comment? >> i am not an md site of have statistics of the top of my head but i know that what tsou said is true. we need best practices and evidence based practice and i've been a nurse long enough to see things done routine because that is what we have always done and new innovations that are more cost-effective overlook because habits so if he is right when you say you have one uniform system to evaluate, to look at if you see deficiencies an abscess in one area you have one system convicts it. when you have 13 different health care providers with 1300 from systems you run into a problem so i would reiterate what dr. tsou said, it will be easier with a single-payer to track deficiencies in the system and what works and what doesn't. >> the bell of the you heard of is a series of four votes, there are three so the members have to leave to vote on the floor. here is how we're going to proceed. we are going to go to

dr. price's questions and then adjourn temporarily. after the 34 votes are over i would estimate would be in the 12:20, 12:30 range we will return and resume. >> thank you mr. chairman i appreciate you watching this hearing and testimony of all and ask unanimous consent article entitled medicare not the title for reform be included in the record. >> without objection. >> i want to thank chairman conyers as well. i was struck by one of his comments on the commitment to health care reform and i am a strong advocate as a physician for appropriate health system reform what i call patients injured reform i would suggest candidly a single payer system isn't patient centered by its definition it is government centered and that's the concern that i have. the common that you made and i think it was enlightening the chairman said we need to determine whether, quote, we want a combination of the

current system or something else, and of quote. and the question is who is the we and if it is we in congress or the bureaucratic nature of the federal government than we have got the wrong we. the we that we need are we the american patients and people. we will not get the right answer and i believe that real reform comes when we in power patience. i've been struck by the testimony about how awful american healthcare is, just straw. the statistics don't bear that at all in fact dr. tsou one of your quotes was by and large the quality-of-care is suboptimal. astounding. the american people would be astounded to learn the care they are receiving a suboptimal. in fact if you look a disease specific criteria the care provided in america all across

all democratic quadrants of society is second almost to none. we have principles to adhere to in the area of health care. everybody has the top three, access, affordability and quality. i add three to that, responsiveness, innovation and choice. i would suggest to everybody listening that none of the principles of your health care that you provide are improved by the intervention of the federal government. not access, access is limited in the programs run by the federal government, not affordability. all of the cost overruns that occurred in the systems run by the government, medicare, medicaid, indian health service, the veterans' health care certainly not quality when you see the limitation of care that is imposed by the federal government responsiveness and innovation in the same sentence as the federal government is rarely used and rightly so and then choices, choices are always

limited by governmental intervention and to the end of the costs which i think is an incredibly important to address. dr. gratzer, would you comment what is included in our estimation of health care costs that may not be included in other asian destinations of their health care costs? >> well, let me -- dr. price, i fully agree with your comments. with regard to what is american medicine do that one wouldn't find elsewhere in the world, research and development would be a great example of that. there is more spent at one facility in the united states anderson on research and development and the reason the entire country of canada. america is the leader in medical technology to solomon and implementation. when people talk about a new truck coming to market is almost surely an american drug and when they talk about innovations on

health affairs rated the top ten greatest innovations in the 20th century seven of them were invented within these borders. more mobile prizes for medicines but americans than nationals of any other country in fact combined. this is a country that exiles in medicine. we shouldn't forget that as we look at reform. >> my understanding is much of the long term care and nursing care is included in our costs for health care in the determination will we spend on health care and that's not the case in other nations. do you know that to be true? >> i'm not in experts on such comparisons but capital costs are not accounted for the same way. canadians spend less money per capita. >> but i would suggest it's not quite the huge gap that american experts might put forward. >> mr. chairman i would suggest the right to health care and other nations that have a -- single-payer to get in line and that is the concern many of us

have is to simply pass something here in washington that is under the guise of giving people the right to health care. we give them the right to get in line for a lesser quality-of-care than is currently provided. there is positive reform on the table i would suggest we ought to look at that as well and i think the chairman. >> at this time the committee will temporarily adjourned. if you turn around you can see the floor voting schedule. there will be three votes. we will come back as soon as we cast the third vote and resume the hearing at that time. thank you. [inaudible conversations]

[inaudible conversations] amol goebel conversations >> all right, ladies and gentlemen, we appreciate your patience and indulgence. we are going to resume. the gentleman from illinois, mr. hare, is recognized five minutes. >> thank you for holding this hearing i consider to be extremely important. i am amazed some of the things i've heard and dr. gratzer, let me say a couple things. it's my understanding when the canadian people were polled, 90% of the people in canada said they wouldn't trade their health care plan for the united states plan and if that is so, if it is

in crisis about only 3% of your canadian friends i think would be in agreement with you. we have heard a lot about lions for health care, having to wait for health care. here we don't have lines, we just get rejected. i think constituents who have had c sections and go in for procedures later and are told they are delighted because preexisting conditions. here we don't have lines, we have people if they lose their job because of no fault of their own that leave and don't have portable health care and had a 31-year-old man who worked part-time jobs, temporary jobs to try to get health care coverage and they found him dead in the shower of a heart attack and his father and mother who were hard-working people said that when the press asked the said are you mad god to cure some and he said god didn't take my son, he made a special place

for my son to go. this government took my son because it didn't have the courage to pass health care that would cover my son when he lost his job and i think when you take a look at where we are today, if mr. castonguay or whatever says it's in crisis i would like him to come and take a look at this system. ceos of that insurance company making $200,000 a day. you have insurance companies giving people a letter in one hand that approves a surgery. the person goes in, has the surgery then get a denial paper after they get home from the hospital, from the same wonderful benevolent insurance company. now i am a card-carrying capitalist but i believe infil single-payer system if this system isn't broken that i don't know what the definition of broken is. and i will tell you i am a fundamental belief for health care i think was mentioned before by the chairman is not a

flight. it is a right but it is not a privilege in this nation that everybody ought to have it. we don't pay doctors, i went to my district, $243 late. doctors, pharmacists not getting reimbursed and have gone out of business. so, while we may not have the lines, what we have is all the statistics mentioned here today. these are real people with real problems, and i leave this at the foot of greedy insurance companies who care more about the bottom line of making profits than about keeping people well. this whole question about the wellness' situation is to blame people. yes, we have to take part of the responsibility but that is like saying if your next-door neighbor has house catches on fire because you smoking we should do nothing about it because it is his fault he was smoking. so we are not going to put the fire out. we are just going to watch it burn. and i tell you the guy that works today repairing lawn

mowers at $8 our -- by the way when her son was dead on a journey she had a heart attack and he ended up with $8,000 borrowed to bury his son and i will tell you that is not what this country is about and some people say why are we having this hearing? we have to have this hearing. the vast majority of the american people support this system. so here we are once again debating whether or not this is doable or not and who has got the best system. i know one thing in my district when i did town hall meetings and by the way i had counties that. not for george mcgovern but every meeting the vast majority of the people there supported single-payer healthcare and i didn't even ask. they brought it to my attention so we have got to fix this system and we have heard about the medicare system the government can't do anything

right. ask a veteran of the would be willing to give up their va health care and the government can't do anything right. ask a senior citizen of the one to stop receiving their social security check, ask somebody on medicare since we can't do everything right if they like health care system. i am not saying they are perfect but we do have an opportunity to change the way we do business and quite frankly, if you don't have a public option to who is going to go in competition with the insurance companies? the are competing against themselves and they are not even covered under legislation so we need to get real from my perspective and all these statistics that we hear people flooding into minnesota and other states to get health care, i don't know about the floods, i'm from illinois, but i do know this, we have a flood of people every day that go to bed and are worried to death their children or themselves are not going to get sick and if they lose their jobs they don't have portability of health care and we have to fix that, this bill will do it

and if i sound a little bit agitated it is because i have one quick question, doctor tsou -- >> the gentleman's time is expired. i do want to get to the other ones. >> i know the chairman of the full committee mr. miller is here. i do want to obviously welcome and thank him for his leadership and see if he would like to add any remarks at this time. >> thank you, mr. chairman. quickly i wanted to ask ms. jenkins a question, because -- we seem to run this argument all the time about how you are fashioning medicine and who is available and who is standing in line and who isn't and who is standing between canadians. and what i am witnessing in my congressional district at this time i think in my district if you have insurance about 50 something close to three out of four people probably have keyser because of the history of the program started in the bay area

but what i see in the public institutions is they are being flooded by individuals who have serious medical problems but no longer have insurance because they've lost their jobs. and so if i go to my original medical center and community clinics we now see this huge flow of people who bring no resources to this medical necessity that they have scheduled on times have become far more difficult than in the past. i don't know, i am not familiar with what is happening in the private sector and the hospitals, but certainly what we see in the public facilities and in the bay area is obviously your medical condition doesn't know whether you are employed or unemployed and you need the help or your children to or your spouse or whatever your situation is with your family and this standing in line and postponement of appointments and

the l.a. times is what is happening in the current system because of the structure of the system. is that your understanding? correct me if i'm wrong but as i travel the facilities it is just stunning what's happened. >> i work in a public facility in california and public this will these are under assault. the public health care has been under assault a long time and i think it was pointed out with the swine flu we haven't funded public facilities anywhere very well and they've been underfunded. >> i'm talking about people who find themselves in a situation they need in some cases immediate medical attention. >> they come through the emergency room which is the most costly way to access the health care system so we are spending more money to deal with the crises because the most expensive costly way to access the system test for the emergency room and people have to be seen so as we see the

unemployment crisis and losing health care you can see a huge flood of people accessing the most expensive way to the system which we emergency room. >> when people come from canada to receive medical care are they doing that on their own or with the government? >> it's pointed out people to come from canada for care but sent by the canadian government to get care they can't get or there's an access problem and the canadian government sends a check book because they pay for it. if there's medical necessity that is urgent and access isn't available they send people to this country for care but they pay for it. so it's not like these people are here because they don't have any other recourse. the government looks at it and if they have a situation they deem as an urgent and needs critical care dewolf send them here and pay for their care. >> we usually send in most instances with what ever insurance they have or we send them to stanford and that is the normal business practice. i assume that isn't interrupted because the national boundaries in this case.

we are not adversaries. >> i think that is a misconception. >> thank you. >> thank you mr. chairman. obviously as minority members return they will have question time. mr. kucinich i think has been among the most fierce and articulate advocates of single payer is recognized. >> gentle, not years. [laughter] there's been a lot of talk about rationing and during the war, people have rations. imagine during wartime if one out of six americans who are getting rations during a critical period when the war, imagine if one out of 61 of able to get rations and they just starved. well, one of six americans starving for health care, 50 million americans can't get any health care at all.

now, dr. gratzer, you tried to make the case for rationing in canada worse than it is in the u.s.. do you know what statistics canada and a lot to the u.s. census says the wait time is across canada for elective surgery? >> why don't you inform us. >> it's four weeks. >> why does canada say to the wheat time for diagnostic imaging like mri? >> i can tell you the government recently looked at that -- >> it's three weeks. >> how many uninsured are there in canada? >> probably relatively few. >> non-or view. how many bankruptcies or there in canada? >> it depends how you define the -- >> notte or view. cunego without care due to high costs due to health insurance companies? >> am i allowed to answer or are

we going to continue -- >> if you have an answer you can answer but if you don't i will answer. >> go for it, sir. >> what's your answer? >> why don't you answer? >> how many on in short americans go without needed care due to the high cost of health care which is due to health insurance companies? >> the witness isn't responding. >> the witness is delighted to speak further on those statistics but you keep cutting me off. >> respond if you have an answer. you didn't get an answer to the other ones. >> if you would like to ask me a question i would like -- >> you have shown a garden here to the members of this committee and to the audience. there's another side of the picture you don't seem to be aware of even there you want to be an expert on canada can you provide us with an answer on this one about america? >> my position is respectful

>> how many americans without health care because the costs? he has no answer. it is one now before. we are trying to make a case that somehow canada is in a mess but we are not focusing on the fact that in the united states there are people that are not getting the needed care. and this gentleman expected us to believe rationing is for worse in canada. i don't know how we can buy that. if single payer is so that maybe the doctor can explain why 60% of u.s. doctors want that according to the peer reviewed internal medicine april, 2008. >> are you going to let him answer this one? >> he can answer it if he can answer it. >> i would suggest many

physicians of the united states are on satisfied with their system and rightly so. i'd suggest many physicians are looking for reform and rightly so but i would suggest many physicians are on aware what goes on in single-payer systems perhaps illustrative well by some of the comments you already made. it's easy for an american audience to look number but i would ask you the end what do you make of studies like the o'neill paper published by the national economic research that showed that americans have better access in terms of chronic care management and cancer outcomes are better south of the parallel, the baby mortality rates are lower in the united states. i would not suggest for a moment the united states is a perfect system, goodness, i've written an entire book but i would suggest looking to the government ration system and government managed system because inevitably those two things are the same would be a mistake for members of congress.

thank you. >> i'm glad that we have other witnesses here. ms. jenkins, the california nurses found a way that was stimulus not underlying the insurance problem also several other means including the creation of 2.6 million new jobs. could you describe how you think a single payer health care system would act as a stimulus? >> well, we would be insuring another 47 million people so there would be an economic stimulus and creation of jobs. we did an economy study where you look at the ripple effect and how it translates into other areas of the economy, wages workers make and how they spend them and how that stimulates the economy and we not only found a single payer system created a net gain of 2.6 million jobs but would increase public revenue by 317 billion in additional employee compensation with new jobs would be another 100 billion which would generate

more tax revenues and these people go out and spend that money in the economies of various stimulus in doing this besides the ethical and moral issue providing care for everyone. >> thank you. the gentleman time has expired. the chair recognizes the gentle lady, ms. mccarthy. >> thank you mr. chairman. i appreciate you having this hearing jenkins i questions towards especially the higher education bill was basically trying in to help nurses get more into the system. we have plenty of people that want to be nurses. unfortunately we don't have the faculties that want to hire professors to be able to teach nursing. the good news is nurses are getting good pay now going back in the 60's we certainly got

terrible pay. but no matter which way we go and you know, i do believe that we have a good health care system. our problem is we have to need people that are not receiving health care and that is what we are trying to fix and that is important for everybody to know that but we are not quick to be able to do that unless we have enough primary-care doctors out there and we need a whole ton of nurses out there because we also have to look to the future. we are not preparing ourselves at all for the baby boomers. they are not going to go to a nursing home i can tell you that right now. they are going to want care in their house and stay in their home as the majority of patients do. so whatever we do with greatest single payer or whether it is going to be a public -- however we come up with something nursing and physicians have to be a part of that and hopefully the physicians will actually get

paid better price. i have blue cross blue shield. i go and have my tests done and i see what the doctors get. it is nowhere where it should be. i think it's embarrassing the pace that we actually give them. you've worked many nights and you are the one that calls doctorate 2:00 or 3:00 in the morning as i did. people forget that. they think they just roll in and take care of people so what do you think we need to do even more so to make sure we have more nurses coming into the system? >> well, we have to fund nursing education to create more slots for people. there's a huge waiting lists i know in california the programs have huge waiting lists waiting for the slots to fill so there has to be education investment to train nurses. senator boxer put forth a bill that would in dustin nursing education and we also have to look at the conditions nurses work under. they have one of the highest

musculoskeletal injuries because the work they do support the bill would be safe patient handling. we need to create safe work environment. it is frustrating to go home and worry about what you missed because you didn't have the time to give the care that you need so we have to make investment and create staff standards to better working conditions. most of us didn't go into nursing to make a million dollars, we went in to take care of people and i think it is important to understand as nurse is we take seriously the role of being the advocate for the patient. we are the last line of defense at the bedside so we need to meet the conditions better for nurses and invest in nursing education. >> coley we are going to be doing that. one more thing i would say is unfortunately across the country we have seen high incidences of infections in hospitals which cause sometimes death to an awful lot of patience. i happen to believe strongly if we had more nurses and better nurse ratio on the floor we

would not see the kind of infections out there mainly beca to actually do the work they need to do. we used to have back in the 60's we might have had one nurse to every ten patients but i have to say about four of them would be self care and the others would be a lot more care being given. we didn't have the infections than. we've basically were well staffed but when the nurses were started to be called in on mandatory overtime they left the profession. my sister left the profession unfortunately. we need to address those things. >> we absolutely do and you are right there has been a speedup in the delivery of care and it is driven by the profit motive that says let's save money and cut staff and so think that tried some of that and that does lead to infections in hospitals and there's other factors that is a big one you have to have

the time to provide safe care which means you have to have some realistic staffing ratios for patients to nurses and hospitals. >> i agree and i hope that through this committee because that is where we are going to be working on the nursing issue on this debate what else we are going to do for health care. thank you. >> we thank the gentle lady for her contributions. not just because you are here that she talks about a person on the deliberations for higher education and health care and is a valuable member for that reason. the gentleman mr. holt is recognized for five minutes. >> thank you mr. chairman. i thank the witnesses for coming. let me begin with dr. angell. you have outlined a number of advantages of a single payer system. i was impressed by an article i read earlier this year.

for example britain created the national health service based on the wartime health system and france created a system based on pre-war independent local insurance program. single-payer systems have some advantages. have you thought about how we could get to that if you see that as the idea from our fragmented system of today? n the writing committee that published an article on the journal of the american medical association august 13, 2003, that goes through how we would convert in considerable detail. excuse me. there's no time to do that here,