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67–817 2012

MAKING HEALTH CARE WORK FOR AMERICAN 

FAMILIES: IMPROVING ACCESS TO CARE 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH 

OF THE

COMMITTEE ON ENERGY AND 

COMMERCE 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED ELEVENTH CONGRESS 

FIRST SESSION 

MARCH 24, 2009 

Serial No. 111–20 

( 

Printed for the use of the Committee on Energy and Commerce 

energycommerce.house.gov 


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COMMITTEE ON ENERGY AND COMMERCE 

HENRY A. WAXMAN, California, Chairman 

JOHN D. DINGELL, Michigan 

Chairman Emeritus 

EDWARD J. MARKEY, Massachusetts 

RICK BOUCHER, Virginia 

FRANK PALLONE, JR., New Jersey 

BART GORDON, Tennessee 

BOBBY L. RUSH, Illinois 

ANNA G. ESHOO, California 

BART STUPAK, Michigan 

ELIOT L. ENGEL, New York 

GENE GREEN, Texas 

DIANA DEGETTE, Colorado 

Vice Chairman 

LOIS CAPPS, California 

MICHAEL F. 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 

ANTHONY D. WEINER, New York 

JIM MATHESON, Utah 

G.K. BUTTERFIELD, North Carolina 

CHARLIE MELANCON, Louisiana 

JOHN BARROW, Georgia 

BARON P. HILL, Indiana 

DORIS O. MATSUI, California 

DONNA M. CHRISTENSEN, Virgin Islands 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

CHRISTOPHER MURPHY, Connecticut 

ZACHARY T. SPACE, Ohio 

JERRY MCNERNEY, California 

BETTY SUTTON, Ohio 

BRUCE L. BRALEY, Iowa 

PETER WELCH, Vermont 

JOE BARTON, Texas 

Ranking Member 

RALPH M. HALL, Texas 

FRED UPTON, Michigan 

CLIFF STEARNS, Florida 

NATHAN DEAL, Georgia 

ED WHITFIELD, Kentucky 

JOHN SHIMKUS, Illinois 

JOHN B. SHADEGG, Arizona 

ROY BLUNT, Missouri 

STEVE BUYER, Indiana 

GEORGE RADANOVICH, California 

JOSEPH R. PITTS, Pennsylvania 

MARY BONO MACK, California 

GREG WALDEN, Oregon 

LEE TERRY, Nebraska 

MIKE ROGERS, Michigan 

SUE WILKINS MYRICK, North Carolina 

JOHN SULLIVAN, Oklahoma 

TIM MURPHY, Pennsylvania 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

PHIL GINGREY, Georgia 

STEVE SCALISE, Louisiana 

PARKER GRIFFITH, Alabama 

ROBERT E. LATTA, Ohio 

(II) 


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(III) 

SUBCOMMITTEE ON HEALTH

FRANK PALLONE, JR., New Jersey, Chairman 

JOHN D. DINGELL, Michigan 

BART GORDON, Tennessee 

ANNA G. ESHOO, California 

ELIOT L. ENGEL, New York 

GENE GREEN, Texas 

DIANA DEGETTE, Colorado 

LOIS CAPPS, California 

JAN SCHAKOWSKY, Illinois 

TAMMY BALDWIN, Wisconsin 

MIKE ROSS, Arkansas 

ANTHONY D. WEINER, New York 

JIM MATHESON, Utah 

JANE HARMAN, California 

CHARLES A. GONZALEZ, Texas 

JOHN BARROW, Georgia 

DONNA M. CHRISTENSEN, Virgin Islands 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

CHRISTOPHER S. MURPHY, Connecticut 

ZACHARY T. SPACE, Ohio 

BETTY SUTTON, Ohio 

BRUCE L. BRALEY, Iowa 

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 

MARY BONO MACK, California 

MIKE FERGUSON, New Jersey 

MIKE ROGERS, Michigan 

SUE WILKINS MYRICK, North Carolina 

JOHN SULLIVAN, Oklahoma 

TIM MURPHY, Pennsylvania 

MICHAEL C. BURGESS, Texas 


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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 ................................................................................................ 2 

Hon. Anna G. Eshoo, a Representative in Congress from the State of California, opening statement .................................................................................... 4 

Hon. John Shimkus, a Representative in Congress from the State of Illinois, 

opening statement ................................................................................................ 5 

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

opening statement ................................................................................................ 5 

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

Texas, opening statement .................................................................................... 6 

Hon. Henry A. Waxman, a Representative in Congress from the State of 

California, opening statement ............................................................................. 7 

Prepared statement .......................................................................................... 9 

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

Tennessee, opening statement ............................................................................ 13 

Hon. John D. Dingell, a Representative in Congress from the State of Michigan, opening statement ....................................................................................... 13 

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

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

Hon. Diana DeGette, a Representative in Congress from the State of Colorado, opening statement ...................................................................................... 16 

Hon. Tim Murphy, a Representative in Congress from the Commonwealth 

of Pennsylvania, opening statement ................................................................... 16 

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

opening statement ................................................................................................ 17 

Hon. Mike Rogers, a Representative in Congress from the State of Michigan, 

opening statement ................................................................................................ 17 

Hon. Tammy Baldwin, a Representative in Congress from the State of Wisconsin, opening statement ................................................................................... 18 

Hon. Ed Whitfield, a Representative in Congress from the Commonwealth 

of Kentucky, opening statement ......................................................................... 19 

Hon. Donna M. Christensen, a Representative in Congress from the Virgin 

Islands, opening statement ................................................................................. 19 

Hon. Kathy Castor, a Representative in Congress from the State of Florida, 

opening statement ................................................................................................ 20 

Hon. Christopher S. Murphy, a Representative in Congress from the State 

of Connecticut, opening statement ..................................................................... 20 

Hon. Zachary T. Space, a Representative in Congress from the State of 

Ohio, opening statement ...................................................................................... 21 

Hon. Bruce L. Braley, a Representative in Congress from the State of Iowa, 

opening statement ................................................................................................ 22 

Hon. Jane Harman, a Representative in Congress from the State of California, opening statement .................................................................................... 22 

Hon. John Barrow, a Representative in Congress from the State of Georgia, 

opening statement ................................................................................................ 23 

Hon. Roy Blunt, a Representative in Congress from the State of Missouri, 

prepared statement .............................................................................................. 178 

WITNESSES

Brian D. Smedley, Ph.D., Vice President and Director, Health Policy Institute, 

Joint Center for Political and Economic Studies ............................................... 24 

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


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VI 

Michael John Kitchell, M.D., President-Elect of Iowa Medical Society, McFarland Clinic PC ...................................................................................................... 47 

Prepared statement .......................................................................................... 49 

Michael A. Sitorius, M.D., Professor and Chairman, Department of Family 

Medicine, University of Nebraska Medical Center ............................................ 54 

Prepared statement .......................................................................................... 56 

Risa Lavizzo-Mourey, M.D., M.B.A., President and CEO, Robert Wood Johnson Foundation ..................................................................................................... 61 

Prepared statement .......................................................................................... 63 

Fitzhugh Mullan, M.D., Murdock Head Professor of Medicine and Health 

Policy, Professor of Pediatrics, The George Washington University ............... 81 

Prepared statement .......................................................................................... 84 

Jeffrey P. Harris, M.D., F.A.C.P., President, American College of Physicians .. 99 

Prepared statement .......................................................................................... 102 

James R. Bean, M.D., President, American Association of Neurological Surgeons ...................................................................................................................... 119

Prepared statement .......................................................................................... 121 

Diane Rowland, Sc.D., Executive Director, The Kaiser Commission on Medicaid and the Uninsured ...................................................................................... 133 

Prepared statement .......................................................................................... 135 

SUBMITTED MATERIAL

Letters from physicians to Mr. Shimkus ............................................................... 180 

Letter from the Georgia Mutual Insurance Company to the Medical Association of Georgia, submitted by Mr. Gingrey ........................................................ 189 


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MAKING HEALTH CARE WORK FOR AMERICAN FAMILIES: IMPROVING ACCESS TO 

CARE 

TUESDAY, MARCH 24, 2009 

HOUSE OF REPRESENTATIVES, 

SUBCOMMITTEE ON HEALTH, 

COMMITTEE ON ENERGY AND COMMERCE, 

Washington, DC. 

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

2322 of the Rayburn House Office Building, Hon. Frank Pallone, 

Jr. (chairman) presiding. 

Members present: Representatives Pallone, Dingell, Gordon, 

Eshoo, Green, DeGette, Capps, Schakowsky, Baldwin, Weiner, Harman, Gonzalez, Barrow, Christensen, Castor, Sarbanes, Murphy of 

Connecticut, Space, Sutton, Braley, Waxman (ex officio), Deal, 

Whitfield, Shimkus, Blunt, Rogers, Myrick, Murphy of Pennsylvania, Burgess, Blackburn, Gingrey, and Barton (ex officio). 

Staff present: Karen Nelson, Deputy Staff Director for Health; 

Karen Lightfoot, Communications Director; Jack Ebeler, Senior Advisor on Health Policy; Stephen Cha, Professional Staff Member; 

Tim Gronniger, Professional Staff Member; Purvee Kempf, Counsel; Anne Morris, Legislative Analyst; Virgil Miller, Legislative Assistant; Camille Sealy, Detailee; Miriam Edelman, Special Assistant; Lindsay Vidal, Special Assistant; Alvin Banks, Special Assistant; Allison Corr, Special Assistant; Brandon Clark, Minority Professional Staff; Marie Fishpaw, Minority Professional Staff; Clay 

Alspach, Minority Counsel; Melissa Bartlett, Minority Counsel; and 

Chad Grant, Minority Legislative Analyst. 

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

Mr. PALLONE. The hearing is called to order. 

Today the subcommittee is meeting for the third hearing in the 

‘‘Making Health Care Work for American Families’’ series. In the 

previous hearings, we heard from the leading experts in health 

care that our delivery system is dangerously disconnected and that 

providing universal coverage means and affordable and quality 

health plans for all. Today we will explore the next step. Simply 

providing universal coverage will not guarantee that everyone will 

have access to the necessary care. We must also eliminate the inequities and disparities in health care, properly support and train 

our health care workforce and make prevention a national priority. 


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As a Nation, we have made tremendous strides in improving the 

health of all Americans. However, as numerous reports have highlighted, there remain significant inequalities with respect to both 

access to health care and the quality of care provided among different ethnic groups in this country. For example, the mortality 

rate due to heart disease and cancer is higher among populations 

including African-Americans, Asian-Americans and Pacific Islanders. The rate of new AIDS cases is three times higher among Hispanics than among Caucasians. I personally am also very concerned about the health disparities for American Indians and Alaska Natives. The mortality rate among Indian infants is 150 percent 

higher than for Caucasian infants, and Indians are nearly three 

times as likely to be diagnosed with diabetes. These disparities are 

not limited, however, to ethnic and racial divides but are consistently also found between genders, geographic area and among different income groups. For example, there are significantly more access-to-care obstacles for rural populations than there are for urban 

populations, and the 2002 Institute of Medicine report found that 

these disparities persisted even when factors such as insurance 

coverage and income level remained constant. 

One of the contributing problems in my mind is the current state 

of the health care workforce. Study after study has proven the importance or primary care yet two-third of the U.S. physician workforce that practice as specialists and the number of young physicians entering primary care fields is declining. In addition to this, 

there are disparities in where these physicians are practicing. Metropolitan areas have two to five times as many physicians as rural 

areas and there is a shortage of physicians willing to practice in 

economically disadvantaged areas, both rural and urban. 

Part of the solution, in my mind, is to strengthen our existing 

programs while at the same time exploring new avenues to reduce 

disparities and expand the workforce. As highlighted in a recent 

Commonwealth Fund report, Medicaid is vital in improving access 

to health care for low-income Americans. Title 7 and 8 of the Public 

Health Service Act are crucial programs to increase the primary 

care workforce and the National Health Service Corps is a very 

successful program to entice young medical professionals to practice in underserved neighborhoods. But we face many obstacles in 

ensuring access for all Americans. I am optimistic that in this Congress we will take action to ensure that all Americans have both 

coverage and access to care. 

I want to welcome all of the witnesses today. I do want to say 

that certain members, not to take away from the others, but Ms. 

Christensen was very crucial in asking that we have this hearing 

today and address some of the disparity issues and certainly Ms. 

Capps, who is our vice chair, constantly making reference to the 

workforce and the need to address those workforce issues. 

Mr. PALLONE. With that I will ask Mr. Deal to begin with an 

opening statement. Thank you. 

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

Mr. DEAL. Thank you, Mr. Chairman. I want to also express appreciation to all the witnesses for being here today. 


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As we move forward in this series of hearings looking at what 

health care reform should encompass, I think there are some fundamentals that we all ought to keep in mind. I believe that some 

of the true issues in health care reform include transparency, efficiency and accountability in the health delivery system, and allowing a system to exist that involves a patient’s right to choose. 

This hearing, of course, is going to focus on access to health care 

services and various proposals aimed to overcome the obstacles to 

care. Unfortunately, too many Americans across the country do 

lack access to quality, affordable medical care. As we all know, 

there are a variety of reasons why this exists. Physical, geographical, cultural and financial influences all play a role in patient access to health care. While there are scores of obstacles to 

stand in the way of receiving it, effective reform such as cross-state 

purchasing of health insurance, association health plans, consumer-driven options that enhance quality and value, and similar 

options which build upon the doctor-patient relationship would 

make great strides forward in bridging the gap that exists under 

today’s system. 

There is a lot of talk in Washington that suggests that the most 

appropriate way to put our health care delivery system back on its 

course is to increase the role of government-run health care programs, particularly Medicare and Medicaid and SCHIP. I of course 

don’t agree with that proposition. Patients receiving care through 

Medicaid oftentimes find it very difficult to find a physician who 

will accept their coverage due at least in part to abysmal reimbursement levels rendered for their services. Medicaid participants 

are frequently forced to travel great distances to receive access to 

needed care. In fact, just before the hearing today I had an opportunity to meet with a group of podiatric physicians from my district 

and they reiterated the challenges that their Medicaid patients face 

in finding a providing who will actually accept their coverage. In 

my rural district in north Georgia, this presents a significant challenge to many of my constituents and funneling even more individuals into government-run health care programs without addressing 

the heart of these programs does not reflect the reform that the 

American people are asking for. 

Additionally, Congress should also consider other forms in the 

health care delivery system. I believe that any package we sent to 

the Floor should include a significant medical liability reform provision. Time and again we have repeated instances of frivolous lawsuits for medical liability cases being brought against health care 

providers as trial lawyers seek to exploit every opportunity to game 

the legal system and yield an oversized award. Unfortunately, we 

have seen as a result physicians continue to change the way they 

practice medicine, usually resulting in an onslaught of medically 

unwarranted diagnostic testing and referrals to other physicians 

solely for the protection of the provider, not the patient, under the 

practice of defensive medicine. 

We are all aware of the significant and growing cost of health 

care. Unfortunately, with the understandably defensive nature of 

the health care delivery system in the United States, we can only 

expect these strains to multiply as the number of Americans receiving care grows. By empowering physicians with the ability to proVerDate Mar 15 2010 23:37 Mar 23, 2012 Jkt 067817 PO 00000 Frm 00009 Fmt 6633 Sfmt 6633 E:\HR\OC\A817.XXX A817

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vide needed health care services without the burden of defensive 

medicine tactics, an estimated $70 to $126 billion per year could 

be saved, outcomes could be improved and utilization of our limited 

medical resources would be more effectively maximized. Rest assured, I value protection of patients’ rights and efforts to reform 

the medical liability system should not be misconstrued as an effort 

to infringe upon those rights. If tragedy occurs, then certainly there 

should be redress for the individual who has been harmed. 

I lost sight of the clock up there. There it is. I finally spotted it. 

I have run out of my time, so I am going to stop, but thank you 

all for being here today. 

Mr. PALLONE. Thank you, Mr. Deal. 

For an opening statement, the gentlewoman from California, Ms. 

Eshoo. 

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

Ms. ESHOO. Good morning, Mr. Chairman, and thank you for the 

series of hearings that you are holding as we prepare legislation for 

health care for everyone in our country. I guess today can be called 

Doctors Day, so welcome to all the witnesses. 

As a Nation we have innovative equipment, I think we have the 

most knowledgeable doctors, we have the widest array of medicines, but if millions of Americans don’t have access to this, obviously something is very, very wrong, and it is worst for minorities 

and lower-income groups. In addition to the 47 million Americans 

who have no insurance whatsoever, there are millions more who 

are underinsured. Racial, ethnic, cultural, socioeconomic and geographical barriers exist in getting people the care they need and 

that is why it is critical for us to keep these factors in mind when 

addressing health care reform and I think that you are going to 

teach us a lot today. 

I look forward to discussing how we can improve Medicaid and 

Medicare as well. There are parts of the country where two out of 

three doctors will not see Medicaid patients, in parts of my own 

district, and it is the heart of Silicone Valley so one might think 

that even though the Gallop Poll said that it is the most contented 

district in the country, we still have many gaps where no doctor 

will take new Medicare patients because they are reimbursed at 

rates far below their costs. The Geographic Price Cost Index, or the 

GPCI, has severely skewed doctor reimbursement rates so low in 

Santa Cruz County that many of my senior constituents have to 

travel an hour or more over a winding mountain road to see a doctor in another county. So this is just one example of how our health 

care system is broken and fails too many Americans. 

I thank each one of you for being here today. I look forward to 

your testimony and most important of all, look forward to all of you 

working with us where in the year 2009, God willing, we will really 

reform the system once and for all. 

Thank you, Mr. Chairman. 

Mr. PALLONE. Thank you, Ms. Eshoo. 

The gentleman from Illinois, Mr. Shimkus. 


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OPENING STATEMENT OF HON. JOHN SHIMKUS, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF ILLINOIS 

Mr. SHIMKUS. Thank you, Mr. Chairman. 

When I started practicing medicine in the same location 30 years ago, my malpractice premium with the same insurer was $10,000 

a year. Today my premium is just shy of $100,000 annually. Major 

malpractice reform with bipartisan support should be a starting 

point for our country’s health care overhaul. Threat of litigation 

causes an inestimable amount of practice of defensive medicine. It 

will not take too many rate hikes for those of us providing obstetrical care in rural counties to say enough is enough and that we 

will not continue to provide high-risk services. 

These days, malpractice insurance premiums are prohibitive. We 

have not been able to recruit new doctors in the area, particularly 

in surgical specialties, due to excessive premiums. Addressing medical liability reform and health care reform will free millions of doctors that can be directed toward improving care and access to care. 

It would also provide for a better distribution of physicians as recruitment and retention of physicians is greatly influenced by the 

medical liability environment of each State. 

I have two additional letters, Mr. Chairman, and I ask unanimous consent that these be submitted for the record. They are from 

doctors in my district and health care providers, especially hospitals. 

[The information appears at the conclusion of the hearing.] 

Mr. PALLONE. Without objection, so ordered. We thank the gentleman. 

The gentleman from Texas, Mr. Green. 

OPENING STATEMENT OF HON. GENE GREEN, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS 

Mr. GREEN. Thank you, Mr. Chairman, for calling this hearing. 

In following my friend from Illinois, if we could handle medical 

malpractice, in Texas we wouldn’t have 900,000 children and not 

covered by SCHIP because the State won’t cover the match because 

we have one of the strong medical malpractice laws in the country 

and we still have a huge number of uninsured. I think we have to 

look at other issues. 

I want to thank you for holding the hearing today on health insurance and access to care. Houston has the third largest Hispanic 

population in the country and I represent an area that is 65 percent Hispanic and medically underserved. In 2007, nearly half of 

the 47 million uninsured in the United States were minorities. Unfortunately, most minority populations have higher rates of diseases like diabetes, cervical cancer, HIV/AIDS and heart disease in 

our community. In fact, Mexican-Americans are twice as likely as 

Anglos to be diagnosed with diabetes. These diseases are mostly 

preventable but lack of access to care is still a barrier to the minority communities in part because of the many health problems in 

the Hispanic community. 

As we know on this committee, access to quality primary and 

preventive care leads to a better quality of life and fewer health 

problems down the road. We will hear today that aside from barriers to primary care, we are facing a shortage of primary care phyVerDate Mar 15 2010 23:37 Mar 23, 2012 Jkt 067817 PO 00000 Frm 00011 Fmt 6633 Sfmt 6602 E:\HR\OC\A817.XXX A817

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sicians. This is troublesome because even if we reform our system, 

we may not have enough primary care physicians to serve all the 

patients who will be entering our health care system. 

We are addressing the issue of health reform but as we move forward we have to reiterate that State and federal partnerships do 

not work if the State cannot come up with the federal match. Texas 

unfortunately has a long history in the SCHIP and Medicare program of not providing the matching funds much to the detriment 

of our residents. Health reform must be at a national level, and if 

we truly want to cover all Americans, although many States have 

their own wraparound programs, some of us do not and we can’t 

leave those uninsured behind. 

Again, I want to thank our witnesses today, and Mr. Chairman, 

I yield back my time. 

Mr. PALLONE. Thank you, Mr. Green. 

The gentleman from Texas, Mr. Burgess. 

OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS 

Mr. BURGESS. Thank you, Mr. Chairman. Thank you for holding 

this hearing. I feel like I am in a Chevy Chase movie, doctor, doctor, doctor, doctor and doctor, but, you know, reading through the 

testimony today, we are going to have an opportunity to touch on 

several important issues and they are issues that have been near 

and dear to my heart for a long time. 

I do look forward to discussing the role of Medicare and Medicaid 

in providing care and the very serious issues we face in ensuring 

that our primary care workforce is able to meet the demands of the 

future and the role of health disparities among the various populations. Some very basic questions that we need to consider. How 

can we think of going forward until we have some solutions to the 

problems that we know exist within our public systems today and 

this hearing might very well serve as a checklist of what we know 

to be broken within those public systems. The federal programs, 

Medicare and Medicaid, that cover well over a third of our population, are headed for a budgetary collapse. We expect these programs to service the populations that they do now and in the very 

near future to serve even more, and the providers in the workforce 

face the threat of annual Medicare cuts, this year to be at 20 percent unless Congress acts before the end of December, and Medicaid reimbursements that are even worse, and to top it all off, the 

Association of American Medical Colleges reports that the physician shortage is expected to exceed 124,000 doctors by 2025. 

I am encouraged to see attention being given to the physician 

workforce issues. I have been concerned about that for some time. 

In my home State of Texas, the number of doctors between 1995 

and 2005 increased by 46 percent, nearly 5,000 doctors, but the 

State is still well below the national average. I believe that a good 

start for Congress is to enact legislation that this committee, this 

subcommittee approved, we approved in full committee that I introduced along with Congressman Gene Green, H.R. 914, the Physician Workforce Enhancement Act of 2009, to create additional residency training programs where historically none have operated in 

the past. We all know doctors are not very imaginative. We tend 


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to go into practice within 50 miles of where we do our training and 

this is a bill aimed at capitalizing upon that fact, but it is only one 

small step. 

I also represent an area that has a significant minority population who suffers from a lack of direct access to medical services 

and obviously the health problems that result therefrom. But that 

is just it, Mr. Chairman. We need a lot of discussion before we proceed on the path of a comprehensive fix but we all know we need 

to proceed. Coverage does not always equal access. Coverage 

doesn’t help the Medicare or Medicaid patient who cannot find a 

doctor willing to accept the program, or worse yet, a doctor who can 

no longer afford to keep their doors open because they have accepted what the government will pay. So simply burdening future generations is not the answer. It is up to us, it is up to this Congress. 

I look forward to the testimony today and I will yield back the 

balance of my time. 

Mr. PALLONE. Thank you. 

The chairman of our full committee, Mr. Waxman. 

OPENING STATEMENT OF HON. HENRY A. WAXMAN, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF CALIFORNIA 

Mr. WAXMAN. Thank you very much, Chairman Pallone, for holding this hearing. 

We have already had two productive hearings in this series on 

health reform. At the first hearing the Institute of Medicine testified that health insurance coverage makes a big difference in personal health. For example, the health of uninsured middle-aged 

adults who have chronic conditions such as diabetes declines more 

rapidly than the health of insured adults with these conditions. 

Overall, uninsured adults are 25 percent more likely to die prematurely than adults with health insurance. The data are overwhelming. Health insurance improves access to care, which in turn 

improves personal health, while we also know that health insurance coverage does not necessarily guarantee access to needed care. 

Racial and ethnic minorities often don’t get the care they need, 

even if they are insured. People living in rural areas of our Nation 

have some of the highest rates of chronic health problems like obesity but some of the lowest numbers of physicians and nurses to 

address these problems. Communities all over the country in urban 

and rural areas alike face growing shortages of primary care physicians and nurses. Coverage for all is essential but health insurance 

by itself won’t solve these shortages. We will need additional measures to ensure that we have enough primary care physicians and 

nurses to meet the Nation’s needs. 

As the Institute of Medicine told us, many more low-income 

Americans would be uninsured today and at greater risk for poor 

health and premature death were it not for expansions in public 

programs like Medicaid and CHIP. Medicaid and CHIP are the Nation’s insurers for low-income families and children and individuals 

with disabilities. However, just as Americans with private health 

insurance do not always have access to needed care, so those enrolled in Medicaid and CHIP may not always have access to the 

care they need. When our committee takes up health reform, we 


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will provide coverage for the uninsured. However, I also want to 

make sure that our legislation addresses the barriers to access that 

insurance coverage by itself can’t fix. Today’s hearing will help us 

craft solutions that will improve access to care for all regardless of 

race, ethnicity or geography. 

I look forward to our witnesses’ testimony. I yield back the balance of my time. 

[The prepared statement of Mr. Waxman follows:] 


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Mr. PALLONE. Thank you, Chairman Waxman. 

The gentlewoman from Tennessee, Ms. Blackburn. 

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

Ms. BLACKBURN. Thank you, Mr. Chairman. Welcome to our 

guests. 

In order to truly reform the Nation’s health care system, I am 

one of those that believes we have to focus on cost reduction, improved quality, increased access to all Americans. True medical liability reform is a critical component of the health reform debate. 

It is concerning to me that there has been little attention on how 

tort reform will affect access to care in the broader health care reform debate. The lack of liability reform hurts patients, hurts our 

constituents, impacts their ability to receive care due to enormous 

added costs incurred in the practice of defensive medicine which 

has driven trial lawyers looking to cash in on what they deem to 

be bad outcomes. Any attempt to make health care available to the 

underserved and uninsured will be doomed to failure if the legal 

costs of practicing medicine are not addressed. 

With reimbursement issues added to the high cost of liability insurance, physicians who are often small business owners must 

weigh the risk of taking new patients, particularly the uninsured, 

if costs exceed reimbursement. A physician in my district recently 

told me without significant and real tort reform, no plan to control 

increasing health care costs will succeed. While it is healthy to consider the best practices for both patients and physicians, the debate 

must be resolved so the medical system can operate in a more effective fashion and be improved to consistently deliver high quality 

of care. 

Mr. Chairman, I would like to ask unanimous consent that I 

enter some letters into the record from physicians in my district 

who have highlighted their concerns with the need for medical malpractice reform in the overall debate. 

[The information was unavailable at the time of printing.] 

Mr. PALLONE. Without objection, so ordered. I thank the gentlewoman. 

Ms. BLACKBURN. I yield back. 

Mr. PALLONE. The chairman emeritus, Mr. Dingell. 

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

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

holding today’s hearing on improving access to health care. This is 

a particularly timely topic since this is Cover the Uninsured Week. 

There are 46 million people in the United States who lack health 

insurance and some have estimated that without action, the number could reach 61 million by 2020. 

It comes as no surprise that the uninsured have trouble accessing quality health care but access is a problem even for those with 

insurance coverage. The high cost of health care and lean insurance benefits have led more than 25 million people to be classified 


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as underinsured. These people are more likely to forego needed 

care because of costs. Furthermore, the Commonwealth Fund reports that in addition to gaps in insurance coverage, Americans 

lack timely access to care, meaning they are not able to see their 

doctors within 2 days of becoming sick. 

As we move forward with comprehensive health care reform legislation, there are a few key issues that we must tackle with regarding to expanding access to care. First and most important, we 

must set a goal that our health care reform bill moves us toward 

universal coverage. That is why I support a provision that would 

require everyone to have health insurance. However, we must insure that care is affordable to everyone and I believe that is the 

only way we can have universal coverage and have it in a fair and 

proper way. Even if we require everyone to have health insurance, 

many Americans will still lack access to health care due to a shortage of primary care providers. Strong primary care systems have 

been shown to reduce costs and improve quality. However, of the 

800,000 physicians in the United States, only 40 percent are primary care providers. By the year 2025, we will have a shortage of 

over 40,000 primary care doctors. Our health care payment systems have essentially subsidized specialty care. 

As we construct new health care networks, one that I hope includes a public plan, nay, that must include a public plan, we must 

move from a fee-for-service payment structure to one that rewards 

quality and patient-centered primary care. We must consider incentives such as loan forgiveness, scholarships and other things to 

draw young medical students into the primary care field. Additionally, we must assess the need for nurses, nurse practitioners and 

physician assistants and we must then invest in a proper way of 

ensuring that that carries forward. These professionals serve on 

the front line of care and play a critical role in primary care and 

prevention. 

We must address the persistent disparities in health care access 

and health outcomes for racial and ethnic groups. Numerous studies have shown that racial and ethnic minorities are consistently 

less likely to receive necessary care, even when controlling for 

other access-related factors. I believe, and I stress this, that health 

care is a right, not a privilege, and failure to address the root 

causes of these disparities is immoral. 

Finally, if it were not for Medicare, Medicaid and CHIP, many 

people would be among the ranks of the uninsured and underinsured. These public programs service one-third of U.S. populations. Any comprehensive reform must ensure the viability of 

these programs. 

I thank you, Mr. Chairman, and I yield back the balance of my 

time. 

Mr. PALLONE. Thank you, Chairman Dingell. 

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

OPENING STATEMENT OF HON. JOE BARTON, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS 

Mr. BARTON. Thank you, Mr. Chairman. I appreciate you holding 

this hearing on issues related to improving access to care. 


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This is the third hearing, and as the witnesses will testify, improving access to health care involves many issues such as getting 

more people into the provider workforce, the role of public health 

programs and perceived health disparities. I am particularly interested in hearing about the role of medical liability reform as it relates to health care access, also about the role physicians can play 

to increase access points in their communities. 

The current medical liability system in the United States affects 

the ability of patients to receive care when they need it. It is well 

documented that doctors are scaling back the care they provide or 

abandoning their practice altogether to avoid being sued. When you 

don’t have providers, that can mean the difference between life and 

death for those patients who don’t have a doctor. 

My home State of Texas is a perfect example of how medical liability reform improves people’s health care. In 2003, Texas voters 

approved a constitutional amendment that included a limit on noneconomic damages while continuing to allow injured parties to be 

fully compensated for economic damages. Prior to that reform, skyrocketing insurance premiums were forcing doctors to flee the 

State, quit medicine or cut back on complex, lifesaving procedures. 

At the height of the crisis, Texas ranked 48th out of the 50 States 

in per capita physicians. In the years since the reform was passed, 

Texas has been transformed from a State in turmoil to a model. 

Doctors are coming back to Texas, patients are getting better care. 

More doctors mean improved access, especially for those Texans 

that are living in poor and medically underserved areas. I would 

urge this committee, Mr. Chairman, to take a serious look at liability reform as we move into the overall issue of health care reform. 

I also believe that we should look at what is working in communities across this country to increase access to care. Last year we 

heard from a doctor in Louisiana whose community was ravaged by 

Hurricane Katrina. Hospitals were closed and residents were without access to needed medical services. Physicians in that community came together to run a physician-owned hospital that provided 

the quality of medical care the residents so sorely need. Now, I 

know it is not the popular conventional wisdom to suggest that 

people helping their community can make a difference without the 

bureaucrats in Washington telling them what to do but it is true. 

Who knows what happens when communities actually work together themselves and don’t look to Washington for the solution. It 

is certainly not the Washington elite who have all the answers. We 

should applaud the people who have stepped up to the plate and 

expanded access to quality medicine in their own neighborhoods. 

This committee has a long history of being involved in the issue of 

physician-owned hospitals. These facilities have consistently demonstrated that they provide high-quality care for patients and 

achieve high patient satisfaction. Patients like receiving their care 

at these facilities. Physicians and nurses like working at these facilities and these facilities continue to top the charts in terms of 

health care quality. You don’t have to take my word for it. Visit 

any physician-run hospital and you can see for yourself. I would extend an open invitation to anybody on this committee to come to 

my district and visit a number of physician-owned hospital facilities in my district if they don’t have them in their own district. 


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When physicians have a stake in the system, they raise the standard of quality care to a level that patients then expect and demand 

from all providers. As we discuss access to care today, we need to 

keep this in mind. We should be expanding the number of providers, not limiting the number of providers. 

Again, I appreciate you, Mr. Chairman, for holding this hearing. 

I have a letter from a doctor-owned hospital in my district, USMD, 

dated yesterday to myself by the chairman of the board that I 

would like to submit for the record if we could get unanimous consent. 

Mr. PALLONE. I am sorry. What is it that you want to submit? 

Mr. BARTON. A letter from a physician-owned hospital in my district. 

Mr. PALLONE. Without objection, so ordered. 

[The information was unavailable at the time of printing.] 

Mr. BARTON. Thank you, Mr. Chairman. 

Mr. PALLONE. Thank you, Mr. Barton. 

Our full committee vice chair, 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. This is a 

very important hearing in health care access on all levels, and I am 

looking forward to hearing the testimony from our panel. 

I wasn’t going to talk about this but it appears to be in the talking points for my friends on the other side of the aisle so let me 

just mention that we did address the issue of medical malpractice 

reform and the concept of federalizing these traditionally State tort 

claims in the 109th Congress and we had a number of hearings in 

that Congress about this subject at which we took testimony, and 

frankly, there is absolutely no evidence that if we federalized these 

torts and we enacted caps on non-compensatory damages that that 

would help bring the cost of medical care down in any way. 

I do think though that we need to address the issue of what is 

happening with doctors’ insurance rates because doctors’ insurance 

rates have consistently increased over the years, even in States like 

my State and Texas and other States where we have had caps on 

non-economic damages for some years, and I think we need to put 

all of this into the mix, but I think it is unfair to try to claim that 

we haven’t addressed this, that we haven’t looked at it or that medical malpractice rates are causing the terrible cost overruns that 

we have in our system. 

Thank you, Mr. Chairman. 

Mr. PALLONE. Thank you. 

The gentleman from Pennsylvania, Mr. Murphy. 

OPENING STATEMENT OF HON. TIM MURPHY, A REPRESENTATIVE IN CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA 

Mr. MURPHY of Pennsylvania. Thank you, Mr. Chairman, and 

thank you to all the doctors present here. We have enough to open 

up a sizable hospital, I guess. Who is minding the patients? 


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All of our concern is to improve access to care and I believe that 

has to include—— 

Mr. PALLONE. Is your microphone not working? 

Mr. MURPHY of Pennsylvania. It was going off and on, sir. I don’t 

know. Maybe someone on that side of the aisle is—— 

Mr. PALLONE. All right. 

Mr. MURPHY of Pennsylvania. But don’t do that to me, because 

I agree. Hold the clock there too. 

Mr. PALLONE. We will try it. Go ahead. 

Mr. MURPHY of Pennsylvania. Thank you, Mr. Chairman. 

I am concerned about some of the inefficiencies that we put into 

the system itself which drive providers away, such as why aren’t 

doctors more willing to be Medicaid and Medicare providers? Why 

are the rules we set forth a problem? Why does a person diagnosed 

with multiple sclerosis have to wait 2 years before they can be 

given medication? Why don’t we pay for disease management of a 

diabetic but are willing to pay to have their legs amputated when 

they have complications? Why won’t we pay an oncologist to do lab 

work on the day of chemotherapy if they are trying to determine 

if a patient can have the chemotherapy? There are so many questions that we have in this area that I think are barriers to access 

and I am hoping as part of the testimony we hear it will include 

how we can improve the health system the government runs 

through the Medicare, Medicaid and VA systems and learn to take 

down the barriers that stand in the way of access to care. 

Thank you very much. 

Mr. PALLONE. The gentlewoman from California, Ms. Capps. 

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

Ms. CAPPS. Thank you, Mr. Pallone, and thank you to each of our 

witnesses today. We have a stellar panel here and thank you for 

coming. 

This hearing is really central to our debate on how we are going 

to improve health care. If we can improve the way we care for the 

most marginalized in our society, then we can certainly improve 

the way we care for everyone. One of the barriers to access today 

is a lack of health professionals: nurses, physicians, dentists, a 

whole array of them. And contrary to what some of our colleagues 

on the other side have said about everyone supposedly being able 

to obtain health care at the emergency room, there aren’t even 

enough health professionals to staff many emergency rooms 24/7 

and 7 days a week. So as we talk about ways to improve access for 

everyone, let us talk about what else we can be doing to educate 

more health professionals and get them into the areas where they 

are needed most. 

I look forward to the testimony. I yield back. 

Mr. PALLONE. Thank you. 

The gentleman from Michigan, Mr. Rogers. 

OPENING STATEMENT OF HON. MIKE ROGERS, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF MICHIGAN 

Mr. ROGERS. Thank you, Mr. Chairman, and thanks to the panelists. 


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Like you, I believe we must take action to provide more Americans with access to affordable, high-quality health insurance, but 

the details on how we get there are important. About 15 percent 

of Americans go without health insurance for some period of time 

every year. At the same time, 85 percent of Americans have health 

insurance, and for many of this 85 percent they have good coverage 

that provides for their families’ needs. We must focus on the 15 

percent. Who are they? How can we ensure that they have access 

to affordable insurance? In reality, a large portion of this group is 

young and goes without insurance by choice. A large part of this 

group is already eligible for government programs but not signed 

up. How should we address these issues? 

In finding solutions to address the 15 percent problem, we must 

be careful not to destroy a system that does work for tens of millions of Americans. I am concerned that some proposals addressed 

today would do just that. Forcing millions of Americans who already have health insurance to accept fewer benefits, reduced access and higher costs is hardly a solution. I believe we can find solutions to provide universal access to health care, lower costs and 

better quality for all Americans. I believe we can strengthen critical safety net programs like Medicaid, Medicare and SCHIP but 

we must work together to achieve this goal. 

Mr. Chairman, I look forward to working with you and the members of this committee on this important issue, and I yield back the 

remainder of my time. 

Mr. PALLONE. Thank you. 

The gentlewoman from Wisconsin, Ms. Baldwin. 

OPENING STATEMENT OF HON. TAMMY BALDWIN, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF WISCONSIN 

Ms. BALDWIN. Thank you, Mr. Chairman. It is notable that we 

are holding this hearing on ensuring access to care during Cover 

the Uninsured Week. 

We are discussing two issues today that are very close to my 

heart, health disparities and primary care workforce shortages. On 

health disparities, the level of inequality in our health care system 

is a shocking injustice. Thanks to several of my colleagues, we have 

recently focused greater attention on racial and ethnic health disparities. I also want to draw attention to the fact that the lesbian, 

gay, bisexual and transgender community also experience significant health disparities. Most well known as an issue, of course, is 

HIV/AIDS but the LGBT community experiences other health care 

disparities as well. We are far less likely to have health insurance 

compared to our straight counterparts. LGBTQ youth are up to 

four times more likely to attempt suicide than their heterosexual 

peers and we also know that many delay care due to fear of discrimination, leading to higher mortality rates from heart disease 

and cancer. To address these disparities, I am developing legislation that I will offer later this year. 

Let me quickly also express my strong concern about our existing 

and looming primary care shortages. To address one small aspect 

of this problem, I offer bipartisan legislation that would provide reimbursement for the costs of graduate degrees in nursing in exchange for a commitment to teach nursing for at least 4 years. 


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Without the worry of educational debt, nurses will be able to devote time to training the next generation of the frontline primary 

care workforce. 

Thank you again, Mr. Chairman, and thank you to our witnesses 

today. 

Mr. PALLONE. Thank you. 

The gentleman from Kentucky, Mr. Whitfield. 

OPENING STATEMENT OF HON. ED WHITFIELD, A REPRESENTATIVE IN CONGRESS FROM THE COMMONWEALTH OF 

KENTUCKY 

Mr. WHITFIELD. Thank you, Mr. Chairman, and I want to thank 

the panel and particularly for listening to all of us this morning, 

and we have heard a lot of discussion today about liability insurance and whatever needs to be done to correct that problem, we 

may have differences of opinion about it but I think it is imperative 

that we focus on the fact that there is a problem. 

Members of the Kentucky Medical Association left my office just 

a few days ago and they referred to the study in Massachusetts 

that showed that 83 percent of doctors practiced defensive medicine 

and almost 28 percent of the tests, procedures, referrals and consultations were ordered to avoid lawsuits. And then almost half of 

America’s medical students in their third or fourth year of medical 

school have indicated the liability crisis was a factor in their choice 

of specialty, threatening America’s future access to high-risk medical services such as a surgery and other specialties, so I think it 

is something we must focus on as we move forward on health care 

reform. Thank you. 

Mr. PALLONE. Thank you. 

The gentlewoman from the Virgin Islands, Ms. Christensen. 

OPENING STATEMENT OF HON. DONNA M. CHRISTENSEN, A 

REPRESENTATIVE IN CONGRESS FROM THE VIRGIN ISLANDS 

Ms. CHRISTENSEN. Thank you, Chairman Pallone, and thank you 

again for this series of hearings that continue to inform and guide 

us as we prepare to reform health care this year. 

Today we are looking at access and several barriers to it. It is 

important to understand that while providing coverage is the 

linchpin of reform, it is not the only thing that must get done to 

ensure access. We must have more and more diverse providers at 

all levels. We need to stop the way malpractice is increasing costs 

and forcing doctors out of practice, and as you will always hear 

from me, we must eliminate disparities and ensure that the system 

we create assures equal access to quality care for every America. 

I want to thank the panelists for the work that they have been 

doing to show us the way forward, and I look forward to your testimonies. I yield back. 

Mr. PALLONE. Thank you. 

The gentleman from Georgia, Mr. Gingrey. 

Mr. GINGREY. Thank you, Mr. Chairman. Before I waive my 

opening remarks, I want to ask unanimous consent to submit for 

the record a letter, Mr. Chairman, from the Georgia Mutual Insurance Company to the Medical Association of Georgia on the question of is tort reform working in the State of Georgia; the response, 


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most definitely. I ask unanimous consent to submit this letter for 

the record. 

Mr. PALLONE. Thank you. Without objection, so ordered. 

[The information appears at the conclusion of the hearing.] 

Mr. PALLONE. If all of you could give me these letters so we can 

take a look at them, I would appreciate it, because I know I am 

always concerned that we are going to have too much for the 

record, but I think you only had a few in each case. 

Mr. DEAL. Mr. Chairman. 

Mr. PALLONE. Yes, Mr. Deal. 

Mr. DEAL. In that regard, I would ask unanimous consent to include in the record the American Medical Association two-page 

statement on medical liability reform and also a two-page letter 

from Richard Scott on behalf of Conservatives for Patients’ Rights. 

I would ask unanimous consent to include those in the record. 

Mr. PALLONE. Without objection, so ordered. Thank you. 

[The information was unavailable at the time of printing.] 

Mr. PALLONE. Next is the gentlewoman from Florida, Ms. Castor. 

OPENING STATEMENT OF HON. KATHY CASTOR, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF FLORIDA 

Ms. CASTOR. Thank you, Mr. Chairman. First I want to say to 

the witnesses, I thought your written testimony was outstanding 

and very, very helpful as we proceed on our health care reform effort. I believe it shows that a consensus is building that broadbased, basic primary care reform, those simple visits to the doctors’ 

offices and clinics will be central to providing affordable access to 

health care for all American families. 

Dr. Mullan, your workforce analysis was particularly terrific, I 

thought, and your recommendations to improve primary care professionals very helpful along with Dr. Harris’s recommendations for 

a national health care workforce policy. Thank you for highlighting 

the arbitrary and outdated caps on physician resident slots that is 

really harming high-growth States like mine, the State of Florida. 

You also had constructive recommendations on the primary care 

pipeline. I want to thank your organization for endorsing my bill, 

the Primary Care Incentive Act, that provides that tuition reimbursement for folks that go and work in community health centers 

and clinics and devote a number of years of community service. Dr. 

Lavizzo-Mourey, you also had some very creative solutions, also 

picked up on a lot of the workforce issues that Congresswoman 

Capps has taken the lead on in nursing, physician assistants, and 

I appreciate that. Dr. Smedley, your analysis and statistics were 

very eye-opening and just demonstrated how health care is really 

our civil rights struggle for our time. Thank you. 

Mr. PALLONE. Thank you. 

The gentlewoman from North Carolina, Ms. Myrick, who waives. 

Mr. PALLONE. The gentleman from Connecticut, Mr. Murphy. 

OPENING STATEMENT OF HON. CHRISTOPHER S. MURPHY, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF CONNECTICUT 

Mr. MURPHY of Connecticut. Thank you very much, Mr. Chairman. We are going to talk a lot over the course of the next few 


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months about making sure that people have insurance but I know 

today we are going to spend time on what should be our second priority, making sure that people that have insurance actually have 

access to care, and I would like to just share one particularly important story from Connecticut. 

Last year in Tolland, Connecticut, in eastern Connecticut, about 

190 dentists got together and decided to provide free care over the 

course of 2 days. The night before that clinic began, there were dramatic, torrential thunderstorms. Through the night, dozens of people lined up soaking overnight waiting for care the next morning, 

and their individual stories, which numbered 700 by the time that 

clinic was done, are shocking but unfortunately too common. There 

was a mother whose children insured through our State’s SCHIP 

program, HUSKY, had been waiting 8 months to see a dentist for 

immediate care. There was a single woman who worked two jobs, 

had insurance but whose deductibles were so high she couldn’t afford to see a dentist. And there were the unemployed workers there 

on COBRA whose employers never offered dental coverage in the 

first place. 

This is just one story not original to Connecticut but they do illuminate a point. Just because you have health insurance doesn’t 

mean that you get to see a doctor, doesn’t mean you get to see a 

dentist. Health insurance without real access is little better than 

no insurance at all. 

I thank the panel for being here and I look forward to your testimony today. 

Mr. PALLONE. Thank you. 

The gentleman from Ohio, Mr. Space. 

OPENING STATEMENT OF HON. ZACHARY T. SPACE, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF OHIO 

Mr. SPACE. Thank you, Mr. Chairman, for holding this important 

hearing, and specifically as it relates to rural health care disparities. 

I had a chance to review some of the testimony for today and I 

couldn’t help but be struck by some of the statistics highlight by 

Dr. Kitchell from Iowa in his testimony. Twenty percent of the Nation’s population resides in rural areas yet 9 percent of our Nation’s physicians reside in rural areas. Rural physicians see up to 

30 percent more patients per physician. The cost of running a rural 

physician’s practice is considerably higher than running an urban 

or suburban city physician practice, and the rural physicians’ expenses, despite being greater, their Medicare reimbursements are 

far less. It is no wonder that some of the counties that I represent 

have one or two practicing physicians serving the entire county, requiring many of my constituents to drive long distances for basic 

care and that doesn’t even cover the specialists. While the primary 

care focus is one that we need to be concerned with, it applies to 

other realms in the health care delivery field as well. Home health 

nurses, medical assistants and other professionals are in short supply. 

One of the critical elements of this issue is the impact that it will 

have on our economy. Developing and training a workforce to meet 

the needs that are glaring in rural American right now will not 


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only enhance access to quality health care, it will provide an important avenue for economic opportunity in an area of the country that 

desperately needs it, so I would like to thank those who have come 

before the committee this morning and look forward to hearing all 

your testimony. 

Mr. PALLONE. Thank you. 

The gentleman from Iowa, Mr. Braley. 

OPENING STATEMENT OF HON. BRUCE L. BRALEY, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF IOWA 

Mr. BRALEY. Thank you, Chairman Pallone. I have been looking 

forward to this hearing because access to care is a primary care of 

mine and a primary concern of health care providers in Iowa and 

their patients. 

Our current system has built-in equities which result in a lack 

of access to care for residents in many rural States like Iowa, as 

my colleague from Ohio has just pointed out. A glaring example of 

this is the Geographic Practice Cost Indexes, or GPCIs. These antiquated formulas ensure that some parts of the country receive 

drastically lower Medicare reimbursement rates than other parts 

and that has led to a critical shortage of doctors in some parts of 

our country. Despite the well-documented efficiency and quality of 

Iowa’s health care system, Iowa health care providers still lose millions of dollars because they choose to care for Medicare patients. 

There is already a physician shortage in areas of Iowa and the existence of the GPCIs is a strong disincentive to those who often 

need it most, Medicare patients. 

Last Congress I introduced the Medicare Equity and Accessibility 

Act, which addresses the GPCI problems. I am going to continue 

fighting for a solution to the GPCIs but in fact this is only a BandAid for a broader problem of disparity of care in rural areas. I look 

forward to hearing more about access to care in rural areas in today’s hearing. 

I also want to welcome my friend, Dr. Michael Kitchell, to the 

witness panel today. Dr. Kitchell is currently the president-elect of 

the Iowa Medical Society and someone I rely upon for sound advice 

on health care policy issues. He is also an expert on policies surrounding rural health care and I want to welcome him and look 

forward to his testimony. Thank you. 

Mr. PALLONE. Thank you. 

The gentlewoman from California, Ms. Harman. 

OPENING STATEMENT OF HON. JANE HARMAN, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF CALIFORNIA 

Ms. HARMAN. Thank you, Mr. Chairman. There is obviously enormous expertise on the panel but there is expertise on this subcommittee too and I surely hope we will pull together and craft an 

excellent bill that addresses this important subject of access. 

Access is tough for the insured and uninsured, especially in California where low reimbursement for Medicaid is pushing more and 

more doctors out of the program. In my district, we are lucky to 

have places like the Venice Family Clinic that provide free quality 

health care to low-income minority population that lacks private 

coverage. Eighty-one percent of the patients seen at the clinic are 


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minorities so the clinic places an emphasis on volunteer translator 

recruitment and medical tutorial programs. Remarkable volunteers 

are the arteries that keep the clinic going. My late father, a physician, devoted his time and passion to serving three generations of 

patients, like father, like daughter, and as a former VFC board 

member, I am a huge supporter of their work. As the Nation’s largest free clinic, 24,000 patients last year, this is the only place for 

most of its patients to access care, helping them to avoid emergency room visits and other serious consequences. Unfortunately, 

many places in the country don’t have Venice Family Clinics and 

that is a model that we should try to include as we draft the access 

part of the bill. 

Thank you, Mr. Chairman. 

Mr. PALLONE. The gentleman from Georgia, Mr. Barrow. 

OPENING STATEMENT OF HON. JOHN BARROW, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF GEORGIA 

Mr. BARROW. Thank you, Mr. Chairman. 

When we talk about access to health care, we are talking about 

different things to different folks. In rural parts of the country, the 

problem is physical access. You got specialist doctors and nurses 

that don’t want to practice in rural areas but you also have groups 

who live in those areas who are slower to seek care in the first 

place. You have a combination of an underserved community of 

high-risk patients. That is a bad combination. On the other hand, 

you have access problems that are financial in nature and we have 

different programs to try to make health care available to different 

groups of folks. We have Medicaid for the poor, we have Medicare 

for the elderly. We have programs like SCHIP for the kids and 

folks who make too much to qualify for Medicaid but not enough 

to get insurance on their own. 

There is another group that is underserved for whom the cost of 

health care isn’t altogether out of reach but it is just out of reach, 

and as a result it might as well be altogether unavailable and that 

is folks who can’t afford to pay the price differential that the insurance industry charges them because of the size of the groups to 

lump them into. If you are in a smaller group, it costs you more 

to get that same health care package of benefits than it does for 

folks who are members of larger groups. The legislation I introduced in the last Congress, the SHOP Act, the Small Business 

Health Option Program Act, addresses this price disparity in ways 

that I think will make health insurance available to more folks 

who can afford to kick in for the cost of care they are drawing out 

rather than drawing out care at the emergency room without kicking in at all, so I hope we can explore ways and means of making 

health care more affordable for folks just by eliminating the price 

differential that folks have to pay for the same benefits package. 

Thank you, Mr. Chairman. I yield back. 

Mr. PALLONE. Thank you. 

The gentleman from Texas, Mr. Gonzalez. 

Mr. GONZALEZ. Waive opening. Thank you, Mr. Chairman. 

Mr. PALLONE. Thank you. 

I think we have covered everybody here for opening statements, 

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tiently and we appreciate that. I want to welcome everyone, and let 

me introduce you starting on my left here, and they are all doctors, 

every one. Dr. Brian Smedley, who is vice president and director 

of the Health Policy Institute, the Joint Center for Political and 

Economic Studies; Dr. Michael John Kitchell, who is president-elect 

of the Iowa Medical Society, the McFarland Clinic; Dr. Michael 

Sitorius, professor and chairman of the Department of Family Medicine at the University of Nebraska Medical Center; and from my 

home State of New Jersey, welcome, Dr. Lavizzo-Mourey, who is 

president and CEO of the Robert Wood Johnson Foundation. And 

then we have Dr. Fitzhugh Mullan, Murdock head professor of 

medicine and health policy and professor of pediatrics at the 

George Washington University; Dr. Jeffrey Harris, president of the 

American College of Physicians; Dr. James Bean, who is president 

of the American Association of Neurological Surgeons; and Dr. 

Diane Rowland, who is executive director of the Kaiser Commission 

on Medicaid and the Uninsured. Now, I am told that you don’t actually have a timer down there so you won’t know when the 5 minutes are up. The only thing more dangerous is when we don’t have 

timers up here. But please try to stick to the 5 minutes if you can 

and of course the statements become part of the record, and we will 

start with Dr. Smedley. 

STATEMENTS OF BRIAN D. SMEDLEY, PH.D., VICE PRESIDENT 

AND DIRECTOR, HEALTH POLICY INSTITUTE, JOINT CENTER 

FOR POLITICAL AND ECONOMIC STUDIES; MICHAEL JOHN 

KITCHELL, M.D., PRESIDENT-ELECT OF IOWA MEDICAL SOCIETY, MCFARLAND CLINIC PC; MICHAEL A. SITORIUS, M.D., 

PROFESSOR AND CHAIRMAN, DEPARTMENT OF FAMILY 

MEDICINE, UNIVERSITY OF NEBRASKA MEDICAL CENTER; 

RISA LAVIZZO-MOUREY, M.D., M.B.A., PRESIDENT AND CEO, 

ROBERT WOOD JOHNSON FOUNDATION; FITZHUGH 

MULLAN, M.D., MURDOCK HEAD PROFESSOR OF MEDICINE 

AND HEALTH POLICY, PROFESSOR OF PEDIATRICS, THE 

GEORGE WASHINGTON UNIVERSITY; JEFFREY P. HARRIS, 

M.D., F.A.C.P., PRESIDENT, AMERICAN COLLEGE OF PHYSICIANS; JAMES R. BEAN, M.D., PRESIDENT, AMERICAN ASSOCIATION OF NEUROLOGICAL SURGEONS; AND DIANE ROWLAND, SC.D., EXECUTIVE DIRECTOR, THE KAISER COMMISSION ON MEDICAID AND THE UNINSURED 

STATEMENT OF BRIAN D. SMEDLEY 

Mr. SMEDLEY. Thank you, Mr. Chairman. I appreciate the opportunity to provide testimony on racial and ethic disparities and 

health care access and quality. 

For nearly 40 years, the Joint Center for Political and Economic 

Studies has served as one of the Nation’s premier think tanks on 

a broad range of public policy concerns for African-Americans and 

other communities of color. We therefore welcome the opportunity 

to comment on strategies for addressing health care disparities. 

As the committee has pointed out, health care disparities are differences in access to and the quality of health care experienced by 

racial and ethnic minorities, immigrants, those who aren’t proficient in English, those who live in rural communities and many 

others relative to more advantaged groups. Left unaddressed, these 


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disparities have the potential to unravel even the best efforts to 

contain health care costs and improve the overall quality of care. 

In addition, their persistence leaves U.S. health care systems poorly prepared to address the needs of some of the fastest growing segments of the population. 

This morning I would like to briefly examine the causes and consequences of racial and ethnic health care disparities and offer 

some policy strategies for their elimination. As I hope to illustrate, 

these disparities are unjust and avoidable. I will therefore refer to 

them as inequities throughout the remainder of my testimony. 

Health care inequities are not new. They are a persistent relic 

of segregation and historically inadequate health care for communities of color. Like access to other opportunities, health care for 

minorities suffered from government inattention for over 100 years 

after the end of the Civil War. Even less than 45 years ago, minorities routinely received inequitable care in segregated settings if 

care was received at all. Today health care is much more broadly 

available but the contemporary context remains shaped by this history. 

I want to note at the outset that while health care access and 

quality disparities are unacceptable, they are not the most important factors that contribute to the widely divergent health status 

of America’s racial and ethnic groups. Some groups, particularly African-Americans, American Indians and Alaska Natives and Native 

Hawaiians and Pacific Islands experience poor health relative to 

national averages from birth to death in the form of higher infant 

mortality, higher rates of disease and disability and shortened life 

expectancies. The large and growing body of public health research 

demonstrates that to address these problems, we must improve the 

social and economic contexts that shape health. As the World 

Health Organization’s report on social determinates of health 

states, inequities in health and avoidable health inequalities arise 

because of the circumstances in which people grow, live, work and 

age and the systems put in place to deal with illness. 

It is clear that many Americans, disproportionately racial and 

ethnic minorities, face health care access and quality inequities. 

Some of these inequities can be explained by socioeconomic factors 

while others cannot. The National Healthcare Disparities Report, 

which is prepared and released annually by the Agency for Health 

Care Research and Quality, has found that African-Americans, Hispanics, American Indians and Alaska Natives fare worse than 

whites on a preponderance of measures of health care access and 

quality. For example, the report finds that minorities are less likely 

to receive even routine evidence-based procedures and experience 

greater communication barriers. 

Now, the NHDR provides a window to the health care experiences of a diverse patient population but it does not disentangle 

the influences of race, income and insurance on health care. A substantial body of evidence, as has been pointed out, demonstrates 

that racial and ethnic minorities receive a lower quality and intensity of health care than white patients even when they are insured 

at the same levels and present with the same types of health problems. Many factors contribute to these inequities and these often 

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derlying factor in health care inequality and that is residential segregation. Racial and ethnic minorities are more likely than whites 

to live in segregated, high-poverty communities, communities that 

have historically suffered from a lack of health care investment. Institutes that serve communities of color are more likely to experience quality problems and have fewer resources for patient care 

than institutions serving non-minority communities. Just as an example, a recent study of African-American and white Medicare patients found that the risk of admission to high-mortality hospitals 

was 35 percent higher for blacks than for whites in communities 

with high levels of residential segregation. Racial and ethnic segregation and inequality therefore set the stage for inequitable 

health care in the United States. 

To solve these problems, we must prioritize and invest in improving the health of communities that suffer from health care inequities. To make the largest gains, we should improve social and economic conditions for health. For example, the federal government 

should enforce provisions to address environmental justice in minority and low-income communities and should establish health 

empowerment zones in communities that disproportionately experience disparities in health status and health care. To improve 

health care access and quality for communities of color, the federal 

government should improve access to health care providers, as 

many on the committee have pointed out. We need to make special 

efforts to ensure that health care resources are better aligned with 

these communities’ needs. We can do so by increasing the diversity 

of our health professional providers, supporting safety-net institutions, providing incentives for providers to serve in underserved 

communities, and addressing the geographic imbalance of health 

care resources like community health centers. We can also promote 

equal high-quality access to care by collecting and monitoring data 

on disparities and publicly reporting these data. We can also encourage the adoption of cultural and linguistic standards and encourage attention to disparities in quality improvement initiatives. 

Mr. Chairman, my time is short and these are but a few of the 

many ideas that will be put forward today, and we look forward to 

working with you as you craft legislation to address these issues. 

[The prepared statement of Mr. Smedley follows:] 


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Mr. PALLONE. Thank you, Dr. Smedley. 

Dr. Kitchell. 

STATEMENT OF MICHAEL JOHN KITCHELL 

Dr. KITCHELL. Thank you, Chairman Pallone, Ranking Member 

Deal and Congressman Braley for inviting me. I practice neurology 

in a 167-member physician-owned multi-specialty clinic in central 

Iowa. We have offices in 21 different sites in rural Iowa and we 

have about 1 million patient visits per year. 

Maintaining access in rural America is difficult because of physician shortages, long distances to travel and fewer services that are 

available. You will hear other speakers today that will talk about 

the shortage of physicians in certain specialties, for example, internal medicine. In Iowa, we actually have 3.7 times fewer internal 

medicine physicians as the State of Massachusetts, and you aren’t 

aware, Massachusetts has recently declared a critical shortage of 

12 different specialties including internal medicine. So if those 

shortages in Massachusetts are critical when we have 3.7 times 

fewer internists, I would say we are just about comatose. 

The medical economic survey has actually shown that rural physicians practice expenses are higher in their survey. They are higher than inner city, suburban and urban physicians. The main reasons for practice expenses being higher in rural areas is the number of patients that we see. When you have half as many physicians in rural areas, you have to see a few more patients. 

Rural physicians are paid less by Medicare for our work despite 

the fact that we work longer hours. Medicare pays rural physicians 

less for practice expenses despite the fact that Medicare has never 

done a survey of the actual practice expense differences for physicians in rural areas. This has been going on for 17 years. Medicare 

pays us less for e-prescribing. You know, I looked for a geographic 

discount on electronic prescribing equipment and I couldn’t find 

any geographic discounts. I looked for geographic discounts on office equipment, computers and yes, even electronic medical records 

and, you know, I couldn’t find a geographic discount on electronic 

medical records. 

Medicare also pays us less for quality, and Congressman Braley 

has been kind enough to sponsor a bill to eliminate the devaluation 

of quality. Medicare pays quality for physicians at a lower rate in 

rural areas. I think that that devaluation of quality is the ultimate 

insult to rural physicians. Some rural Medicare fees are as low as 

one-third of what our private insurance payers are paying us. Some 

health care services are delivered at a loss in rural areas because 

Medicare pays so little. If Medicare expanded or if Medicare would 

cut their payments, obviously there will be more losses, more losses 

of dollars, more losses of service. You can’t make up on volume 

when the cost of the service is greater than what you are paid. 

Congressman Braley, Senator Grassley and Senator Harkin have 

all sponsored legislation to eliminate or at least reduce these geographic penalties. President Obama in October also has come out 

in support of geographic equity. I hope that you will also come out 

in support of geographic equity. 

A lot of what is wrong in health care though is due to the physician payment system. This physician payment system is called the 


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resource-based relative value unit system, that is, our payment system pays for resource use. It should be no surprise then when we 

pay for resource use that we have the most expensive health care 

system in the world. When we pay for more expenses rather than 

pay for the most effective care, we are going to get more expensive 

care and we won’t get as much cost-effective care. 

We need to pay for value, not geography. We need to pay for 

things that matter to the patient. We need to pay for the right 

tests and treatment, not just more tests and treatment. Iowa is a 

good example of a high value in health care. It shows that highquality health care doesn’t have to be so expensive. The Commonwealth Fund has rated Iowa’s health care system as number one 

in children’s care and number two for care of adults. The Agency 

for Health Care Research on Quality, Dartmouth and other researchers have consistently shown that Iowa and Midwestern 

States take the lead in quality and cost-effective care. I testified 6 

years ago at the Senate Finance Committee on the national health 

policy forum and I urged that Medicare pay for value, not volume. 

I urged that Medicare pay for quality, not quantity. Unfortunately, 

over the last 6 years there hasn’t been much progress made in paying for value or paying physicians for quality. The Medicare payment system for quality is called Physician Quality Reporting Initiative, or PQRI. PQRI is definitely a failure. Only 8 percent of the 

Nation’s physicians succeeded with this program. PQRI does not reward quality. It simply rewards reporting. The lowest quality physician in this country could report correctly on three quality measures that they never did any of those measures and they would get 

the bonus. 

Mr. PALLONE. Doctor, I hate to interrupt but you are a minute 

over, so if you could wrap up? 

Dr. KITCHELL. Medicare’s Hospital Quality Rewards program is 

a success because it measures larger groups and systems. So what 

should Medicare do to reward quality and value for physicians? Another lesson that can be learned from Iowa is about coordinated 

care, teamwork and accountability. Quality measures should be 

based on teams, groups and systems. We need to encourage all 

physicians to be part of the system. Middlesex County, Connecticut, 

is a good example of independent physicians getting together, improving quality, improving value and being accountable. We need 

changes in the payment system for geographic equity to reduce cost 

and increase quality of value. 

Thank you, Mr. Chairman. 

[The prepared statement of Dr. Kitchell follows:] 


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Mr. PALLONE. Thank you. 

Dr. Sitorius. 

STATEMENT OF MICHAEL A. SITORIUS 

Dr. SITORIUS. I would like to thank you, Mr. Chairman, for conducting this subcommittee hearing on the accessibility of health 

care. 

I am here to share information about the Bellevue Medical Center, which is currently under construction in Bellevue, Nebraska, 

a suburb of Omaha. The Bellevue Medical Center is an entirely different entity than anything we have seen across the country. It is 

going to be a full-service community hospital providing a wide 

array of services including emergency services 24 hours to one of 

the largest communities in the United States without an acute care 

hospital. It is majority owned by the largest public hospital system 

in the State. It is expected to open in April of 2010. This medical 

center illustrates how hospitals, doctors and communities come together to enhance the access of health care to populations in need. 

I believe the Bellevue Medical Center represents the best in American health care. When we open our doors next spring, we will be 

an example of a public hospital system, a group of committed and 

talented physicians, a supportive city government and a thriving 

and responsive business community that came together to make 

health care accessible to an underserved population. 

Bellevue is the third largest city in Nebraska, it has about 

45,000 residents, and it is home to Offutt Air Force Base and the 

United States Strategic Command. Approximately 10,000 activeduty military personnel, 20,000 dependents and 11,000 military retirees live in the Bellevue area, a very important asset to the Bellevue community. It may come as a surprise that Bellevue has not 

currently or has ever had a community hospital or emergency room 

in the city. The Offutt Air Force military hospital, Ehrling 

Bergguist, closed in 2005 as part of the Base Closure Realignment 

Commission. Though clinics remain at the Ehrling Bergguist Hospital, the remaining same-day surgery and evening urgent care 

clinics will be closing in the fall of 2009. As a family physician, I 

can see firsthand the need for a hospital in Bellevue. There are approximately 180,000 people in eastern Nebraska and western Iowa 

who would benefit from the hospital, and will, in 2010. 

Currently, all the rescue squads in the Bellevue community leave 

that community for access to emergency care. Low-income individuals benefit from this full-service hospital as well. The UNMC Physician Group currently has a clinic in the Bellevue area which 

serves a significant low-income and Hispanic population which live 

in the near south Omaha area. This hospital will provide access to 

care that is currently not available to that population. 

Furthermore, I have a unique vantage point on the medical 

needs in this area. As chair of the Department of Family Medicine, 

we have had an affiliated family medicine residency training program with the Air Force since 1992. Unfortunately, with the closure of that base hospital in 2005, it has made difficult some of the 

training opportunities for one-fifth of the Air Force family medicine 

residents in their training programs. It is then important that we 

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lation to come up with the idea for the Bellevue Medical Center. 

The center is a creative solution to address the health care needs 

of the community of which it is serving. The Bellevue Medical Center is aligned with an academic medical center, the University of 

Nebraska Medical Center and the Nebraska Medical Center. Faculty physicians and community physicians meet community needs. 

When it opens in April of 2010, it will be a full-service hospital delivering adult care, pediatric care, labor and delivery, emergency 

care, inpatient and outpatient surgery and intensive care. This represents a collaborative model involving public, academic community 

physicians and community leaders. The Bellevue Medical Center 

will hold strongly to the values of the existing Nebraska Medical 

Center for its excellence, innovation and quality patient care. In 

addition, it will serve as an educational mission for the medical 

center. It will train 20 percent of the Air Force complement of family practice resident physicians and will allow training in two different locations, the tertiary care academic medical center and the 

community-based Bellevue Medical Center in 2010. 

And in this time of economic downturn, this project also has created jobs. In addition to the hundreds of construction jobs already 

created, the Bellevue Medical Center will employee 600 FTEs when 

opened. 

The Bellevue Medical Center has strong community support. In 

fact, the community is extremely engaged and led the effort to 

make this Bellevue Medical Center a reality. I believe the Bellevue 

Medical Center can serve as a health care model for other communities. The Nation’s health care system needs to encourage innovation through partnerships, in our case, an academic medical center 

partnered with faculty physicians, community physicians and the 

community. I would encourage other academic medical centers to 

consider to replicate what the Nebraska Medical Center has done 

in the Bellevue community. Moreover, the Bellevue Medical Center 

is also a model as it relates to care of our military service members, their families and military retirees. It is our position that our 

military service members, their families and retirees deserve the 

best quality health care possible from a nearby community hospital. The Bellevue Medical Center will be able to provide that 

care. This center will also care for all of the benefits provided 

under the Tri-Care program. The Bellevue Medical Center will accept and look forward to working with the Tri-Care patients. 

In conclusion, as Congress begins to tackle health care reform, 

access to health care must be a significant part of any solution. I 

am proud to say that the Bellevue Medical Center stands ready to 

be part of that solution to expanding access to health care. We are 

excited that your subcommittee has asked us to share our story 

with you this morning. 

Thank you for your attention and interest and I would be happy 

to answer questions when we get to that point. 

[The prepared statement of Dr. Sitorius follows:] 


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Mr. PALLONE. Thank you, Doctor. 

Dr. Lavizzo-Mourey. 

STATEMENT OF RISA LAVIZZO-MOUREY 

Dr. LAVIZZO-MOUREY. Thank you, Chairman Pallone and Ranking Member Deal and members of the subcommittee for this opportunity to testify. 

As has been mentioned, it is Cover the Uninsured Week and 

communities all across the country are calling for fixes to our broken health care system. Expanding coverage must be a priority as 

Congress considers opportunities for health reform, but this alone 

will not fix the problem. In my written testimony, I have touched 

on issues of health care disparities and non-financial barriers to 

health but I would like to focus my oral remarks on the role of 

nurses in ensuring the access to high-quality care and opportunities for addressing the shortage of nurses and nurse faculty. 

If you have ever been hospitalized or had a loved one who was 

hospitalized, you know that nurses make a difference. Nurses’ diligence keeps bad things from happening to patients. Their actions 

prevent medical errors and infections. They keep patients safe from 

falls and from the complications of extended bed rest. They also 

work in community settings to prevent disease, help patients manage their diseases better and avoid unnecessary hospitalizations. 

As Congresswoman Capps noted recently at the White House 

Forum for Health Reform, there is a projected shortage of 500,000 

nurses by 2020. The nursing shortage results from a confluence of 

factors: A shortage of nurse faculty, too few nurses enrolling in 

nursing programs and turnover among experienced nurses. There 

is a vacancy rate of 7.6 percent among nursing faculty which results in far too many qualified students being turned away. Solving 

this problem will require action at the national level and a commitment of resources both public and private. The results of our grantees’ and partners’ work suggest that the following steps must be 

taken. 

First, we need to increase the number of nurses with baccalaureate degrees to create a larger pool of nurses who will qualify 

to pursue faculty careers. Second, we need to increase financial assistance to enable more nurses to attend graduate school and obtain teaching qualifications. Third, encourage private sector to 

adopt evidence-based practices including the use of technology that 

will improve the retention of nurses in their clinical roles. And finally, we need to support research to demonstrate the nurse’s role 

in improving the quality of patient care and improving outcomes. 

It is also essential that funding for workforce development not ebb 

and flow with yearly changes in appropriations to Title VIII programs. 

I want to highlight a few specific promising programs and strategies that address the nursing shortage and the faculty shortage. 

First, at our foundation we found scholarships to support accelerated nursing degrees for students who already have a degree in a 

discipline other than nursing. These are typically students that are 

ineligible for federal aid programs, and I can tell you, these scholarship programs are hugely oversubscribed. Second, we are providing career development awards to outstanding junior faculty. 


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Third, there are many State partnerships of nurses, educators, consumers, business groups, government and philanthropy that are 

working together on practical creative solutions like using shared 

curriculum, online education, simulation centers for training, easing the transition from associate to baccalaureate programs and increasing the diversity of the nursing workforce. Taken together, 

these programs seem to increase the number of baccalaureate-prepared nurses, provide incentives and rewards for nursing faculty to 

educate the next generation of nurses, shorten the pipeline for providing nursing faculty and provide a new cadre of nursing leaders. 

Now, as we consider the critical task of ensuring that the education system can graduate new nurses, we must also retain experienced nurses. We have a demonstration project called Transforming Care at the Bedside that shows hospitals can successfully 

retain nurses through organizational reforms that do not add costs. 

I know that my colleague, Dr. Mullan, will focus on the shortage 

of primary care physicians, but nurse practitioners are an effective, 

high-quality way to fill the gap in primary care, particularly as we 

think about access in rural and other underserved settings. 

So in conclusion, as Congress addresses both the shortage of primary care physicians and the need to control spending, I encourage 

you think about opportunities to use nurse practitioners more widely and effectively. 

Thank you for this opportunity to testify today and for your attention to these issues that reach beyond ensuring health care coverage and allow us to strive for comprehensive, meaningful reform. 

[The prepared statement of Dr. Lavizzo-Mourey follows:] 


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Mr. PALLONE. Thank you, Doctor. 

Dr. Mullan. 

STATEMENT OF FITZHUGH MULLAN 

Dr. MULLAN. Chairman Pallone, Ranking Member Deal, members of the committee, colleagues, thank you for the opportunity to 

testify today. I will be talking about the clinical workforce, largely 

physicians but not limited to physicians. I started as a physician 

in the National Health Service Corps. I served for a period as the 

director of the National Health Service Corps, and in recent years 

I have worked in scholarly pursuits trying to understand the dynamics and policies related to the health workforce. So I have practiced it, I have run it and now I am studying it, and I am here to 

share that with you as much as I can and very expeditiously. 

Massachusetts has been cited as an example, and I will say to 

you, it is an example of my principal premise to you and that is 

that substantial reform and improvement in access and in health 

care in this country will not take place without substantial reform 

and improvement in the health workforce in this country, and the 

experience of Massachusetts has been when you provided expanded 

access, they did indeed come, and where they hit the first bump in 

the road was the absence of a good, strong primary care base, even 

in a State that is well endowed with physicians. So primary care 

is at the core of the reform of the health workforce. 

A few words about the shape and size of the health workforce. 

I offer you this graphic as a way to conceptualize what I consider 

the three phases of the life cycle of a physician and that would be 

medical school, graduate medical education and practice. Clearly, 

practice is a 30- to 40-year proposition and the others presumably 

are somewhat shorter but all three have a character and a legislative component and I suggest you consider those in that regard and 

we will go through them in a moment with the particular legislative potentials of each of those. In general, we do have problems 

in primary care. We have a smaller base compared to many other 

countries in terms of how we approach it. We have an inverted pyramid with a small base and a large wobbly superstructure of people 

engaging in specialty and subspecialty clinical roles. More important than this are the trends in primary care which for a variety 

of reasons ranging from reimbursement to what is in, folks are not 

going into primary care. That is a huge problem for the future and 

one that can be addressed both by investments and financially but 

also by statements by public bodies such as the Congress that this 

is important. 

Overall, my judgment would be in the somewhat contentious 

area of do we have enough doctors, I think we are in the right 

zone. We have a 30-year history now of increasing physician population ratio. We are at about 280 per 100,000. That puts us a little 

bit ahead of Canada and the United Kingdom, a little bit behind 

Germany and France. All these countries including ourselves are 

going to experience problems of aging population and I will address 

those in a moment. 

Our major problem, however, is that they are poorly distributed. 

Physicians tend to be urban. They tend to be in well-to-do areas 

and they tend not to go where the most severe problems are. That 


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has continued to be a problem as we produce more doctors. They 

tend to continue to locate in similar areas. So we can make far better and more prudent use of our workforce if it was better distributed both in terms of geography and specialty, and we have two 

American inventions that are enormous assets in both what is happening now and what should and can happen in the future, and 

those, as referenced by Dr. Lavizzo-Mourey and others, are physician assistants and nurse practitioners, about 70,000 of the former, 

100,000 of the latter. We invented them. Now the rest of the world 

is running to try to catch up but they have shown very effective 

use and they are effective not only in the primary care area but 

in the specialty area. A way to attenuate our need for more specialists is more collaborative work with non-physician clinicians including particularly nurse practitioner and physician assistants. We 

also have in place two very important programs that affect workforce and that is the Nation Health Service Corps as an incentive 

program and community health centers as a deployment mechanism to put folks to work. Those need to be invested in and continue to be recapitalized. 

Now, let us quickly go through this continuum. In medical school 

we are seeing expansion. New medical schools are coming online. 

Old schools are expanding their capacity. This is good. We have in 

addition two very important programs that impact medical education. The first is Title VII in the jurisdiction of this committee. 

It is an old program. It could use reconceptualizing and certainly 

reinvigorating but it is where the federal government offers or can 

offer incentives to medical schools and medical students for different kinds of careers and there is a lot that can be said about 

that important area of investment. And of course, the National 

Health Service Corps, which happily is receiving more attention. 

There are about 3,500 people in the service in the field today. 

About half of those are physicians. You are talking 1,700 physicians, 800,000 physicians in America. This is a very, very small but 

important program. It needs to get on the map in a more major 

way. 

Graduate medical education, a very important area, and primarily the jurisdiction of this committee because it is $8 billion, 

$8.5 billion in Medicare funds that fund the GME largely. It is a 

huge program without, as I have characterized it, a brain. It is 

formulaic. It is not currently available to help with workforce redistribution. A great deal could be done with that. A great deal of attention needs to be paid to that. Modest activities would include 

incentivizing community-based and ambulatory training. More 

major would be realigning Medicare GME with national workforce 

needs with a better, more formal allocation system. 

And finally in practice, a lot could be done if you train them and 

put them out. In an environment that devalues primary care, they 

will find other ways to do other things and charge the system in 

other ways. So practice has to be realigned. We need payment reform. We need practice organization reform, primary care medical 

homes, and finally, health information systems which happily are 

getting attention will make all providers, particularly primary care, 

this information much more effectively. 


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Finally, two ideas that I think need attention. One is, we function in an information-poor environment in terms of workforce 

planning. Data is not good. We need a national center for health 

workforce studies that would on a regular basis work on census 

issues, on analytic issues and on projection issues. And finally, a 

national health workforce commission, a deliberative body perhaps 

on the order of MedPAC that advises the Congress, the Administration and the American people on the issues of workforce, a very 

important, a very difficult, complex area. We need brains at work 

on that day in and day out with the sanction of the Congress that 

would help us think through these dilemmas. 

So I thank you for your time. I would be happy to engage in discussion and participate with the committee as you consider reform 

in this area. Thank you, Mr. Chairman. 

[The prepared statement of Dr. Mullan follows:] 


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Mr. PALLONE. Thank you, Dr. Mullan. 

Dr. Harris. 

STATEMENT OF JEFFREY P. HARRIS 

Dr. HARRIS. Thank you, Chairman Pallone and Ranking Member 

Deal, for allowing me to share the American College of Physicians’ 

views on primary care workforce and how it affects access. 

I am Jeff Harris, president of the ACP. Until recently, I practiced 

in a rural community with a population of 40,000 in Virginia. The 

office in which I practice focused on the delivery of primary care 

and nephrology. This year I have had the good fortune to be president of the American College of Physicians, representing 126,000 

internal medicine physicians and medical students. The United 

States is experiencing a primary care shortage in this country, the 

likes of which we have not seen. The demand for primary care in 

the United States will grow exponentially as the Nation’s supply of 

primary care dwindles. 

The reasons behind this decline in the supply of primary care 

physicians are multifaceted and complex. They include the rapid 

rise in medical education debt, a decrease in income potential for 

primary care physicians, failed payment policies and increased burdens associated with the practice of primary care. Many regions of 

the country already are experiencing primary care shortages. The 

Institute of Medicine reports that it would take about 16,000 additional primary care physicians to meet the needs in currently underserved areas. Two recent studies found that the shortage of primary care physicians for adults will grow to over 40,000, even after 

taking into account the important contributions of nurses, nurse 

practitioners and physician assistants as part of the primary care 

team. Approximately 21 percent of physicians who were board certified in the 1909s have left internal medicine compared to 5 percent who have departed from internal medicine subspecialties. 

Equally alarming is the fact that the pipeline of incoming primary care physicians is also drying up. In 2007, only 23 percent 

of third-year internal medicine residents intended to pursue careers in general internal medicine. This was down from 54 percent 

in 1998. Even more troubling, a recent survey found that only 2 

percent of medical students plan to go into general internal medicine. ACP strongly supports the need to ensure all Americans have 

access to affordable health coverage. As more people are covered, 

though, the primary care workforce needs to grow to take on more 

patients. Primary care physicians are the first line of contact for 

individuals newly entering the health care system. If we do not increase the primary care workforce, it will become impossible in 

many communities for people who do not currently have a relationship with a primary care physician to find an internist, family physician or pediatrician who is taking new patients. In Massachusetts, where health insurance coverage was recently expanded and 

nearly 95 percent of the State’s residents have coverage, the wait 

to see primary care physicians in Massachusetts has reportedly 

grown to as long as 100 days. Yet Massachusetts has a higher physician-to-patient ratio than most other States. 

The cost of providing coverage to more than 46 million uninsured 

Americans will be much higher and the outcomes of care much 


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poorer without more primary care physicians. More than 100 studies referenced in the ACP’s recent paper, How is the Shortage of 

Primary Care Physicians Affecting the Quality and Cost of Medical 

Care, demonstrates that primary care is consistently associated 

with better outcomes and a lower cost of care. For instance, one 

study found that an increase of just one primary care physician per 

10,000 population in a State was associated with a rise in the 

State’s quality rank and a reduction in overall spending by $684 

per Medicare beneficiary. 

The United States needs a comprehensive approach to ensure access to primary care. We should start with a national health care 

workforce process to set specific goals for educating and training a 

supply of health professionals including primary care to meet the 

Nation’s health care needs. In the United States, the numbers and 

types of health care professionals being trained are largely determined by the availability of training programs, the number of applicants and inpatient service needs of academic medical centers. 

But institutional service needs are poor indicators of national 

health workforce requirements, particularly as patient care has 

continued to shift from inpatient to outpatient settings. 

The Institution of Medicine has recommended ‘‘a comprehensive 

national strategy to assess and address current and projected gaps 

in the number, professional mix, geographical distribution and diversity’’ of the health care workforce. Secondly, we need to fund 

programs to cover the cost of medical education for students who 

agree to pursue careers in primary care and subsequently practice 

in areas of the Nation with greatest needs. Third, Medicare payment policies need to be reformed. The career choices of medical 

students and young physicians should be largely unaffected by considerations of differences in earnings expectations, yet Medicare 

payment policies systematically undervalue the comprehensive, 

longitudinal, preventive and coordinated care that is the hallmark 

of primary care. Currently the average primary care physician 

earns approximately 55 percent of the average earnings for all 

other non-primary care physician specialties. Studies show that 

this compensation gap is among the most significant reasons for 

the growing shortage of primary care physicians. To eliminate this 

differential as a critical factor in medical student and resident 

choice of specialty, the average net compensation for primary care 

physicians would need to be raised by Medicare and other payers 

to be competitive with other specialties. We recommend that Congress institute a process that would result in such targeted annual 

increase in Medicare fee schedule payments to make primary care 

competitive with other specialties over a five-year period beginning 

next year. The funding for such payments should take into account 

primary care’s contribution to reducing overall Medicare cost associated with preventable hospital, emergency room and intensive 

care visits, many of which are reimbursed under Medicare Part A. 

Although it may appear to some that our call to increase Medicare 

payments to primary care is self-serving, the fact is that almost 

half of the ACP’s membership practices in subspecialties, not general internal medicine, yet they share our belief that having a sufficient primary care workforce is essential if patients are to have access to high-quality, effective and affordable care. 


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Finally, we need new payment models that align incentives for 

accountable, coordinated patient-centered care including continued 

expansion of the patient-centered medical home. The Commonwealth Fund’s Commission on High-Performing Health Care Systems recently issued a report—— 

Mr. PALLONE. Dr. Harris, I didn’t stop you because I was interested but you are 3 minutes over, so you have to wrap up. 

Dr. HARRIS. I apologize. 

Mr. PALLONE. That is all right. 

Dr. HARRIS. One last paragraph. In conclusion, the United States 

faces a critical shortage of primary care physicians for adults. We 

believe that it is imperative for all Americans to be provided with 

access to affordable coverage. We also know that coverage alone 

will not ensure that patients have access to high-quality and affordable care if there are not primary care physicians available to 

meet those needs. 

Thank you for your patience. 

[The prepared statement of Dr. Harris follows:] 


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Mr. PALLONE. Thank you. 

Dr. Bean. 

STATEMENT OF JAMES R. BEAN 

Dr. BEAN. Thank you, Chairman Pallone and Ranking Member 

Deal and members of the Health Subcommittee for the opportunity 

to address you about patient access to medical care. My name is 

Jim Bean. I practice neurosurgery in Lexington, Kentucky, for the 

past 29 years. I serve currently as president of the American Association of Neurological Surgeons, and this is a member organization of Doctors for Medical Liability Reform, the Health Coalition 

on Liability and Access, and the Alliance of Specialty Medicine. 

Access to effective medical care depends on a number of factors 

and we have talked about them, but one that is too often neglected 

is a barrier to access that is created by a malfunctioning medical 

liability system. I think it is safe to say there is near-universal 

agreement among physicians, patients and policymakers that our 

medical liability system is broken. Defining how is the issue. In 

2005, Senators Hillary Clinton and Barack Obama acknowledged 

this when they co-sponsored medical liability legislation to deal 

with the mounting access-to-care crisis. A 2008 white paper, Call 

to Action, released by Senate Finance Committee Chair Max Baucus, also acknowledges that the current legal environment leads to 

the practice of defensive medicine and calls for alternatives to civil 

litigation so that the administrative costs associated with litigation, 

which account for 60 percent of malpractice premiums, can be reduced. Those at the forefront of health care reform understand that 

it will do little good to achieve universal insurance coverage if the 

doctors who actually supply critical aspects of care are either driven from practice or retire early or simply shun the lifesaving procedures that need to be done because of uncontrolled risk. 

The problem of access to care is especially critical for high-risk 

specialties. We have been talking a lot about primary care but we 

should not forget that the specialty care has to be rendered in a 

safe system. Specialties such as neurosurgery, obstetrics, orthopedics, general surgery, emergency medicine and others, these specialties have been hit particularly hard by lawsuits and rising insurance premiums and they are the same ones who provide critical 

emergency services, and when they leave, they leave enormous 

gaps. The crisis persists despite a clear record of successful reform 

in some States. Mississippi and West Virginia both faced critical 

loss of medical services because of a doctor exodus because of skyrocketing liability costs. Mississippi lost a substantial number of 

obstetricians. Both States, West Virginia and Mississippi, lost 

enough neurosurgeons to endanger their emergency care system. 

Liability State reforms dramatically reversed the trend and doctors 

have begun to return. All States should have the same advantage. 

Perhaps the most dramatic example is Texas. We have heard about 

it. Before reform in 2003 doctors fled the State. Texas ranked 48th 

out of 50 States in physician manpower, and since medical liability 

reform, 69 underserved counties have seen a net gain in emergency 

physicians and a number of other specialists. Access to care was 

clearly improved. 


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While we strongly believe that comprehensive reforms passed in 

Texas should be applied nationwide, other proposed reforms may 

help as well. They include early offers, specialized health courts 

and a presumptive defense by using evidence-based medicine. The 

President endorsed such an approach in a New England Journal of 

Medicine articled printed online. It was entitled Modern Health 

Care for All Americans, and it was published during the presidential campaign on September 24, 2008. I have a copy if you 

would like. He wrote that he would be open to additional measures 

to curb malpractice suits and reduce the cost of malpractice insurance and he further wrote, ‘‘I will also support legislation dictating 

that if you practice care in line with your medical society’s recommendations, you cannot be sued.’’ We strongly support the President’s announced position and look forward to its implementation 

as policy. 

Our President and this Congress are dedicated to reforming our 

health care system and ensuring access to care, but access to quality care must come first and ensuring patient access to care means 

acting out to fix a critically ill medically liability system. 

Mr. Chairman, thank you. 

[The prepared statement of Dr. Bean follows:] 


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Mr. PALLONE. Thank you, Dr. Bean. 

Dr. Rowland. 

STATEMENT OF DIANE ROWLAND 

Ms. ROWLAND. Thank you, Chairman Pallone and Ranking Member Deal and members of the committee, for the opportunity today 

to participate in this hearing on making health care work for 

American families. My testimony today will address the role public 

programs have played in improving access and helping to reduce 

health care disparities. Indeed, health care coverage matters. It 

may not be enough to assure access, but without it, access to care 

suffers and disparities rise. 

Together today, Medicare and Medicaid provide coverage to over 

a quarter of our population, 80 million Americans, our oldest, our 

poorest, our most disabled and among our sickest residents. Both 

programs for over 40 years have been central to our Nation’s efforts 

to improve access to care and the health care of the American people. Medicare has helped to provide access to care for the elderly 

by easing the financial burden for care and opening up access to 

the broad range of medical services and new technology that has 

helped to both extend life and promote better care. Medicare has 

helped not only to improve access to medical care but also to reduce 

racial barriers to care, both through the enforcement of the civil 

rights legislation that led to the desegregation of health care facilities and by providing equal benefits to all beneficiaries without regard to health status, income, racial or ethnic identity or State of 

residence. 

Medicaid is the workhorse today of the U.S. health care system, 

providing coverage for almost 60 million Americans left out of private health insurance and with very special health care needs. 

Medicaid coverage of the low-income population provides access to 

a comprehensive scope of benefits with limited cost sharing that is 

geared to meet the health needs and limited financial resources of 

Medicaid’s beneficiaries who tend to be both sicker and poorer than 

the privately insured low-income population. Medicaid also helps to 

address racial and ethnic disparities and access to care. Because 

minority Americans are more likely than whites to be low income 

and without access to job-based coverage, Medicaid provides an important safety net, today covering one in four non-elderly AfricanAmericans and Latinos. In fact, minority populations compose over 

half of the Medicaid beneficiaries. The comprehensive scope of Medicaid benefits is critical, given the low incomes and complex health 

needs of the population Medicaid services including the chronically 

ill and people with severe disabilities. When the health needs of 

the beneficiaries on Medicaid are taken into account, Medicaid is 

in fact a low-cost program. Both adult and child per capita spending are lower in Medicaid than under private health insurance. 

Medicaid enrollees, however, tend to fare as well as the privately 

insured on important measures of access to primary care. Uninsured children have significantly higher rates of no usual source of 

care. Compared to only 4 percent of publicly insured children and 

3 percent of privately insured children, one third-of uninsured children have no usual source of care. There have been great gains in 

reducing the share of low-income children who are uninsured 


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through the expansion of Medicaid and CHIP demonstrating that 

public programs can provide a solid platform from which to expand 

coverage. 

As the Nation moves forward to consideration of how to provide 

coverage to the over 45 million uninsured Americans today, Medicaid’s role for the low-income population provides a strong platform 

on which reform efforts can be build as evidenced by the recent experience with children’s coverage. One must recall that the uninsured population is predominantly low income, two-thirds with incomes below 200 percent of poverty, or roughly $44,000 for a family 

of four a year. Medicaid provides a strong and tested foundation 

upon which to build these health reform efforts but it could play 

indeed a stronger role if coverage of the low-income population was 

improved through expanded eligibility and reduction of enrollment 

barriers through addressing payment rates and administrative burden to help boost provider participation and promote greater access 

to primary care especially and through a stabilization of financing 

so that the periodic cuts in the program that affect reimbursement 

to providers and coverage for beneficiaries do not need to occur. 

In summary, the Medicaid program has an established track 

record in providing the scope of benefits and range of services to 

meet the needs of low-income population including those with 

chronic illness and severely disabling conditions. Drawing on Medicaid’s experience in already substantial coverage of the low-income 

population offers an appropriate starting point for extending coverage to the low-income uninsured population through health care 

reform. While health insurance coverage is essential to open the 

door to the health care system for these individuals, broader measures as you have heard discussed today need to also be put in place 

as a complement to assure that the coverage card is not an empty 

promise. Thank you. 

[The prepared statement of Ms. Rowland follows:] 


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Mr. PALLONE. Thank you, Dr. Rowland, and thank all of you. I 

know it is a large panel, but you covered a lot of very important 

areas and we appreciate it. We now have questions from the members and I will start with myself for 5 minutes. 

I am going to start with Dr. Mullan and I am going to throw a 

few things at you here. I don’t know if you will have time to answer 

them all but I am very concerned about the financing of medical 

education, you know, the whole idea of Medicare financing GMEs. 

If you were to suggest to me that we probably should have an alternative financing mechanism and not maybe even use Medicare, 

I would like to hear that. But even more important, my concern is 

about, you said 30 percent of the doctors are educated abroad. To 

me, that makes no sense and I don’t think any effort is being made 

to reverse that. If anything, it seems to me that we will probably 

see a situation where more of our physicians are educated abroad, 

and that makes no sense to me. You know, I talk about how I attend events in my district with medical doctors who are raising 

money for Caribbean medical schools rather than for UMDNJ in 

New Jersey. There were reports in the media a few months ago 

about foreign medical schools raising money and buying essentially 

residencies at hospitals in the New York metropolitan areas so that 

their students would have preference for residencies over graduates 

of American medical schools. What does this all mean in terms of 

the quality of physicians that so many are educated abroad, be 

they Americans that go abroad or immigrants? I mean, where are 

we going? Some of these schools, they seem to be opening more and 

more overseas. A lot of them are private, not even government run. 

I don’t know what kind of controls they have. Should we reverse 

this? I am not even talking about the impact on other countries, 

potential brain drain on other countries. That concerns me less. 

Maybe I should be concerned about it but I am not so much. Would 

you address that? Because I hear about it every day at home. I 

know it is a lot to ask you but—— 

Dr. MULLAN. Well, I will try to give the 2-minute synopsis on 

international medical graduates and how we have gotten to where 

we have gotten and what we can do about it. Very quickly, we have 

chronically undertrained. We have not trained sufficient physicians 

in our medical schools, and over the years we have put a lot of investment from the Congress in particular and from State governments into medical education at the medical school level in the 

1960s and 1970s and this had a very good response. We doubled 

the output of medical schools between 1965 and 1980. At that point 

everybody said whoa, we are going to overshoot, and funding was 

throttled back. Schools remain where they were. So between 1980 

and 2005, we lost one medical school, a net loss of one, and the 

graduating class, 16,000, 16,500, every year was the same. Meanwhile over time, the residency opportunities grew, reflecting somewhat the needs of the country, and the opportunity for international graduates who took exams like the U.S. exams, today they 

take exams that are exactly the same to come and fill residency positions and then remain in practice, grew. So that today about 27 

percent of our residents and 25 percent of our doctors in practice 

are graduates of international schools. A minority of these, about 

20 percent today, come from schools in the Caribbean, which are 


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essentially designed for U.S. students to go abroad and come back 

as international medical graduates. That is because the need for 

medical education was not being made onshore. We didn’t have 

enough placements. 

Mr. PALLONE. But Doctor, should we be reversing this? I mean, 

my fear is the quality is good. Is this a way for us to save money 

so we should say great, let us have everybody educated abroad because the cost is less and let that burden be passed onto someone 

else? Does it matter? Are we doing anything to change it? 

Dr. MULLAN. The answer is yes, we should be reversing it. That 

is good domestic policy. It is good foreign policy both. It gives more 

opportunity to domestic students if we have opportunities for them 

to train onshore and it diminishes the brain drain, which is bad 

foreign policy around the world. Many governments are resenting 

the fact that we are pulling their doctors here. The way it is happening and it is happening in a somewhat spontaneous fashion, is 

that medical schools are now growing again, increasing the opportunities. It is estimated that the medical school positions over the 

next 3 or 4 years will grow by 25 percent, and what will happen 

by all estimates is, that as more U.S. graduates come out, they will 

be selected for residency positions and de facto or in passing, the 

international medical graduates will have less opportunities. They 

will be less drawn from abroad. The problem—— 

Mr. PALLONE. But is that true? I mean, was this an aberration 

that I read in the New York Times where these foreign medical 

schools are now essentially buying residencies? 

Dr. MULLAN. The foreign medical schools you refer to are the 

Caribbean commercial schools that are training largely U.S. students abroad and they did conclude—one of them concluded a large 

agreement with the New York Health and Hospitals Corporation 

for medical student places on their wards. It is unclear what will 

happen. U.S. New York-based schools that have placed their students there are in competition for those. Traditionally they have 

not paid for them. And it will be interesting to see how that plays 

out. But I think the point is, if the opportunities for practice in the 

United States for international medical graduates diminish because 

more and more of our positions are being filled by our own graduates, that business will diminish and we will not be so reliant on 

foreign graduates, whether they are U.S. citizens to begin with or 

international citizens. 

Mr. PALLONE. So you think we are reversing this policy and we 

shouldn’t worry much about it? 

Dr. MULLAN. I think we should remain concerned about it. I 

think we are in a period where it is going to diminish. Now, we 

should understand that the number of residency positions in the 

country has remained relatively fixed. In round numbers, about 

100,000 people are in residency every year, about 24,000, 25,000 

new people in a residency each year. If we increase GME funding, 

graduate medical education Medicare funding, we will increase the 

opportunities and that will again begin to draw on the rest of the 

world. So right now where the physicians are capped under Medicare, that is Medicare reimbursement is capped, we are not creating more residency positions so the increased number of U.S. 

medical school graduates will go into a fixed number of positions, 


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and by doing that it will diminish the number of international 

graduates that we bring into our country. 

Mr. PALLONE. Thank you. 

Mr. Deal. 

Mr. DEAL. Thank you. 

I would like to follow up on that too. I had a constituent that I 

asked him what his doctor told him. He said I don’t know, I didn’t 

understand a word he said, and that is a continuing problem. I 

didn’t realize the percentages were as great until I read your testimony. With regard to the New York situation that you talked 

about, if we are funding graduate medical education through Medicare and the hospitals are now entering into private negotiated 

purchases of those slots, are we in effect funding slots through public funding that are now being in effect sold to foreign medical colleges? 

Dr. MULLAN. That is a good question. I think the answer is no, 

because as I understand the agreement in New York, it is for the 

training of medical students, not for graduate medical education. 

The residency slots which Medicare funds remain the same. They 

are filled by both U.S. graduates and international medical graduates. Remember, I said we graduated about 16,000. If you add in 

osteopathic medical schools, U.S. based, we graduate about 18,000 

every year. We offer 24,000 internship positions, post-graduate 

year one. So the difference between the 18,000 we graduate and 

the 24,000 that are offered are filled by international graduates, 

U.S. international graduates and non-U.S. international graduates. 

As the U.S. graduate numbers rise with the 24,000 positions to be 

filled, the international medical graduate numbers will diminish. 

Mr. DEAL. Let me go to Dr. Harris because on a related subject 

to those residency slots, you make the point that we do not have 

enough residents in their post-graduate education going into the 

primary care internal medicine slots. How do we correct that? Is 

that something that the funding should be channeled more in the 

direction of those residency slots rather than the others, or how 

would you suggest we fix that? 

Dr. HARRIS. Well, we do recommend that there be focused GME 

funding on expanding the number of primary care spots. We feel 

that you need to be attentive to that. But the answer comes when 

you interview young people and ask them why are you not choosing 

primary care for a career, and the answers are three. One, it gets 

back to the question about medical education. You can argue that 

fundamentally there is a design flaw with medical education in 

that most medical schools in this country are centered around tertiary care centers where most ill people in the States are sent for 

their care while the most exotic illnesses are sent for very focused 

care. It is intellectually wonderfully satisfying, it is a wonderful 

place to spend 4 years, but there is precious little exposure to what 

the majority of health care is in this country, namely outpatient 

ambulatory care. So one of the things you need to do is increase 

that exposure to show young people that following patients longitudinally, knowing them for years, if not decades, is a pleasure. The 

second thing has to do with the pace and that gets back to the notion of this medical center home or funding for bundled care that 

allows the expansion of the team that gives physicians time with 


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their patients. Remember, 20 percent of the Medicare population in 

this country has five or more chronic illnesses. 

Mr. DEAL. Let me stop you because my time is running out. I understand that. I think your point is well made that the traditional 

residency is in a hospital environment whereas the primary care 

whereas the primary care physicians that we need to be attracting, 

their practice is not going to be necessarily in that hospital environment. We need to have a different environment in which for 

them to complete that exposure. Is that what you are saying? 

Dr. HARRIS. We need to increase their exposure to ambulatory 

medicine during their training. 

Mr. DEAL. But doesn’t that have to be done under the auspices 

of a hospital that is providing the residency program? 

Dr. HARRIS. Yes. 

Mr. DEAL. Okay. Let me go back to Dr. Mullan just a second. 

We know that NIH funding has been significantly boosted as a 

result of the stimulus input. You made a statement in your written 

testimony talking about the rise in NIH funding from $2.4 billion 

in 1970 to $16.3 billion in 2004, and you say creating a robust culture of research at medical schools that dominates medical school 

finances, faculty values and school culture. Now, with this huge influx of new money into NIH, is that going to exacerbate this problem about the focus of medical schools and focus it away from increasing primary care training or is it going to help it? Which way 

it is, or neither? 

Dr. MULLAN. Good question. The stimulus money is focused in 

very practical ways and I think would probably be more practicefriendly perhaps than traditional NIH funding but the point is well 

taken, and I am not here to talk against NIH funding. I am here 

to talk for balance and we need to think if our medical schools are 

being endowed with enormous research money, creating a culture 

that values research and specialism when the problems in the 

country are generalism, we need to think about how to rebalance 

that and medical schools and funding for generalist research is important as well. 

Mr. PALLONE. Ms. Christensen. 

Ms. CHRISTENSEN. Thank you, Mr. Chairman. I didn’t expect you 

to come to me that quickly. 

I thank all of the panelists as I said, for not only your testimony 

today but for the work that you have been doing over the years. 

Dr. Smedley, and I will probably also ask Dr. Rowland to answer, 

I am an advocate of building on the public programs to expand coverage but I have a concern that as we reform the system that we 

don’t perpetuate a two-tiered system of care. There have been several studies that I have seen that have shown that despite the increased access that Medicaid patients have to services, they don’t 

have as good outcomes. They have about the same outcomes as the 

uninsured. So why do you think this is and how can we fix the 

problem? And is there a role for the public plan that we are talking 

about in all of this? Dr. Smedley? 

Mr. SMEDLEY. Sure. First, I agree with Dr. Rowland’s statement 

that Medicaid has been vitally important for low-income communities and communities of color. I have no doubt that without Medicaid, many more people would have suffered unnecessarily and we 


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would have had many more premature deaths. By the same token, 

we know there are some things that need to be fixed and so it is 

important that we try to address the fact that we have tiered 

health care insurance systems, and so to the extent that people of 

color are disproportionately in lower-tier systems, this in itself can 

be one of the many causes of health care inequality and it is important that we take steps to strength Medicaid so that it is not stigmatizing to be a Medicaid patient. I was sharing with you earlier 

a story. I was surprised to walk into a county health clinic in one 

of our northeastern States. I walked into a waiting room that was 

approximately 20 feet by 30 feet, a very small waiting room where 

you could your name if you were called, but yet along one of the 

walls there was a sign that said ‘‘Medicaid patients only.’’ This was 

surprising to me because it further stigmatizes Medicaid patients 

and so to the extent that Congress can take steps to ensure that 

all of our public plans are comparable to private plans in terms of 

coverage, quality, quality incentives and performance incentives, I 

think this will go a long way toward reducing that inequality. 

Ms. CHRISTENSEN. Dr. Rowland, we want to make sure that the 

card isn’t an empty promise. It just seems to me that when you 

have a Medicaid card and another card, you know, it just opens the 

door for bias. 

Ms. ROWLAND. I think there are two things to note here. One is 

that many of our low-income population live in medically underserved areas so much of the discussion we have had today about 

bringing more resources into that area is important. I think the 

second thing to note, however, is that we can do more to make 

Medicaid payment rates more equalized with the rest of the health 

care system and that unfortunately as we gave States greater flexibility over their programs, many of them have used that flexibility 

when they need to cut costs to reduce payment rates, although we 

do see States improve those payment rates whenever their resources are more abundant. So over the last few years before this 

economic downturn, many States moved to up their payment rates. 

I think that the most important thing is to make sure that the card 

provides people with access to physician services and to primary 

care service and I think we should note that within the Medicaid 

program over the last few years the advance of managed care and 

the use of primary care networks has helped to really secure a better access, so I do worry that in some cases the providers willing 

to participate in those networks are not the same as the providers 

willing to provide care to the privately insured. 

Ms. CHRISTENSEN. Thank you. 

Dr. Lavizzo-Mourey, thank you for the work that Robert Wood 

Johnson has done, and I was really interested in the family nurse 

partnership program as well as the others, but we hear an argument and we asked the CBO director, several of us did over and 

over again about savings that would be realized by prevention and 

you talk about a savings that you see in the family nurse partnership program. Their argument is that we will spend more money 

on prevention and so we won’t realize any savings and I find this 

a major obstacle to getting done what we need to get done and 

making the investment. How would you respond to that? 


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Dr. LAVIZZO-MOUREY. Thank you for this question. When people 

talk about prevention, they often lump a number of issues together 

that really should be separated. First, you referenced the nurse 

family partnership program. That is a program, for those who don’t 

know, that invests in the relationship between nurses and momsto-be or young mothers that teaches them how to navigate the 

health care system but also how to provide better health for themselves and their babies so it is an investment in health that happens in the community. The benefits that accrue from that investment happen over a number of years, not 2 or 3 but really over 10 

to 15 years. We continue to see savings up until the child is in 

their adolescence. So one has to look for the savings over a long 

enough period of time, first of all, in order to really understand 

whether there are savings. 

Secondly, we often talk about prevention and we are really referring to clinical services, screening tests and the like, and there 

frankly the results are mixed on whether it is going to provide savings. However, we do know it almost always improves health and 

produces a better value, but one has to also separate from that prevention that occurs at the community level, community-based investments such as reducing obesity, improving physical activity, reduction of tobacco use. These have been shown time and time again 

in large public health studies to reduce the overall costs of care because they improve the health, and we really need to focus those 

three separately if we are going to answer the question of whether 

prevention saves money. 

Mr. PALLONE. The gentleman from Illinois, Mr. Shimkus. 

Mr. SHIMKUS. Thank you. I am going to try to be quick. It is a 

huge panel. I appreciate you all coming and I apologize for being 

in and out like we all have to do when there is business. Let me 

ask a question, and if you can answer briefly and I will try to get 

the whole panel. It depends on how quick you answer. You know, 

Senator Baucus on the other side’s basic premise is Medicaid for 

all, cover the uninsured. Would you support that, Dr. Smedley? We 

are hearing some bad comments on Medicaid here. 

Mr. SMEDLEY. I believe it was Medicare for all, if I am not mistaken, which—— 

Mr. SHIMKUS. Okay. Well, let us assume that we want to cover 

the uninsured through Medicaid. Would you support that? 

Mr. SMEDLEY. Well, it is important that we ensure that everyone 

has comprehensive care and that—— 

Mr. SHIMKUS. So would you support current State-run Medicaid 

system insuring the uninsured today? 

Mr. SMEDLEY. I would support as broad a pool as possible. 

Mr. SHIMKUS. So would you support State Medicaid programs 

covering the uninsured of each State? 

Mr. SMEDLEY. That is an option that can work in many States. 

I am sorry I cannot give you a definitive answer. 

Mr. SHIMKUS. Dr. Kitchell? 

Dr. KITCHELL. Yes, I think that Medicaid should be expanded but 

I also think that we should maintain private insurance for patients 

who need it. 

Mr. SHIMKUS. Okay. Thank you. 

Dr. KITCHELL. As we—— 


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Mr. SHIMKUS. That is good. I really want to go quick and I don’t 

want to be disrespectful. 

Dr. Sitorius. 

Dr. SITORIUS. I am going to second Dr. Smedley. In some States 

it will work, in others it may not. 

Mr. SHIMKUS. Okay. 

Dr. SITORIUS. I am not answering your question. I understand 

that. 

Mr. SHIMKUS. All right. That is good to know when you are on 

the record because that makes a statement about the current Medicaid system. 

Ma’am, I don’t want to butcher your name. I am sorry. 

Dr. LAVIZZO-MOUREY. Lavizzo-Mourey. It is a mouthful, I know. 

Our foundation does not advocate for specific plans but we do have 

principles that suggest that there are a broad array of ways to, as 

Dr. Smedley says, ensure that we can increase the number of—— 

Mr. SHIMKUS. Okay, but my focus is on Medicaid system in 

States as we know today. Covering the uninsured through Medicaid system in States, is that a way to insure the uninsured? 

Dr. LAVIZZO-MOUREY. It is one way among others. 

Mr. SHIMKUS. So you are not going to answer either. 

Sir, I don’t see your nametag. I apologize. 

Dr. MULLAN. Mullan. I would agree it is one of a number of options. It would not be my preferred option. 

Mr. SHIMKUS. Great. 

Dr. Harris. 

Dr. HARRIS. Congressman, in our paper we felt that—— 

Mr. SHIMKUS. Quicker, please. 

Dr. HARRIS [continuing]. Consideration should be given up to 200 

percent of the federal poverty limit for covering people. That would 

capture a sizable number of these people. 

Mr. SHIMKUS. So you are saying yes for 200 percent of poverty? 

Dr. HARRIS. As part of this overall pool of people. That will in 

no way capture all of the uninsured. 

Dr. BEAN. No. The benefits are wide but the pay is so low, you 

won’t get participation. 

Mr. SHIMKUS. Dr. Rowland. 

Ms. ROWLAND. For the low-income population, two-third of the 

uninsured, expanding Medicare would make a lot of sense. 

Mr. SHIMKUS. For the uninsured? 

Ms. ROWLAND. Yes. 

Mr. SHIMKUS. Okay. Let me go with this question. Would you 

trade your current insurance policy for a Medicaid policy, Dr. 

Smedley? 

Mr. SMEDLEY. No. 

Mr. SHIMKUS. Just go down the table. Dr. Kitchell? 

Dr. KITCHELL. As I said, some private insurance—— 

Mr. SHIMKUS. Would you trade yours for a Medicaid policy? 

Dr. KITCHELL. No. 

Dr. SITORIUS. No. 

Dr. LAVIZZO-MOUREY. My plan has things that Medicaid does not 

have in it. 

Mr. SHIMKUS. So that is a no? 

Dr. LAVIZZO-MOUREY. That is a no. 


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Mr. SHIMKUS. Thank you. 

Dr. MULLAN. No. 

Dr. HARRIS. No. 

Dr. BEAN. No. 

Ms. ROWLAND. Yes. 

Mr. SHIMKUS. Thank you. We may give you that opportunity to 

do that. 

Ms. ROWLAND. Medicaid has low cost sharing and comprehensive 

benefits and covers a lot of services that private insurance doesn’t. 

Mr. SHIMKUS. Obviously with the doctor’s question about, or your 

question about someone going into a clinic, being casted as Medicaid only this line versus other lines, that is why I asked that 

question. It is really a follow-up. 

I am really involved, this is my district. I have about 14 community health clinics. They service—Illinois services 1.3 million Medicaid, uninsured, Medicare and for-pay folks. It has been very successful. When I first got elected to Congress, I had zero in my district. Now, the benefits of community health clinics are what? The 

people who practice there are protected by the Federal Tort Claims 

Act. It has allowed them to provide health care to the uninsured. 

Do you think that some model, talking about what happened with 

Texas, what happened in Illinois, although our legislation is being 

reviewed by the Supreme Court—we had medical liability reform 

for my neurologist. There was a time when we did not have a single neurologist south of Springfield because of medical liability. 

Would moving on a Federal Tort Claims Act provision on medical 

liability be helpful in access to care and keeping costs down? Dr. 

Smedley? 

Mr. SMEDLEY. I don’t know if the evidence speaks to that. Community health centers are successful not solely because of tort 

issues but because of—— 

Mr. SHIMKUS. So you are saying that the fact that they don’t 

have liability costs because they are protected, that doesn’t affect 

the way they charge individuals? 

Mr. SMEDLEY. No, they are—community health centers have 

done a marvelous job targeting the needs of low-income and underserved communities. I believe that is the primary reason that they 

are successful. 

Mr. SHIMKUS. I would beg to differ. 

Dr. Kitchell. 

Dr. KITCHELL. Yes, I think community health centers are a good 

idea. We have actually—— 

Mr. SHIMKUS. I am talking about the Federal Tort Claims Act 

protection on community health centers. 

Dr. KITCHELL. That would help, yes. 

Dr. SITORIUS. Yes. 

Dr. LAVIZZO-MOUREY. I practice in a community health center. I 

have to agree with Dr. Smedley that the reasons that they are successful have much more to do with other issues. 

Mr. SHIMKUS. Do you pay any liability insurance when you practice in the community health center? 

Dr. LAVIZZO-MOUREY. No, I do not. 

Mr. SHIMKUS. Okay. Thank you. 


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Dr. MULLAN. Health centers are distinctly successful for other 

causes. Is the tort protection afforded to provides there useful? Yes. 

Mr. SHIMKUS. Dr. Harris. 

Dr. HARRIS. I simply agree with Dr. Mullan. 

Dr. BEAN. Yes, it would help. 

Ms. ROWLAND. I agree with Dr. Mullan. 

Mr. SHIMKUS. Thank you, Mr. Chairman. I think tort issues 

should be part of this health care debate. I yield back. 

Mr. PALLONE. Thank you. 

Mr. Braley. 

Mr. BRALEY. Dr. Kitchell, I want to follow up on some of the 

points you raised in your opening statement, especially dealing 

with geographic reimbursement inequities. You mentioned the Geographic Practice Cost Index, also commonly referred to as GPCI, 

reduced fees for physicians because of where they live. In your best 

estimate, what is the differential in Medicare fees between the 

highest GPCI areas and the lowest GPCI areas? 

Dr. KITCHELL. The differential is 34 percent between North Dakota, Arkansas, and then the highest area is in California. 

Mr. BRALEY. And then to follow up on your point, when you are 

out looking to replace equipment and looking for durable medical 

equipment that you use in your practice, have you found a similar 

inequity of what the cost of that equipment is based upon geographic differences? 

Dr. KITCHELL. No. In fact, about 2 years ago when we decided to buy an electronic medical record, that cost of $21 million for our 

clinic is exactly the same as anywhere in the country. 

Mr. BRALEY. Can you explain in further detail how it is that 

these reimbursement inequities built upon a flawed GPCI formula 

impact access to care in rural areas? 

Dr. KITCHELL. Well, there are some services that are not even 

paid as much as the cost of delivering those services. Let me give 

you an example of a cardiac defibrillator implant. The Medicare reimbursement for that is actually less than the cost of the device. 

So the payment for the labor, the payment for the rent, the payment for all the other services that that patient needs, Medicare 

pays less than the cost of that machine. 

Mr. BRALEY. Now, one of the solutions that has been proposed is 

putting a floor on GPCI inequities and we know that by enacting 

a 1.0 floor on work GPCIs we reduce the inequity even though 

there is still this 8 percent differential you mentioned in your testimony. Do you feel that a 1.0 floor on practice expense GPCIs would 

also decrease rural health care disparities? 

Dr. KITCHELL. Yes, that would be our best solution. 

Mr. BRALEY. Earlier this year I spoke in this committee about 

the need for a reimbursement system that rewards quality. Can 

you explain how a model system might look to provide qualitybased reimbursements to physicians? 

Dr. KITCHELL. Yes. As I said, the PQRI program is flawed. The 

hospital system is doing a good job of rewarding quality. Quality 

needs to be rewarded for teams, groups and systems. Quality is 

team-based care. The medical home model, the bundled systems, 

the shared savings, they rely upon physicians working together 

with non-physicians in teams so we should be encouraging, we 


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should be incenting physicians to be part of teams, groups and systems, and as I mentioned, the Middlesex, Connecticut, example is 

a great example where independent physician practices have gotten 

together in an accountable care organization and they have increased their quality and reduced the costs of care. I think a key 

point for Americans is to understand that by working together, 

physicians and non-physicians working together, we can improve 

quality and we can reduce costs. 

Mr. BRALEY. All right. Dr. Bean, I am going to follow up a little 

bit on your testimony because one thing that was noticeably absent 

from your testimony was a discussion of preventable medical errors 

and there has been a lot of testimony from the panel about the importance of an Institute of Medicine finding relating to access to 

health care but no one has mentioned the seminal Institute of Medicine study in 2000 and the follow-up study identifying the acute 

problem of preventable medical errors and the costs they impose on 

the system. So do you agree that the most effective way to reduce 

malpractice costs in this country is by reducing or eliminating preventable medical errors? 

Dr. BEAN. I am afraid I don’t agree that is going to eliminate the 

malpractice crisis in the areas where malpractice is used or abused. 

I will agree with you that the focus on preventing medical errors 

is not only laudable but highly necessary. 

Mr. BRALEY. Well, can you explain why the existing framework 

for health quality oversight that is in place in this country primary 

through the Joint Commission on Accreditation of Health Care Organizations that is hospital specific has failed to make a measurable decrease in preventable medical errors despite the fact that 

their sentinel-event program has been in place for over a decade, 

and if you take the IOM numbers of 44,000 to 98,000 preventable 

medical errors resulting in deaths in hospitals every year and compare that to the sentinel-event statistics from JACO which show 

that on average only 300 sentinel-event reports are filed per year, 

don’t you agree that there is a gross example of underreporting of 

the problem and a failure on the part of the community to address 

it? 

Dr. BEAN. No, not at all. First of all, if you look back at the studies that were done where the 44,000 to 98,000 figures were drawn 

from, these were extracted from hospital charts in about 1982 or 

1983. That is almost 30 years ago. So there has been a substantial 

change in hospital practices and events since then. When that extraction was done, they were extrapolated from acute charts and 

assumed that this was happened around the country and the medical errors and negligence were equated and that is not necessarily 

so at all. There are things that do happen that are not negligence 

so saying that the medical liability system is going to handle—is 

necessary to prevent all that is wrong. I think that the proper way 

to do it is what we are doing. We are looking at quality events, and 

in fact if the reporting is low, maybe that review should be done 

again to see if that is the reason. Maybe there has been a change 

over the past 30 years. 

Mr. BRALEY. Do you think there are only 300 preventable medical errors a year happening in hospitals in this country? Is that 

your testimony? 


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Dr. BEAN. No, I think that, number one, if you are asking hospitals to report things or doctors to report things in the face of a 

medical liability system where they can be sued for millions of dollars, your incentive to be open is blunted considerably. Change the 

liability system. Make it possible like airlines to report things without being so open to suits that can run you out of practice, and we 

can have a better system for finding and correcting errors. 

Mr. BRALEY. Thank you, Mr. Chairman. I would just like to point 

out that the reporting system I am referring to at JACO is a closed 

system that is not open to the public. 

Mr. PALLONE. Thank you. 

The gentleman from Texas, Mr. Burgess. 

Mr. BURGESS. Thank you, Mr. Chairman, and that is an excellent 

point, Dr. Bean, and I am so glad you made it because the IOM 

study was in fact published 10 years ago and it was from data collected 20 and 30 years ago. It is high time, Mr. Chairman, we 

asked the Institute of Medicine to update that study. The sentinel 

reporting techniques have been around for 10 years. Maybe we 

should look again and see whether we have made any progress. I 

suspect we have, because even then the data from 1982 and 1983 

and the data from 1992 showed significant improvement between 

that 10-year span and that was not accounted for in the publication, To Err is Human. 

Since Mr. Shimkus took my questions, Dr. Rowland, let me just 

ask you, you described a Medicaid program that I just scarcely recognized. In my practice, it wasn’t a workhorse, it was more like a 

Trojan horse and all the people got inside and then you were in 

trouble. But let us think about it for just a minute. You were the 

only one who answered affirmatively to changing what you had 

now for what would be available in the Medicaid system. I offered 

an amendment during our SCHIP debate and I may well offer it 

as stand-alone legislation that would allow members of Congress 

the option of entering the Medicaid system so perhaps they could 

see for themselves firsthand what patients encounter. Would that 

be a good idea? 

Ms. ROWLAND. Well, first of all, I think, sir, that you come from 

the State of Texas and that Medicaid programs are different in different States and so one of the issues that needs to be addressed 

if one is going to build on the Medicaid foundation is to perhaps 

make the program more standard. 

Mr. BURGESS. But we had no other member from Texas on the 

panel here today but everyone declined the opportunity for taking 

an adventure into the Medicaid system. I just offer that for what 

it is worth. Do you think I will get many cosponsors on that legislation from Members of Congress? 

Ms. ROWLAND. I actually doubt it. 

Mr. BURGESS. Yes, I do too. 

Ms. ROWLAND. But I think that it does point out that the program does need improvement as a building—— 

Mr. BURGESS. There is no question that the program needs improvement and I did take Medicaid patients in my obstetrics practice, and the biggest problem I had was finding a specialist to 

whom to refer a patient when she had a problem that was beyond 

my scope and capabilities, and that I think really speaks to the 


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problem that many primary care doctors have when they open 

their doors to Medicaid patients. If they get a complicated abscess, 

if they get a complicated cardiology patient, they literally have no 

place to send that patient, and as a consequence they may be practicing well over their heads, and that is a patient safety issue that 

really should not go unaddressed. 

Dr. Bean, I want to thank you too for your comments about the 

medical liability system. Texas has I think done an excellent job. 

I can’t take any credit for it. I have introduced the Texas legislation in Congress. The bill number is 1468, for anyone keeping scoring at home. This bill actually scores as a savings by the Congressional Budget Office. It is $3.8 billion over 4 years. It is not a huge 

savings. We spend trillions of dollars at the drop of a hat now. But 

still, $3.4 billion to $3.8 billion means something to someone somewhere and I just offer this, Mr. Chairman, as a gift to help balance 

the budget wherever it might be helpful. I will be glad to make my 

modest little Texas medical liability bill available so that other 

States can in fact enjoy some of the things that have happened in 

Texas. 

Dr. Kitchell, in my remaining time, I couldn’t help but notice 

that your notes were handwritten so I assume you haven’t purchased that $21 million record system that is available to you? 

Dr. KITCHELL. We are in the process of phasing it in, yes. 

Mr. BURGESS. I understand why because even from across the 

street, I can tell that your partners cannot read your handwriting. 

Let me just ask you a couple of questions because you have some 

great testimony about the PQRI which I thought was a mistake 

when our side pushed it at the end of 2006. You say it doesn’t actually reward quality it rewards reporting. There was a great article 

in the Journal of the American Medical Association a little less 

than a year ago. I unfortunately don’t remember the author. It was 

tongue in cheek. It recommended that we diagnose liberally, don’t 

be stingy with your diagnoses. If you make more people in your patient panel class 2 diabetics, your hemoglobin A1Cs are going to 

look a lot better and as a consequence you are going to get a better—your payment is going to improve. You reward, you incent the 

wrong type of behavior when you go down the PQRI road but I do 

wonder, and you have the statement that there are methodological 

problems, are these fatal flaws or could these be corrected? And of 

course, one of the biggest problems with PQRI is, we didn’t pay a 

darn thing for anyone to gather the data. It was more expensive 

to try to participate than any bonus that you would get at the out 

end on PQRI but are the problems inherent in PQRI, are they so 

fatal that the program cannot be salvaged and we just need to 

move to a different scheme? 

Dr. KITCHELL. Let me just preface this slightly. The American 

Medical Association physician consortium for performance improvement is developing measures of quality so we cannot only measure, 

we can reward quality. The AMA should take a lot of credit for developing this. They have taken the lead in measuring and rewarding quality. The PQRI program has chosen to use individual measures. The consortium is now working on more team and system 

measures. That is where I think we need to go. The problem with 

the individual measures as a physician, we don’t want to be 


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profiled. We don’t want to be tiered. We don’t want to be rated individuals because our patients vary. Sometimes three physicians 

are seeing one patient so who gets the credit, who gets the blame. 

That is an attribution problem. So these individual measures continue to promote fragmentation of care rather than coordination of 

care by teams and systems. We need to think about how we deliver 

care and we will do better with raising quality, giving patients 

safety, improving the value of their care if we measure by teams, 

groups and systems. So my proposal would be to change the focus 

of PQRI to get away from reporting. Let us do measures. And we 

have some composite measures now and some groups, accountable 

care organizations are willing to be accountable for quality and for 

cost. It is time we allowed those groups of physicians who are willing to be accountable for quality and willing to be accountable for 

their costs to let them do that. 

Mr. BURGESS. Are these along the lines of the physician group 

practice demonstration model that CMS has been doing? 

Dr. KITCHELL. Yes. 

Mr. BURGESS. And I would—— 

Mr. PALLONE. Dr. Burgess, just one more and then—— 

Mr. BURGESS. I would very much favor us considering in the 

Medicare system, which is a federal program, if a group practice 

is under that accountable model, to allow them, allow that group 

for their Medicare patients coverage under the Federal Tort Claims 

Act and I think we can go a long way towards pushing what is I 

think a very effective policy and getting doctors to buy in, and I 

will yield back the balance of my time. 

Dr. KITCHELL. Can I just—— 

Mr. PALLONE. You can answer. 

Dr. KITCHELL. One last comment, and just so you understand, 

the physician group practice demonstration project also included 

independent physicians. They were not a group, a formal group. 

They were independent practicing physicians and they got together 

in groups. 

Mr. PALLONE. Thank you. 

The gentleman from New York, Mr. Weiner. 

Mr. WEINER. Thank you, Mr. Chairman. 

Some of my colleagues on the other side have been engaged in 

a furious process of erecting straw men and then burning them 

down. So let me just clarify a couple of things with your help. First 

of all, my understanding is, the proposal by some is Medicare for 

all, the idea being that it is a model that people are somewhat comfortable with. It is in some interpretations this problem with this 

debate is that some people have gotten stirred about the idea of socialized medicine, forgetting that in fact what the social compact in 

Medicare has been with the exception of problems with cost reduction and things that need to be fixed, it has been a success that 

people appreciate. The other false choice that has been offered to 

us is the idea that not whether Members of Congress should be offered Medicaid but whether Medicaid citizens should be offered 

what Members of Congress have. That is the choice that we confront. What we are trying to do is trying to take programs that are 

obviously deficient and replace them with models that work better. 

So perhaps my colleague from Texas should offer legislation offerVerDate Mar 15 2010 23:37 Mar 23, 2012 Jkt 067817 PO 00000 Frm 00174 Fmt 6633 Sfmt 6602 E:\HR\OC\A817.XXX A817

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ing anyone on Medicaid the same plan that Members of Congress 

have. That would truly be a constructive step forward. It is the 

premise of our entire discussion that the Medicaid system doesn’t 

work very well and it doesn’t treat people as well as it should or 

treat physicians the way it should or reimburse States the way it 

should. That is a given, and to set the straw man up that, oh, well, 

we have to have Medicaid for everyone, wouldn’t that be a terrible 

thing, yes, it probably would not be anyone’s desired outcome and 

I don’t think any of the collective wisdom of the panelists would 

suggest that that is the seminal question despite the somewhat 

overly yes, no, get your answer ready kind of inquisition. 

Let me just now ask a question, if I could. It strikes me that 

Medicaid is a pretty good deal for hospitals and physicians when 

compared to no insurance. We actually have an experience in New 

York City that when there is a Medicaid patient coming in the 

door, a lot of the hospitals in New York are gleeful. At least they 

have someone with some kind of coverage, some kind of predictable 

repayment, some kind of a process that they know that they are 

going to get compensated. So yes, Medicaid looks pretty problematic to a lot of physicians except when compared to what a lot of 

people have, which is no coverage at all. But I want to ask a question about the impetus to get more physicians to go into primary 

care. It seems to me that the market is not functioning efficiently, 

that while there is a demand for more of those, while there are 

more hospitals that are looking and more of our system seems to 

want it, it doesn’t seem like the incentives are getting built in properly. As we figure out how to contract the incentives differently in 

the context of a national health care plan, should we be saying we 

will pay you more? Should we be saying we will pay more of your 

medical education if you go into primary care? Should we say we 

are going to penalize you if you decide to be a dermatologist? I 

mean, what would be the model if we are going to start from 

scratch which to some degree we are. What would be the model 

that would be—and Dr. Mullan, you were the one who I heard 

speak most articulately about it. What do you think that we should 

be doing to structure it so that being a primary care physician 

seems like a better deal? 

Dr. MULLAN. I think the important thing to know is unfortunately there is not a single prescription, a single diagnosis and single prescription here, and it is along this continuum. I think there 

are things that need to be done in the pipeline. There are things 

that need to be done in practice. And as you rightly observed, the 

market is not working. The market is not calibrated in practice to 

support people very well in primary care and that is a financial 

matter in terms of reimbursement. It is also a structure model in 

terms of the hamster in the maze or hamster on the runner-type 

environment that has been created by the need to churn out as 

many patients as possible simply to pay the rent. So the restructuring of primary care with incentives from federal payers as well 

as others will be hugely important to creating a primary care environment which is attractive to make the market better. But if you 

don’t have the pipeline geared to do that, you will have ill-prepared 

people coming and therefore the investments, Title VII, how do 

we—what do we do about the medical school environment, the culVerDate Mar 15 2010 23:37 Mar 23, 2012 Jkt 067817 PO 00000 Frm 00175 Fmt 6633 Sfmt 6602 E:\HR\OC\A817.XXX A817

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ture to make it more friendly to primary care, community medicine, ambulatory care and the like, and with graduate medical education how do we get more people training in those areas with very 

heavy federal investment in that area. 

Mr. WEINER. Can I squeeze in one more question? Is there a 

whole different tier of health care that we maybe need to create on 

the preventive side, on the diagnostic side, on the nutritional side, 

on the testing side? I mean, should we not think about maybe having kind of clinics or mobile things or something that go out and 

find people before they would go and—who might be disinclined to 

go into a doctor’s office or a hospital? You know, we have a whole 

collection of senior centers, for example, in New York City that 

seem like a perfect place to kind of capture people, you know, in 

a non-medical—I don’t know exactly what I am describing. I guess 

it is something before even primary care, you know, to kind of be 

a gateway thing that would—you know, we seem to all worship at 

the altar of getting people early, doing more diagnostic, nutrition, 

all these different things, but should we maybe just think about a 

non—I know it is tough asking, you know, a panel of doctors, but 

should we be thinking about maybe an extra medical type of structure that grabs people in a way that maybe gets them to do the 

things that might keep them out of even primary care? I don’t 

know who is best equipped to answer that. 

Dr. LAVIZZO-MOUREY. I will make a couple of points and I am 

sure my colleagues will as well. One of the things that we know 

about improving the health of people is that if you can take interventions to where they live and work and learn, you can do a much 

better job of improving their overall health. We have learned this 

through school-based health clinics. We know it through community-based investments in prevention, some of which I have referenced before, investments in increasing people’s physical activity, 

reducing obesity and so on. So I would agree with you that there 

is an investment that needs to be made in going to where people 

actually spend the bulk of their time, which is not in a doctor’s office or a health care setting. 

The other point I would like to just make is that we have talked 

a lot about reimbursement and adjusting that. We haven’t really 

talked about the ways in which medical practice has changed and 

needing to keep up a reimbursement system that mirrors that. Patients want to get care, not visits. They want to get phone calls, 

e-mails and other ways to allow them to manage their own care 

outside of a doctor’s office. We don’t really have a reimbursement 

system that encourages and incents that. 

Mr. WEINER. Thank you. 

Mr. PALLONE. The gentleman from Georgia, Mr. Gingrey. 

Mr. GINGREY. Mr. Chairman, I thank you. I just want to say before I get into the questions that this straw man scenario that my 

friend from New York said we Republicans have adopted has been 

taken to perfection by the Democratic majority including President 

Obama, and I think it is probably time for both sides to stop doing 

that as we work in a bipartisan fashion to try to solve this health 

care reform issue. It is hugely important, and I think we can do 

it. I sincerely believe that we can do it. 


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With that, let me turn to Dr. Bean actually. Dr. Bean, in your 

testimony you noted in his health care reform white paper, Senator 

Baucus acknowledged that the current legal environment leads to 

the practice of defensive medicine. That was his quote. I would like 

for you to elaborate on what constitutes defensive medicine and 

discuss the costs associated with this practice. If you remember, 

during the debate between former President Bush and candidate 

Senator John Kerry, in one of the debates that was brought up, 

and Senator Kerry said well, you know, the actual premium cost 

of malpractice insurance is although high for the individual doctor, 

not a significant number, but that is not the real cost and I wish 

you would explain to my fellow colleagues on the committee and 

those in the room what the real costs are in regard to that. 

Dr. BEAN. Mark McClellan did a study back in the 1990s, I think 

it was. The Health and Human Services used that as a basis of a 

2003 study and found that the excessive tests prescribed to be certain and protect yourself from liability would cost at that time 

somewhere between about $45 to $129 billion. Now, that updated— 

Mr. GINGREY. Per year? 

Dr. BEAN. Per year in the health care system. That updated 

today would be about $170 billion, and the study is debated but I 

think it is difficult truly to tell what is in the back of a doctor’s 

mind. There is the diagnostic thing but there is the fear that is lingering in the back that if you don’t cover everything, you are subject to unmerciful liability, unprotected liability. If this were taken 

care of, I think there would be a substantial reduction. The other 

issue about the premium, it is quoted to be a half percent of medical costs. Of course it is trivial because it is just a small proportion 

of doctors with population sustaining it. It is that bigger cost, if it 

is a cost issue that can be saved. 

Mr. GINGREY. Dr. Bean, thank you, and I am going to turn now 

to Dr. Harris because I actually back in 2005 when I introduced 

liability reform, tort reform here in the House, I got a letter from 

American College of Physicians and it said of course supporting my 

position on medical liability reform legislation. The American College of Physicians stated that there is ‘‘strong evidence that the 

health care liability crisis resulted in many patients not receiving 

or delaying much-needed medical care.’’ Dr. Harris, could you 

please explain to us how the medical liability crisis has negatively 

impacted access to needed medical care for millions of Americans? 

Dr. HARRIS. Well, I think that gets to the point that Dr. Bean 

was making and whether there is an element of apprehension 

about doing things by virtue of the threat of malpractice. I mean, 

it is our belief that liability reform should be part of this large effort to reform the health care system in this country, and as you 

know, we favor putting a cap on non-economic damages but we also 

think that in the middle of all this there needs to be some thought 

and look at the potential for other options. As you are all aware, 

the testing of expert courts is one that has been considered, but before making such a momentous step, we would applaud looking 

broadly to see what are the other options. 

Mr. GINGREY. Thank you, Dr. Harris. 

And in my remaining time—Mr. Chairman, remember I did 

waive my opening statement—Dr. Rowland, in your testimony you 


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talked about the Medicaid program and that you recommended 

maybe Medicaid as a platform for extending coverage to the 45 million or so uninsured and maybe not quite that many who are 

underinsured. You know, when I practiced, I can tell you that there 

is a bias against Medicaid recipients. Of course, some doctors won’t 

even accept Medicaid because of the low payment, but even though 

they do, I think that there probably is a stigma, and certainly if 

we use the best Medicaid program in the country, of course, all 50 

are different but if you took the best as the model to offer to those 

who are uninsured, how do you get beyond that stigma? Maybe in 

the brief time, I guess I have at least another minute, for you to 

respond to that question? 

Ms. ROWLAND. Thank you. What we have seen in the implementation of the CHIP program as a companion to Medicaid and many 

States restructured, renamed their Medicaid program and tried to 

eliminate some of the stigma attached with it being a heritage program from the welfare days and have found that in Connecticut, 

for example, the HUSKY program was very popularly received and 

people didn’t distinguish it. When we do surveys of the individuals 

who have uninsured children and ask them about access to public 

programs, they say they would enroll if they were eligible. They 

aren’t always aware that they are eligible and perceive these programs to be a good program. I think the other point though that 

one has to make is that when we look at all the survey research 

over the years, Medicaid and private insurance do relatively the 

same in terms of access to care and access to care measures for the 

populations they serve always far better obviously than being uninsured. So while we have a provider participation issue and that 

could be corrected obviously by improving the way in which providers are paid and we have a primary care delivery system now 

that is being used in many States to promote better care, it is important to really look at the overall structure and eliminate some 

of these State-by-State variations so that it is a better base program for those low-income individuals for whom private insurance 

with high deductibles and large amounts of cost sharing may not 

be adequate, but especially for the population that Medicaid now 

serves, those with severe disabilities and chronic illness where the 

scope of benefits for Medicaid is equally important to the fact that 

it has low levels of cost sharing. So I think you really need to look 

at the population being served. And finally, I would say you also 

need to recognize that Medicaid is far more than a health insurance program and that the majority of its dollars are spent on longterm care and assistance to the elderly and people with disabilities 

that go well beyond what we are talking about in terms of the federal health insurance benefit plan or any other private health insurance plan. 

Mr. GINGREY. Dr. Rowland, thank you, and Mr. Chairman, thank 

you for your indulgence. 

Mr. PALLONE. Thank you. 

Ms. Capps. 

Ms. CAPPS. First of all, let me thank the panel for your persistence and endurance, I guess, with this long morning, and I was 

called many other places but I couldn’t miss coming back to address your statement, Dr. Lavizzo-Mourey. Thank you for highVerDate Mar 15 2010 23:37 Mar 23, 2012 Jkt 067817 PO 00000 Frm 00178 Fmt 6633 Sfmt 6602 E:\HR\OC\A817.XXX A817

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lighting the role of nurses and our nursing shortage. It is not the 

only topic on the table but it is often not on the table so I want 

to thank you for being here and to present that large element in 

health care. In your written testimony you mentioned the need to 

increase the number of nurses with baccalaureate degrees to create 

larger pools of nurses who would qualify among other things for careers in teaching. What efforts do we need to do? I would like to 

really zero in on this, and then one other topic, school-based health 

clinics that I know you are very good at as well to bring to our attention and get on the record here. What efforts need to occur at 

the federal level to increase the proportion of nurses with this level 

of education? 

Dr. LAVIZZO-MOUREY. One of the key issues is funding for scholarships and other financial aid programs for nurses at the baccalaureate level and for nurses who are transitioning from associate 

to baccalaureate. We know that these programs over the last 20 

years have decreased and in the past have been a major source of 

financial support for nurses and I would encourage every effort to 

be made to enhance those. 

Ms. CAPPS. Thank you, and it is so clear that given the cost-ofliving increases, we have less money from federal dollars in nursing education today than we did in the 1970s, and with our shortage, this is something I hope we can do our part in remedying. Of 

course, recruitment and financial aid is one piece of it. Retention 

is another. You mentioned, I would love to have you explain a little 

bit more for all of us, the need to retain newly licensed nurses at 

the bedside and particularly the work of the Robert Wood Johnson 

Foundation in the area that you are calling Transforming Care at 

the Bedside project. Briefly describe this because I still want to get 

to school-based health clinics so that we can understand that this 

is a very important example and there are other examples as well 

as to how we can keep nurses engaged in the delivery of health 

care. 

Dr. LAVIZZO-MOUREY. One of the things we recognize is that the 

pipeline for nurses entering the field is being eroded by the number 

of nurses that are leaving the field and these are often among the 

most experienced clinicians and they have demonstrated, particularly when they are trained at the baccalaureate or above level, 

that it decreases medical errors, poor outcomes and the like. So efforts that will enhance the retention of experienced nurses will directly impact the shortage. 

The program that you mentioned, Transforming Care at the Bedside, really focuses on trying to develop a cadre of nurses who understand the needs at the bedside and can make changes at the 

nursing level but then also disseminate those changes throughout 

the hospital and to other hospitals that empower nurses to do the 

best for patients, improve the patient centeredness and in the process improve the quality of care. So it really speaks to the issues 

that nurses often give for leaving the profession or leaving a particular institution that are non-financial, that is, not being able to 

deliver the quality of care that they feel they were trained to deliver. That is really the core issue that Transforming Care at the 

Bedside addresses. 


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Ms. CAPPS. It is very important, thank you, that we have this ingredient really strong front and center in our efforts to reform 

health care delivery. One other thing, you mentioned the work of 

the Robert Wood Johnson Foundation in addressing health care 

needs of our Nation’s children by investing in school-based centers 

across the country. I have long felt this. It is not just a bias because I have been a school nurse for so many years. Families trust 

their neighborhood schools. They will come there, not just the 

schoolchildren but the whole family. That is a good place to delivery care and we should be thinking about this as a cost-effective 

means and I would like to have you address it, because one of the 

problems is—and I know this very personally—is the shortage of 

school nurses and others. Nurse practitioners can deliver great care 

within the school setting but that is exactly where we are short 

supply. 

Dr. LAVIZZO-MOUREY. Your points are very well taken. There are 

1,500 school-based clinics around the country and they have demonstrated that by providing care in the local environment, the 

school is a local environment, it is a trusted area that is close to 

where people need to get care, you can improve mental health services, you can improve primary care services and other services that 

the children and, as you mentioned, their families would not otherwise receive. So these are cost-effective ways of delivering care in 

the community that addresses, I think, some of the issues that Dr. 

Smedley was mentioning. People need to be able to get care close 

to where they live. 

Ms. CAPPS. Thank you, and I only wish I had time to ask some 

of the others on the panel for your thoughts because it seemed like 

I picked the one person who talked about nurses but I think there 

might be other agreements among the panel members that these 

are areas that we should rightly pursue. Thank you very much. 

Mr. PALLONE. Thank you. 

The gentleman from Maryland, Mr. Sarbanes. 

Mr. SARBANES. Thank you, Mr. Chairman. Thanks to the panel. 

Congresswoman Capps, you needn’t have worried that the topic 

won’t be continued because I am going to ask you the same questions, particularly about school-based health clinics. It is great that 

we have 1,500 school-based clinics across the country but that is 

a complete drop in the bucket in terms of what we could use them 

for, and Representative Weiner introduced this concept of sort of 

creating a different kind of infrastructure for delivering certain 

kinds of care. I am very interested, and the school-based health 

clinic falls right within this, in the concept of place-based health 

care, and I think you addressed this, but let us go where people 

are. I mean, we can walk down the hall here and there is a clinic. 

There is a nursing station suite that we can stop into and it makes 

perfect sense to have those resources on site where you can capture 

certain populations. It is so obvious to me and clearly other members of the committee as well and members here in Congress that 

our schools represent a huge opportunity to do this. I practiced 

health care law for 18 years but for 8 of those years I was part 

time as a health care attorney and part time working 20 hours for 

the State superintendent of schools so I was in schools, and of 

course what I kept seeing was the impediments to education that 


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were represented by the health status of so many of the students 

and the need they had to get these services. 

So I would like any others who would like to join this conversation to talk about this concept of place-based health care, and we 

can we also view it—I would like you to speak in terms of addressing the workforce issues, internships, residencies and other things 

that are associated with those structures, and I would add as well 

the concept of medical home which is typically talked about when 

you are addressing the individual’s care but I think we should be 

thinking in terms of the medical home for certain communities, so 

in other words, the medical home for a school is that clinic. The 

medical home for a naturally occurring retirement community 

where people are aging in place, you know, in significant levels 

would be a clinic. In the school, it could be a clinic that is being 

staffed by not just nurses but pediatricians so you can get the 

workforce issue there. In a clinic where people are aging in place, 

it is a way to expand the geriatrician workforce, et cetera, et 

cetera. So speak to place-based health care as really potentially 

being a revolution in the way we address a lot of these needs and 

the public health needs. Anybody who wants to jump in? 

Mr. SMEDLEY. Congressman, I would just echo your thoughts. A 

focus on place and on communities can help us to really think more 

creatively about how to prevent illness in the first place and as a 

result lower health care costs. The examples that Representative 

Weiner gave of beginning to emphasize prevention are critically important. One of the things that we haven’t talked about is good 

community-based primary prevention. A recent report by the Prevention Institute showed that if we invest just $10 per person per 

year for 5 years, we can save $16 billion in health care costs by 

helping people to avoid illness in the first place. 

Mr. SARBANES. Anyone else? Yes. 

Dr. HARRIS. The American College of Physicians I don’t believe 

has policy per se about community-based clinics. However, obviously the notion of primary care physicians in schools, pediatricians 

and then the family practitioners and internists in settings in adult 

settings, we have said that the patient-centered medical home is 

not the only solution, that we may need to redefine, and the ultimate product will be quite different and perhaps along the lines 

that you are suggesting. 

The last point which I believe is relevant to this is what was alluded to, the role of nurses or nurse practitioners in this outreach 

program. The American College of Physicians met with much of the 

leadership of the nurse practitioner community last July to talk 

about we can work collaboratively to try and expand in this teambased concept, and Mr. Sarbanes, as you may be aware, we just 

published a paper in which we felt that this Medicare demonstration projection with the notion that homes may in certain areas be 

headed by a nurse practitioner, not necessarily a physician, obviously within the scope of practice of nurse practitioners, but it does 

get to the idea that the end product of this discussion will probably 

be a very varied set of options and not one simple solution to our 

health care needs. 

Mr. SARBANES. Thank you all. The other day I was thinking 

about which level of schools is it most important to have these 


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health centers in, so elementary, you think about elementary and 

it is obvious why you should have that kind of resource there. Then 

you think about middle school and it is absolutely obvious why you 

would need it there. And think you think about high school and it 

is beyond obvious why you would need it there. So 1,500, like I 

said, it is a starting point and we also have to make sure that the 

financing mechanism for these centers is one that is not subject to 

the typical way education gets funding because then they will just 

sort of come and go depending on the situations that the schools 

face. So anyway, we will continue to pursue this topic. Thank you 

for your testimony. 

Mr. PALLONE. The gentlewoman from Florida, Ms. Castor. 

Ms. CASTOR. Thank you very much. 

Just picking up on what Mr. Sarbanes and Ms. Capps were saying, I want to ask a quick SCHIP question. Years ago the precursor 

to SCHIP started in Florida under Governor Lawton Chiles. It was 

conceived early on as making it as easy as possible for parents to 

enroll their children in health insurance when they started school, 

when they started the school year. Unfortunately, in the intervening years the political leadership in Florida changed and folks 

there saw enrolling kids as a cost rather than an investment and 

we lost a lot of ground and we lost that link between the start of 

school and signing up children for health insurance, making sure 

they got their checkups and immunizations. Are States across the 

country, do other States still have that link? 

Ms. ROWLAND. Many states really use and the Johnson Foundation has helped to promote through its Covering Kids initiative the 

first day of school as a real day to try and alert parents to the fact 

that their children may be eligible. There is more than can be done 

to use the schools as an enrollment facility and to simplify the enrollment but it has been one of the main outreach focuses for many 

of the States in their efforts to enroll more children and I think it 

is a very critical place in the community for people to come. One 

of the things I was going to note is in New Orleans where Katrina 

destroyed so much of the health care system, they are rebuilding 

it community by community and using the schools as really the 

focus for where they put their clinics and for where they organize 

their services which will also help contribute to more people being 

able to gain access and participate. 

Dr. LAVIZZO-MOUREY. I would just add that there are other ways 

for people to find out about SCHIP but there are other areas, other 

locations where people naturally gather than can be used to increase enrollment and tying enrollment to other kinds of services 

like school lunch programs and the like, makes it easier for parents 

to make that linkage and not have to go to extraordinary ends to 

actually get enrolled and stay enrolled. 

Ms. CASTOR. Yes, I was surprised to learn when I had my local 

housing authority director paying a visit on a totally separate topic, 

he said back a few decades ago the housing authorities used to 

have very expansive clinics in some urban areas. That makes a lot 

of sense. In my urban county in Tampa, Florida, it is Hillsborough 

County, it is about 1.2 million people, about 15 years ago there was 

a fork in the road. They were paying for very expensive care in our 

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ter way, and said instead, let us shift from property taxes to a different revenue source. We would take a half-cent sales tax and develop this collaborative effort with the hospitals and doctors and 

community health centers and have established a number of neighborhood clinics that really out in the neighborhoods. Some community health centers and then other hospitals have their own clinics 

where their doctors have to take turns and teaching hospitals, a lot 

of the residents from the University of South Florida are there, and 

it is a model program, and I know there are some other models in 

San Antonio and I believe in Oakland. How do we—as part of this 

health care reform effort, how do we incentivize these communities? What is going to be the role? I don’t want health care reform to happen in a vacuum. There are some good things going on 

out in the world. 

Dr. LAVIZZO-MOUREY. I am familiar with some of those programs 

because our foundation helped fund many of them, and I think before I address the issue of incentives, let me just speak to one of 

the major disincentives that was operational in many of those programs. They were, as you say, locally generated, addressed the 

needs of the local population but many of them found that they 

could not sustain themselves because the base was not large 

enough to cover the costs of people’s insurance and health needs 

over a longer period of time, and that is really one of the things 

that has made us favor federal programs that can ensure that 

these locally generated programs actually have the funding base to 

provide care not just in prosperous times but also in times when 

the community is not as prosperous. 

In terms of the incentives, I think one of the things we saw in 

putting out applications for these kinds of programs is that communities do know the kinds of services that they need and they will 

come together and organize to provide those kinds of services, so 

I think that providing that kind of a mechanism is going to be a 

valuable incentive. 

Ms. CASTOR. And it takes money. The administrative costs are 

very low. They aren’t any HMOs involved. It is administered by the 

county and the hospitals love it because they are getting compensated for medical services that otherwise would go uncompensated and charity care. But if you have some other ideas and examples of communities that have programs like that that are working, 

I would appreciate it. 

Thank you, Mr. Chairman. 

Mr. PALLONE. Thank you. I think that concludes our questions 

but I really want to thank you all for being here today. I know it 

was a large panel, it covered a lot of things, but it was very worthwhile in our efforts to put together reform legislation. The way it 

works, you may get additional questions in writing and then we 

would ask you to respond in writing, I think within the next 10 

days or so. But again, thank you for your input. As you can see, 

there is really a lot to cover here but we are determined to move 

forward with reform this year. 

So without objection, the meeting of the subcommittee is adjourned. 

[Whereupon, at 1:10 p.m., the subcommittee was adjourned.] 

[Material submitted for inclusion in the record follows:] 


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