue

to decline, and that’s thanks to consumer empowerment and competition.

As we examine options to increase the affordability of health care coverage we

should not be in a race to see how many people we can lure into government programs. That is literally a race to the bottom, and we cannot afford either the rising

cost or the declining quality. Instead we should look for ways to increase competition, provide more choices and flexibility in obtaining coverage, and ensure that consumers are aware of the health care they consume.

I look forward to hearing from today’s witnesses to get their perspectives and

ideas on this important topic.

Mr. PALLONE. Thank you.

The gentle woman from Illinois.

Ms. SCHAKOWSKY. Thank you, Mr. Chairman. Because I am anxious to hear the witnesses, and I too want to welcome our former

colleague, Senator Daschle, and one of the great leaders for working Americans, Gerald McEntee of AFSCME.

I just want to say that this is perhaps the most important issue

on the minds of the American people. If we can grapple with how

are we going to be able to reform our system that is completely disintegrating and not working for employers or employees, for older

Americans for children, it is simply broken, and I look forward to

working with this wonderful committee under your leadership and

that of Mr. Dingell to solve the problem.

I yield back.

Mr. PALLONE. Thank you.

I recognize the gentleman from Michigan, Mr. Rogers.

Mr. ROGERS. I pass at this time, Mr. Chairman.

Mr. PALLONE. And then the gentle woman from California, Ms.

Eshoo.

OPENING STATEMENT OF HON. ANNA G. ESHOO, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF CALIFORNIA

Ms. ESHOO. Thank you. Mr. Chairman, I am going to place in the

record my full opening statement.

I didn’t think I was going to say anything, but I can’t resist. I

have been in the Congress now, this is my 15th year, and when I

first came here in 1993, at the top of my list was to address health
16

care in the country. There are some that rejoiced that the attempt

failed but I think gauging all the years that have gone by and

where we are now, it is not a cause for celebration. The issue of

health care is front and center to America’s competitiveness. It

makes all the difference between life and death for too many people

in the country. There are children that have dropped through the

cracks. There are parents that can’t get what they need for their

children. There are small businesses that can’t afford to insure

their workforce, and with all due respect to whomever said something about a tax credit, I have yet to meet someone at a town hall

meeting that has come begging for a tax credit to resolve their dayto-day problems, the health care that they face with their small

business or with their family. It is very easy for Members of Congress to throw stones. We have got one hell of a good health care

policy and the United States Government pays for part of it.

So I am really looking forward to the ideas and the statements

of the people that are here today. Perhaps it is going to take a national election and the details might be hammered out by this committee, and I hope I am here for that. But when I look over America’s history, it was a struggle for Medicare to be enacted, for Social

Security to be the law of the land, and that generations now have

benefited from that and we keep building on that system. I think

it is going to take a national election, a new President, a reinvigorated Congress to do this, but if we get to it before that, I look forward to being up at home plate to help knock the ball out of the

park. This is serious business, and I have to tell you at this point,

I am tired of the incrementalism.

So I look forward to hearing from the very distinguished former

majority leader. Thank you for coming to us, to Mr. McEntee, to

talk about where the grass roots are that are going to help lift this

country, get us going in a better direction, and thank you, Mr.

Chairman, for always caring about this issue and having the hearing, yet another hearing on it. Thank you.

[The prepared statement of Ms. Eshoo follows:]

PREPARED STATEMENT OF HON. ANNA G. ESHOO, A REPRESENTATIVE IN CONGRESS

FROM THE STATE OF CALIFORNIA

Mr. Chairman, thank you for holding this important hearing on the crisis of the

uninsured.

This truly is a crisis that is nearing critical levels, with roughly 47 million uninsured individuals in the U.S. today. Approximately 6.5 million uninsured people live

in my home State of California.

We all agree that the high cost of health care is the biggest obstacle to care. Due

to annual double-digit premium increases, private health insurance is not an affordable option for many families and individuals. Small businesses are increasingly unable to offer health insurance benefits, and many companies that are able to provide

benefits find it necessary to pass more and more of the costs on to their employees.

With respect to low-income families and individuals, many are simply unaware

that they or their children may qualify for State or Federal insurance programs.

When we look at the patchwork of public services that are available to the most

vulnerable populations, we see different categories of people eligible for services

from State to State. This creates gaps in eligibility that particularly children fall

through. That’s why we need to make sure that eligibility requirements are reasonable and consistent, and that eligible children are actually enrolled in plans.

I believe first and foremost we should immediately address the 9 million uninsured children in our country. I’m proud to be an original cosponsor of the Children’s Health First Act, which makes improvements to the successful Medicaid and

State Children’s Health Insurance Program (SCHIP) to help these public programs

work better at finding and enrolling eligible children.
17

We also have our work cut out for us to address the 40.5 million uninsured adults

in America. I think there are several ways we can extend health insurance options

to more Americans, including:

• Allowing broader access to insurance plans available to Federal employees and

Members of Congress under the Federal Employees Health Benefits Plan;

• Improving and expanding State programs (including Medicaid and SCHIP) to

cover young adults, pregnant women and very low-income single adults; and

• Establishing State and national multi-insurer pools to provide comprehensive

and affordable health insurance choices to small employers and the self-employed.

It’s encouraging that so many groups and States are working to tackle the problem of the uninsured. In my congressional district (CA–14) the county of San Mateo

is working to put together a program for insuring all its residents. California Governor Schwarzenegger released a proposal to cover all uninsured adults and children, and in his State of the Union address, President Bush outlined a proposal for

addressing the crisis of the uninsured. We should debate the merits of each proposal

and I hope that today’s hearing will be instructive to us.

We cannot continue to ignore a problem as large as 46 million uninsured people

and certainly not the 9 million uninsured children.

Thank you, Mr. Chairman, and I look forward to working with you in addressing

this important issue.

Mr. PALLONE. Thank you, and I think that concludes our opening

statements. Other statements for the record will be accepted at this

time.

[The prepared statements of Ms. Baldwin and Ms. Solis follow:]

PREPARED STATEMENT OF HON. TAMMY BALDWIN, A REPRESENTATIVE IN CONGRESS

FROM THE STATE OF WISCONSIN

Thank you, Mr. Chairman, and thank you to the witnesses who are joining us for

this very important discussion.

Mr. Chairman, I commend you for holding this hearing, highlighting America’s

uninsured crisis. When I first came to Congress in 1999, I came with a clear goal

of reforming America’s crumbling health care system and making sure that every

American has access to affordable, comprehensive health care.

While there are many Members of Congress who share this goal, such as yourself

Mr. Chairman, I was shocked and disappointed at how many Members were content

sit back and watch as the number of uninsured Americans grew year after year. For

far too long, no hearings were held on the uninsured and our former majority simply

recycled tired, ineffective proposals which they claimed would reduce the uninsured

but which did not.

So I am delighted that now, just 4 months after retaking the majority, that you,

Mr. Chairman, have worked with Chairman Dingell to draw attention to this vitally

important matter.

I think that many in this room know that it was Chairman Dingell’s father, John

Dingell Sr., who first proposed legislation calling for national health care. That bill

was H.R. 2861 and the year was 1943. And we’re still talking about the need for

this legislation over 60 years later.

Last night, I led a special order hour on the House floor, highlighting the issue

of the uninsured. We all know the numbers:

• 46 million Americans do not have access to needed health care

• That’s 15 percent of our population.

• Millions more are underinsured.

But what I highlighted last night is that there’s a face, and a story, and a family

behind every single one of these 46 million Americans. They are mothers, fathers,

sons, daughters, workers, and above all Americans. I believe that health care is a

right, not a privilege for some.

I look forward to today’s discussion and again, thank you Mr. Chairman for drawing attention to this hugely important issue during ‘‘Cover the Uninsured Week.’’
18

PREPARED STATEMENT OF HON. HILDA L. SOLIS, A REPRESENTATIVE IN CONGRESS

FROM THE STATE OF CALIFORNIA

Today’s hearing is extremely timely, because this week marks the fifth anniversary of ‘‘Cover the Uninsured Week’’. This past Monday, I led a Special Orders hour

with my colleagues from the Congressional Black Caucus and Congressional Asian

and Pacific American Caucus in honor of National Minority Health Month. Chairman Pallone also joined us in talking about the health disparities that communities

of color still face.

Although preventive medicine and advances in medical technology have improved

life expectancy and overall health for a large number of Americans, not all Americans are benefiting equally. Not everyone has the means to access our health care

system. Communities of color continue to suffer from significant disparities in the

overall rates of disease incidence, prevalence, and mortality in the population as

compared to the health status of the general population. Disparities continue to persist, and we must eliminate health disparities by identifying significant opportunities to improve health.

The reauthorization of SCHIP is one such opportunity, especially since the number of uninsured people affects us all. It is a national problem that needs a national

solution. Reducing disparities in children’s access to health care is extremely important because minority children are less likely to see a doctor when they are uninsured. For example, uninsured Latino and African American children are more likely to forgo needed medical care than other uninsured children. Public insurance programs are vital to communities of color; more than half of insured Latino children

are covered by Medicaid and SCHIP.

I believe that SCHIP reauthorization should support community health workers

and should allow States to provide health coverage to legal immigrants. Community

health workers have been proven effective in enrolling children in public insurance

programs. As a Member of Congress who is committed to providing health coverage

for children, reducing health disparities, and increasing the enrollment of low-income children in SCHIP and Medicaid, I strongly believe that we must redress the

arbitrary exclusion of lawfully residing immigrants from these programs by including the Immigrant Children’s Health Improvement Act in SCHIP.

I applaud the States’ efforts to provide coverage for their residents, and I also believe that the Federal Government has a responsibility to make sure that everyone

has access to health insurance. The cost of private health insurance continues to

rise astronomically, and very few affordable options are left. I talk about health disparities, because members of racial and ethnic minority groups make up a disproportionate share of the uninsured population. The uninsured rate for Latinos

was 33 percent in 2005. In a country that prides itself on equality, it is evident that

our health care system is broken when people suffer from a lack of access to health

insurance. We must make access to affordable, quality, linguistically and culturally

appropriate health care for all Americans a national priority.

Mr. PALLONE. We will now turn to our witnesses, and I would

ask our first panel to come forward and take their seats behind

your nametags there.

Thank you, and I want to welcome our distinguished first panel.

Let me start from left to right and introduce the witnesses that are

here. First is Senator Tom Daschle, who of course has been mentioned was the majority leader. He is now a distinguished senior

fellow at the Center for American Progress, and I would just say

by way of introduction that a day does not go by without your

being mentioned in the context of health care. Yesterday I spoke

at a minority health care event and they were talking about your

Health Care Disparities Act, which you took the lead on, and now

today right as we speak, the resources committee is marking up

the Indian Health Care Improvement Act, which you were another

lead sponsor of, so thank you for being here today.

Next is Mr. Michael Smith, who is the secretary of the Agency

of Administration from the State of Vermont, and then we have

Gerald McEntee, who is the international president of the American Federation of State, County and Municipal Employees. Several
19

members have already mentioned him and his and AFSCME’s contribution to this health care debate, which has been really crucial.

Thank you for being here. And then we have Ms. Grace-Marie

Turner, who is president of the Galen Institute in Alexandria. Next

is Mr. Rotzler. Mr. Gary Rotzler is from Utica, NY, and he is here

testifying on behalf of the American Cancer Society. And then next

is Mr. Tony Montville, who is president and CEO of Healthtek Solutions Inc. from Norfolk, and then last is Ms. Colburn, Susan

Colburn, who is vice president of benefits for AT&T Services from

San Antonio. I also want to give you a particular welcome because

you have a lot of people that work for AT&T that live in my district.

Let me just mention, we are going to have 5-minute opening

statements from each witness. Those statements will be made part

of the hearing record. Each witness may in the discretion of the

committee submit additional brief and pertinent statements in

writing for inclusion in the record. I will start with Senator

Daschle.

STATEMENT OF HON. THOMAS A. DASCHLE, DISTINGUISHED

SENIOR FELLOW, CENTER FOR AMERICAN PROGRESS

Mr. DASCHLE. Thank you very much, Mr. Chairman and members of the committee. I am very grateful for the opportunity to testify and I am especially thankful to each of you who mentioned me.

It is so good to see so many of my former colleagues again. I am

also honored to appear on such a distinguished panel.

Clearly America has so many challenges, but I can’t think of one

that is any greater than health care. You all have mentioned the

extraordinary problems we face with the uninsured and we mark

the week of the uninsured this week, and note that there are 45

million Americans who don’t have health insurance today but that

is just the beginning of the problem. Costs, as several of you have

mentioned, have gone up exponentially, 80 percent in just the last

6 years alone. As a result of costs, as a result of the lack of access,

we see the denial of care, the delay of care and in many cases premature death. So like some of you, I wonder why this has not obtained the kind of priority in this country that it so richly deserves,

and I think in part we failed to address it successfully because we

have lived under a certain set of myths, and those myths have

acted in some ways like a minefield, destroying this opportunity to

move ahead on meaningful health care over and over again, and

that minefield has been devastating as we have attempted to address this issue in the past.

Time doesn’t really allow the opportunity to talk about all the

myths but I want to talk just about three. One is that we have the

best health care system in the world. It is a myth. Far from it. We

rank 28th in infant mortality, 35th in life expectancy today. We

have already mentioned the number of uninsured. We are told that

about 100,000 people a year die because of medical mistakes. And

I would ask, with 28th and 35th, where would we be if that is

where we came out in the Olympics? How long would it take us to

come up with an Olympic champion? We have the Mayo Clinics

and the Cleveland Clinics and other wonderful institutions around

the country but I refer to them as islands of excellence in a sea of
20

mediocrity. So we don’t have the best health care system in the

world.

The second is that universal care somehow is going to cost more

money. Every other country in the world that has had universal

care has brought down costs, now added to the costs, and as so

many of you said, we have actually seen dramatic increases in the

cost over the course of the last several years, in part because we

can’t contain those costs as a result of universal coverage. We have

cost shifting that goes on in our system that causes the average

taxpayer to pay about $900 in additional costs out of the $6,700 per

capita that we all pay as Americans in taxes, premiums and outof-pocket expenses. Businesses now cite health costs as their single

biggest challenge. We spend more on health care at Starbucks than

we do on coffee, more on health care at General Motors than we

do on steel, and now we are going to see next health costs in business in the Fortune 500 exceed the amount of profit that that Fortune 500 group will make. Costs are a problem and universal coverage is one way to address it.

The final myth we live under is that somehow reform means rationing. Well, we ration today in the most unfair and egregious

way. We do it on the ability to pay. I can’t think of a more egregious way, to do it and in the United States today 30 percent of

Americans are all we have today that actually get first-day coverage when they need health care, one of the lowest of all the industrialized countries.

So Mr. Chairman, we have grappled in part with the effort to

deal with climate change living under these myths, and while we

have failed in the past to address comprehensive health care, we

have attempted to deal with it incrementally, as some of you have

mentioned. And while we have succeeded in working around the

edges, even in the most recent years we have fallen short in our

efforts to address the problem even on an incremental basis. This

year we have the opportunity to deal around the edges in a very

important way, with the SCHIP program, and what a disappointment and a disaster it would be if we didn’t actually extend

through reauthorization the SCHIP program. We need to pass

mental health parity. We need to ensure that we pass genetic discrimination prohibition. Those are incremental steps we can take

this year but even if we do all of that, I have to tell you, we are

not going to solve the problem.

The only way we are going to solve the problem is to deal with

it in a comprehensive way, and there are three things that have

to be done. First, we need leadership, political, business and organization. As part of the Center for American Progress, I have been

very, very pleased to see the coalition of business leaders and labor

leaders come together for the first time to say now we must pass

comprehensive reform; we can’t delay. We also have to think out

of the box. We have to use paradigms that work in other forms in

our society, and I am one who believes the Federal Reserve System

would work very well in our health care system too. We need a private system and a public infrastructure. We need a decision-making board that is partially insulated from the day-to-day political

pressures that otherwise Members of Congress feel. The Federal

Reserve System applied to health care could do that. Finally, we
21

have to realize that even if we create the best framework, unless

we deal with one other issue, we will never solve the problem, and

that is, our change in lifestyle. A recognition that we have to address meaningful wellness and preventative-care efforts. We have

to do for obesity in this country what we have done with safety

belts and with helmets and with tobacco. If we can apply the same

approach, that same ability to encourage wellness and health promotion, I think we can solve this problem.

Teddy Roosevelt once said that the greatest joy in life is to work

hard at work worth doing. I can’t think of a job more worth doing

than this.

Thank you very much.

[The prepared statement of Mr. Daschle follows:]

TESTIMONY OF HON. THOMAS A. DASCHLE

Health Reform is the Most Important Domestic Policy Issue

• It affects our health, security, and global competitiveness

One of the Obstacles to Reforms is Myths

• Myth one: We have the ‘‘best’’ system, when in reality there are islands of excellence in a sea of mediocrity

• Myth two : We cannot afford reform, when the reality is we can’t afford the status quo

• Myth three: We don’t ‘‘ration’’ care, when we have the worst kind of rationing:

by income and illness, by age and disability

Recent Efforts Have Focused on Incremental Reform

• There have been a number of major pushes for comprehensive reform in the

United States.

• Since the last one, energy has been spent on incremental reform

• What has been done, and should be done this year—SCHIP, mental health parity, genetic non-discrimination, for example—are critical and meaningful

• But such policies are plugging the holes in a failing system

Comprehensive Reform of the Health System and Beyond Is Needed

• New leadership is needed, including businesses, with the goal being an accessible, affordable, and quality-based health system for all by 2012

• A new framework is needed, which allows for private delivery in a public system

• Health reform is necessary but not sufficient to deal with the 21st century

health challenges—in particular that of obesity and chronic disease

Good morning, Chairman Pallone, Ranking Member Deal, and distinguished

members of the Committee. It is good to be with you this morning, in the midst

of Cover the Uninsured Week, to discuss this critical topic.

This Congress, and this country, faces numerous challenges, at home and abroad.

Few, in my opinion, are as critical as those facing our health system. About 45 million Americans lack coverage altogether. Being uninsured means delayed care, denied care, preventable disease, and premature death. Millions more who are insured

remain at risk of bankruptcy due to health bills. These bills add up. At $2 trillion

per year, we outspend the next most expensive Nation by 50 percent. American

businesses pay about $500 billion of this. This cost has crowded out wage increases,

business investments, and hurt our global competitiveness. And we pay more for

less, not always getting quality worthy of our spending. Stated simply, health reform is the most important domestic policy issue.

MYTHS BLOCKING HEALTH REFORM

Despite these clear problem, health reform has not made it to the top of the political agenda. One reason is myths about our current system and reform. These myths

are like ‘‘landmines’’ that have derailed past efforts to create a universal, value-oriented health system.

The first myth is that the United States has the best health care system in the

world. There’s no doubt that some Americans have access to the best care anywhere.

Any real solution needs to maintain our leadership at the cutting edge of medicine.

But we need to be honest with ourselves. Not all our care is excellent.
22

Thousands of people die from medical errors every year. Americans are more likely to experience medical, medication or lab errors than people in countries like Germany and the United Kingdom.

Plus, few American realize that we are far behind and falling relative to comparable nations in the basic measures of health. Can we say we have the best system when our life expectancy is 35th in the world, lower than Cyprus and Singapore? And, can we say we have the best system when our infant mortality rate is

41st in the world and rising? A story over the weekend documented a spike in infant

deaths in Mississippi and the South. There is simply no excuse for such deaths that

might have been avoided with better health care policy.

The second myth we need to debunk is that the U.S. cannot afford to do any better. In point of fact, we cannot afford to continue this current system. We spend 16

percent of our economy—or $2 trillion—each year on health care. We spend nearly

$6,700 per person, which is roughly 50 percent more than the number two country,

Switzerland. GM pays more for health benefits than steel. Starbucks pays more for

health benefits than coffee. If trends persist, health benefit costs will eclipse profits

in the Fortune 500 companies by 2008. As a matter of health policy and economic

policy, we need to act to rein in the Nation’s health spending.

The third myth is that universal coverage will inevitably lead to rationing. This

ignores the fact that we ration now. Health care is delayed or denied to the uninsured and under-insured. Cancer can mean bankruptcy and asthma can consume

college funds. Being older or sicker, or even having a family history, can make a

person uninsurable—doomed to spend years worrying about the next illness’s financial rather than health implications.

Even on the traditional measures of ‘‘rationing’’, we fare worse. Thirty percent of

sick Americans have access to same-day care, compared to 45 percent in the United

Kingdom. Americans find it three times harder to get care at night and on weekends

without going to emergency rooms compared to those in New Zealand. And we are

more likely to have to wait to see a specialist than sick people in Germany. It’s ironic that the U.S., compared to its competitor nations, offers fewer people less accessible care.

INCREMENTAL REFORM

I know that you, and many other lawmakers, recognize the truth of our health

system crisis, and have tried to act on it. Several presidents, and even more Congresses, have attempted but failed to enact health reform. I, myself, have some scars

to show for it.

The response has been to focus on incremental reform. In the late 1990’s, a number of policies were enacted and implemented that make coverage better and more

accessible for millions of Americans. This year, you may be able to take additional

strides in improving the system. For example, you have the opportunity to extend

insurance parity for mental illness and protect Americans from genetic discrimination. Perhaps most importantly, the State Children’s Health Insurance Program is

up for reauthorization. Improving and extending this successful program that has

served millions of low-income children is not just an option but a necessity.

But it would be a mistake to believe that these policies are more than fingers in

the dam. They cannot solve the health system’s problems. There is no pathway of

incremental steps that will improve and expand health coverage for all. The only

solution is comprehensive reform.

COMPREHENSIVE REFORM

So, what will it take to finally pass comprehensive reform? First, we need to have

to have leadership. There has to be a President and a Congress that both say, ‘‘The

time has come for us to deal with real health reform.’’ Success will demand that

everyone check ideology at the door—and that everyone focus not on what ideology

dictates should work, but on what experience shows will work.

To get to that point, there needs to be business leadership. Businesses are a major

payer of health care and player in the political system. At the Center for American

Progress, we helped form Better Health Care Together, a business-labor coalition

with the goal of comprehensive reform by 2012. I am optimistic that the CEOs of

companies like AT&T, WalMart, and CostCo will force the debate in the halls of

Congress.

Second, we need to think outside the box. One idea that I’ve been working on is

to run our health care system in a way similar to our Federal Reserve system. Our

Federal Reserve system works, in large measure, through the private sector but is

governed by decisions made within a Federal Governmental infrastructure. Just as

the Federal Reserve System protects difficult decisions on monetary from political
23

pressure, I would like to see a framework that insulates health care decision-making

about cost and financing. If we could fix our financing system, I think we could fix

a lot of the other problems involved with our health care system today.

Lastly, health reform is absolutely necessary to improving our Nation’s health.

There is no excuse in the wealthiest nation in the world for a person to suffer or

die needlessly due to financial barriers to care. We can and must end uninsurance.

But this will not be sufficient to improve health. A growing tide of chronic illness,

in part induced by obesity, will strain our health system and Nation. It could mean

that the next generation of children may have shorter life expectancies than that

of their parents for the first time in this Nation’s history. As we consider how to

make critical health policy changes, we should consider broad-based interventions

beyond the health system, in schools, workplaces, and communities. This would give

the Nation, at long last, the health it deserves.

Mr. PALLONE. Thank you so much, and I forgot to mention on the

prevention side your being a runner and you are always promoting

that as well. That is very important. Thank you, Senator.

Next is Mr. Smith.

STATEMENT OF MICHAEL K. SMITH, SECRETARY, AGENCY OF

ADMINISTRATION, STATE OF VERMONT

Mr. SMITH. Thank you, Mr. Chairman, and thank you for the opportunity to testify before your committee on health care. As you

are aware, this is one of the most significant and challenging issues

we face as a Nation and as individual States. We simply cannot afford to continue the status quo of high insurance costs, high health

care costs and inadequate quality in our health care system.

Ten months ago, Governor Douglas, a Republican, and the Democratic-controlled legislation in Vermont, reached consensus on a

groundbreaking health care reform package in our State. This reform is comprehensive in that it has over 35 different initiatives to

cover our uninsured, improve our health care quality and curb the

growth in health care costs. It is being hailed by many experts as

the most comprehensive legislation to provide universal access

while at the same time lowering health care costs and improving

quality.

I am going to focus today on just two of these initiatives in my

testimony, but in the written material supplied to the committee

we provided a full description of our reforms.

The first initiative is called the Catamount Health Plan, a product available on the private market in October 2007 that will be

available for the uninsured Vermonter. Catamount Health is mandated in statute to be comprehensive in benefits, and affordable.

The benefits will be subsidized by the State of Vermont, depending

on your income, up to 300 percent Federal poverty level, and if you

have employer-sponsored insurance and cannot afford it, your premiums for that insurance will be subsidized depending on income.

If it is less expensive for the State to do so, you can make a choice

on which plan you want to be on, depending on which is less expensive for the State. The only requirement is that the employer-sponsored insurance plan be substantially similar to the Catamount

Health Plan in terms of benefits and deductible costs. In Vermont,

many employers have such plans. The goal is to reach an insured

level of 96 percent by 2010. The plan is financed by increases in

the tobacco tax, premiums, Federal Medicaid match, and an assessment on those employers not now offering health insurance. The
24

plan has been carefully crafted to conform with ERISA requirements.

The second major component of our health care reform is called

the Blueprint for Health, which is our statewide initiative to provide all Vermonters who have chronic conditions and those at risk

of developing them with the information, tools and support they

need to successfully manage their health. Over 50 percent of all

adult Vermonters have one or more chronic conditions and caring

for people with chronic conditions consume 70 percent of the $3.5

billion spent in Vermont in 2005 on health care. National data indicates that only 55 percent of people with chronic conditions get

the right care at the right time. We must do better to improve the

outcomes and bring down health care costs.

Launched by Governor Douglas in 2003 and endorsed by the Vermont General Assembly in 2006, the Blueprint for Health is not

the typical disease management program. Instead, the Blueprint is

proactive and holistic and is designed to change our health care

system to focus on chronic care equally with that of acute health

care. To accomplish this, the Blueprint creates public policies that

support healthy lifestyles and effective health care. It provides

community-centered programs and activities to encourage and

maintain healthier lifestyles. It provides self-management tools for

individual participation and empowerment. It develops new electronic health systems for physicians’ offices and other health care

settings statewide. It coordinates reimbursement and care coordination approaches across all payers including insurers, State government and nonprofit health care organizations. Our goal is to

have this new health care delivery approach in place statewide by

2011.

In conclusion, in order for health care reform to be successful, it

needs enormous buy-in from a variety of organizations and people.

We found that out in Vermont. Governor Douglas was just one of

10 people awarded an Impact Award by AARP for his work in

health care. The first line of the write-up of the award said, ‘‘Sometimes politicians can rise above politics.’’ I urge you to remember

this line as you move forward with your deliberations regarding

health care reform. We need to put aside party affiliations and act

on behalf of all our country’s citizens and businesses who are struggling every day with these issues.

Thank you very much, Mr. Chairman.

[The prepared statement of Mr. Smith follows:]

STATEMENT OF MICHAEL K. SMITH

Thank you for the opportunity to testify before your committee on health care reform. As you are aware, this is one of the most significant and challenging issues

we face as a nation and as individual States. We simply cannot afford to continue

with the status quo of high insurance costs, high health care costs and inadequate

quality in our health care systems.

Ten months ago, Governor Douglas, a Republican, and the Democratically-controlled legislature reached consensus on a groundbreaking health care reform package for our State. This reform is comprehensive, in that it has over 35 different initiatives to simultaneously cover our uninsured, improve health care quality and

curb the growth in health care costs. It is being hailed by many experts as the most

comprehensive legislation to provide near universal coverage, while at the same

time lowering health care costs and improving quality.
25

I am going to focus on just two of these initiatives in my testimony today, but

in the written material supplied to the committee, we have provided a fuller description of our reforms.

The first initiative is the Catamount Health Plan, a new product available on the

individual private market in October, 2007 that will be available for uninsured Vermonters. Catamount Health is mandated in statute to be comprehensive in benefits,

and affordable. The premiums will be subsidized depending on income, up to 300

percent FPL, and if you have employer sponsored insurance and cannot afford it,

your premiums for that insurance will be subsidized, depending on income, if it is

less expensive for the State to do so. The only requirement is that the employer

sponsored insurance plan be substantially similar to the Catamount Health plan in

terms of benefits. In Vermont, many employers have such plans.

The goal is to reach an insured level of 96 percent by 2010. The plan is financed

by increases in the tobacco tax, premiums, Federal Medicaid match (assuming Federal approval of an amendment to our 1115 waiver), and an assessment of those employers who do not offer health insurance. The plan was carefully crafted to conform

with ERISA requirements.

The second major component of our health care reform is the Blueprint for

Health, which is our statewide initiative to provide all Vermonters who have chronic

conditions, and those at risk of developing them, with the information, tools, and

support they need to successfully manage their health.

Over 50 percent of all adult Vermonters have one or more chronic conditions, and

caring for people with chronic conditions consumes 70 percent of the $3.5 billion

spent in Vermont each year on health care. National data indicate that only 55 percent of people with chronic conditions get the right care at the right time. We must

do better to improve outcomes and bring down health care costs.

Launched by Governor Douglas in 2003 and endorsed by the Vermont General Assembly in 2006, the Blueprint for Health is not the typical disease management program. Instead, the Blueprint is proactive and holistic, and is designed to change our

health care system to focus on chronic care equally with acute health care. To accomplish this, the Blueprint simultaneously:

• creates public policies that support healthy lifestyles and effective health care;

• provides community-centered programs and activities to encourage and maintain

healthier lifestyles;

• provides self-management tools for individual participation and empowerment;

• develops new electronic health systems for physicians’ offices and other health

care settings statewide; and

• coordinates reimbursement and care coordination approaches across all payers,

including insurers, State government and non-profit health care organizations.

Our goal is to have this new health care delivery approach in place statewide by

2011.

In conclusion, in order for health care reform to be successful, it needs enormous

buy-in from a variety of organizations and people. Governor Douglas was just one

of 10 people awarded an ‘‘Impact Award’’ by AARP for his work in health care.—

The first line of the write up for the award said, ‘‘Sometimes politicians can rise

above politics.’’ I urge you to remember this line as you move forward with your deliberations regarding health care reform. We need you to put down your party affiliations and act on behalf of all our country’s citizens and businesses who are struggling every day with these issues.

Mr. PALLONE. Thank you, Mr. Smith.

Mr. McEntee.

STATEMENT OF GERALD W. MCENTEE, INTERNATIONAL

PRESIDENT, AMERICAN FEDERATION OF STATE, COUNTY,

AND MUNICIPAL EMPLOYEES

Mr. MCENTEE. Thank you, Mr. Chairman and members of the

committee.

We have a health care crisis of unprecedented proportions. Cost

of coverage is exploding. It threatens the economic security of

working families. It strains State budgets. It overwhelms safety net

providers, it reduces the competitiveness of American businesses,
26

and 45 million people live with the fear that they or a loved one

will need care for which they cannot pay.

One such person is Joann Baumer of Fort Madison, Iowa. Joann

is a homecare attendant who works full time providing services to

the elderly and the disabled. Joann has no health coverage. After

having necessary surgery, it took Joann and her husband 5 years

to pay off her hospital bill. Now she and her husband spend $400

per month for prescription medication.

Joann Baumer’s story is far from unique. The crisis of the uninsured is a problem for everyone in America and that includes the

1.4 million members of our union, AFSCME. A significant share of

the premium paid by AFSCME members and their employers goes

to offset the cost of uncompensated care. There are scores of proposals to address this crisis and so we have developed principles

to evaluate them. But ultimately this is not a matter solely of policy or resources. It has been said earlier today, it is a matter of political will. America’s working families demand relief from this crisis and they expect their national leaders to have the vision and

political resolve to forge a bold solution. The starting point for

health care reform must begin with a commitment to cover every

man, woman and child in America. This is both a moral and economic imperative.

Let me give you our vision of what health care reform should

look like. First, everyone should have affordable, comprehensive

coverage. Second, while the market has an important role to play,

our Government must play the central role in regulating, financing

and providing health care. Third, financing should be fair and

shared by all. Fourth, frontline health care workers must have an

active voice in improving the quality of our health care system.

Who else knows more about it? And finally, as we approach reform,

we must be mindful to do no harm. This means that until we have

a comprehensive reform, changes in the health care system must

not undermine existing coverage.

Unfortunately, the health care plan proposed by the President in

his budget this year does exactly that because his plan makes fundamental changes in the tax treatment of coverage. It would actually encourage employers to drop health benefits for their workers.

Ultimately, the President’s plan would make those who have adequate coverage pay more for it without achieving universal coverage. We oppose his proposal and other plans that would break up

risk groups and send families into the individual market where

costs are higher and coverage is also denied. We must also realize

that the absence of action at the Federal level has forced States to

pursue their own reform initiatives. We are concerned about the direction of some of these reforms. For example, the Massachusetts

model attempts to achieve near-universal coverage through the use

of individual mandates. The most recent cost estimates for coverage

of a Massachusetts family with an income of $50,000 would include

a $7,000 premium and a $2,000 deductible. Health care costs that

approach 20 percent of total income are unaffordable and unacceptable to working families.

It is our hope that the State efforts prompt action at the Federal

level. Ultimately, only the Federal Government has the resources

and the legal authority to implement the changes that are needed.
27

Among the health reform initiatives under discussion in this Congress, two deserve particular mention. Chairman Dingell’s Medicare for All plan offers a viable path to attaining universal coverage, provides the security of extending the trusted Medicare plan

to everyone under age 65 but also includes choice for families. We

are also supportive of the Americare plan introduced by Representative Stark and cosponsored by a number of committee members

including Representatives Waxman and Schakowsky. This bill

would also leverage the administrative efficiencies of Medicare.

In closing, I would like to add a note about the importance of

quickly reauthorizing the State Children’s Health Insurance Program, a top priority for our union and all unions. It is crucial that

the Congress build on the success of this program by allowing

States to expand coverage to the millions of children who remain

uninsured. In particular, we urge you to remove the prohibition

that excludes the children of low-wage State workers from SCHIP

and we also urge that you address the funding inequity of the Commonwealth of Puerto Rico.

I appreciate the opportunity to testify and will be happy to answer any questions you may have. Thank you, Mr. Chairman.

[The prepared statement of Mr. McEntee follows:]

TESTIMONY OF GERALD W. MCENTEE

America’s health care system is in crisis. The cost of coverage is exploding. It

threatens the economic security of working families, it strains State budgets, it overwhelms the capacity of safety net institutions and it reduces the competitiveness of

American businesses. And shamefully, 45 million people live with the fear that they

or a family member will need care for which they cannot pay. Those fortunate

enough to have coverage too often receive poor quality care.

The crisis of the uninsured is a problem for everyone in America, and that includes the 1.4 million members of my union, the American Federation of State,

County and Municipal Employees.

The United States is a great nation—we can, and must, do better.

Unlike European health care systems to which it is frequently contrasted, the

American health care system is not a monolithic, unified system. Rather, it is a complex system of many inter-related parts, all of which must function efficiently to

keep the system in optimal order.

Like the links in a chain, if one link exhibits stress or cracks, it puts more strain

on the other links. The uninsured represent a broken link in our system, putting

enormous pressure on both employer-sponsored health plans and public programs.

Moreover, this broken link is a moral failure for our Nation. Much of the massive

growth in the uninsured is attributable to individuals losing coverage through their

jobs. The erosion of employer-sponsored health coverage is a particularly troubling

trend for America’s labor unions, and it should be of primary importance to every

American because of the damage it represents to our overall health care system.

In the year 2000, 69 percent of Americans under age 65 had employer-sponsored

health coverage. By last year, that figure had dwindled to 60 percent.

Clearly, many employers are dropping insurance for their workers, because of its

cost and the growing complexity of administering benefits. However, other large,

profitable companies never provided health insurance to the majority of their workers in the first place, instead directing them to public programs at taxpayer expense. And an increasing number of workers who have employer-sponsored coverage

are paying more in out-of-pocket costs for scaled-down benefit plans.

For those workers still fortunate enough to have health insurance, the specter of

underinsurance is all too prevalent. Far too many American working families are

just one serious illness away from bankruptcy. In fact, medical debt is now the second leading cause of bankruptcy in our Nation, and 29 percent of low-to-middle income families report that medical debt contributes to their chronic credit card debt.

The lack of adequate health care coverage is making the American Dream more and

more of an illusive target, rather than an attainable goal, for working families.
28

Sometimes, when I talk about the crisis of the uninsured, members of the media

or the public ask me, ‘‘Why does your union care about the uninsured? Union members have good health benefits. This doesn’t affect them.’’

First of all, most of our members have good health insurance coverage, but not

all of them. Some of the workers in new sectors that we are organizing, including

those who perform home health care/personal service attendant work and those who

provide in-home child care, do not receive health benefits as part of their job. I think

most Americans would agree with me that it is a travesty when those on the

frontlines of providing care to our children, our elderly and our disabled do not have

health coverage themselves. We are working hard to find ways for these often lowwage workers to get access to health coverage, but it has been a difficult and complicated task.

But the full answer to that question about union members and health coverage

is that, yes, most AFSCME members do have good health insurance coverage. In

many cases, we have had to fight long and hard to develop these health benefit

plans. But just because union members have good health benefits does not mean

that we are not impacted by those without coverage.

It cannot be overstated that the crisis of the uninsured is everyone’s problem, including those of us who have insurance. The elaborate shell game of cost-shifting

that is built into our insurance rates to pay for uncompensated care means that

each time the number of uninsured rises, so do our premiums. In one recent analysis of uncompensated care, it was estimated that two-thirds of uncompensated care

is being absorbed by private payers and passed along in the form of higher insurance premiums. In 2005, this cost added over $900 to the average annual premium

for family coverage.

The number of uninsured would be doubled without the safety net provided by

the Medicaid program. As a union that represents many workers throughout the

Medicaid program in States across the Nation, we are proud of how effective this

system has been at providing vital health services for low-income families and individuals. But the Medicaid system has been strained to the breaking point by absorbing more and more individuals who have either lost employer-sponsored coverage

or who cannot afford to pay sky-rocketing premiums.

The effect of rising Medicaid costs has been devastating to State budgets. Although States have admirably tried to keep their Medicaid costs under control, the

growing strain of the newly uninsured represents huge opportunity costs in the public sector. States cannot adequately invest in their education system or their public

infrastructure in general because of the growing budget share assumed by Medicaid.

This inability to invest will leave a harsh legacy on future generations who will be

ill-prepared to compete globally, or even to contribute fully to our society. To date,

the Administration has failed to respond to the gravity of the challenges presented

by Medicaid cost growth. Instead, it only offers States greater flexibility and block

grants. Neither approach can adequately address the needs of a safety net health

care system that is straining to assist a larger and sicker population.

The problem that the growing number of uninsured represents for both the employer-sponsored system of health coverage and the public system of coverage makes

it the number one policy priority for AFSCME and the entire labor movement. The

question of health coverage has been the primary point of contention in every major

contract our union has bargained over the past several years. For years now, our

members have foregone wage increases to maintain their valued health benefits.

Yet, even this imperfect trade-off is becoming unsustainable as soaring health care

costs far outpace wage increases nationally, and American workers fall further and

further behind.

America’s working families demand relief from this crisis. And they expect their

national leaders to have the vision and the political resolve to forge a bold solution

to this problem. Many proposals have been put forth to address this crisis. But ultimately, this is not simply a matter of policy or resources, it is a matter of political

will.

To help evaluate these plans, my union has worked with the AFL-CIO to create

a set of guidelines for what comprehensive health care reform should include. This

is what we think effective health care would look like:

• Everyone should have health care coverage, without exclusions or penalties.

• While the market has an important role to play, our government—as the voice

of all of us—must play the central role in regulating, financing and providing health

care.

• Coverage should be accessible through the largest possible groups that pool

risk to ensure coverage regardless of gender, age, health status or other factors.

• Coverage should be affordable and comprehensive.
29

• Unions and employers should continue to play a role and retain the ability

to supplement coverage.

• Individuals must retain the ability to select their own health care providers.

• Financing should be achieved through shared responsibility, which means that

risk should be shared broadly to ensure fair treatment and equitable rates, and everyone should share responsibility for contributing to the system through progressive financing.

• Reform efforts must include effective mechanisms for controlling costs, requiring information on provider performance and enhancing efficiency.

• Frontline health care workers must have an active voice in improving the

quality of our health care system and making it more efficient.

As the debate over reform proceeds, we must be mindful to do no harm. This

means that until we have a comprehensive alternative for everyone, reform efforts

should not undermine existing coverage or put people at risk of unmet health care

needs.

And finally, it is our firm belief that only the Federal Government has the resources and legal authority to implement the systemic reforms necessary to create

comprehensive change. Therefore, the ultimate responsibility for health care reform

lies with the Federal Government.

Now, I want to comment briefly on how current reform plans line up with our

guidelines and which we think will be effective in achieving lasting reform.

As the crisis of the uninsured has expanded, the administration’s response has

been inadequate at best. In his latest budget request, President Bush put forward

an initiative based on tax credits. In its analysis of the President’s proposal, the

Commonwealth Fund estimates it would cover an additional nine million individuals

at most. Because of the fact that his proposal treats employer-sponsored health coverage differently under the Federal tax code, it would actually encourage employers

who currently offer coverage to drop health benefits for their workers. Ultimately,

the President’s plan would fail to achieve universal coverage while forcing those who

have adequate coverage to pay more for it.

The underlying philosophy of this plan is that employers, and our Nation as a

whole, should abandon collective responsibility for health coverage, along with the

shared risk associated with it. Instead, according to this view, each individual must

take responsibility for his or her own health coverage, through high-risk schemes

like high deductible health plans and health savings accounts (HSAs), even if this

coverage requires increased out-of-pocket costs and eventually causes the individual

to lose coverage altogether.

We oppose his proposal and other plans that would break up risk groups and

leave families on their own to purchase coverage in the individual insurance market.

The absence of action on health care reform at the Federal level has forced States

to pursue their own reform initiatives, largely out of desperation. Although systemic

reform requires Federal action, we commend States for attempting to address the

issue comprehensively. However, we are concerned with the direction reform efforts

have taken in some States.

For example, the Massachusetts reform model attempts to achieve near-universal

coverage through the use of individual mandates that require those without access

to coverage through their jobs to buy coverage in the individual market. Although

there are subsidies to help low-income families, many working families will be

forced to pay much higher prices for coverage. The most recent estimates for coverage under this initiative for a family with an income of $50,000 would include a

$7,000 premium and a $2,000 deductible. Health care costs that approach 20 percent of total family income are unaffordable and unacceptable to working families

and they will ultimately doom this plan to failure.

Among the new health reform initiatives being discussed in this Congress, two deserve particular mention. The Medicare for All plan, proposed by Chairman Dingell,

offers a viable path to attaining universal coverage. It offers the security of extending the trusted Medicare plan to everyone under age 65, but it also features attributes of choice by allowing enrollees to select any one of the health plans offered

to members of Congress.

We are also favorably impressed by the AmeriCare plan introduced by Rep. Stark.

This plan would build on our existing employer-sponsored system of coverage, but

would also leverage the administrative efficiencies contained in Medicare to create

a new system of universal coverage.

Both of these initiatives meet our guidelines of covering everyone, offering comprehensive benefits, exerting effective cost controls and employing equitable finance

mechanisms.
30

In closing, we would like to add a note about the importance of Congress expeditiously reauthorizing the State Children’s Health Insurance Program. It is crucial

that the Congress build on the success of this program by allowing States to expand

coverage to the millions of children who remain uninsured. In particular, we urge

you to remove the prohibition from coverage that excludes the children of low-wage

State employees and also many local government employees. A janitor who cleans

a State building or a local school should not be treated differently than a janitor

who cleans the bank building down the street. For many low-wage workers, the employee premium for family coverage is simply unaffordable. The children of these

workers should not be denied coverage, just as the children of workers in the private

sector and in the Federal sector are not denied coverage.

We also urge you to address the funding inequity for the Commonwealth of Puerto

Rico. This program is quite modest, covering only children up to 100 percent of poverty. We believe that the Federal Government needs to be a full partner in that program.

The health care crisis poses a serious threat to the future of our Nation. We have

a moral and economic imperative to solve this problem, and the starting point is

to provide coverage for every man, woman and child in America.

Mr. PALLONE. Thank you.

Ms. Turner.

STATEMENT OF GRACE-MARIE TURNER, PRESIDENT, GALEN

INSTITUTE

Ms. TURNER. Chairman Pallone, Mr. Deal, distinguished members of the committee, thank you very much for the opportunity to

testify during Cover the Uninsured Week, which interestingly coincides with Small Business Week. I think that is an interesting convergence that shows the added attention we need to bring to small

business in America.

Our core focus at the Galen Institute is finding ways to increase

access to health insurance for Americans, particularly private insurance. In expanding access to coverage, it seems wise to focus on

who is most likely to lack coverage and why. As several members

have mentioned, 160 million Americans have access to coverage

through the workplace, but this system is not meeting the needs

of an increasingly mobile workforce. Young people, minorities,

workers for small businesses and lower-income workers are most

likely to be uninsured. With so many competing demands for taxpayer dollars, it seems wise to look at the opportunities to build on

this source of private coverage and take advantage of not only

these efficiencies but also of the resources that are already on the

table.

There have been suggestions this morning about expanding access to public coverage but I would like to offer two thoughts and

present some research that I think may help to consider Hippocrates’ warning to first do no harm to the system as those programs

are considered. Researcher Jonathan Gruber from MIT has said

that, and this is a quote, ‘‘Despite an enormous expansion of public

health programs over the past 20 years, the number of insured continues to grow.’’ His estimate suggests that expansion of public insurance is crowding out private insurance at the rate of about 60

percent. He finds that this crowd-out is most likely to affect those

in higher income categories who are eligible for these programs and

who are the main target populations for SCHIP expansion.

Further, I believe it is incredibly important that we not make it

more difficult for businesses and especially small businesses to pro-
31

vide and to afford coverage. Milliman and Company actuary Mark

Litow has said that expanding Government programs is putting

added pressure on private health insurance and that is because

public programs pay sometimes only 30 cents on the dollar of hospital and doctor’s fees, and if those businesses are to stay afloat,

they have to find someplace else to go to recoup the resources, and

that is forcing up the premiums for private health insurance. People wonder why are these costs going up, and as public programs

expand, it forces more of those costs onto private insurers, which

pay an average of about 67 percent of costs.

If we were to think about how can we fit our health care system

into one that is a 21st century system that recognizes we have a

mobile workforce, four in ten workers change jobs every year, allow

health insurance to be more portable, take advantage of the opportunities for private coverage that are out there, I think there are

some policy initiatives that could help support that goal. First of

all, making the tax break equal so you can get the same tax break

whether you purchase your health insurance through the workplace or on your own through new kinds of groups. For a lot of people, that is not going to be nearly enough and I have heard a lot

of talk about some kind of added cash support whether it is refundable tax credits, health certificates, vouchers, whatever kind of

credit to help people, especially those who are left out of the current system to provide coverage and purchase coverage. Further,

there are a lot of people who are eligible for public programs, eligible for Medicaid, eligible for SCHIP. Many of them may have jobs

that may take up the private coverage at work if they had a little

more help, allowing premium support for SCHIP dollars and Medicaid dollars to give them that extra boost to be able to purchase

private health insurance at work, and then also to create new opportunities for people to purchase group health insurance. Representative Shadegg’s bill to allow cross-state purchasing of health

insurance I think would also really liberate the market and force

new efficiencies in the market.

Building of private coverage, in conclusion, I think would be both

more economical for taxpayers and also give workers eligible for

public subsides the dignities of private insurance coverage with its

broader access to private physicians and medical facilities.

Thank you, Mr. Chairman. I look forward to your questions.

[The prepared statement of Ms. Turner follows:]

STATEMENT OF GRACE-MARIE TURNER

With the increasing ability of the medical profession to save and improve our

lives, Americans value the security of health insurance to cover their health costs.

For public policy solutions to be effective in reducing the number of those who do

not have the security of health insurance, we must look beneath the numbers to see

who is uninsured, why, and what solutions are likely to work to expand coverage.

Analyses show those who are most likely to be uninsured are young adults, those

working for small businesses and their dependents, lower-income workers, and minorities. Either we can dramatically expand public programs to cover this population or we can find new ways to help them access private coverage. I would suggest that, with so many competing priorities for taxpayer dollars, we find ways to

strengthen access to private health insurance.

Research by Jonathan Gruber of MIT shows that despite an enormous expansion

in public health programs over the last 20 years, the number of uninsured continues

to grow. Gruber’s research suggests that most of the rise in public insurance comes
32

from a fall in private insurance. He finds that crowd-out is most likely to take place

with those in upper income categories—the target category for SCHIP expansion—

because they are more likely to have options for private coverage.

Further, it is essential that legislative changes not make it more difficult for employers to provide coverage by inadvertently driving up their premiums. Milliman

Actuary Mark Litow argues that expanding government programs puts added pressure on the cost of private health insurance. Public payers pay less to doctors and

hospitals, and as these public programs expand, private plans must pay more. Their

costs rise, driving up premiums and causing more people, especially individuals and

small businesses, to drop out of the market, thereby swelling the ranks of the uninsured.

Changes are needed to our health care system to meet the challenges of a changing workforce and 21st century economy. America can lead the way by putting in

place new policies that combine a general tax deduction or credit with additional

financial assistance for lower-income people, and flexibility to turn SCHIP and Medicaid benefits into defined contributions, thereby retargeting existing funds to increase access to private health insurance. Building on this base of private coverage

would both be more economical for taxpayers and also would give workers eligible

for public subsidies the dignity of private insurance coverage, with its broader access to private physicians and medical facilities.

Chairman Pallone and distinguished members of the committee, thank you for the

opportunity to speak with you today during this week of national attention on ‘‘Covering the Uninsured.’’ To introduce myself, I am Grace-Marie Turner, president of

the Galen Institute, a non-profit public policy research organization that I founded

in 1995 to focus on market-based policy solutions to the problems in our health sector.

Our core focus at the Galen Institute is offering solutions to expand private health

insurance to the tens of millions of people in this country who are without coverage.

With the increasing ability of the medical profession to save and improve our

lives, Americans value the security of health insurance to cover their health costs.

When we look at the trend lines for health insurance coverage in the U.S., it is clear

that we must chart a new course.

The number of people without health insurance is steadily rising, now 44.8 million, according to recent revised Census Bureau estimates, 1 and the number of people with coverage through the workplace is falling, from 69 percent in 2000 to 61

percent in 2006. 2

If public policy solutions are to be effective in reducing the number of uninsured,

it is important to look beneath these numbers to see who is uninsured, why, and

what solutions are likely to work to expand coverage.

Analyses show those who are most likely to be uninsured are young adults, those

working for small businesses and their dependents, lower-income workers, and minorities. I would like to offer suggestions for new strategies to increase coverage for

those who are most likely to be without insurance.

A profile of the uninsured

About 80 percent of the uninsured are workers or their dependents. These are

people who make too much to qualify for public programs, such as Medicaid and

the State Children’s Health Insurance Program, but don’t have the good, higherpaying jobs that come with health insurance. These are the people that are in what

we call the ‘‘Galen Gap.’’ Our logo is a conceptual depiction of this group that represents our largest public policy challenge. 3

We have two choices: Either we can dramatically expand public programs to cover

this population or we can find new ways to help them access private coverage. I will

describe research by Jonathan Gruber of MIT which suggests that the former may

not be the best strategy and suggest ways that existing public funds could be used

to expand access to private coverage for this target population.

Who is most likely to be uninsured?

• Young adults: Among young adults aged 19–24, 38.2 percent do not have health

insurance.4 For this population of people who are overwhelmingly healthy and believe in their invulnerability, the cost of insurance is the biggest issue.

• Employees of small businesses: Only 60 percent of small firms offered coverage

in 2006. And the smallest firms are least likely to provide coverage: Only 48 percent

of firms with 3 to 9 workers offer health insurance to their workers. The drop in

employment-based health insurance has been primarily among small companies employing 3 to 199 workers. In contrast, 98 percent of large firms with 200 or more

workers offered health insurance in 2006. 5

The reason firms cite for not offering health insurance is the high cost of coverage,

with 74 percent saying that the high price of premiums is a ‘‘very important’’ reason
33

they don’t offer health insurance. 6 And some firms are just too small to manage

their businesses as well as the complexities of health insurance. The National Restaurant Association says, for example, that some employees may only work for a restaurant for a few days, making it almost impossible to enroll these workers in

health plans and for their job to be a stable source of coverage. • Lower-income Americans: In 2005, 37 percent of non-elderly people with incomes

under 100 percent of Federal poverty were uninsured compared to just 7 percent

of those with incomes of 300 percent of poverty or above. 7 Lower-income workers

need targeted subsidies to help them afford insurance. • Minorities: An estimated 32.3 percent of Hispanics are uninsured, compared to

10.7 percent of whites and 19 percent of blacks. 8 This suggests that outreach to

the Hispanic community with new options and information about those options

would be an important component of an effort to increase enrollment in health insurance. And even though a profile of the uninsured captures these primary categories, the

actual faces in this group without coverage are ever-changing. According to the Congressional Budget Office, the uninsured population is constantly shifting as people

gain and lose coverage. Furthermore, the length of time that people remain uninsured varies greatly. Some people are uninsured for long periods of time, but more

are uninsured for shorter periods. About 45 percent are uninsured for four months

or less. 9 This is primarily a phenomenon of our system of job-based health insurance where people lose their health insurance when they lose their job and have

periods of uninsurance while they wait to get covered again.

And many of the uninsured are eligible for public programs. Twenty-five percent

of the uninsured are eligible but not enrolled in public programs. Another 20 percent have incomes high enough to afford coverage, defined as 300 percent of poverty

or above, according to a report published in Health Affairs. 10

The CBO says that 16 percent are continually uninsured for more than two years,

and they tend to be people with less education, those with low incomes, and Hispanics. These longer-term uninsured would seem to be an important group for Congress’’ attention as they clearly have fewer opportunities for private coverage.

Crowd out

As Congress focuses on the problem of the uninsured, it would be helpful to look

at the success of past strategies in expanding access to public coverage, especially

through Medicaid expansions and the creation of the State Children’s Health Insurance Program.

Over the past two decades, the number of people without health insurance and

the number of people with publicly-supported health insurance both have risen. 11

According to Jonathan Gruber of MIT, from 1984 through 2004, the share of the

non-elderly population in the U.S. that is uninsured rose from 13.7 percent to 17.8

percent. At the same time, the share of the non-elderly U.S. population that is publicly insured rose from 13.3 percent to 17.5 percent. In other words, Gruber shows

that despite an enormous expansion in public health programs, the number of uninsured continues to grow.

Gruber’s research suggests that most of the rise in public insurance comes from

a fall in private insurance. His data show that, between 1984 and 2004, the share

of the U.S. non-elderly population with private health insurance fell from 70.1 percent to 62.4 percent. His estimates suggest that expansions of public insurance are

crowding out private insurance at the rate of 60 percent. That means, in general,

that private insurance coverage is reduced by 60 percent as much as public insurance rises.

Because there is a great deal of attention to expanding the State Children’s

Health Insurance Program, it is important to look at these findings to make sure

that a program expansion wouldn’t simply be replacing private insurance with taxpayer-supported coverage. Gruber finds that crowd-out is most likely to take place

with those in upper income categories—the target category for SCHIP expansion—

because they are more likely to have options for private coverage.

It is only logical that people would opt for public coverage if it were offered because taxpayer-supported insurance is almost always less expensive for recipients

than private insurance. But it may be worth rethinking this strategy if the goal of

the added spending on SCHIP is to reduce the number of uninsured. Gruber’s research suggests that expanding SCHIP could add more children to public rolls but

not have a significant effect on reducing the number of uninsured children.

According to the Kaiser Commission on Medicaid and the Uninsured, a surprising

percentage of poor and near-poor adults—those earning 200 percent of poverty or

below—have employment-based or other private health insurance. 12 The Kaiser

study shows that 45 percent of non-elderly people who earn between 100 percent

and 199 percent of poverty (up to $20,420 in 2007) have private health insurance,
34

either coverage they get through work (39 percent) or individual policies (6 percent).

About a third of lower-income adults are uninsured and one-quarter have public coverage, primarily through Medicaid or SCHIP.

Clearly it would be a mistake, with so many competing priorities for taxpayer dollars, to replace private coverage for those who have it with expanded public health

programs.

MAKING PRIVATE INSURANCE MORE EXPENSIVE

It also would be helpful to examine the consequences of a major expansion of

SCHIP or other public programs on the market for private insurance.

Expansion of government health programs drives up the cost of private health insurance, according to health actuary Mark Litow of Milliman Consultants and Actuaries. Here’s why: He estimates that private health plans pay about 64 percent of

the full charges of doctors, hospitals, labs, etc. Medicare pays about 37 percent of

these ‘‘undiscounted’’ charges. And Medicaid pays only about 30 percent. 13

It’s only logical that the more of the market that is taken up by programs paying

only 30 percent of a provider’s charges, it is going to put more pressure on others

to make up at least some of the difference. Litow argues that expanding government

programs puts added pressure on the cost of private health insurance. As public programs expand, private plans must pay more. Their costs rise, driving up premiums

and causing more people, especially individuals and small businesses, to drop out

of the market, thereby swelling the ranks of the uninsured.

With 160 million Americans receiving their health coverage through the workplace, it is essential that legislative changes not make it more difficult for employers

to provide coverage by inadvertently driving up their premiums through expansion

of public programs.

Hippocrates’ dictate to ‘‘First, do no harm’’ would seem useful guidance.

ALTERNATIVE IDEAS TO EXPAND COVERAGE

Changes are needed to our health care system to meet the challenges of a changing workforce and 21st century economy.

Tying health insurance to the workplace is not meeting the needs of a workforce

that is increasingly independent and mobile. The Labor Department reports that

four in ten Americans leave their jobs every year, with virtually all of them moving

on to a new job. 14 With this kind of job mobility, it is extremely difficult to tie

health insurance to the workplace and expect people to have continuity of coverage.

We need a system that allows people to have health insurance that is portable, insurance that they can own and control, and insurance that fits the needs of families

and their budgets.

Portability of health insurance would help not only those who are uninsured, but

also those who are worried they could lose their coverage. It would give new security

to millions of workers who are worried that if they lose their jobs, they will lose

their health insurance. With the cost of health insurance and health care rising

every year, they fear they would not be able to afford coverage on their own. The

middle class is increasingly afraid that they are one premium payment away from

joining the ranks of the uninsured.

America can lead the way in creating a health care system that fits with our 21st

century economy by putting in place new policies that respond to consumer demands

for more affordable, portable health insurance. • The first step would be giving favorable tax treatment of health insurance to

people whether they buy coverage on their own or get it at work, as President Bush

has proposed. • Congress also could offer refundable tax credits for those in lower-income categories who need additional help in purchasing policies. • Further, Congress could allow those eligible for public programs to apply the

value of the subsidies for which they are eligible toward the purchase of private

health insurance. This would mean that citizens could take the value of their Medicaid benefit and apply it toward employer-offered coverage. Or they could take the

value of their SCHIP subsidy to add their children to their policies at work. • And legislators could create new opportunities for people to purchase group

health insurance through organizations that may be more stable forces in their lives

than their jobs, such as churches, labor unions, and professional and trade associations.

This combination of a general tax deduction or credit, with additional financial

assistance for lower-income people, and flexibility to turn SCHIP and Medicaid benefits into defined contributions would retarget existing funds to increase access to

private health insurance.
35

Building on this base of private coverage would both be more economical for taxpayers and also would give workers eligible for public subsidies the dignity of private insurance coverage, with its broader access to private physicians and medical

facilities.

Consumers, not just in the United States but in all developed countries, are demanding a much greater role in decisions involving their health care. Women, especially, believe that they, rather than a corporate human resources director, could

make better decisions involving health coverage for their families if only they were

given the chance. 15

Giving people more power and control over their health care and health insurance

creates new incentives for people to be more engaged in managing their health.—

Many companies realize this and are instituting new programs to give employees

incentives to better manage their health spending. A number of studies have shown

that if people are given the tools, the information, and the incentive to manage their

care, outcomes can be dramatically improved. And we could transform our health

care system into one that responds to the changes of a 21st century workforce and

meets the needs of a diverse population of health care consumers.

Thank you for the opportunity to talk with you today about these important

issues. I would be happy to answer any questions you might have or to provide additional information.

Endnotes

1 ‘‘Census Bureau revised 2004 and 2005 health insurance coverage estimates,’’

U.S. Census Bureau, March 23, 2007. ‘‘http://www.census.gov/Press-Release/www/releases/archives/health—care—insurance/009789.html’’ 2 ‘‘Health benefits offer rates,’’ Employer Health Benefits 2006 Annual Survey,

Kaiser Family Foundation, Washington, D.C. September 26, 2006. ‘‘http://

www.kff.org/insurance/7527/’’ 3 The Galen Institute logo is a conceptual depiction of a central problem in the

health sector that affects Americans under age 65 without health coverage. The horizontal axis represents a given individual’s income. The vertical axis represents the

likelihood that individual is eligible for health coverage and the value of taxpayer

subsidies for the coverage.

People on the left side of the scale with the very lowest incomes are most likely

to qualify for taxpayer-supported health programs, especially Medicaid, although in

some States, even the poorest residents may remain uninsured if they don ’t meet

certain qualifications.

As an individual moves up the income scale, the likelihood of qualifying for government health programs declines. Those on the right side of the scale with higher

incomes are much more likely to have job-based health coverage, which is generously subsidized through the tax code.

Working Americans with modest incomes are most likely to be uninsured and are

caught in the trough, which we call the Galen Gap. They earn too much to qualify

for public programs but are unlikely to have the good jobs that provide health insurance as a tax-free benefit. 4 ‘‘The uninsured in America, first half of 2005: Estimates of the U.S. civilian noninstitutionalized population under age 65,’’ Statistical Brief #129. June 2006. Jeffrey

A. Rhoades, PhD. Agency for Healthcare Research and Quality, Rockville, MD.

‘‘http://www.meps.ahrq.gov/papers/st129/stat129.pdf’’ 5 ‘‘Health benefits offer rates,’’ Employer Health Benefits 2006 Annual Survey,

Kaiser Family Foundation, Washington, DC, September 26, 2006. ‘‘http://

www.kff.org/insurance/7527/’’ 6 ‘‘Health benefits offer rates,’’ Employer Health Benefits 2006 Annual Survey,

Kaiser Family Foundation, Washington, DC September 26, 2006. ‘‘http://

www.kff.org/insurance/7527/’’ http://www.kff.org/insurance/7527/ 7 ‘‘The uninsured: A primer. Key facts about Americans without health insurance,’’ Kaiser Commission on Medicaid and the Uninsured, Washington, D.C. October 2006.‘‘http://www.kff.org/uninsured/7451.cfm’’ 8 ‘‘Revised estimates of persons without health insurance: 2005,’’ U.S. Census Bureau.‘‘http://www.census.gov/hhes/www/hlthins/hlthins.html’’ 9 ‘‘The Uninsured and Rising Health Insurance Premiums,’’ testimony by CBO Director Douglas Holtz-Eakin before the Subcommittee on Health, Committee on Ways

and Means, U.S. House of Representatives, March 9, 2004. http://www.cbo.gov/

showdoc.cfm?index=5152&sequence=0 10 ‘‘The uninsured and the affordability of health insurance coverage,’’ Lisa

Dubay, John Holahan and Allison Cook. Health Affairs. Nov. 30, 2006. ‘‘http://content.healthaffairs.org/cgi/content/abstract/hlthaff.26.1.w2
36

11 ‘‘Crowd-out ten years later: Have recent public insurance expansions crowded

out private health insurance?’’ Jonathan Gruber and Kosali Simon. National Bureau

of Economic Research Working Paper 12858, January 2007. ‘‘http://www.nber.org/papers/w12858’’ 12 ‘‘The uninsured: A primer. Key facts about Americans without health insurance,’’ Kaiser Commission on Medicaid and the Uninsured, Washington, D.C. October 2006. ‘‘http://www.kff.org/uninsured/7451.cfm’’ 13 Release of data pending by Milliman Consultants and Actuaries, Mark Litow,

Principal and consulting actuary. Information from private e-mail exchange April

20, 2007. ‘‘http://www.milliman.com’’ 14 ‘‘Job openings and labor turnover: November 2006,’’ Bureau of Labor Statistics,

United States Department of Labor, January 10, 2007. ‘‘http://www.bls.gov/

news.release/archives/jolts—01102007.pdf’’ 15 ‘‘In America. Focus on women,’’ Bob Herbert, The New York Times, September

28, 2000.

Mr. PALLONE. Thank you, Ms. Turner.

Mr. Rotzler.

STATEMENT OF GARY ROTZLER, UTICA, NY, ON BEHALF OF

THE AMERICAN CANCER SOCIETY

Mr. ROTZLER. Good morning, Mr. Chairman, members of the

committee. I very much appreciate the opportunity to testify here

today. My name is Gary Rotzler and I am a private citizen speaking on behalf of the American Cancer Society. I am also speaking

for millions of American families who cannot afford or do not have

access to meaningful health insurance. As a result, they have little

access to preventative care and preventing sickness and death.

I speak with authority on this matter because my wife, Elizabeth

Jean Harvey, died of breast cancer. Had we had insurance and had

she had timely care, the treatment that might have arrived, she

might be alive today and certainly would have had more time. I

married Betsy in 1978 and I will never regret it.

In 1979, I took a job with Bendix, an aerospace manufacturing

company. One of the most pressing questions on my mind during

the interview, besides the wages, of course, was ‘‘tell me about your

health coverage,’’ and it was good coverage. By 1989 I had worked

with Bendix, then known as Amphenol, still known as Amphenol,

for 10 years but the economy in upstate New York had undergone

some profound transformations. Manufacturing jobs had been lost.

While putting together company functions like Unity Day, management was secretly negotiating buyouts. It was one in a long line

of buyouts and takeovers that affected a lot of Americans. The business ended up being owned by a finance company, LPL, and later

KKR, who major interest was downsizing. Seeing the handwriting

on the wall, I got lucky and took a job with ShopVAC. They had

been offered some financial incentives to open a plant in a nearby

town.

A few years later, the plant closed. Although I found temporary

work in construction, sometimes 7 days a week, and Betsy was

doing daycare, we found ourselves for the first time and only time

without health insurance. In the meantime I continued to look for

engineering positions in the area. In the fall of 1994, I began to

wonder how we were going to make it through the winter. Then I

received what in retrospect turned out to be good news and bad

news. The good news was, my old aerospace company, Amphenol,

was in the process of qualifying electrical connectors for the Inter-
37

national Space Station and had a temporary job for me. The bad

news was, they offered no benefits. I took the temporary job with

the hopes of turning it into a full-time position so that I might obtain health insurance for my family. In the meantime, I checked

into health insurance through the temp agency but the cost was

way beyond my budget. Some of the other coworkers that I worked

with were in similar situations

By the summer of 1996, I was still no closer to getting a full-time

job and by September of that year Betsy indicated that she had

some trouble. She had always been energetic and strong and dynamic but she began to lose energy and feel fatigued and complained of back pain. She didn’t want to go to the doctor’s because

it was too expensive and we really thought we needed to save the

money for more real medical emergencies like my daughter Amanda, who had injured a leg the year before and it ended up costing

$600. Neither of us realized how dire Betsy’s medical condition

was. She had gone 2 years without medical exams and lived with

the pain, hiding it from us. And once she leveled with me, we got

her to a free clinic, and the diagnosis was breast cancer, which was

confirmed at a local hospital through an MRI. Once we knew how

sick she was, I was able to get her to a specialist at Memorial

Sloan Kettering Cancer Center. Betsy died 4 days later, leaving me

and my three children alone, 17, 13 and 9. Betsy was 36.

In retrospect, we may have been able to do more but we had no

idea how truly sick she was. You can’t imagine going to a doctor’s

office and confessing you have no insurance. There is an instant reaction. You become a second-class citizen and questions of payment

supersede questions of treatment. The fact is, we had no health insurance because I couldn’t afford it. Other Americans have insurance that turns out to be inadequate for their needs. Others find

the system so complicated and confusing, they don’t know which

way to turn. Yes, when you find yourself with cancer, you figure

out the system, but by that time it is too late.

Numerous studies including one that has come out from the

American Cancer Society demonstrate that people who lack insurance delay going to the doctor until they are sick and their outcome

is worse for that.

For those that would like to know more about my testimony and

my story, you could refer to a book that just came out, ‘‘Sick’’ by

Jonathan Kahn.

Mr. Chairman, the American Cancer Society has developed a

statement of four essential principles that define meaningful health

insurance. They call these the four A’s. In its most basic form,

meaningful insurance must be adequate, available, affordable and

administratively simple. It sounds good to me and I would ask that

the American Cancer Society’s Statement of Principles be included

in your hearing records.

Thank you, Mr. Chairman, and members of the commitment, for

this opportunity to speak to you today.

[The prepared statement of Mr. Rotzler follows:]

TESTIMONY OF GARY DONALD ROTZLER

Good morning, Mr. Chairman, and members of the committee. I very much appreciate the opportunity to testify today. My name is Gary Rotzler, and I am a private
38

citizen speaking on behalf of the American Cancer Society. I am also speaking for

the millions of American families who cannot afford, or do not have access to, meaningful health insurance. As a result they have little access to preventive care that

prevents sickness and death.

I speak with authority on this matter because that is what happened to my wife

Betsy Jane Harvey. She died of breast cancer. Had we had insurance, and had she

had timely care and treatment, she might be alive today—we certainly could have

given her more time than she had.

I married Betsy in 1978, and I will never regret it.

In 1979, I took a job at Bendix, an aerospace manufacturer and one of the most

pressing questions I asked during the interviews was ‘‘tell me about your health coverage.’’ It was good coverage.

By 1989, I had been working for the same company for 10 years but times had

changed. The economy of upstate New York where I live was undergoing a profound

transformation. Manufacturing jobs were being lost. While we were asked to pull

together in company functions like ‘‘Unity Day,’’ management was secretly negotiating a buy-out. It was one of a long line of buy outs and takeovers that affected a

lot of Americans.

The business ended up being owned by a financial company (LPL and later KKR)

whose major interest was downsizing. Seeing the handwriting on the wall, I got

lucky and took a job with ShopVAC, a commercial vacuum cleaner manufacturer

that had been offered financial incentives to open a plant in a nearby town.

A few years later the plant closed down.

Although I found temporary work in construction seven days a week and Betsy

was doing daycare, we found ourselves, for the first time, without health insurance.

In the meantime, I continued to apply for engineering positions.

It gets cold in upstate New York and in 1994 I began to wonder how we would

make it through the winter. Then I received what in retrospect turned out to be

good news and bad news. The good news was that my old aerospace company was

in the process of qualifying products for the International Space Station and had

a temporary job for me. The bad news was that they offered no benefits.

I took the temporary job with the hope of turning it into a full time position so

that I might obtain health insurance for my family. In the meantime, I checked into

health insurance through the temp agency, but the cost was way beyond our budget.

My other coworkers were in a similar situation.

By the summer of 1996 I was still no closer to getting a full time job. By September of that year, Betsy gave me the first indication at what we might have in front

of us. I knew it wasn’t good, that she was in danger.

She had always been incredibly strong and energetic—it was her dynamic energy

that kept the five of us together. She began to lose energy, feel fatigued, and complain of a chronic pain in her back. She didn’t want to go to the doctor because she

said it was too expensive. We needed to save our money for what we thought were

real medical emergencies—like my daughter Amanda’s leg injury the year before,

which ended up costing $600. Neither of us realized how dire Betsy’s medical situation really was.

She had gone two years without a medical exam and was living with her pain—

hiding it from us really. But finally it got so bad she leveled with me. We took her

to a free clinic, where the doctor examined her for just a few minutes, and delivered

the news—she probably had breast cancer.

We took her for an MRI at the local hospital where her cancer was confirmed.

Once it was clear how sick she really was, we were able to get her into Memorial

Sloan Kettering Cancer Center, but it was too late. Betsy passed away in my arms

four day later leaving me and our three children aged 17, 13, and 9.

In retrospect, we may have been able to do more for her—but we had no idea how

truly sick she was. And you can’t imagine what it is like going into a doctor’s office

and confessing that you have no insurance. There is an instant reaction—you become a second class citizen—questions of payment supersede questions of treatment.

The fact is, we had no health insurance because I could not afford it. Other Americans have insurance that turns out to be inadequate to their needs. Others find the

system so impenetrable and confusing that they don’t know where to turn.

Yes, when you find out you have cancer, you figure out the system. But by then

it’s often too late.

Numerous studies, including ones that have come out of the American Cancer Society, demonstrate that people who lack insurance delay going to the doctor until

they are sick and then they have worse outcomes.

Mr. Chairman, the American Cancer Society has developed a statement of four

essential principals that define meaningful health insurance. They call these ‘‘the

four A’s.’’ In its most basic form, meaningful insurance must be adequate, available,
39

affordable, and administratively simply. It sounds right to me, and I would ask that

the American Cancer Society’s Statement of Principles be included in your hearing

record.

Thank you, Mr. Chairman and members of the committee for the opportunity to

speak to you today.

Mr. PALLONE. Thank you, Mr. Rotzler. Without objection, we will

put that document into the record, but I just want to thank you

for coming here and telling us personally your account with your

wife, and it had to be very difficult but it is really helpful to us,

and that is why it is important you be here. Thank you.

Mr. PALLONE. Mr. Montville.

STATEMENT OF TONY MONTVILLE, PRESIDENT AND CEO,

HEALTHTEK SOLUTIONS, INC.

Mr. MONTVILLE. Chairman Pallone, Ranking Member Deal and

members of the Health Subcommittee, thank you for the opportunity to be here with you today. I am Tony Montville, founder and

CEO of Healthtek Solutions. For the past 18 years my company

has provided IT software and consulting services to hospitals in the

United States and Canada. I am also here on behalf of the U.S.

Chamber of Commerce. I am an active member of the Small Business Council.

I have had a unique perspective watching the evolution of our

health care industry over the last two decades. The majority of our

work has been on business office systems and hospitals. That

means every time there were regulatory changes that impacted patient information, we were the company that was called in to modify the hospital systems to comply.

I am also a small business owner and have to deal with the same

trials and tribulations that all small business owners deal with

which include offering my highly skilled employees health care benefits in order to retain their talents. To that end, I made it my goal

to offer health insurance to my employees and pay 100 percent of

their premiums. Unlike many companies my size, I have a geographically diverse workforce with employees living and traveling

all over the country. I need to have a health plan with a national

network of physicians and reasonable out-of-network fee schedule.

Because I have fewer than 50 employees, there are only eight companies currently offering a national plan that meets my needs and

only three that will underwrite a policy for my company because

less than 50 percent of my employees reside in Virginia.

Several years ago I was taught a very hard lesson about the

business of insurance. About 2 months after renewing my health

insurance policy, one of my employees, a 24-year-old human resources assistant, was diagnosed with a very curable form of cancer. Within 1 month of that diagnosis, my insurance was canceled

without notification for clerical issues and within a few weeks my

employees started to get claims denied, saying we no longer had insurance. When I contacted my insurance carrier, I was informed

that they had every right to cancel my policy and they had no intention of reinstating it, however, they would be more than happy

to write a new policy with significantly higher premiums. I had to

scramble at the 11th hour to avoid problems with preexisting conditions for my employees and selected the most cost-effective com-
40

petitor. Even with a new carrier, my premium was doubled. The

following plan year, my HR assistant left Healthtek, and when my

insurance came up for renewal, my rate dropped back down by 35

percent.

I have since migrated to a plan with a high deductible pairing

with the option of choosing a health reimbursement account or

health savings account. Most of my employees chose the HRA option, which I fund at 75 percent of their deductible. By offering this

type of plan, we can put some accountability for health care spending habits in the hands of my employees and have them become

more cognizant of how they spend their health care dollars. This

plan sponsors a wellness program that focuses on prevention and

lifestyle. The spotlight on prevention includes ensuring my employees get annual physicals that include blood pressure, cholesterol,

mammogram and prostate screening among other necessary routine care. The focus on lifestyle offers employees perks and recognition for hitting various levels of participation and goals. I would

designate a wellness coach, who communicates the success of my

employees. We share who is taking a karate class, yoga, Pilates,

walking their dog after work or trying to quit smoking. I am encouraged by the efforts and changes that my employees are making

and I believe that prevention and wellness is a vital factor in longterm cost reduction in health care.

A small business should not be penalized for its lack of size or

diversity of its workforce. We want to offer affordable, dependable

health insurance to our employees and the type of flexibility that

will keep us competitive in our respective marketplaces. To ensure

this, we call upon Congress to help. Congress should examine legislative proposals that can help drive down costs and increase flexibility and employer options in our health system such as promoting

widespread adoption of health information technology and by reforming our medical liability system.

I have also been a longtime supporter of small business health

plans. This type of national plan would be beneficial to my employees who live and work all over the country. I am also supportive

of legislation that would amend the Tax Code to allow small businesses to set up simple cafeteria plans and flexible spending accounts for their employees.

Lastly, I encourage Congress to take note of the success that

many employers and employees are experiencing by changing our

focus from a sick care system to a health care system through preventative care. The Chamber shares my dedication to prevention,

wellness and overall health management and believes, like I do,

that this is the only way we will see true savings in our health system. Proposals that would offer tax credits to employers who provide comprehensive wellness programs for their employees would

be a great help in promoting these efforts.

Thank you for the opportunity to join you today. I look forward

to working with you to find health care solutions and I am happy

to answer any of your questions.

[The prepared statement of Mr. Montville follows:]
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Mr. PALLONE. Thank you.

Ms. Colburn.

STATEMENT OF SUSAN COLBURN, VICE PRESIDENT,

BENEFITS, AT&T SERVICES, INC.

Ms. COLBURN. Mr. Chairman and members of the subcommittee,

AT&T is pleased to have this opportunity to discuss the state of

health care today and why every American needs health care coverage.

First, I need to start and say that AT&T would like to thank

Chairman Dingell for his leadership in this area. We applaud the

fact that he has introduced health care legislation every session

since he became a Member of Congress in 1955 and for his efforts

to reduce the cost burden of health care in America.

Today there is a lot of debate about what to do. AT&T believes

every person in America should have access to quality, affordable

health insurance coverage. We also believe business, government,

individuals must work together and share responsibility in this endeavor.

I would like to discuss with the subcommittee what AT&T is facing as a company and with regard to health care some of the actions we have taken to address this growing concern.

AT&T is one of the largest private healthcare providers in the

Nation. We cover more than 1.2 million lives. We spend more than

$5.5 billion annually. This includes over 175,000 union members,

about 125,000 management employees, over 300,000 retirees and

the dependents of all of those groups.

AT&T has continued to provide its employees and retirees with

affordable health care coverage at a time when many companies

are cutting back significantly or eliminating coverage entirely. We

are very proud of the fact that AT&T continues to provide these

benefits to our employees and retirees and their dependents. We

view employer-provided medical benefits a competitive

differentiator and an important tool in building a quality workforce

but the financial commitment is large and it is getting larger.

While it is our desire to continue providing these benefits to our

employees and retirees, we find ourselves in an industry where

competitive pressures may threaten our ability to do that. Our

competitors typically do not provide this same comprehensive benefits coverage that is almost entirely subsidized by their employer

to their active employees and even less likely to provide health care

coverage to their retirees. This puts AT&T at a distinct cost disadvantage at a time where speed and efficiency is critical to the

Nation’s broadband development.

At the same time, we face the realities of the global marketplace.

We compete with firms from around the world which do not have

the same health care costs and health care costs are one of the factors which affect a company’s decision regarding location of its employees.

Given this backdrop, the natural question is, what can be done

to address these problems. AT&T has worked diligently to control

its own health care costs but we believe no single employer can

solve the problem on its own. It will take a concerted effort on be-
46

half of employers, individuals and the health care industry to tackle these very difficult issues.

Employers should provide tools and education to employees in

order for them to properly utilize their plan. Employers need to

stress the importance of wellness to the participants in their health

care plans. Regular physicals and screenings should be a part of

every health care plan in order for individuals to detect issues before they become problematic.

It is critical that accurate quality and cost data be available to

consumers so that they are able to make informed decisions, and

to that end, AT&T was an early supporter of Secretary Leavitt’s

Four Cornerstones of Value-Driven Health Care, which include a

call for transparency of provider data including cost and quality

data. Another cornerstone addresses increasing the use of technology in the health care sector. AT&T believes the use of technology is absolutely critical in order to introduce more efficiency

into an inefficient and fragmented health care industry. AT&T is

in direct discussions with our service providers on how technology

can be better utilized by their contracted physicians and facilities.

Finally, as plan sponsors, we should incorporate efficient and effective design and concept into our plans in an attempt to mitigate

costs. But one of the other key components of this equation is the

individual patient. The time is critical for individuals to be responsible for their own health. This responsibility includes lifestyle

changes that improves their health such as engaging in weight

management and smoking cessation programs and following treatment protocols prescribed by their physician, particularly adherence to drug therapies.

Another issue is the uninsured. Large numbers of uninsured increase the cost of coverage for the population that actually provides

insurance. The cost of caring for the uninsured, particularly by hospitals, is partially subsidized by providers adding their unreimbursed costs to the price they charge patients with insurance. This

cost shift is a problem for companies like AT&T that are trying to

do right by their employees. In addition, as you know, the lack of

insurance directly affects the type and amount of health care services the uninsured receive.

In terms of the health care industry, it must step up and adopt

technology that improves efficiency in operations at a faster rate

than they are today. In addition, the industry can do more in the

way of reporting both quality and cost data for individuals to make

informed decisions.

Regarding the Government, it must continue to support employer-based systems by not eroding the protections provided under

ERISA. Having a common set of rules for a national employer like

ourselves to follow increases the efficient provision of health care

coverage across the Nation.

Mr. PALLONE. Ms. Colburn, you are over a minute so if you could

summarize.

Ms. COLBURN. Certainly. To summarize then, any legislation

should proceed only after assessment of the effects of reform on numerous considerations and these have to include the effect on quality, efficiency and cost of health care, preservation of patient

choice, reduction and elimination of systemic costs driven by health
47

care, nondiscriminatory impact on American corporations, and the

elimination of the drag on global competitiveness.

Thank you for the opportunity to speak today.

[The prepared statement of Ms. Colburn follows:]
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Mr. PALLONE. Thank you. That concludes our statements by the

witnesses, and I am just going to recognize myself for 5 minutes

to ask some questions.

I wanted to start out with Senator Daschle, and I know you have

addressed why to some extent why you think that the crisis of the

uninsured really is a crisis and why it impacts us, but I know that

every time we do polling we see that people care more about health

climate change and the crisis in health care than any issue, but if

you could tell us why having so many uninsured really is a threat

to our country, and I know there are a lot of competing ideas about

what to do about it but what specifically do you think we should

do about it?

Mr. DASCHLE. Well, Mr. Chairman, I think that is such a good

question and I would just give three parts to the answer. I think

you just heard from one of our witnesses whose wife had an extraordinary demonstration for all of us as to what happens when

we don’t have insurance, the tragedies that are multiplied by the

millions around the country. That in and of itself is one huge reason why I think we as a country need to be concerned. The lack

of productivity that is resulting from it in addition to the tragedy

is something we certainly need to recognize. The second part of it

is that, as I said earlier, the cost shifting that occurs is really

something we need to be very concerned about. You look at all

costs in health care in my view as balloon and there are three components. There are taxes, out-of-pocket expenses and premiums.

We can squeeze down the premiums by providing more tax credits

but somebody is going to pay for that balloon. That $2 trillion is

still going to be paid for. The cost shifting we are told by many

studies that have been put out now is about $900 of the $6,700 per

person that we pay. So we are all paying more as a result of the

cost shifting that goes on. Finally, I think it is just the humanitarian thing to do. We are the only industrialized society that

doesn’t have health care and I can’t imagine what we want to say

about society, what we want to say about our children and grandchildren in the future if we say that somehow we are willing to accept the reality that 45 million today, perhaps 55 million in 20

years, won’t have insurance, not to mention all the underinsured

besides.

Mr. PALLONE. Thanks. I appreciate that.

President McEntee, I wanted to ask you about the employersponsored system, a couple questions. If employers that you negotiate with were to drop the health coverage they provide, what kind

of alternatives would the employees have? Is it really possible for

them to go out in the individual market? That is No. 1. And second,

I know you have seen workers laid off and as a result losing their

health coverage, what do you think about the employer-sponsored

system? I know we talked about public systems versus employersponsored. Obviously you still think that the employer-sponsored

system is critical.

Mr. MCENTEE. Yes, we do. We think that an employer mandated

part of this system is critical to us. Our people, we have 1,400,000

members and I would say that a good guess would be that they are

all public workers or at least 95 percent, they average probably

about $25,000 to $30,000 a year in terms of salary. If they would
53

lose their health care coverage, have to go through the individual

market, which is much more expensive than group coverage, these

individuals themselves would actually be denied coverage in the individual market for minor health issues and it wouldn’t be affordable to them in the private market to get health care coverage.

That is why we believe that an employer pool is mandated in this

particular case. Our people just couldn’t afford it. There is no question about that, and we have had the opportunity to see this because we have thousands and thousands and thousands of people

in the population who are childcare workers and home health care

workers who have no health care through the employer. We are

trying to negotiate it for them as we organize these workers. But

what they end up is through the private sector and through the

private system with no health care at all, and as a result——

Mr. PALLONE. I wanted to ask in the same vein because my time

is running out, what about what the President has proposed in this

regard? He is talking about a tax on employer coverage and that

would help people if they want to go in the individual market. Do

you want to comment on that in the context of this?

Mr. MCENTEE. Well, we just think that it is misdirected, that it

would encourage employers to drop their health plans when over

time in the beginning some but then over time probably all and

that they would drop their health plans because they lose this tax

rebate that they now receive and that the President would take

away. It would force in our judgment our people we represent,

workers in general, to pay more for what in fact would be skimpier

coverage in the individual market. It would not help low-income

families who already have little or no tax liability. The tax benefit

for them will not pay for health care insurance policy at all.

Mr. PALLONE. Thank you. I appreciate it.

I recognize Mr. Deal.

Mr. DEAL. Thank you, Mr. Chairman.

I am going to ask questions that hopefully we can get everybody

to respond to. The first question is, we have heard reference to the

Tax Code treating people fairly. Is there anybody on the panel that

would be opposed to the concept that the Tax Code should treat everybody fairly when it comes to paying for the cost of health care

whether it be a small business versus large business, individual, et

cetera? Should we equalize or at least try to equalize as much as

possible the Tax Code treatment of the cost of health care? Anybody disagree with that proposition? I see no response.

If we have public programs such as Medicare, Medicaid, SCHIP,

should we allow a portion of those benefits if the individual chooses

to do so or the State, as it may be, should we allow them to use

a portion of those benefits to buy into an existing employer-offered

health policy if the individual has that option? Would anybody

agree that we should not afford that option in these programs? I

don’t see anybody. Yes, Ms. Turner.

Ms. TURNER. I believe that is a very good idea so I think if the

question is a yes or no, that yes, we do agree.

Mr. DEAL. OK. I think everybody seems to agree to that. It is

getting a little tougher as we go down my list. Does anybody disagree with the proposition that small businesses ought to be treated the same as large businesses in particular as it comes to the as-
54

sociation health plans to allow them to pool together to be able to

purchase at a lower rate by pooling their people together? Does

anybody oppose those, and if so, why.

Mr. DASCHLE. I want to address both of your last two questions,

if I could for just a second.

Mr. DEAL. OK.

Mr. DASCHLE. First of all, on the SCHIP question, I think obviously we want to provide as much flexibility as possible to those

who are in need of insurance. I worry a lot about the inefficiency

and the complications that would come from something like that.

Vouchers sometimes work, sometimes don’t. I don’t know that I

have seen any record with regard to vouchers where we have seen

that they have worked all that well, but that would be the one concern I have is whether we further complicate it. Obviously we don’t

have enough money right now to provide SCHIP funding for the

universe of children that are in need of it. We are about 9 million

children short today and we are still struggling with how we are

going to find ways to provide the funding for SCHIP. Under the

current circumstances, I think this would probably add to the complications.

Mr. DEAL. But we know, Senator, that many of those SCHIP

children, their parents work for companies that do provide health

insurance benefits, they just do not participate sometimes because

they don’t feel they can afford the extra premium. I think we would

have to have a standard, in other words, it would have to meet the

same equivalent as good or better than the SCHIP program that

the State offers, otherwise they wouldn’t choose that option anyway. I guess that was my point.

Mr. DASCHLE. With regard to the associated health plans, as long

as they aren’t allowed to get out from under the ERISA needs that

are there across the country. That has always been the issue is,

there are real serious problems as the attorneys general have all

noted that we would have to address with regard to ensuring that

the benefits and the viability of the associated health plan can be

maintained. Oftentimes they can’t because they get out from under

ERISA requirements which as our witness from AT&T noted is

really one of the most problematic parts of dealing with the associated health plans as they are currently proposed.

Mr. DEAL. Let me go to another area.

Mr. MCENTEE. Could I make a comment on those AHPs? We are

willing to look at it. We are all here willing I think to look at everything because the problem is so dire. But at least preliminarily in

what we have looked at, that there is a possibility that with these

small business flexibilities that you would give, it could possibly

override the regulations in terms of States that presently give better benefits and may end up costing the small businesses more and

may end up giving less benefit to the worker, but we are willing

to look at anything and everything——

Mr. DEAL. Well, I think you should since none of your members

apparently are going to be affected by it, and ERISA does override

those small restraints already.

Mr. MCENTEE. Of course, ERISA is a problem for every State in

terms of trying to put into effect their own particular State benefit

and plan.
55

Mr. DEAL. Unfortunately, my time is out.

Mr. PALLONE. Ms. Eshoo.

Ms. ESHOO. Thank you, Mr. Chairman. Thank you to all the witnesses. I could just keep listening and listening and listening.

Senator Daschle, thank you for trying to separate fact from fiction with the myths in our system. I have the privilege of representing one of these islands of excellence, Stanford Medical Center and everything that is attached to it, but I have a community

that may be about a mile and a half east of that medical center,

East Palo Alto, not Palo Alto but East Palo Alto. It is the poorest

community in the area. Most people don’t think that there is anything poorer in Silicon Valley. So I agree with what you said.

Mr. Rotzler, thank you for being here today. I think to honor you

and all those that you are speaking on behalf of that we really do

something meaningful, that we really get something done. All these

different moving parts, what I think are the smaller things. I think

it would be a big step for the committee to take it, but in the context of health care in our country, we should insure all kids in this

country. Imagine the United States of America struggling to come

up with something to insure something. They are the cheapest to

insure. Whatever the bugs are in the plan that we have now, we

should debug it and insure them all. That would be one heck of a

down payment and a confidence builder in the American people

that we can get something done. Health information technology,

Mr. Rogers and I are working on that. I like all those things. I try

working on them to make a difference. But I think what we need

to examine, and I am fascinated about what is going on in my own

State of California. We have a Republican Governor that is trying

to negotiate with the legislature really a universal plan where it

is mandatory that every Californian be in it and be insured. The

Democrats are kind of hedging. They are saying they are doing the

same thing but it is really not the same thing. It is a model worth

watching. I appreciate, Ms. Colburn, what your company is doing.

I don’t agree with your telecommunications policies here in the

Congress but I salute you for what you are doing with your employees.

Now, what I would like to ask is, because our country’s health

care insurance has really been employer-based in our country, that

has been the nub, that has been the heart of it, now these legacy

costs, the costs relative to competition are killing businesses. We

hear it, we know it, we experience it in our own communities.

Major corporations come in here and tell us that. What can you tell

us from AFSCME’s point of view? You are talking to major employers.

Senator Daschle, you are a smart man. You have your pulse on

the larger things and the movements that are taking place in the

country. Is there a possibility in your view that major businesses

will come around to universal care? Now, this term scares the hell

out of the Republicans but I have to tell you that I think if major

corporations came here and said it is time to revise this system, I

think that there may be some converts, and if we can speak to at

the same time about lowering the costs, you mentioned, Senator

Daschle, the three things that balloon, so universal coverage but

also with universal coverage comes a reduction in costs. Boy, would
56

we have a deal. Do you see any glimmer of hope relative to American businesses and what they are experiencing driving this? See,

I think that is where the answer is going to come from and that

is what is going to put some spine in the Congress, I think, because

when businesses come around, it kind of sanctifies things. They

drive all of this too. Can you comment on it? Do you have any stories you can share with us or some kind of movement in that

arena?

Mr. DASCHLE. A couple of thoughts, first of all, the fact that

AT&T is at the table I think is a real exciting development and you

are seeing more and more business, whether it is Dupont or GE or

so many of the companies that have gotten involved now in coalition building with labor and with other organizations like AARP.

I think that is an extremely positive thing and it goes to the point

I was making earlier. We have got to have the commitment of business and leadership in business to be able to move this forward.

On the flip side, one of the sad things I just experienced a couple

months ago was talking to the chairman of a large corporate entity

who decided to move to another country because they didn’t want

to pay the health costs in the United States, and I worry about our

global competitiveness if we are not more effective in dealing with

cost containment than we have today, and the only way you can

truly deal with cost containment is to look at it in a universal context. You can’t simply say we are going to take a piece of it and

contain that cost because it affects all the other pieces.

Ms. ESHOO. It is like punching a pillow. You put a dent in it and

something else pops up.

Mr. DASCHLE. Exactly, and so we really have to look at it in a

comprehensive way.

Ms. ESHOO. Thank you.

Mr. MCENTEE. Yes, I would just mention back with that Clinton

health care plan, there was a point in time that in discussions with

the labor movement and big business in this country, because they

were getting hammered then in terms of health care costs and

globalization but then it finally didn’t work out in part. I know that

former leader Gephardt is now holding discussions with big business and big labor, particularly the industrial unions, whether it is

the machinists or whether it is steel, whether it is auto, who are

genuinely affected by this, as well as their employers to look at

some kind of move, some kind of plan. I know they are looking seriously at Medicare for all. I know that. What will come of it, I don’t

know, but at least it is a try and a step in the right direction.

Mr. PALLONE. Thank you.

Ms. ESHOO. Thank you, Mr. Chairman, and thank you to all the

witnesses. I think you have really been outstanding.

Mr. PALLONE. Thank you, Ms. Eshoo.

Dr. Burgess.

Mr. BURGESS. Thank you, Mr. Chairman. Since Ms. Eshoo

brought up the issue of universal health care, let us just go down

the table and ask the question. If our goal is universal health care,

Ms. Colburn, should that be an employer mandate, an individual

mandate or just back off and let the Government do it all?

Ms. COLBURN. Well, I think what we would say is that we are

not really prepared today to say that we are totally locked in on
57

any one idea nor have we alienated any idea and I think to your

point we have got to be open to work with Government, with the

unions, with other large business. There has obviously not been the

answer that has surfaced——

Mr. BURGESS. So you would like flexibility. All right.

Ms. COLBURN. But we are looking at everything.

Mr. BURGESS. Mr. Montville, the same question. Employer mandate, individual mandate or let the Government do it all?

Mr. MONTVILLE. I am all about options. I am a small businessman and——

Mr. BURGESS. So you like flexibility also?

Mr. MONTVILLE. I really like flexibility, yes.

Mr. BURGESS. Mr. Rotzler, do you have a thought on that?

Mr. ROTZLER. I will defer at this point. I don’t have any comment

on policy.

Mr. BURGESS. Ms. Turner?

Ms. TURNER. I think we need to get the market working properly

and find out how many people would buy health insurance on their

own if it were more affordable, more flexible and people had more

options than they do now. We need a truly competitive market for

insurance. Then I think we can see what do we need to do to get

to universal coverage. But I think we need to start first by fixing

the market.

Mr. BURGESS. President McEntee?

Mr. MCENTEE. We think it is well worth looking at a combination of all but we think a major pillar has to be an employer mandate but we are willing to look at a combination of all.

Mr. BURGESS. Well, a combination of all would include letting the

Government do it all would then be mutually exclusive, but I appreciate your point and so the employer mandate would be part of

what you would——

Mr. MCENTEE. Yes, that would be a main pillar of it, of course.

Mr. BURGESS. Mr. Smith?

Mr. SMITH. Sure. We incorporated the private market with Government assistance in terms of making sure that we did get the uninsured insured. We steered away from the individual mandate

until 2010 to give our outreach programs a chance to succeed. We

found that we have mandated insurance for car insurance in the

State of Vermont yet we still have 10 percent of people who are uninsured for car insurance. We wanted to take this other approach

first. The product that we offer with the cost we think will be

enough so that we don’t need an employer mandate as we move

forward.

Mr. BURGESS. And Senator Daschle?

Mr. DASCHLE. I believe we ought to have a private system in a

public framework. One way to accomplish that is an individual

mandate with employer responsibility. We ought to get the employers out of health management but I do believe that the employers

have a responsibility to be part of the larger effort to finance our

health care system.

Mr. BURGESS. The issue always comes up, if we were going to

make the Medicaid system today, say we didn’t have it and we

were going to start it from scratch, surely we wouldn’t design a sys-
58

tem that requires 2,700 waivers in order to work. Would what you

envision be your Federal Reserve Board type of structure?

Mr. DASCHLE. Well, there always is going to be a need for a Federal role just as we have in our banking system. There is a specific

role that only government seems to be able to function within our

economy and our society and I think that is certainly going to be

true in health care in the future. But you are right, I think the

Medicaid/Medicare system was primarily a product of compromise

all the way through beginning all the way back in 1965. You could

design a lot more efficient system. You could design a lot more effective coverage. But nonetheless, I think we are always going to

have to have some option for those who can’t afford to pay for

themselves.

Mr. BURGESS. I need to get back to the Medicare issue but Ms.

Turner, I wanted to come back to you and the concept of getting

the market more involved and we have actually heard it approached from several ways. Mr. Montville talked about his experience. Mr. Rotzler, I guess I would be interested to know when you

found yourself between jobs and without insurance, was there an

option in the private market for you to go to and it was simply

unaffordable or was there no product available?

Mr. ROTZLER. It was unaffordable at the time, and I was working

and figured that it would be a full-time job and had no reason to

believe that my family was in any kind of danger.

Mr. BURGESS. It is nowhere near the tragedy you sustained but

I had an adult child at that same year and tried to buy an individual policy for her because she was unemployed, and I just simply

couldn’t find one. No one really wanted to talk to me. I was willing

to write a big check but no one was willing to do that. I do like

what Mr. Montville talks about, his health reimbursement accounts

with the health savings account. I think that would be my vision

of a first-class system. I had a medical savings account when I was

in medical practice after you guys allowed them in 1997 but fast

forward from 1994 to 2004, 2005, and a young person today can go

on the Internet and buy, albeit a high-deductible policy but they

have got some coverage if the catastrophe strikes. They are going

to pay for their routine care sure enough out of pocket because the

deductible is so high and for some people that will be a barrier.

They won’t get their routine care done. But I guess when someone

said we have done nothing, that is not exactly true and there are

options that were not available there as short as 10 years ago and

I know because I did try to buy that policy in 1994 and it just was

unavailable to me for an individual purchasing it for an individual.

I have gone over time, Mr. Chairman. I appreciate your indulgence.

Mr. PALLONE. Thank you, Doctor.

Next is the gentleman from Texas, Mr. Green.

Mr. GREEN. Thank you, Mr. Chairman, and I appreciate our

panel and their patience.

Senator Daschle, I want to thank you for being here today and

your wealth of experience on the subject. Yesterday our Oversight

and Investigation Subcommittee heard from a family whose child

now needs a kidney transplant as a result of her eating spinach

contaminated with E. coli. The family indicated they can no longer
59

pursue any advancement in their careers that would lead to a

change in employers because the child’s access to health care is dependent on their employer-sponsored health insurance. They fear

that a future employer would either not cover the child or they

would be faced with unaffordable premiums due to the child’s preexisting condition, maybe even for the year period of time that is

traditional. Can you speak to that situation that specifically affects

how many Americans who want to advance their careers and improve their productivity and are making these kind of decisions and

also would a public system free the family from this situation?

Mr. DASCHLE. Well, this is just another example. Dr. Burgess

was just talking about one of his own children having lack of access

to health insurance because of a preexisting condition. I know of

people in South Dakota, Congressman Green, that drive 50 miles

in one direction not because they want the job but because they

want the health care. It is affecting lifestyle in South Dakota as it

is in virtually every State in the country. Health care is becoming

one of the largest motivation in seeking employment today because

in large measure there are so many people either with preexisting

conditions or the inability to afford the health insurance they can

buy without a preexisting condition. It shouldn’t be that way in a

country. How many times are we making decisions on jobs that

have nothing to do with the value of the job or the productivity

that one might consider in a job more well suited for that individual but is not taking that job simply because they don’t have access

to health care. So I think your question is a very appropriate one

and it is one of the many policy implications here that we have got

to address.

Mr. GREEN. Mr. McEntee, we recently had a case in our district

of a woman who had a brain aneurysm, and I am not one to pick

on certain companies, but she had health insurance through her

employer at Wal-Mart and she was originally misclassified as a

part-time employee that had a $25,000 cap on the coverage. We

were lucky enough, we had Memorial Hospital in Houston who

agreed to assist the lady. In hindsight, Wal-Mart found out she was

misclassified and she was a full-time employee and had been there

for more than a year and so she did have hospital coverage. In my

view, we have enough pressure on our charity systems, because

that is what Memorial Hospital did to a person who was working

full time and individuals with health insurance shouldn’t be part

of that program. Can you or any of the panelists speak about how

many employers may have these limited maximum policies because

when you have a brain aneurysm that is $100,000 and you have

a $25,000 cap on your insurance?

Mr. MCENTEE. Well, we do have a number of them that have a

cap but it is getting tougher and tougher and tougher out there.

Our people in the public sector, not all but many, have pretty decent health care plans that they gave up wages, vacation days, sick

time in order to get these health care plans. Number on their

minds all across this country no matter who the employer is,

whether it is the State of Pennsylvania or it is the State of California or whomever, in our negotiations today the first thing that is

mentioned is, you have got a halfway decent health care plan but

we have to change it, it is too costly, we have to change it and as
60

a result if we keep it the way it is, there will be no wage increase.

Now, once again I said our people average about $25,000 to

$30,000 a year. So at every negotiation we go in today, that is the

primary topic between the employer and the people that we represent. Every poll that we take, every meeting that we go to, the

first thing that is mentioned is how about health care, what is the

Congress going to do, what is the Government going to do, what

are they going to do about universality, what are they going to do

about these co-pays, what are they going to do about these kinds

of things. It has been mentioned here, we are the strongest,

wealthiest country in the world. We still don’t insure all of our

kids. And now instead of going in the direction where we are going

to have better insurance, we are going in the direction at least as

we see it where we are going to have less.

Mr. GREEN. Mr. Chairman, I know my time is out but I want to

thank Ms. Colburn from AT&T, and just for the record, I have had

the CEOs of a lot of companies sit down with me, and I will quote

Shell Oil particularly, because of the high price of natural gas in

our country and the high price of health care, they are transferring

production to the Netherlands, and North Sea gas is cheaper than

what we can get in Texas even for our natural gas but the health

care costs, and so following my colleague from California, we have

a problem and whether it is a CEO or a blue-collar worker, we

know it and we need to deal with it in Congress and hopefully it

will be at the suggestion of both sides of the bargaining table that

we can deal with it, so thank you.

Mr. PALLONE. Thank you.

The gentle woman from New Mexico.

Mrs. WILSON. Thank you, Mr. Chairman.

Ms. Turner, I had a couple of questions I wanted to direct to you.

As I understand it, the current SCHIP program allows States to

provide premium assistance for eligible children to purchase employer-provided health care but there hasn’t been a lot of participation in this approach. I wonder if you could talk about any impediments that States have encountered in setting up these programs

and offer any suggestions about how we might be able to address

these impediments.

Ms. TURNER. Thank you, Mrs. Wilson. I do think a lot could be

done to allow SCHIP dollars to be used to help people add their

children to their employment-based coverage, but right now the

rules and regulations make it incredibly cumbersome for States to

actually comply with the rules governing this part of SCHIP. We

have actually done some research on this, and there are only a few

States that have gone through multiple hoops to try to comply.

They have to qualify the employer’s insurance as consistent with

SCHIP insurance. They must continue to regularly monitor the

business to see if that employee is still working for that company.

It is cumbersome for employers. It is cumbersome for the States

and most States just throw up their hands and say that is just too

difficult. So I think giving added flexibility to the States, looking

at some of the States that have been able to do this and learn from

them. We can provide you some additional research on what some

of those States. The General Accounting Office recently did a study

looking at this particular issue and I do think that added flexibility
61

could really allow those dollars to be used more efficiently and to

allow families to stay together on the same policy by allowing an

SCHIP allocation to be used to buy into employer coverage, but the

rules and regulations right now are incredibly cumbersome.

Mrs. WILSON. Are there any particular States that have worked

out these problems and done well or are there particular barriers

in the regulations that you would recommend that we look at when

we reauthorize SCHIP?

Ms. TURNER. There are several States. I have not looked at that

research recently. I believe Rhode Island is one of them that has

actually had some success, maybe Connecticut.

Mrs. WILSON. Without putting you on the spot, perhaps if you

could——

Ms. TURNER. I will send you that paper, because there are some

States that have said this is important to us, we will do this, and

we will provide that information to you, Mrs. Wilson.

Mrs. WILSON. There is a separate issue, and that has to do with

health savings accounts and I understand that you were one of the

proponents of establishing them and in many cases they are more

affordable for people than regular insurance plans. Can you talk

about the impact of health savings account on the uninsured and

particularly how many enrollees in health savings accounts have

been previously uninsured? Is it expanding access?

Ms. TURNER. American’s health care plans actually recently released a study looking at all of its members that offer health savings accounts insurance and they found that a quarter of those purchasing insurance, and these are primarily big companies, were

previously uninsured and they find that one of the reasons that

they are particularly attractive is that the insurance is less expensive. It is a higher deductible policy but it protects people against

losing their homes, losing their cars, losing their life savings if they

do have a major medical event. So people are buying insurance in

sort of the true form and then a surprising number of them also

are funding the accounts but I think that the numbers for some of

the smaller companies may even be higher. So between a fourth

and a third of previously uninsured.

Mrs. WILSON. Do you think that the low-hanging fruit is already

gone out there for health savings accounts or is there more potential for them to expand or reduce the number of uninsured?

Ms. TURNER. Absolutely. The Labor Department’s figures are

showing that four in 10 Americans change jobs every year, I think

there is an ever-growing need actually for people to find other options for more affordable health insurance.

Mrs. WILSON. Thank you very much.

Thank you, Mr. Chairman.

Mr. PALLONE. Thank you.

Mr. Rogers.

Mr. ROGERS. Thank you, Mr. Chairman.

Mr. Montville, you talked about moving from an insurance-led

health care product to kind of a consumer-led product, HSAs, if you

will. You said you saw and witnessed in your company a change

in lifestyle. Can you talk about that briefly?

Mr. MONTVILLE. Sure. I chose to fund 75 percent of the HRAs

when I switched to a high-deductible plan and I considered funding
62

100 percent but felt that by there being a level of accountability on

the part of my employees, they would be more responsible with

their health care dollars, and I had a lady that worked for me that

every time her son was sick she would run off to the emergency

room, but as soon as she realized that once the funds were depleted

in that health reimbursement account, once they were depleted

there was money out of her pocket before the plan kicked in, people

were a lot more fiscally responsible with the way they were spending their dollars.

Mr. ROGERS. So you saw a change in their behavior because they

were responsible for their own administration of health care? Is

that correct?

Mr. MONTVILLE. That is correct.

Mr. ROGERS. And so they did turn into more of a preventative

consumer, did they not?

Mr. MONTVILLE. Slowly.

Mr. ROGERS. But you did see it?

Mr. MONTVILLE. Yes, I did.

Mr. ROGERS. And as the economics caught up with it, certainly

their attitude changed, right?

Mr. MONTVILLE. Very much so.

Mr. ROGERS. Ms. Colburn, you mentioned the foreign competitors. Do you feel the European Union, would that be included in

your foreign competitors component when you talked about competing globally?

Ms. COLBURN. European Union. Also, even the emerging domestic telecommunications market. When we talk about competitors it

is a whole new ballgame and a lot of those don’t offer health care.

Mr. ROGERS. Sure, but let me just give you an example with the

French, 75 percent of those bills are paid for by payroll contributions from both employers and employees so that is a pretty heavy

tax, isn’t it, when you start talking about those kind of numbers?

And then the last 25 percent comes from Government, patients and

supplemental insurance. That is a pretty expensive health care system that is supposed to be free, isn’t it?

Ms. COLBURN. Well, it certainly sounds like it, yes.

Mr. ROGERS. And in some cases, you said that their health care

is better, and let me give you another European competitor of

yours. In Great Britain, you have to wait more than a year after

being diagnosed to begin chemotherapy. The British Government is

now spending a small fortune and they are trying to correct this

by 2010 to get it down to 3 months. Is that a better health care

system than the United States when you are diagnosed with cancer?

Mr. COLBURN. It certainly doesn’t sound like it.

Mr. ROGERS. So if you had—God forbid, and I am a cancer survivor so I don’t make light of this easily, but would you rather get

sick in France or Canada or where they have these waiting periods

or would you rather get sick in the United States if you had cancer?

Ms. COLBURN. I would really rather not——

Mr. ROGERS. I guess I say that because I had a very big manufacturer tell me how great the British system was and he was a

very senior CEO and I would argue that the AT&T executives are
63

well compensated, probably in higher tax brackets and rightly so,

given your levels of responsibility. Fair to say? This particular

manufacturer said this is a great system, and I said oh, really did

you like the waiting periods, and he said I didn’t go to the waiting

periods, I bought my own plan. Do you think it is fair that we

shove into this is a government-run system and then have those

who have a little more affluence be able to buy out of that system?

Is that a good system?

Ms. COLBURN. Well, first of all, we haven’t espoused any government-run system. In fact, if anything, where we are today is much

more in line with Mr. Montville. We have put in a consumer-directed plan for our management and many of our management——

Mr. ROGERS. That is a very important distinction, so you are not

here today saying that the Government ought to run health care?

Ms. COLBURN. I’m really saying that we are looking at everything

and we are really very much willing to work with all parties——

Mr. ROGERS. Would you support a government-run health care

system?

Ms. COLBURN. We haven’t espoused to it but we haven’t alienated it.

Mr. ROGERS. That is interesting.

Mr. Montville, when you went through this process of changing,

there are a lot of rules and regulations.

Mr. MONTVILLE. Constantly.

Mr. ROGERS. Lots of rules and regulations.

Mr. ROGERS. Some estimates in America are as high as 30 percent of it, maybe even more, almost a third, is rules and regulation

compliance, has nothing to do with x-rays or prescriptions or seeing

a doctor. In your experience, it was pretty heavy, wasn’t it, the

rules and regulations that you as a small business had to kind of

wade through to get your employees connected to a health care

plan?

Mr. MONTVILLE. Yes, it was very extensive.

Mr. ROGERS. And that is expensive, isn’t it? You know as a small

businessperson that rules and regulations and Government intervention is expensive.

Mr. MONTVILLE. Yes, it is.

Mr. ROGERS. That is interesting. So I find it interesting that the

panel today, and I think we all want to get to the same place, but

what we are calling for is this huge intervention in a system that

I think is pretty expensive because the Government has intervened

so heavily already.

Ms. Turner, you talked about HSAs and getting back to that free

market. Do you believe that Government rules and regulations and

a complicated system and 2,700 waivers under our Governmentrun health care system that we have because we can’t quite get it

right is the most efficient way to allow somebody to buy health care

in the United States of America?

Ms. TURNER. I think that if consumers had more control over the

dollars, they would say this paperwork is nonsense. People are buried in paperwork when they go to the doctor, the hospital. They

don’t understand it. And it is incredibly expensive for our system.

I think a lot of that inefficiency could be wrung out if consumers

were to say I am going to buy health insurance from a company
64

that doesn’t burden me with all that paperwork and one of the

things that health savings accounts do is allow people to access

physicians for routine care with much less of that paperwork. I

think about Jiffy Lube, for example. Imagine if our car insurance

covered an oil change or having the car lubricated. You wouldn’t

be able to see through the Jiffy Lube. It would have a huge back

shop asking ‘‘what is your insurance company?’’ ‘‘Well, you are not

due yet for your oil change and what is your co-payment? And here

is your insurance and all this paperwork.’’ The oil change would

cause two or three times what it does. If we can pay for some of

those routine changes for those who can afford it on our own and

leave the insurance for the big stuff, I think we could bring a lot

of people——

Mr. ROGERS. Isn’t the great part of HSAs that first $5,000 in deductible which sometimes the employer matches and sometimes not

but there is some match program. That is money that would normally go to the insurance company, wouldn’t it?

Ms. TURNER. Absolutely.

Mr. ROGERS. And that is now going into consumers’ pockets instead of going to the insurance company, isn’t it?

Ms. TURNER. And some employers, it is $1,000 deductible. It is

not always a $5,000 deductible. You are absolutely right that that

is money that people get to keep to spend on their health care bills

rather than sending to the insurance company.

Mr. ROGERS. That is a pretty good bet. If we went after things

like defensive medicine and we did health information technology,

there is a way, maybe not one solution but isn’t there a way that

we can line up events that we can do to make health care less complicated and confusing and as one witness said, more affordable,

more accessible without losing the quality? Don’t you think that if

we have the real courage to do this, we have to take all of the individual pots and put them together?

Mr. TURNER. Absolutely, and I am headed to Las Vegas for the

Consumer Directed Health Care Congress, and it is astonishing to

see the Expo Center, the number of private companies, entrepreneurial people coming up with solutions to make our health sector smarter, faster, better, cheaper by using new technologies and

engaging some of those technologies.

Mr. ROGERS. And where we have seen the private sector intervene in health care markets, costs have either stabilized or gone

down, have they not? Just a simple yes or no.

Ms. TURNER. Absolutely.

Mr. ROGERS. Last question for Mr. Daschle, if I may, sir. Senator, thank you for your service to your country. We certainly appreciate it. Thanks for still being involved in policy debate. Don’t

you think we are obligated, given all the things that we are trying

to do with health savings accounts, which isn’t going to be for everybody and with health IT and defensive medicine and all these

artificial costs in the system, before we go and blow that up and

go to this centralized Federal Reserve System or whatever you

want to call it that has heavy Government regulation and oversight

and all those things, don’t you think we are obligated to try all of

these other things to get people connected to health care first so

that we can expand our health care pool?
65

Mr. DASCHLE. I am so glad you asked that, Congressman Rogers.

I think that we have got to leave ideology at the door if we are

going to make decisions at all on the left and on the right. I think

if you look at the Medicare Program, you can say that we have

done a lot with it in the last 30 years, about 4 percent administrative costs versus something like 15 to 20 percent on the private sector. You have got universal access. You have got costs on a per capita basis at a much lower level. So all things considered, I think

one can say that there is always going to be a role for Federal programs. There is always going to be a role to cover children and

cover those who don’t have the means to purchase insurance, those

who like Congressman Burgess’s son or daughter didn’t have the

ability because of a preexisting condition. We are going to have to

deal with those and that is going to involve public programs. But

that isn’t to say that public programs alone should be the exclusive

way with which we provide care. There ought to be a choice. There

ought to be opportunities if they exist and can be provided in an

administrative way that ensures universal access and quality. I see

no reason why private systems don’t have a role as well but they

have to be merged together in a way that allows one system rather

than the multiplicity of systems we have today.

Mr. ROGERS. But you would——

Mr. PALLONE. We are over, Mr. Rogers.

Mr. ROGERS. But we were just getting warmed up, Mr. Chairman.

Mr. PALLONE. Yes, but we have to move on. Thank you. And let

me thank all of you. This was a very good panel and I appreciate

your responses.

Mr. BURGESS. Mr. Chairman, if I could just make one last point

if I wasn’t clear that 25-year-old in 1994 who could not get health

insurance in 2004 can go on the Internet to Google and type in

health savings account and probably find a high-deductible policy

which they can afford, between $55 and $65 a month for a 25-yearold nonsmoker in my home State of Texas. So the landscape has

changed and it has changed largely because some of the things you

did in 1997 and some of the things we did in 2003 with the Medicare Modernization Act.

Mr. Chairman, I would also like to submit one question in writing to the panel——

Mr. PALLONE. Yes. Well, the members can submit additional

questions. I should mention to you that you may get additional

questions in writing from the members.

Mr. BURGESS. Several people brought up ERISA and I am just

not clear on all of the ways that——

Mr. PALLONE. All right. We have to move on here. You may get

questions in writing within the next 10 days from us, and again,

thank you so much for participating. This was really worthwhile.

Thank you.

I will ask the next panel to come forward, if you will. We are

going to be changing the name cards and then you can figure out

where to sit.

Let me welcome all of you, and I would like to go left to right

here and introduce each of you. We have two New Jersey people

here today. First on my left is Reverend Heyward D. Wiggins III,
66

who is with the PICO National Network from southern New Jersey, and then we have Dr. Robert E. Moffitt, who is director of the

Center for Health Policy Studies at the Heritage Foundation, and

then our second New Jersey guy is Dr. David Knowlton, president

and CEO of the New Jersey Health Care Quality Institute in Trenton, and then Dr. Joseph Antos, who is the Wilson H. Taylor Scholar in Health Care and Retirement Policy at the American Enterprise Institute, and last is Dr. Jeanne Lambrew, who is associate

professor at George Washington University School of Public Health

and Health Services here in Washington, DC.

I would ask each of you to give us an opening statement for 5

minutes, and I will start with Reverend Wiggins.

STATEMENT OF REVEREND HEYWARD D. WIGGINS III, PICO

NATIONAL NETWORK

Mr. WIGGINS. Thank you, Chairman Pallone. Members of the Energy and Commerce Committee, thank you for inviting me to speak

about the moral imperative to provide health coverage to the millions of our Nation who are uninsured, beginning this year with

our most precious resource, our children.

I pastor the Camden Bible Tabernacle Church in Camden, New

Jersey. It is a city where more then one-third of the families lack

health coverage. I worked over the past decade with the Camden

Churches Organized for People to revitalize my city. I am proud to

be here on behalf of the faith-based PICO National Network. Since

1973 PICO has brought people of faith together to revitalize communities and expand opportunities for families in 150 cities and

towns across the country.

A generation ago the faith community led the civil rights movement. Today PICO’s more than 1,000 congregations and 1 million

families nationwide are a driving force behind the movement to expand health coverage in America beginning with covering all children. For communities of faith, the force behind both movements

is the same. God created each of us in his image and we have a

sacred responsibility to protect the dignity and well-being of every

person.

Two weeks ago the New Jersey State Police airlifted Governor

Jon Corzine to Cooper University Hospital in my city of Camden.

Cooper is a level-one trauma center that fights as hard to save a

young person shot on the streets of Camden as it does to heal a

Governor. Like Jesus, our trauma centers open their arms to the

poor and the forgotten. The value that our hospitals place on every

person’s life is sacred whether they be a poor child, a drug dealer,

prostitute or a public official. It is a fundamental cornerstone of our

society that has deep roots in our religious traditions and the

teachings of Moses, Jesus and Mohammed. None of us in this room

would wish to live in a nation that did not value every person as

a child of God.

Yet when it comes to the uninsured, we have lost our moral compass. We have deceived ourselves that a slow death is no death.

The National Academy of Science estimates that 18,000 people,

adults and children, die prematurely each year because they lack

health coverage. Hundreds of thousands more face unnecessary

pain and suffering. Go to the Cooper Hospital emergency room. You
67

will see hundreds of people waiting all day to see a doctor. They

come too late, they wait too long and they pray that in the end

charity care will cover the cost. Yet it is society that ultimately

pays the price when we deny people the health coverage they need

to keep themselves and their families healthy.

When people have reliable health coverage for their children and

themselves, they have the tools to bring strong, healthy families

and communities. Access to health care is a conduit to a vibrant

and productive society. Indeed, we have a moral and constitutional

obligation that the founders of our country thought important

enough to include as part of our inalienable rights to protect the

right to the pursuit of life, liberty and happiness. All of us are not

able to pursue their dreams and their vocations in a society that

has no viable way to heal all of its people. We join with the prophet

Jeremiah who asked this question, ‘‘is there no balm in Gilead, is

there no way for us to get healing in this land?’’

PICO’s faith-based federations and congregations have led many

different efforts to cover the uninsured and improve health conditions in our communities. For example, we have established mobile

health care clinics that visit public housing complexes and low-income communities in Orlando, Florida. We fought for and won increased funding for safety nets and coverage for the uninsured in

California, Colorado and Virginia.

For the faith community, it is unacceptable that a nation as

wealthy as ours would leave 44 million Americans uninsured. As

we work to find resources to cover the uninsured, which must be

a high priority for Congress, our Nation needs to invest in more

prevention. We begin with our young people but we don’t end with

them.

With your commitment, the movement to cover the uninsured beginning with children will not be deterred. Together we will make

this the healthiest, most successful generation in American history.

We will see a day when every person has access to good health and

all of God’s children, young and old, can travel from coast to coast

and not be concerned with having an unplanned health crisis and

perishing because they cannot get treated in the land of the free

and the home of the brave. The songwriter says, and I end with

this, ‘‘My country tis of thee, sweet land of liberty, of thee I sing;

land where my fathers died, land of the pilgrims’ pride, from every

mountainside, let freedom ring.’’ We need to cover our children and

our Nation.

Thank you so much for listening.

[The prepared statement of Reverend Wiggins follows:]

TESTIMONY OF REV. HEYWARD D. WIGGINS III

Chairman Pallone, members of the Energy and Commerce Committee, thank you

for inviting me to speak about the moral imperative to provide health coverage to

the millions in our Nation who are uninsured—beginning this year with our most

precious resource, our children.

I pastor Camden Bible Tabernacle Church in Camden, New Jersey, a city where

more than one-third of families lack health coverage. I have worked over the past

decade with Camden Churches Organized for People to revitalize my city. I am

proud to be here on behalf of the faith-based PICO National Network. Since 1973

PICO has brought people of faith together to revitalize communities and expand opportunities for families in 150 cities and towns across the country.
68

A generation ago, the faith community led the Civil Rights Movement. Today,

PICO’s more than 1,000 congregations and one million families nationwide are a

driving force behind the movement to expand health coverage in America, beginning

with covering all children. For communities of faith, the force behind both movements is the same. God created each of us in his image. We have a sacred responsibility to protect the dignity and well being of every person.

Two weeks ago the New Jersey State Police airlifted Governor Jon Corzine to Cooper University Hospital in my city of Camden. Cooper is a level-one trauma center

that fights as hard to save a young person shot on the streets of Camden as it does

to heal a governor. Like Jesus, our trauma centers open their arms to the poor and

the forgotten. The value that our hospitals place on every person’s life as sacred—

whether they be a poor child, a drug dealer, a prostitute or a public official—is a

fundamental cornerstone of our society. It has deep roots in our religious traditions,

in the teachings of Moses, Jesus and Mohammed. None of us in this room would

wish to live in a nation that did not value every person as a child of God.

Yet, when it comes to the uninsured we have lost our moral compass. We have

deceived ourselves that a slow death is no death. The National Academy of Sciences

estimates that 18,000 people, adults and children, die prematurely each year because they lack health coverage. Hundreds of thousands more face unnecessary pain

and suffering. Go to the Cooper Hospital Emergency room. You will see hundreds

of people waiting all day to see a doctor. They come too late, they wait too long and

they pray that in the end charity care will cover the cost. Yet it is society that ultimately pays the price when we deny people the health coverage they need to keep

themselves and their families healthy.

When people have reliable health coverage for their children and themselves they

have the tools to build strong healthy families and communities. Access to health

care is a conduit to a vibrant and productive society. Indeed, we have a moral and

constitutional obligation that the founders of our country thought important enough

to include as part of our inalienable rights, to protect the right to the pursuit of—

life, liberty and happiness.— Today, the reality is that we are not all able to pursue

our dreams and our vocations because our society does not viable system to heal

all its people. We join with the prophet Jeremiah who asked, ‘‘Is there no Balm in

Gilead?’’ Is there no way for us to get healing in this land?

PICO’s faith-based federations and congregations have led many different efforts

to cover the uninsured and improve health conditions in our communities. For example,

• We’ve helped establish mobile health-care clinics that visit public housing complexes and low-income communities in Orlando, FL and other cities

• We’ve fought for and won increased funding for safety net clinics and coverage

for the uninsured in California, Colorado, Virginia and other States.

• We’ve worked to pass Tobacco Tax measures to provide care for the uninsured

in Missouri and California

These efforts and other efforts to protect the uninsured are important. The health

care system is broken and increasingly out of reach of too many families. It can only

be fixed with participation from the faith community, business and civic leaders and

local and State government. We find hope in the creativity of local initiatives on the

uninsured. But our Nation cannot succeed, cannot live up to our promise, without

strong and determined health care leadership from Washington.

For the faith community it is unacceptable that a nation as wealthy as ours would

leave 44 million Americans uninsured. As we work to find resources to cover the

uninsured, which must be a high priority for Congress, our Nation needs to invest

more in prevention. We must be good stewards of our resources, so that people get

early intervention that prevents expensive treatment down the line. As Congress

works to expand coverage for the uninsured we urge you to build on the success of

existing programs and initiatives. This year PICO and the broader faith community

have united behind an effort to strengthen and expand the State Children’s Health

Insurance Program to help States cover uninsured children.

We begin with our young people because they are our future and because we have

a chance this year to get results. No child should rely on an emergency room for

their treatment or run the risk of life-long disability because they lack health insurance. With help from SCHIP we have reduced the number of uninsured children by

one-third; but morally we cannot abide with having millions of children without

health coverage in the United States; we cannot abide with rising infant mortality

rates; we must start by making certain that every child has health coverage and

access to high quality medical attention.

That is why PICO has engaged in the SCHIP reauthorization debate since it

began, testifying before this committee and engaging hundreds of clergy in a united
69

stand on covering uninsured children. We continue to urge Congress to move quickly

to deliver on its commitment of $50 billion in additional resources for SCHIP reauthorization. We urge Congress to strengthen SCHIP by giving financial incentives

and support to encourage States to reach and retain all eligible children. And we

support giving States the option to cover pregnant women and documented immigrant children and continue to support State efforts to expand eligibility. We will

be working closely with Congress—and keeping a close eye on Congress—over the

next three months to ensure passage of a good SCHIP bill that strengthens children,

strengthens families, and strengthens communities.

While our policy focus this year is on SCHIP reauthorization and children’s coverage, our faith communities will remain engaged in this issue until everyone has

access to affordable health coverage. After all, we are all children of God, regardless

of our age.

With your commitment the movement to cover the uninsured, beginning with children, will not be deterred. Together we will make this the healthiest, most successful generation in American history. We will see a day when every person has access

to good health, when all of God’s children—young and old—can travel from coast

to coast and not be concerned with having an unplanned health crisis and perishing

because they cannot get treated in the land of the free and the home of the brave.

The song writer said it this way, My country ’tis of thee, sweet land of liberty, of

thee I sing; land where my fathers died, land of the pilgrims’ pride, from every

mountainside, let freedom ring!

Thank you all for listening.

Mr. PALLONE. Thank you, Reverend.

Dr. Moffitt.

STATEMENT OF ROBERT E. MOFFITT, DIRECTOR, CENTER FOR

HEALTH POLICY STUDIES, THE HERITAGE FOUNDATION

Mr. MOFFITT. Chairman Pallone, members of the committee, I

just want to express my deep appreciation for the opportunity and

the honor and the privilege to testify before your committee today

on this important issue. The views that I express in this testimony

are my own as director of the Center for Health Policy Studies.

They do not necessary represent an official position of the Heritage

Foundation. I think that should be clear.

Mr. Chairman, given Washington’s gridlock on health policy over

the past few years, it is not surprising that many States are starting to take a bold lead in health care reform. It is also not surprising that survey research shows that the American people are supportive of the States taking the lead in health care reform and trying out different options to expand coverage for our people. State

officials are wrestling with rising employer costs on the ground, the

increasing access problems, especially for low-income working people. Health insurance markets in many States are also deeply

flawed, resulting in less competition, more market concentration

and oftentimes characterized by excessive Government regulation.

The professional literature on the uninsured shows that this

problem is not simply a problem of people having difficulty getting

access to health insurance. It is also even more of a difficulty of

people keeping it once they get it. Perhaps the best single analysis

of this data on the uninsured was conducted by Pamela Short and

Deborah Graefe of Pennsylvania State University and it was recently published in Health Affairs, and Mr. Chairman, with your

permission I would like to submit that Health Affairs article for the

record.

Mr. PALLONE. Without objection.
70

Mr. MOFFITT. In their analysis of the Census Bureau data over

the period 1996 through 1999, they found that only 12 percent of

the uninsured population was uninsured over the entire time. In

fact, the overwhelming majority of the uninsured are persons who

are in and out of coverage, getting coverage, losing it, often with

a change of employment. So in effect, the vast majority of the uninsured Americans are people who are transitioning in and out of an

unstable health insurance market.

The policy problem then is how to make health insurance stick

to the person, not simply the job, and that policy problem is acute

for persons who work for small businesses. Small firms that do

offer coverage usually offer workers and their families no choice of

coverage, and if a worker tries to buy health insurance on his own,

he must pay for it with after-tax dollars. This was a topic mentioned in your last panel. But this could mean on the ground adding between 40 to 50 percent to the cost of a policy for the same

level of benefits that that worker may have gotten through the

place of work.

So the Federal Tax Code is not neutral about where you get your

health insurance. If one gets health insurance outside of the conventional employment-based arrangements, one is punished with a

very heavy tax penalty.

Mr. Chairman, my focus is on the State issue and I would just

like to mention briefly the situation in Massachusetts. During the

initial stages of the debate in Massachusetts, Governor Romney invited me and my colleagues to travel to Boston to discuss the

health insurance markets in Massachusetts. In response to that request, we helped the Governor design an entirely new market for

health insurance which would get around the current limitations of

the Federal Tax Code which are so problematic in this system

which undercuts both the choice of health insurance and the portability of health insurance coverage, particularly for employees in

small businesses. The model for this approach was the stock market, basically a new market that would operate like a consumerbased market for stocks and bonds and equities and securities, a

single place where an individual would be able to buy a product

and keep it regardless of one’s change in life or circumstance or job.

Mr. Chairman, we have published an article in Health Affairs on

the Massachusetts plan. I would also like to submit that for the

record with your permission.

Mr. PALLONE. So ordered without objection.

Mr. MOFFITT. Because employees would be able to designate the

exchange or, as the Massachusetts legislature called it, the connector, as their employer planned for the purpose of the Federal Tax

Code, all of the premiums for health plans offered in that exchange

or that connector would be tax-free and therefore all the benefits

for the employees would also be tax-free just as they are today

under conventional employment-based health insurance. So the

achievement then is that with an exchange or a connector, you

would be able to have broad employee choice of health plans without compromising the tax-free status of health insurance coverage.

Individuals and families would be able to pick the plans of their

choice. They would have a property right in their health insurance

just like they do in other types of——
71

Mr. PALLONE. I am going to ask you to summarize. You are over

your time.

Mr. MOFFITT. OK. And take it from job to job without a tax penalty.

Mr. Chairman, there are a number of things we could do but the

first thing I would mention is that we would have to change the

tax treatment of health insurance and at least establish equity in

tax policy. A second point is that Congress could promote State experimentation and the Health Partnership Act that has been sponsored by Congresswoman Tammy Baldwin and Congressman Tom

Price would go a long way to promoting that State experimentation. And finally, I think that States ought to look at the opportunity for grants from the administration under its affordable

choices program. That also offers States a great opportunity to advance coverage.

Thank you very much, Mr. Chairman.

[The prepared statement of Mr. Moffitt follows:]

TESTIMONY OF ROBERT E. MOFFIT

Mr. Chairman and Members of the committee, my name is Robert E. Moffit. I am

director of the Center for Health Policy Studies at The Heritage Foundation. The

views I express in this testimony are my own, and should not be construed as representing any official position of The Heritage Foundation.

Given Washington’s gridlock on health care policy over the past few years, it is

not surprising that many States are taking the lead in health care reform. It is also

not surprising that the American people are supportive of States taking the lead

role in reform. According to a Dutko Worldwide poll conducted in January 2007, 74

percent of voters prefer to give more power to State and local government, and 72

percent prefer that State and local government experiment with strategies for expanding health care.

The States differ markedly in the range of their problems and their internal capacities to cope with them. States vary radically in their demographics, their economic profiles, their level of employment and poverty, the strength of their employment-based health insurance, and the functioning of their individual health insurance markets.

Most States are struggling with a number of common problems: Top among them

is the problem of Medicaid costs and the functioning of the Medicaid program itself.

Low reimbursement rates discourage doctors from taking new Medicaid patients.

Meanwhile, Medicaid obligations have been consuming a far greater portion of State

budgets, squeezing out other priorities. The National Governors’ Association reports

that Medicaid has surpassed education spending in many States.

Beginning this year, States are faced with a new fiscal challenge. The Government Accounting Standards Board will require States to begin calculating and disclosing the expected future costs of their retiree health benefits, just as the Financial Accounting Standards Board requires such disclosures for private companies.

State retiree benefits are often more generous than private sector benefits, and that

means that many States are going to be faced with large unfunded liabilities for

State and local retiree health benefits. This will impose new pressures to raise taxes

or to reduce other budget categories. Failure of State officials to act will hurt State

bond ratings.

Beyond that, State officials are wrestling with rising employer costs, and increasing access problems, especially for low-income working people. Health insurance

markets in many States are also deeply flawed, resulting in less competition, more

market concentration, and excessive government regulation.

THE NATURE OF INSURANCE

As a practical matter, health insurance problems are heavily concentrated in

small businesses, where employers often cannot afford to offer their employees a

policy and where the administrative costs and tasks of securing a policy are particularly daunting.

The professional literature on the uninsured shows that the problem is not simply

a difficulty with people having access to affordable coverage; it is more a difficulty
72

of people keeping it once they have it. Perhaps the best single analysis of the data

on the uninsured was conducted by Pamela Short and Deborah Graefe of Pennsylvania State University and published in Health Affairs (2003). In their analysis of

the Census Bureau data over the period of 1996 through 1999, they found that only

12 percent of the uninsured population was uninsured over the entire time. In fact,

the overwhelming majority of the uninsured were persons in and out of coverage;

getting coverage, losing it, often with a change of employment. So, in effect, the vast

majority of uninsured Americans are people who are transitioning in and out of an

unstable health insurance market.

The policy problem, then, is how to make the insurance stick to the person, not

the job. That policy problem is acute for persons who work for small businesses.

There is another facet of this problem. Can employees get the specific kind of coverage they want or need? Small firms that do offer coverage usually offer workers

and their families no choice of coverage. If a worker tries to buy health insurance

on his own, he must pay for it with after tax dollars. This could end up adding between 40 percent to 50 percent to the cost of a policy for the same level of benefits

that the worker might have been able to get through his employer.

The Federal tax code, then, is not neutral about where persons get their health

insurance. If one gets health coverage outside of conventional employment-based arrangements, one is punished with a heavy tax penalty.

THE CONCEPT OF A HEALTH INSURANCE EXCHANGE

In order to tackle these related problems, a number of health policy analysts have

suggested the creation of health insurance exchanges: new markets for health insurance for small businesses employees that ease their access to coverage, reduce the

administrative costs for small businesses owners, and allow individuals to own their

own health insurance policies.

In the initial stages of the health care debate in Massachusetts, former Governor

Mitt Romney invited me and my colleagues at Heritage to provide advice and assistance on the creation of a health insurance exchange as part of a comprehensive reform of the health care system in that State. In response to that request, we helped

the Governor and his staff design an entirely new market for health insurance that

would get around the current limitations of the Federal tax code, which undercuts

both the choice and portability of health insurance coverage, particularly for employees in small businesses.

The model for this approach was the stock market, and the new market was designed to work like a consumer-based market for stocks, bonds, equities, and securities: a single place where one could buy the product that one wanted and keep it

regardless of changes in life circumstances and employment. The concept of the

stock exchange was thus grafted onto the health insurance market as an ‘‘insurance

market exchange.’’ The Massachusetts legislature renamed it ‘‘the Connector’’ and

significantly modified its authority beyond what we had originally proposed.

It is vital to understand what the health insurance exchange, as proposed by my

colleagues at Heritage, is not. It is not a regulatory agency; it is not purchasing

agent, buying health plans on behalf of individuals or businesses; it does not negotiate the rates and benefits of health plans like the Federal employees program; and

it does not enforce a comprehensive standardized benefits package for health insurance. Its functions are purely administrative: It simply processes premium payments, government subsidies for low-income persons, and the paperwork for small

employers.

The role of employers would be retained, but changed. Instead of the traditional

defined benefit approach to employees’ coverage, the model would encourage defined

contributions, particularly for smaller firms that do not have the financial wherewithal to participate in today’s employer-based health insurance system. So the new

market would function through defined contributions to the health plans of the employees’ choice.

Former Governor Romney added another feature to the exchange: If an employer

did not want to contribute anything to an employee’s health insurance, the employer

nonetheless would be required to offer a flexible spending account, a Section 125

plan, so that the employee could make tax free premium payments and benefit from

the generosity of the Federal tax code.

In the exchange, individuals, not employers, purchase health insurance plans. The

exchange will ease access to health insurance coverage for many workers in nontraditional jobs, including part-time and seasonal employees, contractors and sole

proprietors, and individuals with more than one job. Small business employees

would be able to pick and choose health insurance plans, including health savings

account plans.
73

Because employers will be able to designate the Connector as their employer plan

for the purpose of the tax code, all of the premiums for health plans offered in the

exchange will be tax free, and the benefits for the employees will also be tax free,

just as under conventional employer-based health insurance. The achievement, then,

is that the Connector will provide for broad employee choice of health plans without

compromising the tax-free status of health insurance coverage. Employees would be

able to pick health plans of their choice, have a property right in their insurance

policies, and take their coverage from job to job without a tax penalty. Personal

ownership and control of health insurance policies would thus characterize the new

market. This is a major structural change in health insurance.

HELPING LOW-INCOME WORKERS

For years, health care economists have been debating the best way to integrate

low-income individuals and families into the private health insurance market, as an

alternative to rising uncompensated care costs or Medicaid expansions. On a bipartisan basis, many policymakers have proposed refundable tax credits—basically

vouchers—to help people buy private health insurance.

Within the $2.2 trillion in national health care spending, there is a great deal of

cost shifting, including reimbursements from both the private sector and the public

sector for uncompensated care. One thing that States could pursue, especially in cooperation with the Federal Government, is a policy that would use existing government funding for the uninsured to provide them with the means to secure private

coverage. Once again, in Massachusetts, policymakers pursued this approach and

redirected, with waivers from the U.S. Department of Health and Human Services,

hundreds of millions of dollars in existing government subsidies to provide coverage

for the uninsured through a sliding-scale voucher program.

Massachusetts’s taxpayers spent $1.3 billion in 2005 on hospitals and other institutions to provide care for the uninsured and those who did not pay for it. Federal

law, of course, requires hospitals to care for persons entering the emergency room

regardless of their ability to pay.

The new Massachusetts law transforms these subsidies into direct financial help

to individuals, in the form of ‘‘premium assistance’’ for the purchase of private

health insurance. Subsidies will be available to individuals and families with incomes up to 300 percent of the Federal poverty line. Eligibility, in other words,

broadly tracks an earlier Bush Administration proposal for a refundable health care

tax credit program for low-income families that would phase out at $60,000 per

year. This also is a major change in health care financing.

The Massachusetts compromise reflects the political coloration of Massachusetts.

There is plenty of room for criticism of the Massachusetts law on strict policy

grounds. How it will work is another matter. But it is well to remember that it is

in the early stages of its implementation, which will continue for another three

years. In any case, it is far too early to make definitive evaluations.

What Massachusetts does prove is that with the political will, compromise at the

State level is possible. Unsurprisingly, other States are looking at this very carefully, and they should be.

A SUPPORTIVE FEDERAL ROLE

There are a number of steps Congress could take to aid State experimentation in

health care reform. First, Congress could help States cope with the uninsured in one

simple step: provide tax equity in the purchase of health insurance. There are a couple of ways to do this. President Bush has proposed a universal standard deduction,

which would go a long way toward eliminating the current distortions in the tax

code and providing fairness in the tax treatment of health insurance. Others have

proposed refundable tax credits. At the very least, Congress should provide tax

breaks or subsidies to people who do not or cannot get health insurance through

the place of work. A combination of the universal standard deduction and a system

of refundable tax credits would be the best solution.

Second, States could aid State experimentation with special grants. There are two

promising approaches. The first is congressional assistance to the States through

the enactment of broad goals to reduce the uninsured, the provision of policy tools

to accomplishing this objective, and special grants to enable States to achieve coverage expansion using their preferred policy approaches. This approach has broad

bipartisan support and is embodied in the Health Partnership Act legislation, sponsored by Representatives Tammy Baldwin (D-WI) and Tom Price (R-GA). Similar

legislation is sponsored by Senators Jeff Bingaman (D-NM) and George Voinovich

(R-OH).
74

Another approach is being advanced by the Administration. The Bush Administration has signaled its intention to provide grants to the States—known as the Affordable Choices program—to help them cover the uninsured. This is an Administration

priority and a real opportunity for States to enter into an agreement with the Federal Government to address this pressing policy problem.

The Founding Fathers designed the Federal system as a way of allowing a diversity of options in a very diverse and dynamic country, the most revolutionary society

in the world. We can improve our health care system, and we can do it because of

the opportunities afforded by our unique Federal constitution, the product of the

Founders— peerless political wisdom.

Thank you. I will be happy to answer any questions you may have.

Mr. PALLONE. Thank you.

Mr. Knowlton.

STATEMENT OF DAVID L. KNOWLTON, PRESIDENT AND CEO,

NEW JERSEY HEALTH CARE QUALITY INSTITUTE

Mr. KNOWLTON. Thank you, Mr. Chairman, members of the committee and invited guests and staff.

I am president and CEO of the New Jersey Health Care Quality

Institute. It was founded 10 years ago. It is a nonprofit, nonpartisan foundation. Our purpose is to ensure the quality, accountability and cost containment are all closely linked to the delivery

of health care services in New Jersey.

I want to thank you for giving me the opportunity to give you

a brief glimpse into the state of health care in our home State of

New Jersey. As you know, Mr. Chairman, in New Jersey we are

proud to be at or near the top of a number of statistical categories.

We have one of the Nation’s highest per capita incomes. We are

home to more high technology, pharmaceutical and biotechnology

companies per square mile than any place in the world. We are

home to the University of Medicine and Dentistry of New Jersey,

the largest freestanding public health university in the country.

Our college and professional sports teams, particularly our women’s

basketball team and varsity football team at Rutgers, compete at

a championship level.

Unfortunately, we also rank near the top statistically in some

categories where we are not quite so proud. According to the

United States Census, we are home to more than 1.3 million uninsured. Almost a quarter-million of those are children. The New Jersey Business and Industry Association reported just earlier this

month that for small businesses, the cost of providing coverage has

increased 80 percent in the last 5 years. As a result, businesses in

New Jersey providing coverage have dropped dramatically in the

past 4 years so that now in every five small business owners simply cannot afford health insurance.

It is important for us to understand why so many Americans and

New Jerseyans are uninsured if we are going to be successful in

forging a solution. Some of the uninsured are between jobs. Some

are starting new jobs with an insurance waiting period. There are

those who work for employers who do not offer insurance and some

lost their insurance when they had to stay home or reduce their

working hours to care for aging parents, sick kids or a disabled

spouse. For most uninsured Americans, there is no health care system but rather a blotchy, frayed patchwork of unreliable and inconsistent programs, providers and facilities. The bottom line is that
75

in many cases the uninsured live shorter lives than comparable insured populations. Their crime is merely being too poor or too disabled or underemployed or simply holding down a part-time job.

For all of these reasons, the Quality Institute decided to become

involved in our home State on the issue of health care reform. We

knew where to start. We knew that we needed to do all we could

to enroll all who are eligible for State-sponsored coverage and we

knew we would have to properly utilize and manage the Federal

dollars available to us for that purpose. Then we knew we would

have to make sure that those who have health coverage were able

to keep it. We simply could not afford to lose more ground in this

struggle. Beyond that, we knew we had to get creative and find solutions that would provide affordable and adequate coverage for

every man, woman and child in our State.

Last summer New Jersey State Senator Joe Vitale and I gathered together stakeholders and experts and we engaged in weekly

frank and open dialog directed toward finding a lasting solution to

the tragedy of the uninsured in New Jersey. We quickly came to

some consensus and established some basic elements or pillars for

our reform. They included the following: Universal health insurance coverage is our goal. That health insurance coverage must be

affordable and it must be portable so individuals can take it with

them. In order to achieve universal coverage, our plan includes a

mandate that every individual residing in New Jersey have health

insurance. Individuals will be responsible to provide proof of health

insurance when they file their State income tax return. Those who

do not have coverage will be placed into a new State health plan.

We intend to implement FamilyCare to the extent permitted and

to enroll all New Jerseyans who are currently eligible for Medicaid

and FamilyCare but not presently enrolled. If a New Jersey resident presents for care without insurance, their provider will place

them into the new plan and provide billing information.

Unfortunately, even with comprehensive universal coverage,

there will be some who will remain uninsured, undocumented populations, homeless and others who are hard to reach. For those

people we created a safety net, a network of care centers who will

partner with hospitals to provide primary care and specialty care

to these populations. This will mean better quality care and it will

contain costs.

Our plan moves the uninsured into one self-funded plan to take

advantage of the law of large numbers so that the healthy and sick

balance each other out and result in more affordable health coverage. This new health insurance plan will be a commercial-grade

product with commercial reimbursement and with benefits modeled

after the current standard plan in the New Jersey employer market.

Mr. PALLONE. I am going to have to ask you to summarize as

well because you are over the time.

Mr. KNOWLTON. Mr. Chairman, we believe the time to act is now.

The pessimism and gloom which permeated the Nation for much of

the last decade after we failed to tackle this issue has been replaced by new optimism and openness and hope in this century. We

feel we have a Governor who is very supportive of trying to get this
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universal coverage done and with the leadership from Senator

Vitale, we think we are going to get it done.

[The prepared statement of Mr. Knowlton follows:]

TESTIMONY DAVID L. KNOWLTON

Mr. Chairman, members of the committee, invited guests and staff.

My name is David Knowlton and I am president and CEO of the New Jersey

Health Care Quality Institute. The Quality Institute was founded 10 years ago and

is a non-profit, non-partisan foundation. Our purpose is to ‘‘undertake projects that

will ensure that quality, accountability and cost containment are all closely linked

to the delivery of health care services in New Jersey.’’ We achieve this by fostering

collaboration amongst all stakeholders in the State’s health care delivery system so

that purchasers and health care consumers more fully realize the benefits of the

linkage between quality, accountability and cost containment.

The Quality Institute seeks to empower health care purchasers and consumers by

publishing the results of objective research, comparative data on providers, and

other pertinent educational information so that purchasers and consumers may

adopt value-based purchasing practices and be able to make informed decisions on

the merits of various health care programs, treatments and services. We were designated as the lead agency in New Jersey for the national Leapfrog Group effort in

2002.

I want to thank you for giving me the opportunity, on behalf of the group I lead,

to give you a brief glimpse into the state of healthcare in our home State of New

Jersey. More importantly, I want to share with you the work we are undertaking

to come to grips with New Jersey’s uninsured population.

As you know Mr. Chairman, in New Jersey, we are proud to be at or near the

top in a number of statistical categories. We have one of the highest per capita incomes. We are home to more high technology, pharmaceutical and biotechnology

companies per square mile than any place in the world. We are home to the largest

free-standing public health university in the county, the University of Medicine and

Dentistry of New Jersey. Our college and professional sports teams, particularly our

women’s basketball team at Rutgers, consistently compete at a championship level.

Unfortunately, we also rank near the top statistically in some categories of

healthcare for which we are not particularly proud:

According to the United States Census, we are home to more than 1.3 million uninsured, 240,000 of them children.

Research conducted for New Jersey’s outstanding Robert Wood Johnson Foundation tell us that one out of every seven children in our State received no medical

care last year as a result of being uninsured.

The New Jersey Business and Industry Association reported earlier this month

that for small businesses, the cost of providing coverage has increased 80 percent

in the last five years. As a result, businesses in New Jersey providing coverage for

their workers has dropped dramatically in just the past four years and now, one in

every five small business owners simply cannot afford health insurance.

Research conducted for New Jersey’s Hall Institute of Public Policy by Dr. Sherry

Glied and Edward Broughton revealed the following:

The cost of healthcare in our State consumes 11 percent of the State’s Gross Domestic Product and has been rising rapidly since the turn of the last century. In

fact, at $6,500 per capita healthcare costs are a full 10 percent above the national

average. Those rapidly rising costs come after a 1998 benchmark which revealed

that New Jersey paid the highest premiums for single plans and the third highest

for family plans of 40 States studied. In fact, research from the Kaiser Family Foundation shows that New Jersey pays amonth the highest costs in the Nation in both

health insurance costs and health care costs.

The Glied-Broughton study further found that the ‘‘high cost of health care and

health insurance in New Jersey affect the State’s residents, both as consumers of

health care services and as taxpayers. High health costs make it harder for people

to afford coverage, whether purchased in the non-group market or through employment. High costs also mean higher taxes to support State-financed health programs,

including the States share of Medicaid and NJFamilyCare and the State employee

health insurance program.’’

But while New Jersey may be suffering a little more as a result of its high costs,

its situation is not unique. The problem of the uninsured in America is not confined

to any particular State or region.
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In America, the most powerful economic force mankind has ever known, there are

amongst us citizens who have seen loved ones die because they did not have medical

coverage.

There are Americans who have been forced to declare bankruptcy or sell their

homes to pay for medical care. There are horrendous disparities which reveal that

Hispanics and African Americans are more likely to be uninsured than white Americans, even though white Americans constitute the absolute majority of the uninsured. One out of every three young adults between the ages of 18 and 24 in the

United States lacks health care coverage.

It is important for us to understand why so many Americans are uninsured if we

are to be successful in forging a solution.

Some of the uninsured are between jobs. Some are starting new jobs with an insurance waiting period. Others work for such low salaries that they cannot afford

insurance. There are those who work for employers who do not offer insurance at

all. Some of the uninsured work for small businesses with limited cash flow. Some

are uninsured because of shifting family situations. Some lost their insurance when

they had to quit work or reduce their working hours in order to care for aging parents, sick children, or disabled spouses.

The consequences of being uninsured or underinsured are significant. Finding

yourself uninsured is not simply an inconvenience—it is often life threatening.

For most uninsured Americans, there is no health care ‘‘system,’’ but rather a

blotchy and frayed patchwork of unreliable and inconsistent programs, providers,

and facilities. Most of the uninsured routinely experience delays in getting care for

a variety of medical problems

The uninsured rarely if ever go to the doctor for a checkup. They rarely receive

ongoing supervision of chronic problems, and they almost never get treatment until

their pain becomes unbearable or intractable complications set in.

The uninsured are left to their own devices to manage their health problems. The

uninsured learn who is willing to write a prescription or give out free drug samples

without examining them. Some will take only half of a prescribed drug dose so that

their medicine will last longer. The uninsured will share prescriptions with friends

and relatives. They will skip doses until they can afford a refill. The uninsured play

a high-stakes guessing game when they choose which of their several prescriptions

they can afford to purchase. They will self-medicate in ways that would appall

trained health care providers and they will take large and frequent doses of overthe-counter pain medications such as ibuprofen and Tylenol in order to get through

the day or night.

The Institute of Medicine has concluded that the uninsured receive less preventive care and poorer treatment for both minor and serious chronic and acute illnesses. The bottom line: In many cases, the uninsured live shorter lives than comparable

insured populations. Their ‘‘crime’’ is being too poor or too disabled or underemployed or simply someone holding down three or four part-time jobs. Their sentence is sometimes the death penalty.

For all of these reasons, the New Jersey Health Care Quality Institute has decided to become involved in our home State on the issue of health care reform. We

understand that without access to care, you cannot possibly have quality care.

We know where to start. First, we must do all we can to enroll all who are eligible

for State sponsored coverage through SCHIP programs. We have to properly utilize

and maximize the Federal dollars available to us for this purpose. We have to make

sure that those who have health care coverage are able to keep it. We simply cannot

lose more ground in this struggle.

Beyond that, we must get creative at the State level and find solutions that provide affordable and adequate coverage for every man, woman and child in our State.

That is the journey on which we now find ourselves in New Jersey. Last summer

New Jersey State Senator Joe Vitale and I gathered together stakeholders and experts and engaged in a weekly, frank and open dialogue directed toward a lasting

solution to the tragedy of the uninsured in New Jersey—all of them. Those around

the table included health care professionals, business and labor leaders, public policy makers and many of the State’s leading opinion leaders.

We quickly came to some conclusions and established ‘‘pillars’’ for our reform effort:

Universal health insurance coverage is our goal. Health insurance must be affordable, and it must be portable so individuals can take it with them as they move

in and out of employment or from one region of the State to another.

In order to achieve universal coverage, our plan includes a mandate that every

individual residing in New Jersey have health insurance—an ‘‘individual mandate.’’

Under our reform individuals will be responsible to provide proof of health insur-
78

ance when they file their State income tax return. If they do not provide proof of

health insurance, they will be placed by the State into the new State health insurance plan.

We intend to expand FamilyCare to ensure that we are using all the Federal dollars we have available to us. We also must enroll all New Jerseyans who are currently eligible for Medicaid and FamilyCare but who are not yet enrolled.

If, for whatever reason, a New Jersey resident presents for care without insurance, the hospital will place them into the new plan and provide billing information

to the new plan.

Unfortunately—even with a comprehensive universal coverage plan—there will be

some who remain uninsured. They are the undocumented populations, homeless,

and others who are hard to reach. For those people, we must have a safety net. Our

plan will create a network of Collaborative Care Centers who partner with hospitals

to provide primary and specialty care to these populations, so hospitals are only responsible for their emergent care. This means better quality care, and it contains

cost. The hospitals and centers will be eligible for reimbursement for actual care

provided to the remaining uninsured.

This new plan will replace the current plans offered in the State’s individual market. This successor plan will be sold to individuals and their families (not employers), and will be licensed by our Department of Banking and Insurance and administered by our State Health Benefits Plan.

In the current Individual Health Coverage market, coverage is unaffordable because people are spread out among many plans and policies, and because of adverse

selection (where sick individuals buy coverage and the healthy do not). Our plan

combines all individuals together so we can take advantage of the ‘‘law of large

numbers,’’ so the healthy and the sick balance each other out and we are able to

provide an affordable health insurance product.

The health insurance plan will include a statewide network of providers, and will

be designed as one plan with two options: A standard HMO and a PPO with an outof-network option. This plan will be a commercial grade product, with commercial

reimbursements and with benefits modeled after the current Standard Plan in the

Small Employer Market. We will require that where an employee does not have coverage, his or her employer must provide them access to a Section 125 flexible-spending account so the employee can purchase their health care coverage with before tax

dollars.

Our plan will be offered to all New Jersey residents, and State subsidy will be

provided on a sliding scale based on what is affordable to the individual or their

family based on their income level and family size. Our current charity care and

related hospital subsidies will be redirected over time to provide premium assistance

in the new plan.

In New Jersey today, two-thirds of those who have health insurance coverage receive it from their employers. We must pursue reforms in the current employerbased markets to ensure that employers who are providing coverage to their employees now can afford to continue to do so.

Last, we must ensure that quality and cost-containment are important elements

of our reform. Increased transparency of quality and cost data, public reporting of

that data, advances in the interoperable use of health information technology, providing consumers the tools to make the best health care decisions, and attention to

chronic disease management are all part of that solution,

We still have some details to work out but we believe we are on the verge of

transformational reform in New Jersey.

Furthermore, we believe the time to act is now. The pessimism and gloom which

permeated the Nation for much of the last decade after we failed as leaders to tackle

this issue has been replaced by new optimism and hope in this new century.

Particularly in New Jersey, the stars are aligned: we have a governor who is committed to transformational change. In fact, I would suggest to you that Governor

Jon Corzine today understands the value of quality and accessible health care better

than any other chief executive in the Nation. We also have stakeholders who have

decided to roll up their sleeves and be part of the solution rather than sit on the

sidelines and be part of the problem.

In the coming months legislation will be introduced in both houses of our Legislature to establish affordable and accessible health care coverage for each and every

one of our State’s citizens. It will be a real plan that can work. More importantly,

it will make a very real difference—not only in the everyday lives of more than a

million of our State’s uninsured citizens—but in how we feel about ourselves and

our responsibility to those less fortunate.

I would like to leave you today with the words of the Founding Father for whom

this city is named. In his Farewell Address as George Washington was leaving pub-
79

lic service at the end of two terms as our President, he warned future leaders

against ‘‘ungenerously throwing upon posterity the burden which we ourselves

ought to bear.’’

We believe New Jersey is at a crossroads. We can continue to ignore Washington’s

sage advice; or, we can do something. We have made our choice and are ready to

lead. We believe this is a burden that we ourselves need to bear. We hope others

will soon follow.

Thank you for providing this forum for what may very well be the Nation’s most

urgent issue.

Mr. PALLONE. Thank you.

Dr. Antos.

STATEMENT OF JOSEPH R. ANTOS, WILSON H. TAYLOR SCHOLAR IN HEALTH CARE AND RETIREMENT POLICY, AMERICAN

ENTERPRISE INSTITUTE

Mr. ANTOS. Thank you, Mr. Chairman and members of the committee. It is a real privilege to appear here today to discuss the

challenges facing the uninsured.

We have an opportunity and an obligation to seek solutions to

the health system problems that have put insurance out of the

reach of millions of Americans. However, we must also recognize

the limitations of policies that are narrowly focused on increasing

the number of newly covered individuals without also addressing

broader system issues. Those issues have an impact on everyone

who uses health care in this country whether or not they have insurance. Certainly we need to make progress for the uninsured but

we should also be realistic about what we can and cannot achieve

by expanding access to health insurance.

Unfortunately, this is not a panacea. Access to health insurance

does not guarantee that care will be either appropriate or affordable. Access to health care unfortunately does not guarantee good

health and further, there is no magic bullet that will solve the

problems facing the uninsured. Expanding subsides for health insurance will prove to be unsustainable unless we also undertake

more fundamental reforms. Bluntly, universal coverage will not

lower costs, not unless we also undertake the reforms that address

the drivers of health care costs in this country.

The uninsured are not easily characterized. They come from

every sector of society. Their reasons for not having coverage vary

but cost is the dominant concern. Some individuals simply cannot

afford insurance even though they need it. Others may be able to

purchase coverage but do not think the value outweighs the cost.

The mismatch between cost and value is at the heart of our

health system crisis. We spend over $2 trillion annually for health

care but there is a growing sense that we are not getting our money’s worth. This crisis is driven principally by perverse economic incentives, massive information failures, uncompetitive markets and

a health system that does not adequately meet the needs of highcost patients.

However, work is proceeding on many fronts to correct these

problems and to promote a more efficient and effective health system. Many States, most notably Massachusetts, have developed innovative solutions through the use of Medicaid waivers. Employers,

insurers and providers are developing new approaches that could
80

reduce unnecessary health spending and enhance the quality and

effectiveness of health care.

Congress has numerous opportunities to build on what works

and improve what doesn’t. That includes reforms such as the insurance market reforms that people have talked about earlier including the proposal by Mr. Shadegg, promotion of information transparency—we need more information in the system—and support for

the kinds of clinical studies and the kinds of information development that will help determine what works in medicine and what

doesn’t.

Congress also has an opportunity to correct a defect in Federal

tax policy that fuels rising health care costs and disadvantages

those who most need our help to purchase insurance. As you know,

premiums paid for employer-sponsored health insurance are excluded from taxable income. For the average earner, that tax break

can reduce the cost of coverage by nearly a third. This provision

provides greater advantages to those with higher incomes and

those who have more generous health insurance coverage though

their employers; in other words, people with good jobs. Lower income workers and those who do not have access to employer coverage do not get the same help.

President Bush has proposed to replace the open-ended tax exclusion of employer-sponsored health insurance premiums with a

standard tax deduction. The deduction would be available to everyone purchasing insurance whether they purchased it through their

employer or they got it on their own in the individual market. Persons buying a lower cost policy would benefit from the full deduction. Those buying a more expensive policy would not receive additional tax benefits above the standard amount. That is a push in

the direction of fairness.

The proposal is not perfect. The most common criticism is that

the deduction should be augmented with a refundable tax credit for

low-income individuals. I agree with that. Nonetheless, the proposal is bold. It would rein in a massive entitlement that promotes

inefficient forms of insurance and exacerbates the problems of the

uninsured. This is a positive step. Congress should embrace it.

The Congress has indicated its intention to expand the State

Children’s Health Insurance Program by $50 billion over the next

5 years. Such an expansion could draw substantial numbers of children out of private coverage that they already have and into the

public program. Better targeting of the funds and enhanced State

flexibility to manage their programs would minimize this crowd-out

effect and direct our subsidies to those who are most in need. That

is particularly important when budget resources are scarce, as they

are this year.

To conclude, although a great deal of attention will be paid to the

SCHIP reauthorization and appropriately so, Congress should take

the opportunity to address broader health system problems. The

high cost of health care is——

Mr. PALLONE. Dr. Antos, again if you could summarize.

Mr. ANTOS. I am almost done. Thank you, Mr. Chairman.

Mr. PALLONE. OK.

Mr. ANTOS. Congress has an opportunity to build upon the efforts

that have already been made in the public and private sectors to
81

promote better value for our health care dollars. We can and must

find ways to slow the growth of health spending, improve the effectiveness of care and make health insurance more accessible for the

uninsured and more affordable for everyone.

Thank you very much.

[The prepared statement of Mr. Antos follows:]
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Mr. PALLONE. Thank you.

Dr. Lambrew.

STATEMENT OF JEANNE M. LAMBREW, ASSOCIATE PROFESSOR, THE GEORGE WASHINGTON UNIVERSITY SCHOOL OF

PUBLIC HEALTH AND HEALTH SERVICES

Ms. LAMBREW. Chairman Pallone, Congressman Deal, members

of the subcommittee, thank you very much for inviting me here to

testify. I am Jeanne Lambrew, an associate professor at George

Washington University.

Comprehensive reform has not been seriously discussed in Congress for over a decade, but as the first panel suggests, the problems are large and expanding. Stated simply, millions are uninsured, millions more are underinsured. We overpay for an underperforming system and this poor performance has literal life and

death consequences.

Public support for change is growing along with the problems.

One recent poll found that guaranteeing health insurance for all

Americans is the top domestic issue, ranking higher than cutting

taxes. And we have recent proof as we have heard that health reform is possible to achieve. Massachusetts enacted legislation last

year. California is debating how, not whether, it should cover all

residents and other States like New Jersey and Vermont are not

far behind.

These bipartisan successful efforts shatter the prevailing wisdom

that the status quo is inevitable. They challenge the belief that ideological wars will wage on forever, and they also shed light on what

might be the pathway to get from our current system to universal

coverage. Romney’s plan to a lesser degree, Schwarzenegger’s plan,

some of the presidential candidates’ plans all resemble a plan similar to one that myself and my colleagues put out in 2005. Our plan

would achieve universal coverage by building on what works in the

system. Medicaid, SCHIP, possibly Medicare will be expanded to

become gap-free safety nets. Employer-based coverage would be

supplemented with a new purchasing pool for group health insurance. Assistance would be provided to ensure that people who cannot afford it will get that coverage and all Americans would share

in the responsibility for getting and keeping health coverage.

Covering all Americans is necessary but not sufficient to forge a

21st century health system. We need to lay the groundwork for improved efficiency and quality. In addition, we need to emphasize

prevention. We at the Center for American Progress would cover

prevention out of health insurance and create a new wellness trust

to pay for it directly in all settings like schools and the workplace.

Laying this infrastructure for ensuring and expanding coverage

will require an investment. My colleagues and I propose to pay for

it with a small targeted value-added tax. Other ideas exist as well.

But irrespective of the financing source, Federal spending probably

needs to be raised to lower national health spending. Lower costs

would result from insuring all Americans in a simpler, seamless

system. We could reduce administrative costs which on a per-person basis are nearly six times higher than comparable nations.

Lower costs would also result from emphasizing wellness since

nearly 80 percent of our health costs today result from chronic ill-
95

ness. And efficiency policies like harnessing information technology

could yield tens of billions in system-wide savings. Simply, we cannot sustain Medicare or even reduce our structural budget deficit

if we fail to control health care cost growth.

A consensus on reform is neither elegant nor ideal but the fact

that policy leaders on both sides of the aisle are beginning to circle

around this kind of framework for reform suggests that we are

within reach of figuring this out. Progress is not possible without

leadership though. Encouraging support for reform among business

leaders, political leaders and health care leaders is part of the work

we do at the Center for American Progress. We are making headway. For example, AT&T, who we heard from before, Wal-Mart,

SEIU are all involved in this Better Health Care Together coalition

which is committed to trying to get to a reform system that has everybody in, that is value-oriented by the year 2012.

But unfortunately, insuring all American does not seem to be a

priority of the current President. His budget’s tax policy would likely accelerate the erosion of employer-based coverage while providing no viable alternative. High-deductible plans and scaled-back

Medicaid benefits could replace uninsurance with underinsurance.

And, his budget would underfund children’s health, causing a decline in the number of children covered. Such policies could make

matters worse.

This Congress does have an opportunity, however, to make inroads. This committee could advance health information technology, prevention, comparative effectiveness research, among others. These would lay the foundation for reform. But most importantly, this committee could successfully reauthorize the State

Children’s Health Insurance program. SCHIP has covered millions

of low-income children through a strong Federal-State partnership.

Extending and improving it would prove that where there is a will,

there is a way.

So in closing, I encourage you to do what you can do this year

so in 2009 we can come back and have this debate that hopefully

is on our doorstep.

Thank you.

[The prepared statement of Ms. Lambrew follows:]

TESTIMONY OF JEANNE M. LAMBREW

Reasons Why Health Reform Should Be On the Agenda

• Serious health system problems

• Public opinion support

• Recent proof that reform is possible

Emerging Consensus On How to Get from Here to Universal Coverage

• Build on what works and make sure coverage is affordable

• Improve as well as expand coverage

• Recognize that we need to spend up-front to save in the long-run

What Needs to be Done

• Build leadership

• Block policies that go in the wrong direction

• Lay the groundwork for reform (e.g., information technology, prevention)

• Successfully reauthorize SCHIP

Chairman Pallone, Congressman Deal, and members of the Committee, I am

Jeanne Lambrew, an associate professor at George Washington University and senior fellow at the Center for American Progress. I thank you for the opportunity to
96

testify today. I am particularly encouraged that you are focused on the challenge

of covering all Americans. Comprehensive health reform is daunting. Presidents

from Truman to Clinton tried and failed to enact legislation, and numerous bills to

expand and improve coverage have languished in Congress. Considerable political

capital, legislative skill, and will are needed to change a system that affects onesixth of our economy and every single American. But, we are coming to the point

where the effort it takes to repair the crumbling system may be greater than what

it will take to build a better system.

Comprehensive health reform has not been seriously discussed in Congress for

over a decade, but as the first panel suggests, the problems are large and expanding. The number of uninsured is roughly 45 million and growing. People who lack

coverage have neither the same access nor the same outcomes as those with coverage. 1 Adding to their ranks are an estimated 16 million under-insured: people

who, despite having coverage, are inadequately protected against health costs. 2

These same people who work hard to pay for coverage and care don’t always get

their money’s worth. One study found that only 52 percent of people received care

that clinicians recommend. 3 And, we have the most expensive system in the world

by any measure. We pay $2 trillion or about 16 percent of our gross domestic product on health care—about $700 million more than peer nations, adjusted for wealth.

4 Stated simply, we overpay for an underperforming system. And this poor performance has literal life and death consequences.

In addition, public support for change is growing. A March New York Times / CBS

News poll found that guaranteeing health insurance for all Americans is the top domestic policy issue, ranking far higher than immigration or cutting taxes. 5 For the

last decade, the idea of a Federal guarantee of health insurance for all Americans

had had more than 56 percent support, rising to close to two-thirds support in the

last year. 6

And, we have recent proof that health reform is possible to achieve. Massachusetts enacted legislation that will insure all State residents beginning on July 1.

California is in the middle of a debate over how, not whether, to insure all of its

residents. And States like Pennsylvania, Illinois, Vermont, and Maine are not far

behind.

These bipartisan, successful State efforts shatter the prevailing wisdom in Washington that health care interests, protecting the status quo, are uncooperative and

insurmountable. They belie the belief that the ideological wars will wage on forever.

They also shed light on what might be the pathway from our current system to universal coverage. Romney’s plan, to a lesser degree, Schwarzenegger’s plan, and some

of the presidential candidates’ plans resemble one that my colleagues and I proposed

in 2005. 7 It would achieve universal coverage by building on what works in the

system. Medicaid, SCHIP, and possibly Medicare would be extended to become gapfree safety nets. Employer-based coverage would be supplemented with a new purchasing pool for group health insurance. Assistance would be provided to ensure

that all people could afford coverage. And, all Americans would share the responsibility for getting and keeping health coverage, and keeping themselves well.

Covering all Americans is necessary but not sufficient to forge a 21st century

health system. We need to lay the groundwork for improved efficiency and quality.

This requires comparative effectiveness research to guide our payment and quality

promotion policies. Health information technology is needed to improve system performance. And, new ways of setting health policies that lower political interference

and raise private-sector trust are in dire need. Senator Daschle has been exploring

an idea to model health system governance on the Federal Reserve. 8 In addition,

emphasis must be placed on prevention. We would carve prevention out of health

insurance and create a new Wellness Trust to pay for it in all settings, like schools

and workplaces. 9

Laying this infrastructure and insuring the uninsured will require an investment.

My colleagues and I propose paying for it with a small, targeted value-added tax.

Other ideas like an employer ‘‘pay or play’’ have been proposed as well. Irrespective

of the financing source, Federal spending probably needs to be raised to lower national health costs. Lower costs would result from insuring all Americans in a simpler, seamless system. We could reduce administrative costs, which on a per-person

basis, are nearly six times higher than in comparable nations. 10 Lower costs would

also result from emphasizing wellness. Today, nearly 80 percent of our health costs

result from chronic disease, much of which is preventable. And, harnessing information technology could yield system-wide savings of over $100 billion per year. 11

These investments are not only beneficial but necessary. We cannot sustain Medicare—or reduce our structural budget deficit—if we fail to control health care cost

growth.
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Consensus on health reform, by definition, is neither elegant nor ideal. A feasible

plan cannot solve all the system problems. It will be called too bold by some and

too timid by others. But the fact that Republican governors and Democratic presidential contenders are circling in on the same approach to improving and expanding

coverage for all Americans suggests that reform is within reach.

Progress, however, is not possible without leadership. Encouraging support for reform among political, business, and health care leaders is part of the work of the

Center for American Progress. We were encouraged by the show of support for universal coverage at the presidential forum on health reform that we co-sponsored

with SEIU in Las Vegas last month. 12 We are making headway in collaboration

with the Better Health Care Together coalition in cementing support for legislation

to provide coverage for all, greater value, and shared responsibility for managing

and financing a new American health care system by 2012. 13

Unfortunately, it seems clear that insuring all Americans is not a priority of the

current President. He did not embrace the recommendation of the bipartisan Citizens’ Health Care Working Group to cover all Americans by 2012. 14 Instead, the

President proposed replacing the employer tax exclusion with a standard tax deduction for health insurance. This would likely accelerate the erosion of employer coverage while providing no affordable alternative for many. 15 His advocacy for highdeductible plans and scaled-back Medicaid benefits could replace the problem of uninsurance with under-insurance, as people gain coverage that may not afford them

access to care. 16 And, his budget would under-fund children’s health, causing a decline in the number of children insured in public programs, according to the Congressional Budget Office. Such policies could exacerbate our health system problems.

This Congress, however, has an opportunity to make inroads into reform. This

committee may advance and enact legislation on health information technology, prevention, and comparative effectiveness research. Most importantly, this committee

has the responsibility to reauthorize the State Children’s Health Insurance Program. This program has successfully reduced the number of uninsured children. It

has built good working relationships between Federal and State governments, Republicans and Democrats, and special interests and advocates. Strengthening the

program with the same support that created it would prove that, where there is a

will, there is a way. And it would help pave the way for the next Congress, in 2009,

to begin the legislative process on comprehensive health reform.

Notes:

1 Hadley J. 2007. ‘‘Insurance Coverage, Medical Care Use, and Short-term Health

Changes Following an Unintentional Injury or the Onset of a Chronic Condition,’’

JAMA, 297(10): 1073–84. 2K Schoen C, Doty MM, Collins SR, Holmgran AL. (June 14, 2005) ‘‘Insured but

Not Protected: How Many Adults are Underinsured?’’ Health Affairs Web Exclusive,

:http//content.healthaffairs.org/cgi/reprint/hlthaff.w5.289v1. 3 McGlynn EA, Asch SM, Adams J, et al. (June 26, 2003). ‘‘The Quality of Health

Care Delivered to Adults in the United States,’’ New England Journal of Medicine,

vol. 348, no. 26, pp. 2635–45. 4 National Health Accounts, National Health Spending, 2005 available at: http:/

/www.cms.hhs.gov/NationalHealthExpendData/downloads/highlights.pdf;

McKinsey Global Institute. (January 2007). Accounting for the Cost of Health Care

in the United States. New York: McKinsey Global Institute. http://

www.mckinsey.com/mgi/rp/healthcare/accounting—cost—healthcare.asp 5 Toner R. and Elder J. (March 2, 2007). ‘‘Most Support U.S. Guarantee of Coverage,’’ the New York Times. 6 Teixeira R. (March 23, 2007). ‘‘Public Opinion Snapshot: Universal Health Care

Momentum Swells,’’ The Center for American Progress, available at: http://

www.americanprogress.org/issues/2007/03/opinion—health—care.html 7 Lambrew JM, Podesta JD, and Shaw T. (March 23, 2005). ‘‘Change In Challenging Times: A Plan For Extending And Improving Health Coverage,’’ Health Affairs

Web Exclusive: W5–119–132. 8 Daschle T. (December 15, 2006). ‘‘Trading Power for Progress: A Health Care

‘‘Fed’’ to Reform Coverage,’’ Center for American Progress, available at http://

www.americanprogress.org/issues/2006/12/health—fed.html. 9 Lambrew JM and Podesta JD. (October 17, 2006). ‘‘Health Prevention as a Priority: Creating a Wellness Trust,’’ Washington, DC: washingtonpost.com. http://

www.washingtonpost.com/wp-dyn/content/article/2006/10/16/

AR2006101600880.html. Lambrew JM and Podesta JD. (2006). Promoting Prevention and Preempting Costs: A New Wellness Trust for the United States. Washington, DC: Center for American Progress; Lambrew J.M. (April 2007). A ‘‘Wellness
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Trust’’ to Prioritize Disease Prevention. Washington, DC: Brookings Institution, The

Hamilton Project. 10 McKinsey Global Institute. (January 2007). Accounting for the Cost of Health

Care in the United States. New York: McKinsey Global Institute. http://

www.mckinsey.com/mgi/rp/healthcare/accounting—cost—healthcare.asp 11 Hillestad R, Bigelow J, Bower A, Girosi F, Meili R, Scoville R, and Taylor R.

(2005). ‘‘Can Electronic Medical Record Systems Transform Health Care? Potential

Benefits, Savings, and Costs,’’ Health Affairs24(5): 1103–17. 12 For information on the forum, see: http://www.americanprogressaction.org/

events/healthforum/ 13 Freudenheim M. (April 6, 2007). ‘‘New Urgency in Debating Health Care,’’ The

New York Times, available at: http://www.nytimes.com/2007/04/06/business/

06schism.html?ex=1177473600&en=679393f4626c26e6&ei=5070 14 For information on the Citizens’’ Working Group, see: http://

www.citizenshealthcare.gov/. The law creating the group required the President to

respond to its recommendations. This response was transmitted by Secretary

Leavitt to Speaker Pelosi on March 13, 2007. 15 Burman LE, Furman J, Leiserson G, and Williams R. (February 15, 2007). ‘‘The

President’s Proposed Standard Deduction for Health Insurance: An Evaluation,’’ Tax

Policy Center, available at: http://www.taxpolicycenter.org/publications/template.cfm?PubID=411423

Mr. PALLONE. Thank you, and thank you all. We will take some

questions now and I will start by recognizing myself for 5 minutes.

I wanted to ask Mr. Knowlton, obviously a State like our own

has major problems in terms of financing anything new and yet

you believe and I believe that we are embarked soon on this effort

to try to achieve universal coverage. So maybe explain to us why

New Jersey sees the benefit of universal coverage and how that

outweighs the financial costs that might be involved.

Mr. KNOWLTON. Mr. Chairman, I think that you can’t afford not

to do it. I think that what happens is, the cost has been escalating

in New Jersey, the cost of what we are providing in charity care

and hospital subsidies is about the same as what our actuaries tell

us it will cost us to cover everybody universally. So we are going

to have a concern on how we do a transition to a new system and

help our hospitals out but by and large we are going to be spending

about the same amount. We are just redirecting how we are spending it. And yet we are giving astronomically better care to people

and people better access to care. You heard the gentleman whose

wife died talk about what it felt like to be uninsured. We are going

to step away from that, I think, so I think it will be a good investment.

Mr. PALLONE. And in that same regard, the plan you proposed

creates a new health care market rather than using the currently

existing market. Why did you design it that way?

Mr. KNOWLTON. We wanted to get one large pool and we wanted

to get the underwriting advantage that we got from the law of

large numbers. We wanted to stay away from a basic and essential

plan or a catastrophic plan or a high-deductible plan. I am not

going to comment on whether that is good for people on the commercial market who may choose it but we did not want it to be creating windows of uninsurance for people that were coming in from

the uninsured. In New Jersey, hospitals are seeing a larger growing segment of bad debt that is coming from high deductibles and

from people that aren’t being reimbursed, so we didn’t want to substitute one problem for another.

Mr. PALLONE. Thank you.
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I wanted to ask Dr. Lambrew, we have heard about how some

of the members on the other side have commented on how or some

of the other witnesses from the previous panel that if you expand

public programs, Medicare, Medicaid or SCHIP, that that might

lead to crowd-out, so to speak, and specifically you talk about the

role that these public programs play and whether they are good use

of Federal dollars and whether expansions would help with the uninsured, whether that is smart and link it to the whole crowd-out

issue.

Ms. LAMBREW. Well, it is an excellent question and I think you

all anticipated this question when in 1999 Congress authorized a

Federal evaluation of the State Children’s Health Insurance Program. That evaluation found ‘‘The program did not lead to widespread substitution of SCHIP for employer coverage, even though

almost all families enrolling their children had at least one working

parent.’’ A related study found that of those working parents, most

of them were not in employer-based coverage. They were in jobs

that did not offer health insurance coverage, and in a survey they

found that of those recent enrollees in SCHIP, 43 percent were uninsured, another 29 percent were previously on Medicaid whose

families earned too much income to then stay in that program, and

of the 28 percent that had private coverage, fully a fourth said

their families could no longer afford that coverage. So this is not

a program, according to the Federal evaluation, that is in trouble.

But I also think it is important to go back to the study that GraceMarie Turner talked about. Jonathan Gruber, who is a former colleague of mine, wrote a letter in response to some of this use of

this research saying, ‘‘I am somewhat disappointed to see my recent research being used to attack this valuable program. We find

no evidence of crowd-out associated with SCHIP per se.’’ He goes

on to say that there is always some degree of crowd-out in any sort

of public program expansion but ‘‘I find that the public sector provides much more insurance coverage at a much lower cost under

SCHIP than these alternatives. Tax subsidies mostly operate to

buy out the base of insured without providing much new coverage.’’

So I think we have to be very clear about the studies that we are

using as we debate this program so we design our programs effectively.

Mr. PALLONE. Just a general question, I guess I will ask it of you

because otherwise it will take all afternoon if I go through the

whole panel, but we keep having this debate about improving or

making employer-based coverage more robust versus expanding the

public program, and I don’t have any ideological basis, at least I

don’t think I do in that regard. If I could find a way to get all the

employers to cover everybody who is working and that we wouldn’t

need as much Federal dollars, that would be fine with me. And

there have been proposals out there like Senator Kerry had a proposal to take catastrophic off the table so that employers wouldn’t

have to pay for catastrophic care. How do we juxtapose those two?

It would be great to expand the employer-based system but I know

there are limitations. If you just would comment on it.

Ms. LAMBREW. It is a great question and a very difficult one. I

would potentially argue that if the goal is to solve the one problem

that we could solve, which is covering the uninsured, that I think
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we have to look at a mix of public and private programs. 150 million people are insured through the employer-based system today.

That is not going to go away overnight. People mostly like that coverage. We need to provide alternatives. I will be very clear about

that. We all need to look at pools, look at what Massachusetts has

done, look at what other people have proposed to find viable alternatives but I think a mix of public-private programs is probably the

unique American solution to this. But I do want to go back to this

issue of, does the President’s proposal, which we have heard about

a lot today with this tax fairness really get at that and because it

doesn’t actually work on the where people get insurance, there is

a real risk that it actually is unfair because what it would do is,

take away a worker’s tax subsidy, tell that worker that you may

get an amount, a standard deduction which could be less for a

union worker or an older worker or people in high-cost areas and

then they have no place to get insurance. In most States, there is

no guarantee issue, meaning that you are guaranteed a coverage

policy to be offered to you, nor a guarantee that that coverage is

meaningful and affordable. So I actually think it is unfair to think

through the idea of taking away what we have now and not replacing it with something fully developed.

Mr. PALLONE. I have to say that I think one of the mistakes that

was made in the Clinton days was that the impression was being

given, even if it wasn’t true, that people were going to lose what

they have and I think whatever we do, we have to make sure that

if you have good coverage and you like it, that we don’t reduce it

and we don’t take it away.

Thank you. I know I went over, and I am sure my colleagues will

take note of that.

I recognize Mr. Deal.

Mr. DEAL. We would never take advantage of you.

We are going to be dealing with the reauthorization of SCHIP,

of course, one of the issues that is going to be before this subcommittee and full committee. Dr. Knowlton, I understood from

your testimony that you had 240,000 uninsured children in the

State of New Jersey. Is that correct?

Mr. KNOWLTON. Yes, sir.

Mr. DEAL. The information that I have would indicate that over

half of those, in other words, 125,000 of those are from families

that are under 200 percent of poverty. In other words, 22 percent

of all children in your State from families that are under 200 percent of poverty are still uninsured.

Reverend Wiggins, before we expand a program to include fami- lies of four with incomes of $82,600, which most of us in my State

don’t consider to be the poor of the poor, wouldn’t it be reasonable

to require that we get at least 90 percent of those that are in families below 200 percent of poverty, get them covered first before we

start spending this money on the richer families? Wouldn’t that

seem reasonable?

Mr. WIGGINS. I think processes is key and eventually everybody

should be included. I think it is just a matter of just really determining where we are in this process. If the lower number is not

being covered under 200 percent of poverty level, we need to definitely include them and that may be the first step. It may be back-
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wards possibly now but everybody should be included and that is

our aim. That is the moral objective.

Mr. DEAL. But I know your program does a great deal of outreach and trying to get people covered. But the program was initially established to insure children in families under 200 percent

of poverty.

Mr. WIGGINS. That is correct.

Mr. DEAL. And yet in your State that goes up to 350 percent of

poverty, you still have 22 percent of those children that are below

200 percent of poverty are uninsured. Shouldn’t we put more emphasis on increasing the number of those children that are covered

first?

Mr. WIGGINS. I would agree.

Mr. DEAL. OK. I am not going to take advantage of the chairman’s time but I do have a number of other questions that I think

we need to try to explore, and the first is, Dr. Lambrew, I agree

with you that wellness has to be a component of this. I am going

to look into more about your wellness trust, I think that you advocate. One of the things that I have advocated is that as we look

at SCHIP, if we are looking at trying to get that increase on the

number of children under 200 percent of poverty enrolled or whatever the State establishes as its percent of poverty, one of the key

places to do that is to find the children where they are and that

is schools, and I notice your testimony alludes to you think that

schools are a component in this wellness factor.

Would anyone think it was improper for the reauthorization of

SCHIP to allow States to use a portion of their SCHIP funding to

establish things like a school nurse program? I personally believe

that that is where you are going to find the sick child. That is

where you are more than likely to have somebody to call that parent and say your child needs to see somebody else and if they say,

well, we don’t have any insurance, to find out why they don’t have

any insurance. Does anybody think that would not be a good flexible option in SCHIP?

Ms. LAMBREW. I would just say that States can do this today

with what is called their 10 percent funds. Up to 10 percent of

their allotments are allowed to be used for direct services, administrative costs, et cetera.

Mr. DEAL. But I don’t know of any that are doing that, do you?

Ms. LAMBREW. It is a question I don’t know offhand but I would

say that I think it is something in the reauthorization process, emphasizing the use of the 10 percent funds for wellness, obesity reduction, which is a huge challenge that we must address would be

some way to do this as well as linking health insurance to school

lunch programs and some of the free and reduced food programs

that we have at schools. That would be a great way to find some

of those children.

Mr. DEAL. OK. I realize that this is a very complex problem and

I think all of you have acknowledged that it is not one simple solution to any of it.

Dr. Moffitt, I thought it was very interesting in your testimony

that looking at who the uninsured really are, that most of them are

people who are sort of in and out of jobs.

Mr. MOFFITT. Overwhelmingly.
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Mr. DEAL. They lose, I believe you said only 12 percent were consistently there.

Mr. MOFFITT. Only 12 percent. That was the finding of the study,

and I will tell you, Congressman, it is the best single thing in the

English language I have ever read on the uninsured because what

Graefe and Short did is take that data and look at that in great

detail and they found that basically the problem is people losing

coverage.

Mr. DEAL. And we know that a good portion of the uninsured are

in that 17- or 18- to 24- or 25-year bracket, presumably the largest

portion of the uninsured and they presumably are the healthiest.

Mr. MOFFITT. Yes, they are.

Mr. DEAL. And I don’t know that we can get an answer but I

guess the next question I have never seen answered is, what is the

health status of the uninsured? If a large portion of them are these

younger healthier people but they are uninsured, how does the

overall uninsured picture stack up as to where they fit in the overall climate of health in the country?

Mr. MOFFITT. I think you have answered your own question. We

know that health status and health conditions vary with age. That

is why, for example, you have insurance rating that rates differently between people who are higher in age than lower in age.

But the truth is that most young people who are uninsured are

overwhelmingly healthy. The number of people who are uninsurable, that is to say people who are very, very ill, people who are

uninsurable technically is actually a relatively small proportion of

that population. Now, we have to design programs that are going

to deal directly with them and I am very much in favor of doing

precisely that. But the burden of my point was, is that the current

employment-based health insurance arrangements we have today

are not compatible with a 21st century economy where anywhere

between one in three and one in four people are changing jobs

every year. We have got to have a situation where people have stability in their health insurance coverage. If they have stability in

their health insurance coverage, they are going to have continuity

of care, and if you have continuity of care, you are going to have

better outcomes.

Mr. PALLONE. Thank you.

Dr. Burgess.

Mr. BURGESS. And Dr. Moffitt, I would just add to that last

thought that if you have continuity of your health insurance, the

administrative burden borne by the individual trying to figure out

what is the co-pay, what forms do I have to fill out, when does this

trigger this event, all of that is known to the individual and they

are less likely to be lost in the morass of regulations, which is one

of the things we heard about at the last panel.

Mr. MOFFITT. That is correct.

Mr. BURGESS. I want to talk to you a little bit about the Massachusetts plan. When I first read about that I was certainly prepared not to like it and someone came from Massachusetts and

talked to me about it and I thought well, maybe it doesn’t sound

so bad, don’t tell anyone back in Texas I said that, and then Governor Romney came and spoke to a group of 14 or 15 of us here

when he was still Governor and on some levels it did make some
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sense. A lot of things about Massachusetts you cannot extrapolate

to the rest of the country.

Mr. MOFFITT. No, you cannot.

Mr. BURGESS. And in my home State of Texas, Massachusetts

doesn’t even make up a decent-sized county, but I really like the

concept of coupling an HSA which is bought with after-tax dollars

and through that insurance connector that you talk about, it is

suddenly available with pre-tax dollars. That seems to me to be a

powerful step that you have taken in Massachusetts or that you

have outlined for Massachusetts and one that I would like other

States to emulate. I took that concept to my State senator, who

now is working on the Lone Star connector, and while there will

be no plan that mirrors Massachusetts in Texas any time soon,

that concept is one that I think could extend the availability, the

reach and the grasp of the health insurance that is available in an

HSA to particularly that population that you referenced, the 17- to

24-year-old that is generally bulletproof; why do I have to spend all

this money on this product, that amount of money could in fact fill

up the SUV and the bass boat for the weekend and I could have

a lot better time. But if there is a way to get it to them and get

into their consciousness that this is a good investment, I think

many more people will take it. It is interesting to me too that the

flexibility that we provided in the Deficit Reduction Act of 2005 for

all of the arrows that we have caught over that bill, the flexibility

provided to States to allow them to begin to experiment with these

things—again what is applicable and viable in Massachusetts may

not be reasonable in Texas but we have got Massachusetts with

Governor Romney, Vermont with a Republican Governor, California with a Republican Governor, and Texas is looking into doing

some things with a Republican Governor. Of course, Jeb Bush before he left office was experimenting with some things. These are

positive steps that are being taken by the States as a result of the

flexibility that we built in for them in the Deficit Reduction Act.

We passed that in 2005. is there anything you would like to add

to that?

Mr. MOFFITT. No, I think that is exactly my point. You mentioned the Deficit Reduction Act and the waiver authority by the

administration. Right now there are about 18 States that are experimenting with significant Medicaid reform. That is wonderful.

One of the points that I tried to convey in my formal statement to

the committee is that we are the heirs of political genius. The

Founding Fathers designed a Federal system to enable a diversity

of policy options. There is profound disagreement in Congress over

which we should go in health care policies.

Mr. BURGESS. As you have seen today.

Mr. MOFFITT. Certainly. There is profound disagreement at this

table, but nevertheless, the point is that we have a tremendous opportunity to promote experimentation at the State level, we can

learn from that. We will find out what works in Massachusetts and

what doesn’t in California or any other State. But the point is, we

will have a chance to see on the ground how these attempts to

change the financing and delivery of health care are actually working out in improving outcomes and coverage.

Mr. BURGESS. Thank you.
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Dr. Antos, if I could just briefly, you talked about insurance market reforms. I am not entirely in agreement with you about the

President’s plan though I am grateful that he brought it up but in

so many ways, and I don’t want to be heretical when I say this,

in so many ways it seems like this is a plan for insurance companies and not for patients. That is, insurance companies are going

to sell more insurance as a consequence of perhaps the premiumsupported tax subsidy at the lower end. Do we need to be concerned about that? Do we need to be concerned that this is a policy

that seems to be directed more toward an insurance company than

it does towards taking care of patients?

Mr. ANTOS. I am not sure I agree with your characterization but

isn’t it better for insurance companies to sell insurance to people

who don’t have coverage now than for those people not to have coverage?

Mr. BURGESS. Well, obviously that is the thrust of this committee

and hearing today and I referenced that in my opening statement.

I wonder if we are taking the wrong approach to this. I like the

concept of transparency. If we are going to do a consumer-directed

health plan, transparency is key. Again, Texas has done I think a

great thing by putting TXpricepoint.org up on the Internet. Anyone

can go there. In my home county, in fact there is a significant difference between getting your hip fixed at one hospital versus another. The information now that is lacking is the information about

doctors and again, I will probably get some pushback from this

from my friends in the physician community but that information

is going to be important for patients to have as well if we are truly

going to develop a plan that is reasonable for people. Is there a

point at which the health care premium, is there a percentage of

the health care premium that should be returned for patient care,

for paying for health care or is that a number that just is simply

unknown?

Mr. ANTOS. The so-called loss ratio is a magical number in politics but it isn’t a very magical number in health insurance. There

is an excellent article by Jamie Robinson at the University of California at Berkeley who explains all this. I will be delighted to send

that to the committee.

Mr. BURGESS. Please.

Mr. ANTOS. And he makes the point that, a fundamental point

about life in this country, accountants rule us, and so depending

on how you organize your business structure, you can make the administrative costs look very high or very low. The fact is that at

least some of the administrative costs are absolutely necessary, if

we are going to have the kind of insurance that we are talking

about, third-party payment, if we are going to have somebody else

pay the bills, then that somebody else has a fiduciary responsibility

to us to make sure that the bills are appropriate and to negotiate

reasonable prices and so on. That costs money. We wouldn’t have

the kind of take-up of generic drugs in this country—we are up

over 60 percent now—if it weren’t for the fact that somebody was

pushing us to do it. So it is not all waste. Another point that I

think needs to be made is that while insurance companies can certainly become more efficient, they can do a better job of embracing

the kind of health information technology that is appropriate at
105

that end to make it easier for you and me to use our health insurance and to get better information and do the right thing in the

first place rather than to go from doctor to doctor and make the

wrong decisions consecutively. There is work being done in that

area. It is slow but then everything else is in the health sector.

Mr. BURGESS. Isn’t that the truth?

Mr. PALLONE. We are at 3 minutes over almost so——

Mr. BURGESS. Dr. Lambrew, can I just ask you, you said an increase in Federal spending, do you have an idea as to what

that——

Mr. PALLONE. Doctor, please. We have got to move on. It is 3

minutes.

Mr. BURGESS. Let her answer the question. Do you have an

idea——

Mr. PALLONE. I have to stop. Listen, thank you all. I really appreciate it. I think this was—no, I know, but it is 3 minutes. We

have to stop. Thank you all really. You gave us some real insight

into what we have to do and particularly to what some of the

States are doing. So I want to thank you all. We have a process

whereby members can submit additional questions for the record

and then you would answer them, and those will be submitted

within the next 10 days.

And without objection, this meeting of the subcommittee is adjourned.

[Whereupon, at 1:25 p.m., the subcommittee was adjourned.]

[Material submitted for inclusion in the record follows:]
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STATEMENT OF THE AMERICAN CANCER SOCIETY

Dear Chairman Dingell, Rep. Barton, Chairman Pallone and Rep. Deal:

On behalf of the American Cancer Society, we welcome your invitation to participate in the Energy and Commerce Committee’s Health Subcommittee hearing entitled ‘‘Living Without Health Insurance: Why Every American Needs Coverage.’’

The testimony of Mr. Gary Rotzler speaks to the experience of millions of American families who are either seriously underinsured or who have no health insurance at all. In the case of Mr. Rotzler, his beloved wife Betsy died prematurely because she did not have access to preventive health services that might have revealed

her breast cancer at an earlier, perhaps treatable stage. We know that the research

is clear—people who lack insurance delay going to the doctor until they are sick and

then they have worse outcomes.

While some Americans have no insurance, others have varying levels of inadequate coverage with little real understanding of how financially vulnerable they

may be. Over the years, the Society has worked to provide information, comfort and

assistance to people who have learned they have cancer. Our Health Insurance Assistance Project (HIAP) operates 24 hours a day in 26 States providing patients information about the disease, medicines, available clinical trials, doctors, and insurance. Incidental to this process, we have captured the stories of thousands of people

for whom the health care system has failed in some serious way.

Out of these real-life experiences, we have developed four essential principles that

define meaningful health insurance as part of a larger effort to elevate the importance of access to care to the country’s ability to defeat deadly diseases like cancer.

The principles state that health insurance must be:

• Adequate—with timely access and coverage offering the full range of evidencebased healthcare services, including prevention and early detention, and supportive

needs, including acute treatment with access to clinical trials, chronic disease management and palliative care.

• Affordable—with total costs not excessive and based on the patient’s ability to

pay.

• Available—with coverage available regardless of health status or claims history,

and that it be renewable and continuous.

• Administratively simple—with benefits, financial liability, billing procedures,

and processes for filing claims that are easy to understand, and so consumers are

able to compare plans when making choices about health insurance.

• These principles highlight major problems in the health care system—problems

which continue to impede progress against cancer and other major diseases. As you

move forward with your examination of health insurance, we would like to work

with you to incorporate and operationalize these basic principles into health insurance reform legislation. Thank you again for inviting the American Cancer Society

to testify today, and we look forward to working with you.

Sincerely,

Daniel E. Smith

National Vice President,

Federal and State Government Relations

Wendy K.D. Selig,

Vice President, Legislative Affairs

AMERICAN CANCER SOCIETY STATEMENT OF PRINCIPLES ON WHAT

CONSTITUTES MEANINGFUL HEALTH INSURANCE

The American Cancer Society is the nationwide community based voluntary

health organization dedicated to eliminating cancer as a major health problem by

preventing cancer, saving lives and diminishing suffering from cancer, through research, education, advocacy, and service. The American Cancer Society has set ambitious goals for significantly reducing the rates of cancer incidence and mortality

along with measurably improving the quality of life for all people with cancer.

‘‘The ultimate conquest of cancer in America is as much a public policy aspiration

as it is a scientific and medical challenge. There are many stakeholders in the cancer fight actively doing their part to defeat this disease, but it cannot be done without the sustained leadership and strong commitment of government. We are poised

to make gains so substantial that we now can talk about a time when cancer is no

longer a killer and is instead just a chronic condition, or even better, a disease for

which a cure is a realistic, frequently achieved goal. Our Nation’s current health
119

1 Dr. John Seffrin, American Cancer Society CEO, Statement to ACS Board of Directors during January 2006 meeting.

1 U.S. Census Bureau figures originally estimated the number of uninsured in 2005 to be 46.6

million, but have recently been revised to 44.8 million (http://www.census.gov/Press-Release/

www/releases/archives/health—care—insurance/009789.html) uninsured persons in the United

States. We in the Catholic health ministry believe that the number of uninsured in our Nation

represents both a health crisis and a moral crisis on an unprecedented scale, and I would like

to begin by thanking the subcommittee for taking the time to examine this urgent issue.

care system is not up to this challenge. If we are to ultimately conquer cancer our

system must ensure that all Americans have access to high quality care.’’ 1

Improving the Nation’s health care system requires a new partnership for the Nation that will facilitate the coverage and delivery of quality evidence-based cancer

care and work to eliminate disparities and inequities in the current system. This

will require a commitment from the private, public, and not-for-profit sectors and

individuals. Stakeholders in the health care system, from doctors, hospitals, and insurers, to employers, and not-for-profit organizations, all have critical roles to play.

All Americans have an obligation, as well, to take responsibility for their own health

to the extent possible, by pursuing healthy lifestyles, and educating themselves

about their health needs, including ways to prevent and detect cancer.

A critical aspect of improving the health care system is to define and ensure access to meaningful public or private insurance. This includes adequate financing.

Our Nation has had much conversation on the insured and uninsured and less on

what it means to be meaningfully insured. Below is the statement of the American

Cancer Society on what constitutes meaningful health insurance.

STATEMENT OF PRINCIPLES

It is a fundamental principle of the American Cancer Society that everyone should

have meaningful public or private health insurance.

Meaningful health insurance is adequate, affordable, available and administratively simple.

Adequate health insurance means:

• timely access and coverage of the complete continuum of quality, evidence-based

healthcare services (i.e., rational, science-based, patient-centered), including prevention and early detection, diagnosis, and treatment • supportive services should be available as appropriate, including access to clinical trials, chronic disease management, and palliative care • coverage with sufficient annual and lifetime benefits to cover catastrophic expenditures

Available health insurance means:

• coverage will be available regardless of health status, or claims history

• policies are renewable

• coverage is continuous

Affordable health insurance means:

• costs, including premiums, deductibles, co-pays, and total out-of-pocket expenditure limits, are not excessive and are based on the family’s or individual’s ability

to pay • premium pricing is not based on health status or claims experience

Administratively simple health insurance means:

• clear, up-front explanations of covered benefits, financial liability, billing procedures, and processes for filing claims, grievances, and appeals are easily understood

and timely, and required forms are readily comprehensible by consumers, providers

and regulators

• consumers can reasonably compare and contrast the different health insurance

plans available and can navigate health insurance transactions and transitions

TESTIMONY OF SISTER CAROL KEEHAN, DC

On behalf of the Catholic Health Association of the United States (CHA), the national leadership organization of Catholic health care providers, I would like to

thank Chairman Pallone for this opportunity to provide testimony on the problems

associated with the approximately 46 million 1

CHA and its members are longtime advocates on behalf of the uninsured. In our

most recent history, particularly following the failed attempt in the early 1990’s to
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2 AHA Survey of Hospitals, 2001–2005 (2005 is the latest year of data available from this

study)

3 Kaiser 2003 Health Insurance Survey, http://www.kff.org/uninsured/upload/The-Uninsured-and-Their-Access-to-Health-Care-Oct–2004.pdf

4 Public Opinion Strategies, National Survey, May 9–13, 2006

address this problem, CHA has made covering the uninsured a top advocacy and

public policy priority for the Catholic health ministry year after year. We do so for

many reasons. As health care providers, we know that access to affordable care is

vital to the individual’s health and to the overall health of our Nation collectively.

We also see the tremendous problems in our facilities associated with the lack of

health insurance—the time and resources that are spent in providing acute care

when regular and preventive care would have been more suitable, and the desperate

situations of those lacking coverage that force them to turn to their local hospital

after the rest of our health care system has failed them. Along with other health

care provider groups, we have made Congress aware of these problems in the past

and will continue to do so as we seek a solution to them.

But above all else, the Catholic health ministry believes that in a nation so richly

blessed as ours it is simply immoral that anyone should go without access to adequate care. This central belief—that health care is not a privilege afforded to the

wealthy but a basic human right for all—is at the heart of our ministry’s history

and mission. Long before any Government regulations were established concerning

the care given in hospitals, our ministry’s facilities welcomed all those who sought

their services. Catholic hospitals and clinics, largely run by religious congregations,

tended the poor and sick who had no where else to turn. We believe that our advocacy and service on behalf of the Nation’s uninsured continues that very tradition.

Many of our facilities have responded to current health care needs through such

measures as establishing health clinics in their communities to provide care for lowincome families or providing other innovative services to promote good health

among the uninsured. Over the past five years, we have seen a 16.8 percent increase in the number of health clinics sponsored and supported by Catholic hospitals

in response to the growing number of uninsured and underinsured. But as these

needs continue to grow year after year it is becoming increasingly difficult for hospitals and clinics to fill in the gaps.

Simply put, our Nation cannot and should not continue to suffer the ill effects of

having members of our society, so many of whom are working hard to support their

families, go without health insurance. Unfortunately, their numbers continue to

rise. From 2000 to 2005 the number of uninsured rose by nearly 7 million. During

this time, from 2001 to 2005, Catholic hospitals also registered this increase in the

number of uninsured through a rise in the provision of uncompensated care. The

average uncompensated care cost to Catholic hospitals increased by 47 percent during this period, and continues to grow. 2

We also know that many of the uninsured do not seek or delay seeking care. According to the Kaiser Family Foundation, over three times (47 percent) as many of

the uninsured report postponing care due to cost as those with insurance (15 percent), and a much higher percentage of the uninsured (35 percent versus 9 percent)

report situations in which they needed care but did not receive it. 3

Clearly, even though our Nation’s hospitals continue to provide care to so many

who have no other options, the number of those who do not seek care at all or only

seek care at its costliest point has cast a pall of inefficiency over the entire U.S.

health care system. This situation cries out for change.

But the problem of the uninsured goes well beyond being an issue that should

concern only the Nation’s hospitals. Can anyone imagine what the consequences

would be if we were to report that approximately 15 percent of the entire population

was being denied access to such necessities as food or clean water? Or even to a

basic education? Why should we think the number of uninsured is any more acceptable, particularly given that nine million of these are children? This problem does

not represent simply a financial burden on the health care system or a challenge

for U.S. policymakers—it is a question of justice that highlights our failure to promote and protect the dignity and well-being of every single person. As long as any

individual, particularly the poorest and most vulnerable among us, goes without access to adequate care we are diminished as a nation and as a moral society.

Thankfully, Americans increasingly seem to view this situation as unacceptable

and are beginning to demand a solution. In a public opinion survey done for CHA

last year, the percentage of respondents ranking ‘‘providing affordable quality

health care’’/ as a priority for the Government was greater than ‘‘creating jobs’’ and

‘‘reducing Government spending and taxes’’ combined, and only equaled by ‘‘ensuring homeland security.’’ 4
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As the demand for a solution continues to grow, we also recognize that there are

many beneficial interim steps that Congress and the Administration could take to

help alleviate the growing problem of the uninsured, particularly in regards to the

scandal of having so many uninsured children in the U.S. CHA continues to work

with members of Congress on both sides of the aisle to ensure that this year’s reauthorization of the State Children’s Health Insurance Program contains at a minimum adequate funding to help cover the children currently eligible for this program

but not yet enrolled. We are grateful for the efforts of Chairman Dingell on this

issue and for his introduction of the Children’s Health First Act to help accomplish

this. Ensuring that none of our children has to go without access to care is a vital

first step in helping to cover the uninsured, and hopefully will give all who care

deeply about this issue the necessary momentum to keep moving forward.

As this subcommittee knows, when it comes to considering how best to find a solution to provide health coverage for everyone, there has been no lack of widely varying ideas to accomplish this. People of good faith from many different philosophical

and political perspectives have proposed ideas relying on Government, individual

and free market solutions over the past several years. I believe this is a positive

sign, showing concern about the uninsured across the political spectrum and inviting participation from diverse groups to tackle the problem. At CHA we have welcomed ideas from many different perspectives to help cover the uninsured, and we

continue to welcome them. We also have identified some critical characteristics for

a proposed solution that we hope will be beneficial to those seeking action. We believe that any proposal to cover the uninsured should:

• Make health care accessible and affordable for everyone, regardless of employment status, one’s age, financial means, or health status;

• Provide basic health benefits to everyone including services across the life span

of care—preventive, primary, acute, long term, and end of life;

• Provide for the poor and vulnerable with special attention to the particular

needs of low-income families and individuals, immigrants, the elderly and individuals with disabilities;

• Share responsibility for financing among Government, employers, and individuals;

• Encourage effective participation in decision making by providing patients and

their families with information about health care providers, plans, and procedures,

based on their quality and efficacy.

Legislative solutions must embody these characteristics in order to ensure access

to care for everyone. Any legislation that does not will only serve as a stopgap measure and push the need for a comprehensive solution even further down the road.

Let me close by once again urging this subcommittee, and indeed all in Congress

and the administration, to keep pushing for a solution to provide health coverage

for everyone in our Nation. Looking back through our history there are so many outstanding examples of seemingly insurmountable problems that we collectively have

faced and overcome—many would say that this is in fact a defining characteristic

of our country and its people. Given that history, surely we can move ahead to solve

the problem of the uninsured despite how difficult this situation seems. It is a problem that has gone on for far too long, and one that Americans from all walks of

life and political backgrounds agree is simply unacceptable. This is the moment to

take action, and the Catholic health ministry stands ready to assist all those who

seek a solution.

Thank you.
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QUESTION FROM MR. DEAL TO GRACE-MARIE TURNER

Chairman Frank Pallone asked witness Dr. Jeanne Lambrew about studies which show that expansion of public health programs has an effect on

crowding out private health insurance. Dr. Lambrew described a Federal

study which she said shows that crowd out is not a problem, and she indicated that Jonathan Gruber’s research does not indicate significant crowding out, as your testimony reported. Could you please help us to reconcile

her comments with your testimony on the important issue of crowd out?

In a paper published by the National Bureau of Economic Research in January

2007, MIT Professor Jonathan Gruber and Cornell Professor Kosali Simon state that

‘‘crowd-out remains a pervasive phenomenon for recent public insurance expansions.

Our central estimates suggest crowd-out of about 60 percent; that is, the number

of privately insured falls by about 60 percent as much as the number of publicly

insured rises.’’ Gruber and Simon also find that that crowd-out is a ‘‘family phenomenon.’’ They add that ‘‘Crowd-out estimates are much larger when family-wide

effects of eligibility are accounted for, incorporating a spillover onto other family

members of eligibility expansions.’’

Jonathan Gruber and Kosali Simon, ‘‘Crowd-out 10 years later: Have recent public

insurance expansions crowded out private health insurance?’’ National Bureau of

Economic Research Working Paper 12858. January 2007. http://www.nber.org/digest/aug07/w12858.html

In analyzing this data, Linda Gorman of the Independence Institute in Boulder,

Colorado, observes that Gruber and Simon extend the literature on crowd-out by addressing family as well as individual eligibility and by using a variety of techniques

to create robust estimates of crowd-out for the eligibility expansions that occurred

between 1996 and 2002.

She says that Gruber and Simon find that there is considerable crowd-out associated with these recent expansions of public insurance and that anti-crowd-out provisions, such as waiting periods and cost-sharing, have increased crowd-out.

The estimates use the 1996 and 2001 panels of the Survey of Income and Program Participation (SIPP). They are based on 405,389 observations and include information on family and individual characteristics, individual and family public program eligibility by State, employment, and data on State waiting periods and cost

sharing. Simple tabulations of changes in enrollment by income group suggest that

crowd-out ranges from 47 to 92 percent. Estimates using regression analysis suggest

that when the dependent variable is individual coverage, crowd-out is modest, from

24 to 37 percent. When a measure of family eligibility is substituted for individual

eligibility, crowd-out is more substantial, ranging from 61 to 68 percent. Adding additional statistical controls to account for differences in State insurance trends increases the estimate of crowd-out to 78 percent to 81 percent.’’

Source: Linda Gorman, ‘‘Public Insurance Expansions Crowd Out Private Health

Insurancee,’’ NBER Digest, August 2007; based upon: Jonathan Gruber and Kosali

Simon, ‘‘Crowd-Out Ten Years Later: Have Recent Public Insurance Expansions

Crowded Out Private Health Insurance?’’ National Bureau of Economic Research,

Working Paper No. 12858, January 2007. http://nber.org/digest/aug07/

w12858.html

In a comprehensive study on SCHIP published in May 2007, the Congressional

Budget Office says it is difficult to authoritatively determine crowd out of private

coverage. But it concludes: ‘‘On the basis of a review of the available studies, CBO

concludes that the reduction in private coverage among children is most probably

between a quarter and a half of the increase in public coverage resulting from

SCHIP. That is, for every 100 children who gain coverage as a result of SCHIP,

there is a corresponding reduction in private coverage of between 25 and 50 children.’’ The study says that crowd out is most likely to take place among children

whose parents have higher incomes and who are more likely to already have private

coverage—the very populations that the Congress is targeting for its SCHIP expansion.

‘‘According to CBO’s analysis of data from the Current Population Survey, 50 percent of children in families with income between 100 percent and 200 percent of the

poverty level had private coverage in 2005. The rate of private coverage rose to 77

percent among children between 200 percent and 300 percent of the poverty level,

89 percent among those between 300 percent and 400 percent of the poverty level,

and 95 percent among those over 400 percent of the poverty level.’’

The State Children’s Health Insurance Program, Congressional Budget Office,

May 2007. http://www.cbo.gov/ftpdocs/80xx/doc8092/05-10-SCHIP.pdf
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Therefore, I believe the literature is clear, especially in light of the CBO study

published after the committee’s hearing, that crowd-out is a significant problem, especially with the expansion populations targeted in the SCHIP legislation passed by

the House of Representatives on August 1, 2007.

QUESTION FROM MR. BURGESS TO JEANNE LAMBREW

In your testimony you said that $150 billion increase in Federal spending

would cover the uninsured, and that you would propose covering this cost

with a VAT tax. How accurate is this $150 billion estimate, and how would

you structure the VAT?

The details of the proposal will determine the Federal cost to cover the uninsured.

In an article in Health Affairs in 2005, my co-authors and I estimated that, depending on the nature of the financial assistance, the annual Federal cost of covering

all Americans could range from $100 to $160 billion (see Lambrew JM, Podesta JD,

and Shaw T. (2005). ‘‘Change in Challenging Times: A Plan for Extending and Improving Coverage,’’ Health Affairs, W5–119–132). We based this range on estimates

of a set of health proposals done for the Robert Wood Johnson by the Lewin Group,

in addition to conversations with other cost estimators. Coverage for all could be

achieved for less, or could cost more, depending on the policy. In my testimony, I

used $150 billion as an illustration of the high end of this range.

There is a degree of uncertainty in any estimates, by definition. Health care cost

projections must take into account future changes in coverage, technology, inflation,

and other factors that are difficult to predict. In addition, how people, firms, and

providers will react to a reformed health system is unclear, since we have little past

experience in the U.S. on which to draw. It is not always the case that projections

are too low; for example, both SCHIP and the Medicare drug benefit cost significantly less than the Congressional Budget Office predicted in their initial years of

operation.

To the extent that policy makers are uncomfortable with this uncertainty, they

can build in policy mechanisms to address it. For example, policy makers in Massachusetts allow a public-private Board to modify key aspects of the plan like the cost

sharing and financial assistance schedule. This allows them to calibrate the plan design, without returning to the legislature, to meet budget constraints.

The VAT is one of many options for financing health reform. I have supported this

option because it is broad-based and ensures shared responsibility: everyone both

pays and benefits under health reform financed in this way. It is also consistent

with how our competitor nations finance their health programs. To ensure that it

is progressive, its revenue should be used for income-related financial assistance

and certain exemptions should be included (e.g., small businesses, food, education,

religion, and health care). With such exemptions, based on other research, a VAT

of 3 to 4 percent should be sufficient to finance health reform.

QUESTION FROM MR. BURGESS TO HON. TOM DASCHLE

In your testimony, you mention the important protections that ERISA

provides. Could you share with the subcommittee some of the concerns you

see that State regulation poses to employers’ efforts to provide health care

to their employees nationwide?

The Employment Retirement Income Security Act (ERISA) has, among other provisions, provided firms with the option of self-insuring for health benefits. This option has been taken by a number of large employers to use their economies of scale

to achieve better results in providing high-quality, affordable health care to workers

than commercial insurers could. At the same time, ERISA has exempted health coverage through these firms from State consumer protection and health reform policies. This has posed barriers to some States that have aimed to enact legislation

to reform their systems. As such, there are advantages and disadvantages of ERISA

from the vantage point of health policy. But one thing is certain: national health

reform is needed, and in that context, ERISA along with other laws that affect

health benefits will likely be re-examined, modified, and/or overhauled.

QUESTION FROM MR. BURGESS TO MICHAEL K. SMITH

In your testimony, you mention the important protections that the Employment Retirement Income Security Act provides. Could you share with
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the subcommittee some of the concerns you see that State regulation poses

to employers’ efforts to provide health care to their employees nationwide?

It appears that my testimony about the Employment Retirement Income Security

Act (ERISA) may have been unclear or was misunderstood. As you know, ERISA

was implemented in 1974 to regulate private sector pension programs, including

health coverage, and it supercedes or preempts any State laws that relate to employee benefit plans. While the initial objective of ERISA—to encourage employers

to sponsor plans and not be subject to multiple, varying State laws—was good, this

preemption is now hindering States’ goal to provide health coverage to all residents.

For example, ERISA prohibits States from requiring that employers provide information to the State about their health benefit plans. Many States are trying to assure that all residents have comprehensive and/or affordable coverage, but cannot

develop strategies, proposals or cost estimates without information from employers

about their benefit structures. These strategies can take multiple forms, including

assisting employers with affordability of their coverage plans or assisting employees

to purchase employer offerings. For example, Vermont and other States are offering

premium assistance to low income residents to purchase employer-based coverage,

but ERISA prohibits States from requiring that employers participate or share information about their benefit plans with the State to facilitate implementation of these

premium assistance programs. Finally, ERISA’s preemption provisions are somewhat vague, creating doubt about what States can and cannot do with regard to requiring employers to help pay for broad-based financing to expand health care coverage for State residents.

Hopefully, this has adequately clarified the intent of my remarks about ERISA.

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