message and it needs to be consistent. >> my most important point is every school needs a nurse. every child deserves to be safe and healthy and an opportunity to learn. >> thank you, mary. just one of nurse? [laughter] if you're going to ask, ask big. [laughter] you know, as i listen to the panel it's interesting because a lot of things that the three of them at the state, local level have to say or parallel a lot of with the secretaries were saying that the federal level. and if there's any take away -- i wrote down about five takeaways. these are sort of messages that come over and over again. one is planning is essential.

the time of the crisis is not the time to call up your health worker, mental health worker. i think secretary don king talked about our efforts at the department of education and secretary sebelius talked about her efforts, secretary napolitano and this is about planning and we encourage every school in the country if they don't have a plan to get a plan and tested with the plan together to make sure they partner it with folks from homeland security, folks from the public health, folks from the mental health site. this is a community effort, it isn't just a school eckert. number two as i think mary talked about this and belinda talked about this somewhat, and sue talked about this and this is the uniqueness to schools. we come from urban areas, suburban areas, rural areas and there isn't one-size-fits-all and when we began to do the planning we need to take into consideration the uniqueness and the resources available and build a plan are not that. number three is it's all about

the old song you've got to have friends, while you've got to have partnerships and this is about partnerships. this is like facebook and the more friends you have -- this is about how many partnerships can we build. this is about good, strong, effective partnerships. and if there's one thing we preach at education to the staff it's that we've got to reach out to people who we don't even normally deal with and forge those partnerships and alliances because we know as educators we cannot do it ourselves. fourth, it's about communicate, communicate, communicate. one of the things, and i think belinda, you mentioned it, which i found very interesting, is it's not only communicate, communicate, communicate, but also communicate at the local level. your parents are also much interested in what we have to say from washington, they were interested in what you had to say about the district, right? did you find the same thing, mary?

>> [inaudible] >> okay. and last week, and i hope that all of us never forget this, is that schools are about teaching and learning. and that we need to find ways to basically continue that process if we have to close schools. and last, i want to give a pitch for my colleagues at the centers for disease control and prevention and the department of education who are working on a system to help monitor school closings. i think it's absolutely essential and vital as we close schools if we have to close schools in the fall is we have information that -- timely information, accurate information on what is happening in wisconsin and texas and what's happening in new york city and all that so hopefully all of you work with your groups and associations to help us work through and develop an effective monitoring system. let's give the panel a round of

applause. they did a phenomenal job. [applause] all three of the panelists will be here throughout the day. please go up, introduce yourself, ask questions and trust me, they have a lot of questions for you. again, thank you very much. [applause] >> thank you very much. i would like to ask the next panel to come forward. they do you are welcome to stand up and stretch in your seats for about 30 seconds. that's good for public health. [inaudible conversations]

>> [inaudible conversations] >> we are pleased to start this panel on lessons learned from states and localities. and first i'm very pleased to introduce the moderator dr. steve the director of the influence coordination unit at centers for disease control and prevention. he has many years of experience at the cdc in areas of international health, malaria, immunization program and national center for environmental health. he's joined by three very distinguished panelists. first dr. arnold director of public health for the illinois department of health. he's been in that position since october, 2007 and previously served as medical director for bioterrorism and preparedness for the chicago department of public health. dr. arnold also served the national guard for 24 years and currently is also the state surgeon for the illinois army national guard.

dr. marcy late and his assistant commissioner for the new york city department of health and mental hygiene. she has played a leadership role in many new york city public health responses for example west mile five is in 1999 and to the world trade center attacks and anthrax in 2001. she's frequently lecture on a national and international circuits on preparedness and infectious diseases. and last but not least, we have expected of director of the navajo nation division of health. he has held this position since june, 2003 and he has over 30 years of experience and social services, child welfare and health care including 12 years with the navajo area indian health service. dr. read will start as moderator. >> thank you. it is a great pleasure for me to be here today moderating this session reviewing what we've learned and what we need to plan

for in the future. we have got a great plan panel as you heard and what's great about this panelist the spectrum of experience and situations that represents that we have got new york city arguably the brunt of the h1n1 epidemic focused in urban areas. we've got got trouble perspective in indian country, rural situation and then from illinois both geographically and epidemiological in between the two extremes. but before we turn to the panel on want to reflect just for a moment as a person at this point in the program is actually a reassuring to me that what i am going to say you have already heard before service will be echoing the remarks made up to this point. the first -- the first point i want to touch on is the importance of planning and exercising. and this pandemic we prepared

for wasn't the one we actually experienced, but the plans that we developed and exercised were critical in the first few months. mosul much for what we actually did or executed but for the process of knowing what questions we needed to address and process for answering those questions. and so, at this point we have new factors and assumptions, so as you heard already there is a new planning process that needs. what's different about this planning process is that it is an open ended that we have to have new plans in place for what may occur in the coming months and we may see an upsurge in cases. having said all of that we need to maintain the flexibility that we used in the first few cases that we are going to be confronted by new facts. the second thing i want to point out is the importance of partnership in responding and i might even use a different word

than partnership. what we have executed is the ability to work as a team and it goes beyond partnership. everybody has their role but we know what they are and we work together. this is especially relevant for our state and local partners since the national response in a lot of ways is the sum of those state and local responses. and at the federal level, what we need to do is to create an environment where those local decisions and planning process these can be most effective. so, i just want to reiterate in the spirit of teamwork that now is the time to be planning, and this needs to occur at all levels of the partnership. and just as a closing point, i want to reiterate how important communications have been in this whole response and that it will be very important when forward.

i think we have done a -- we've recognized the need to tell people what we need to know, what we don't know, what we are doing and again create the environment with the right kind of decisions made at individual and at institutional levels. so we have a lot of work ahead. this is different from most emergency responses. it this is not bring to the short-term response. we don't know how many months we are going to be responding, but we do know it will be all weigel and we should expect new facts, we will be confronted with new facts and have to make decisions that can't be completely anticipated at this point. but in working together, we can plan working in partnership and we will work to protect public health. so with those introductory remarks let me turn first to dr. arnold to tell about the situation in the illinois.

>> okay, first of all don't worry about the slides. i'm gwen to go through those very quickly. my wife also installed a pop-up blocker so i will be stopping at some point very shortly. [laughter] so, the first slide i naturally going to go to the first slide there are about 19 key resource sectors. as i start this i want to acknowledge the president, secretary sebelius, secretary napolitano, also secretary duncan. very essentials people to have coordinated effort. other messages were incredible. i also want to recognize the doctor from the cdc. he saved my blood pressure and my life many times by his announcements on the tube.

also to nih and doctor now assistant secretary with hhs, they have a good person as we have multiple people in the room i want to thank the military for its continued service and that includes the public health service, the cdc did a phenomenal job in the spring. that really brought this to a good point in time. the association of territorial officials worked with them and actually did an incredible job bringing the right messages and the american public health laboratories. you can name the association of the epidemiologist, there are multiple agencies that came together to make this a success including dhs and all of its branches. one of the things i wanted to point to is this one area for the public health and health care sector back in the early 1900's we had separation between sanitation and public health for

some reason. many of the public health sanitation avenues have been separated in the state much of the sanitation infrastructure is independent and operates independently from us. they are private sector entities many of them. those sanitation services if they were to fail would give the onset of a potential of a secondary epidemic in the middle of a crisis. we must pay attention to the sanitation sector. this is one slide i always liked how and why. how is the science question valid or invalid whereas why is one in theology, philosophy, mental health and legal and it's really fallacies of logic and explanations ideological opinions. those things are two separate questions when we are answering a question of science we still have to keep in mind that a community operates in both

sectors and it works with the why question. very few people during katrina asked me why did my house get blown down. they know a geological phenomena came through and asked me why did it happen to me so we must always have a human dimension and compassion that our associations have for reaching the people. here are models i liked some are wrong summer useful. in god we trust, all other spurring data. that's actually the cry of the monotheists scientist. also fear is that counsel and this is a public state paradigm. the department was many times right in the middle of the hourglass. the point where the sand passes through, and what i heard from above was follow me but lead yourselves from the federal level and from the locals, give

resources that we can handle alone and lead ourselves. [laughter] so that left us in a very peculiar situation. so things like the associations actually help us work through that. these are very essentials to get through this old paradigm. we also worked with that esf a function and esf-6 function of the we are relatively confined into the esf-8, essentials support functions. okay what we did and away the first state to conduct the exercise in may 2006 called flu ex. he is working in l.i. stage right now and funds legislation, passed some on-the-spot legislation that actually allowed us to distribute the

stockpile. he took a very serious consideration of all of the exercise is we had done in the past. this year i actually had my entire senior staff, 42 idp h staff go through nims training, 100, 200, 700 come 800 then 300, 400 level. they also -- that was to be worried also the cdc training which they have brochures outside on the table in march actually they put the cap on this so that when in april that can flow came along with the cdc guidance and the other organizations we were able to put people into the public health emergency operations center and an operational mode. rubber on the ground. they fell into position, set up their command structure and were operational from day one. they know exactly where they

were. they walked in amazement up to me and said i know where i am and they knew what their functions were. very important to this kind of training in the background. interagency collaboration. the illinois emergency management agency, my counterpart and my state is director andrew velázquez. it was critical to have his coordination and collaboration. it brought us a very long way. this is different from that old bottleneck i was talking about with the hourglass model. this requires people to knock down the walls and start working together to find solutions to problems. also the illinois national guard was essential. the illinois department of human services and the illinois department of transportation worked together to make sure this worked. the multiple community-based faith based and guarantee based organizations as well as

volunteer organizations were essential, those are our emergency response volunteers, nurses and medical personnel. very essential. i also want to come end of the cdc and nih. all of the institutions putting information out because he saved this country during an economic downturn billions and billions of dollars. that isn't being said yet. but billions and billions of dollars. you stop the crisis from happening by controlling the messaging and making sure people remained calm. i talk about public health many times as being very close to being analogous to a car you drive to work every day and never think about the break. but let the break fail at an intersection and you have morbidity and mortality. so i'm going to go very quickly for the rest of the slides. this one is the guidance focus

establishment of the authorities through nims, operational planning objectives, clear-cut strategic goals, definitive implementation strategies, and equivocal responsibility assignment. you are responsible to get this done, your name. measurable performance objectives and monitoring of agency continuity operations planning. it is essential to keep the balance in the agency. public health monitors water, food, it does many other things, neonatal screening, nursing home care, you name it. a very vast array of services we can not allowed to lapse. other things with g.i. s mapping and population movements, deploying members, migrant farmworker camps, commercial transportation, graduation ceremonies, community spring season events were a problem. faith based celanese, business

meetings and inaccurate census data as we have movement around the state without realizing where the populations are without the 2010 census being in debt. okay. pharmaceutical distribution which had five major regions we used, that was the distribution point for this act will implementation. these were the convoy routes we had through the state. because of the coordination between the army, our unit at the department of public health and several other agencies of transportation, we were able in 16 hours to distribute the 25% of the national stockpile given by the cdc to 102 counties, 95 local health departments and 356 hospitals throughout the state, 16 hours, no injuries. it was because they planned,

exercise and knew exactly what they had to do. this is the case count through and i want to show you the time frame, this is may 14th. so this is where the actual cases were occurring. this is top line call. this was on the 12th. look at all of the hot line calls and these were not even affected. it was all media driven. they were responding to what they were listening to in the media. okay. and these are the cases. we mapped out of the migrant camps because the forms we were worried about the migration and they were also trading as though they were army camps. they were not only a possibility of bringing infection in but susceptible to infection as well and could act for an explosion of local outbreaks. the things we did, as an s

deployment 16 hours, three state idp each laboratory locations so we did a confirmatory test in-house with assistance through the cdc, sample search capacity flexibility because of the locations, springfield and chicago and carbondale are separate geographical all states or about 290 miles long so we have redundancy in case something happens in one of the lab areas. cdc community mitigation strategy was also implemented, beautiful document, can indications we had the hot line. we went through the poison control center and that was with idp h because they were used to handling stress. they were able to talk to people without having to be worried, they could calmed them down, lay their fears and they know how to handle people so we actually had

communication lines, spanish, english and in other languages house well. multilingual was important and the media and hospitals, local health departments and state and emergency operation center. they were critical for making sure we had weekly if not daily meetings with some of them to bring all of the departments together to bring all of the hospital's together on calls and the private practitioners who were doing it in strategic calls making sure everyone was on the line from the agencies so everyone was listening to the same message. also the star, 21 radio system we put in a year ago that has allowed us to communicate with all hospitals at the distribution sites. it worked out very, very well. the fifth based organizations we actually had a pandemic flu ambassador programs. we have had that in existence for about two years.

it encompasses 7,000 face based institutions in a database with 500 being on the main 80 or broadcast ministers during the pandemic flu outbreak we have been putting information into their missile let's or documents to hand out in the faith based institutions. the 35 seized were always contain, cover, clean. we made sure they had a simple message and that we kept going for the community. the faith based institutions are trusted organizations with the local health department as well and our communities sectors. we do not have enough private sector interaction and that is what the leadership is about. this is a current situation, 3,002 to 59 cases in illinois. 6,762 cents were tested and 37 of 102 counties, some 37 counties are affected currently.

there were 14 deaths mostly in people who had underlining medical conditions but we did see that particular situation with asthma as being one of those that stood out in our groupings. it was also seasonal flu vaccination campaign. it is essential for us to do this. we are mounting one now. the reason is if you do push the seasonal flu vaccination program what you will do is allow us to stop potentially 36,000 deaths that occur every year as one of the things. second thing is you will decrease the prevalence of seasonal flu because if i had the flu and i am on that educated about this, with the symptoms are i'm going to my doctor, i'm going to my hospital. it could prevent a surge on hospitals, local health departments and private practice if people are immunized against the seasonal flu because once

the media were john starts people are going to come in so it's important to do that. it also saves businesses and employees from getting sick from seasonal flee when you also have people out from potentially h1n1 there's also the preparation for a mass vaccination and surges we continue to monitor these things and the last slide as to follow the cdc outlined according to age now and this is the total number of cases and the number of deaths for each of these categories and you can see it's almost a distribution as we thought with this group the 25 to 49 be more affected. at least preliminary from this data. what we needed, some things we need other than founding with a smile, more wireless access for laptops, workspace templates and

emergency operations centers, pre-identify and traditional stuff to support the pheoc and distribution sites and we need staff. my staff was at the image of being burned out. we have got to get and make sure we have a staff that is sustainable for the long haul. the national guard made a mention from the bureau one of the major generals and what his statement was is that in the army there is one of these statements that says in the day the bea weare. people who are becoming ill should be put on the cyclist so when they are recovered they can be reinterpreted in areas where you have potential risks for exposure. also better private-sector involvement and much clearer definition of the usage and when it is appropriate to use an mi5

mask orloff mask. even a coif basque can stop you from inoculation and maintain local drop site database and restructure all of the incident action plans for partner integration. so that's all i have to say in won sohn said. -- one sunset. [applause] >> thank you, dr. arnold. now we will hear from dr. marcy from new york. >> good morning. i don't have any slides which is unusual for me and i am a new yorker so i talk fast. a lot of people have talked about the importance of planning and i am definitely a proponent of emergency response planning ahead of time and ironically we were in the midst of finalizing a revision of the 2006 pandemic plan this spring when the h1n1 outbreak of life in new york city and although overall the planning process for pandemic helped the response this spring

there were definitely several assumptions that ended up not being applicable to this particular outbreak. first, we thought we would have morning ahead of time a pandemic was occurring and that it was more likely to be recognized overseas prior to its arrival in new york city and second, we were preparing for the worse case scenario in 1918 like pandemic and we thought that we would be able to address my older for the worst-case scenario but we hadn't thought through in enough detail how we might need to modify our actions fortunately and new york city we were able to identify the introduction of the swine flu into the city early after its arrival since new york city as you heard in the last session and presented as a highly explosive outbreak at st. francis prep high school in queens which was just two days after the cdc first announced the initial cases in california

and only one actively a day before the first confirmation that h1n1 was causing an outbreak of severe respiratory disease in mexico. a challenge though of being one of the first affected sites was that there was no information yet on the viral transmission characteristics or its virulence, as we had to make our initial decisions on how to respond in the absence of the data that we had hoped would be available and though initially the new york city outbreak was primarily associated with the high school within two weeks we started to see evidence of more widespread community transmission first in the area around the high school and then eventually all areas of the city and as of yesterday we had identified over 900 hospitalized cases and 47 deaths and we estimate the several hundred thousand new yorkers were infected. and though the miracle impact was probably no worse than the seasonal flu as other speakers diluted to is that younger age groups were more severely affected. in new york city about 43%

fossilized cases occurred in children, and 96% of deaths occurred in people less than 65 psp one .. epidemic for pandemic, identify

whether the people are at risk for complications for those affected by h1n1 and if there were any different from seasonal flu. second we wanted to try that trajectory of the outbreak in did this by focusing on how their illness using existing electronic surveillance system. not a good sign. existing electronic, the outbreak -- i should be ok. [laughter] use derrin surveillance system for emergency department and primary care visits which allowed us with minimal staff resources to monitor this geographic spread in the age groups affected and third reading several population based telephone service to provide information on the overall infection rates in the city in order to estimate of hospitalization and a fatality rates and allow us to compare

the severity with seasonal flu and lastly we did if you epidemiologic modeling studies with both cdc and academic partners to assess by a transmission characteristics such as incubation and generation time. in response to outbreaks in institutional settings was intense obviously in schools but also city jail system. in new york city we have system hundred public schools with every million students and rationale for school closure was not to mitigates any widespread, we realize that was possible but to prevent transmission to those at highest risk in that particular affected school community if it was experiencing existing or increased incidence of influenza like illness at the school. our policy was not based on just having one or more confirmed cases. and told a closed 55 schools for five to seven days, none of which experienced a recurrence when reopened. as far as correctional settings our main city jail has over

13,000 inmates on average in a given day and when the initial cases were recognized around the time we started to seek limited transmission we implemented it and aggressive screening, isolation, prophylaxis and restriction policy to contain the outbreak and were very successful. we have 100 confirmed cases, very little sustained transmission in any housing units and no deaths in the correctional facility. as far as public communication we did numerous press releases and press conferences, in number of black shoes were developed to address a wide range of issues and translated into opera and languages. we tried to share information as soon as it was available using multiple modalities which had detailed at the same logic updates available on-line. we distributed over 21,000 educational posters and brochures and tree -- about 54,000 h1n1 related calls to our public call center. as far as medical provider of

education we did a number of health alert through our network to get up-to-date information to our medical partners and developed new york city specific guidance documents to help providers in new york deal with triage patients presenting with nonspecific a fever and respiratory illness as well as guidance on the use of the antiviral and a proper precautions or infection control and personal protection. we tried to make ourselves available to our medical partners by doing almost daily conference calls especially at the start of the outbreak with our hospitals as well as separate calls with private providers and a committed to health clinics and mental health agencies and our provider access line or call center was opened seven days a week and a little over 5,000 calls. although our response to health care will be addressed in the afternoon session in much more detail by dr. debra. here with me today we like other affected cities experience extremely high patient visits and our emergency department and

primary care centers mostly involving children. two briefly touch on some of the challenges and opportunities that we faced from is surveillance perspective the absence of having comparable of surveillance systems for seasonal flu made it difficult to compare are dated to the regular flimsies and and our findings that data describing are in perspective and especially to quickly determine if the outbreak was more severe and more restrictive control measures and unusual for flume justified in paris second it was difficult to compare our findings to the rest of the u.s. since different types and intensity of surveillance methods and public health lab testing criteria were used and unlike as many states also reporting members of my cases and quickly determined that wasn't feasible and even if we tried it wouldn't be rep. we like other states have a public health lab capacity so in new york we prior to rest

testing early on for hospitalized and pillowcases only and not overwhelm our city lab with the other cases. we are able to successfully educate our clinicians who initially wanted to use test results for clinical management but since h1n1 was really the predominant respiratory pathogen in the city during both may and june the tremendous sessions should be based on clinical presentation of influenza like illness and not on test results and finally the surveillance that we did to determine the number of hospitalized cases was extremely labor-intensive and that money not sustainable for a more prolonged or severe pandemic especially given limited that diagnostic capacity. counting every case was never part of our pandemic plan, line to focus our resources on collecting the data we need to make a public health decisions. as far as learning from this for the fall we are planning for surveillance approach that will allow us again to monitor the

course and reject three of the outbreak in a more sustainable and efficient way and allow us to identify any changes in a characteristic of the virus. it will continue to enhance our sent from a surveillance systems which were extremely useful in allowing us to the trajectory of the african to tell where activity was most intense in this city as well as the age groups impacted. we will probably take a sentinel or sampling approach to case based surveillance for some real animus and mountainous and work with a representative sample of hospitals and primary care clinics to provide information on the types of viruses circulating since not all influenza illnesses may be due to h1n1 and allow us to assess whether the virus is clinical and characteristics are changing. i like to work with federal agencies aren't in their academic partners to plan ahead of time for the types of of this clinical studies that we should conduct at the sentinel sites to

address the key knowledge gaps such as how best to manage patients who are chronically ill not getting better despite anti-viral treatment and recognize the need for consistent surveillance approach nationwide to allow for better comparison of surveillance members. i probably our biggest challenge this spring was having to put the and consciously develop a policy on school closures as we began to see more committed to a wide transmission and increasing number of affected schools. at a time this was in a way that we didn't yet have data on how severe or contagious the virus was. we did follow the federal guidance of the time that recommended closure for even one confirmed case in a school which we thought in new york city was unrealistic and unnecessary. our experience however give some opportunities to be better prepared for the fall reflected a wealth of data on both schools were closed and those that were on our watch list but remained open to husband and determine

the impact of school closures on the transmission. we are collaborating with cdc on a survey of close calls to help assess both economic impact of school closures on families as well as what children actually did it when not in school. and the rear in the process of reassessing our approach with a fall like many of you with a more aggressive closure policy likely being limited to this an area where the virus becomes material and especially in children. leslie though not we simply communication. from a risk mitigation perspective it was very talented and beyonce are reassurance regarding our finding that the go over all the illness was mild we were sometimes recommend a more restrictive and extraordinary public-health measures than we normally do for seasonal flu, most obvious thing closing schools. was also very difficult articulating our rationale for how we're approaching our school closure decisions because it

wasn't a simple numerical cut off or formula and ensuring timely notification of that particular school committee when a closure decision was made. we also found it difficult to use public message in that sense to help dampen the demands on our emergency departments especially for those less severely ill or the seeking testing for reassurance are to return to work or school especially for those who didn't have any easy access to medical care. on the other hand, we were in that some of our messages regarding persons who didn't need to seek early treatment and not being heard well, especially among persons who might not consider themselves at higher risk including pregnant women or parents and children with mild asthma. with respect to provider communication it was sometimes challenging to expand our policy differences with cdc especially with respect to respiratory protection as we along with several other states did not recommend it routinely use of a respirators and as was the need

for the type of measures and committed these settings, it is unrealistic for persons at high risk in new york city to avoid crowded places. as far as opportunities in which everything else we now have some time i think this summer and based on our experience to improve our communication tools and messages and that this especially to leverage of the tools that are available palm our federal partners. as well as working through some of our policy differences given that the knowledge we all gain from the spring and findings of the current flu season and the southern hemisphere. i just want to in the during the first two weeks of the outbreak in new york city i used to tell my staff when it was mostly limited to st. francis high school in queens that my nickname for the outbreak was swine flu 2009, the best prepared mr. l ever and though it ended up being much one than in jail or exercise because i'm still learning how we are fortunate in that in the experience we just had and the

lessons we learned openness and a much better position to raise the town is we're all concerned about in the fall so thank you and soren that i couldn't talk. [applause] >> our final speaker, the executive director of the division of health. >> thank you. greetings from the navajo land. i want to extend my greetings to secretary sebelius, secretary napalitano, secretary duncan, and the state government and also all you're distinguished ladies and gentlemen. again i am from the navajo nation and the executive director of the lahood division of health and i'm honored to be here and speak to the distinguished group here. would like to do is alan flag to a high that some of the things we have worked on it in navajo

land. i want to give you a sense of where we're coming from by doing , the nomination is only one of over 500 indian nations in this country so i wanted give you a sense of how the indian nations operate, the land base. also wanted to share with you the lessons learned from our perspective and then also with some recommendations. again in the navajo nation is only one of the over 500 indian nations in the country. and each nation is different. it has its own culture, it has its own way of looking at things, on values and a own way of dealing with the emergencies. for the nomination we are located in the four corners region. we have the land that expands to this id of arizona, new mexico, and utah.

and the nomination is about the size of the state of west virginia, 26,000 square miles. the land is mostly rural, 728% of the roads are paved. we have 9,000 miles of public roads and only 22 percent roads are paved said this means to him that in inclement weather conditions is really hard to get around. the population density is 7.1 persons per square mile so it is a very rural, over the weekend during the fourth of july i was invited to a family gathering near a place called the pine springs. i went from my home and tried to gallop on i cornyn and went west and then it turned right near hot, arizona and turned north and drove 18 miles on dirt roads, washboard, if you know what i'm talking about.

it took me one important -- it took me one an hour and 30 minutes to travel 18 miles -- and that is the conditions we have in our communities and on navajo land have 300 people registered, about 200 reside on the nomination. in addition to the three states region we are also located in three different federal regions under region six in dallas, also have to work with the region eight office in denver, colorado, and also have a third place which is region nine in san francisco so any time that we have to do with different federal programs we have to be aware of a stiff and settings. the health care delivery system is such that the indian health service is the primary health care provider of the navajo people. vesicant organization that is very active and health care delivery system is in the navajo division of health which is where i'm coming from and then

also we have when we, that contract writers. programs that and on minister that federal programs that used to be administered by federal agencies and we have indian health services that provide services to over 200,000 active users and one year we have served about 1.2 patient visits. let me also say that navajo traditional healing practice is still part of the health care delivery system. we have navajo people that get sick and they do not hesitate to utilize the native practitioners and we still hold them very dearly. over the years the navajo nation had to do with a number of public health emergencies, such as tuberculosis, hunter virus, hiv, and other diseases such as

salmonella and e. coli and then also sometimes we have to get involved with what we call operation mott left, we also had to help people we had to deal with forest fires and now we also have to get involved with the h1n1. then they give you a sense of how we dealt with the h1n1 outbreak this past spring. we first got the information in april and right away we set up a meeting with the navajo area indian health services and then initiated the whole alert face for team and then set up an incident management team and then also said of the emergency command center that was manned by the navajo bioterrorism program and then we also resorted to that epidemiology's center and then these programs have the daily contact with the

navajo area indian health services, also had to contact with the states of arizona and mexico and it worked very closely with the surrounding 13 counties. and then a very fortunate that we are able to respond quickly according to the information we got some of the navajo area indian health services, altogether 71 suspected cases that were reported, 13 cases were confirmed, and nine individuals were hospitalized. we were very fortunate that all of these individuals recovered. now let me turn to some of the things that i want to share with you in terms of of the lessons learned and a working with the various entities. so many challenges and then some of the gaps that we saw there were several.

one has to do with there are issues of related to multi jurisdictional issues. there is also a lack of comprehensive public health policy, a plan because when you work with the various entities by the counties in the states, you have to understand them, you have to understand the rules and regulations. there is a definite need to develop formal agreements between the various entities with the nomination and when you don't have a very comprehensive plan, this may contribute to delay as services and also long the delay of distribution of drugs so sometimes we do need medical supplies that need to be delivered quickly which you have to get into checking with someone and that someone is to check with someone else again so that is what we go through, but

in spite of all that i think we have a good working relationship with most of the entities that have to work with. secondly there issues related to the lack of infrastructure and information technology. there is a definite need for one definite strategic national stockpile facility in navajo area, there is also a need for adequate information technology that would allow us to process data collection and also to analysis including disease recording and reporting systems. right now we have to wait and look for one entity for a certain report and didn't and then at the end try to bring in altogether. there are issues related two culturally specific information communication system. for example, one-third of the

navajo population speaks navajo language. this means that someone has to take the time to translate information. once the information is translated then we have to disseminate the information and the available mass media that we have is local radio station, it is very useful. we have a radio station, very use all and other produce stations in border towns and then we also had to resort to some of the staff within it now home bioterrorism program and we have one individual, a lady that was very good and translating information. she has her own way of translation and coming up with good messages and she was saying something like -- [speaking in

native tongue] -- what does that mean cranks' she was saying you are out there listening to me and i take this time to do your own prevention. while you are washing your hands, perhaps you can sing happy birthday. [laughter] that is very effective and so i say whenever i get questions about h1n1 i say and this young lady's name is ileana, i say, well, this into a lean man, she says everything is okay then everything will be o.k. so that is the kind of individuals that we have in the communities and these of the kind of individuals that are very rare and they can help us to communicate directly with our constituents and our customers.

the other thing that i wanted to mention is due to the remoteness and the mountainous terrain, than that of a pot -- the nomination -- uses mobile telephones and seller of phones and a lot of times to get into remote areas and you may have a cellphone but it doesn't always work. just as i describe to you over the weekend i went 18 miles north of up by 40. once i got 10 miles away from interstate 40 my cell phone was useless. no communication. i also wanted to know there are issues related to lack of out of quote technical resources and may need to adequately prepare for an emergency, and the outbreaks of any infectious diseases. a lot of times we don't have the real sources. have indian health services as a primary health care provider put in as well documented in his only son and a half the amount

that is needed so a lot of times in these cases is indian home services within the have the resources are not that have to become part of our partner so that we also have some existing emergency response structures that may have to be activated but most of the time there are not properly funded so we have to resort to the existing resources and honor to make it functional let me mention some of the strategy is that help us prepare for the response to h1n1. fortunately the nomination in partnership with the navajo area indian health services in 2006 we did what we call vaccination exercise. the exercise we brought together various governmental agencies

including the state, county, law enforcement, a childhood resources and in one day we were able to vaccinate 24,000 people in the span of a hours and this is through the use of 15 distribution sites so with one day of vaccinating 24,000 that in total lead to vaccinating 80,000 people in one year so that was a very helpful exercise that we did and we repeated the exercise of on. by the timing to the exercise people were vaccinated and able in that one day mack's fascination or able to pick up additional 6,000 but in the end in a given year 2007. able to exceed 80,000 individuals. another thing that we learned was that establish -- we also

have begun to use the national incident management system and than by using them for able to utilize this cdc how emergency response and led to the stage, the local government and childhood health directors so in that process while we have these existing protocols and policies, we are able to do less to these policies and protocols and in the process i think we always learn new things and always trying to make our system is better. so also in the process we are fortunate to have also opening up new doors to other new resources and other technical support. than some of the of opportunities that we seem it again and we hope that h1n1 does not come here again but we have to has has been said by previous

speakers, we have to be prepared. the nomination again i am sure this is true for all indian nations, we want to be partners with the states and burners with the counties and also want to make sure that we try to take care of those issues related to a jurisdictions because a lot of times people do get hung up on jurisdictional issues and i think that needs to be dealt with. also need to deal with what can pertain to cost sharing plans and also need to warm or with plans that can be cornyn in and also have a good public information system. so it's that that we close by saying i do appreciate again for being invited and i think the navajo nation is certainly here along with other indian nations

coming here to work with different agencies and the department of health and human services. in particular cdc i think we need to make sure that cdc cannot make sure that all the state agencies contact with all respect of indian nations throughout the country. and then in summary, i think we are prepared if it does occur and then that we have to do the work involved i hope that we'll get enough resources to augment the health care delivery system and that we know -- now have and be able to work on things. i think it is important and it has been said before we do a proper planning and preparation and certainly this does mean establishing that close working relationship and partnership with all entities in the nation's and it's a barn to work on cost-sharing plans. data and information sharing. of cdc in indian health

services, they do have a data warehouse is but a lot of times i think it is very trying to get information out so that is information that needs to be available to all indian nations and then there is definitely a need for technical assistance and training. i think the last thing is public information is very important. and many times in a country that one size does not for all hands is very important that every state work with respect to indian tribes and nt -- every in the nation has their own resources and individuals who have the resources that we can be able to mobilize and be able to be a part of the work team. then finally again i applaud the the the problem of health and human services for working on preparing for any possible h1n1

outbreak again but in the process i again want to say keep emphasizing that indian tribes need to be involved and indian tribes are ready to work with you. thank you very much. [applause] >> thank you very much. it is clear that there is a breath of experience and learning and i'm going to open the floor up for questions to the panelists, but let me start off with the question of my own and that is that the epidemic after this point has affected all of our institutions and i would like to just to think about where the legacy of this response is likely to be when it eventually is over. >> [inaudible] i think the legacy for the initial responses

to the public health system has really responded in a tremendous way with all the associated organizations in national governance council has been a really instrumental. we also have a national process that is going on so it is going to require that because we are is a emergency start on the local level. and all the state, local and federal and always in the process of developing any kind of incident action planning so are the association's like w.h.o. and all the others need to be part of the process of developing any kind of planning that goes and the federal so they can make the good of mind with the local levels because the local house apartments called me and many of them we were able to assuage them from that moving out on us and making sure that they stayed engage with us so it is very important that the federal doctrines translate into common languages

that people can understand and appreciate and also comply with. >> having been involved in emergency response planning for several years i think it is always time to engage some key sectors in really coming to terms with what the issues will be of the experience of a real event so i think the real legacy of what happened in new york city is that we have been able to leverage this experience to bring together other key partners including our emergency management partners and public safety partners as well as critical infrastructure to really think through the issues are begin to rethink the the issues with us hopefully in a more operational and realistic way in the event that we have immersive year pandemic in the fall and island and into that our health care planners who we have been able to engage must

then some of the other sectors but there are some key lessons learned that we haven't expected with a surge on our emergency departments and clinics so we expected that, we thought we could minimize it with some public communication and it was more challenging. we learned a lot that will hopefully give us opportunity to engage more broader spectrum of partners especially to deal with continuity of operations that will help with other emergencies as well. >> good morning again. again as i emphasize i think local involvement is very key and then i think it is very easy for indian tribes to be left out and i think it is very important and also in every indian community there are oil some resources that are unique and then i think they need to be

involved, the tribal leaders need to be part of the discussion and again we have always said from the indian community that one size does not that all and have done a number of public campaign such as the work with cms on medicaid and medicare. we have said over and over that indian tribes need to be involved and how you get the message across and then how you do your national campaign. we are being asked to do something and in the process of disseminating information we have to take that responsibility to break down, to inside information and then tried to get someone that can be able to convey the good information and the right information to all our customers so i think we can be able to establish that partnership early and then be able to be at the table. i think we can go a long ways.

thank you. >> thanks, and there are questions from the floor, if you could go to the microphone and introduce yourself that would be great. >> association of territorial. we talk about some populations but not in a poor and vulnerable population and out like to have them comment on that -- with this outbreak we have many undocumented individuals who feared coming forth for health care because they were afraid of it legal action being taken in based on the active seeking health care. in addition we have many people who work in the service sector and other industries for the have no set time and no benefits

and that they don't worth and don't make money and don't eat so we're going to have to deal of that issue if they're going to be able to stay home with their children are they themselves ought to work so the two things i asked you to comment on, one is can you comment on what to the to do to deal with folks who are undocumented so they are not afraid to see care for themselves or their children. every new legal action. secondly how are we going to assist the people who don't have the benefits which is a large part of the population so they can stay home other children or not go to work themselves? >> both of those are very insightful questions. the undocumented question was very important to us in illinois state because we had 50 migrant camps, people were coming into the area and we had no idea of who was coming into the area. and they are usually followed by

a mobile units to provide their medical care so we actually identified their infrastructure for health services and made a link with them but i think you're absolutely right, until that the stigma is removed warren had the ability for us in the federal level to say you are able to treat people without repercussions for their status, we will have trouble with those populations people wanted to come forward voluntarily so i think it had to be a policy change and within our legal structure that we make the change but also how we deliver services and the community level, on the local level. the second part was i think we also need to talk about how to assist families that are coming in against the healthcare system and i can't afford to participate. when they are taking off from work i think the business community and that is where the

leadership comes up and talking to businesses about how to take care of your workers that are valuable to you but are at a disadvantage because they don't have access to health care, how you change your policies and creative ways of dealing with that as far as scheduling and also providing health care of services and house support for children who are ill the future they are treated in a proper environment so i think those resources and money to the school system and through the health care system needs to come to address that issue really for front and in a short time. we don't have a very long time to have this national model in place. does it require the right paper in requires action really. >> how will briefly comment on the last question because i

agree, is a critical issue and when we did a survey is of the closed schools to get a sense of what people who were supposed to be staying home, there is a percentage of even high school kids who end knowledge that was schools are closing and a rail there were still going to work so getting that message about staying home if you are ill is a critical johns especially for in more severe pandemic and facilitating that we need to ensure that all workplaces have policies that our billing to loosen up in the event of a pandemic to allow their workers to stay at home and provide the opportunity for them to work at home so that are not coming to the workplace and i think that responsibility needs to start with government policies of the federal, state and local levels some it is part of our pandemic discussions in the past and appear on an accelerated pandemic planning schedule as

well specifically dealing with this issue within government as a month as are private business partners. >> the first american native people, there is always a mention of the treaty rights and also the right to receive services in this country and oftentimes i think it has been raised again at one point they wanted to use december 2005 there was a model past and had to work on to deal with the need to have a citizenship and identity and. any time that anyone called for assistance from medicaid there was a requirement for the citizenship documentation and and what we learned in the process we hope this doesn't happen again. and is with navajo 17,500 navajo

were over 60 years old and over 90% and not have a printer certificates and and even those under 60 including myself did have a birth certificates and we had a challenge to work on which was two really come up with some documentation that would show that we have the right to receive services if we applied for medicaid, for example, so in these kind of discussion and think the hope that we work hard to fully understand it with indian tribes are at and then fully understand the counties in the states also need to work with us in terms of getting the information corrected. thank you. >> we're going to take these final two questions but i ask for very short questions and answers as well. >> thank you very much, when i heard the panel say this was a

dress rehearsal and folks were still tired i was wondering about discussions about strategies for the marathon for public health and our other sectors of the local level, the federal level one thing that could help would be relieved of the state employees that are on federal funds. use 5% of their time for emergencies and may be expanding that for the marathon and the strategy but i was wondering about local and state strategies of. >> , okay, for the state's strategy of one of the things we are looking at is merely one of the lessons learned from the spring and was how to rotate your staff and ensure that you're appropriately covering times and that your focus is in the right place as far as testing. a lot of the energy went into doing a lot of testing initially and that filicide because we started telling people not to come in for testing. it to stay home. also the cdc been a very good

statement about air travel here it is already here so why are we comply with our airports. those things helped us to refocus our energies and move our staffing in the correct direction and is jim it correctly, but all the states are facing cutbacks right now, all the states are facing layoffs and and think that those things cannot happen in the public health sector and education sector especially with this happening now and homeland security sector. this is the time it is critical, we don't know what will happen in the fall, these areas cannot afford to have cuts. if anything we should try to increase because in of the staffing shortage which pre-existing me actual pandemic itself. >> i will make a very brief comment which is something we instituted in new york city was a flame out or burn out policy and i want to emphasize how born in is to take care of ourselves during these things in the town for people working too many days

in a row and to many hours and there's actually a limit on how many days to give work without taking a break. we had our mental health, part of the department of health and york city, actively doing outreach to make people taking breaks they needed. and having those plans in place ahead of time as well as a rotating staff mike knightley -- and there was and as many people who rotate through. >> i just wanted to make a few comments. in these to the navajo nation and i think this is probably too for and that indian nations, we have what is, a navajo nation pandemic influenza plan that we're working on. every time that we deal with certain incident it does get updated and i think in some committees there is always a need to get some technical assistance to do that capacity so that is very important. and then the there is always a

need of technical assistance. thank you. >> just a final question. really quick with dancers. >> out of my 27 questions, for the people of wisconsin, we know that we don't have the surge capacity of skills, infectious disease, epidemiologist are emergencies like this one. we also have a chronically unaddressed massive epidemic that is ongoing in this country of sexually transmitted diseases. could we perhaps look at cdc level and the state level and beyond a hiring more communicable disease epidemiologist to work on the as to the epidemic and keep in reserve part massive emergencies like this fall? >> yes,, yes, yes. [laughter] but i also wanted to thank the the federal government and the

speed and in the amount of interest, secretary sebelius and secretary napalitano come mcginnis bunning but there was a reinstitution of immunization of our public trust i think in the spring as well and i think we need to stay on that pathway. doing things like that making sure we have is that for epidemiology and those things are moving in that direction. >> i am actually going to let that be the final comment. i would say that as cdc people from all over the agency were working on a response. are limited and i think that managing wish to have and the short-term to the highest priority areas is keen a matter what the response. i want to thank our panelists and the audience for their participation. [applause]

now part of the senate health committee series on the overhaul of health care. in this to our portion you'll hear debate on women's health issues, medical malpractice and public health insurance option.

>> annexes though we have about eight people here. and know a couple are on their way. if there is no objection i would ask that we go ahead and proceed with the amendments. i understand that senator coburn is ready to go with an amendment and we recognize senator coburn. >> thank you mr. chairman. i have amendment number 205. >> ok, just a minute. all right and we need to give this down so that we can your senators when they offer their amendments, please. can i this is a real straight for the amendment and i want to talk about why i am offering the amendment. what do we know about medicaid outcome data? here is what we know, that if you are a medicaid patient and have -- if you have coronary

artery bypass surgery the river to person likely to die and 80 percent with a heart attack becoming if you present with congestive heart failure, if the present as a medicaid patient accused extremists you are less likely to get their appropriate heart catheterization and management of your heart condition. these are all published studies. what else we know about medicaid? we know that children who are on medicaid programs and schip have a lower rate of immunizations and kids who aren't and we also know that have an increased rate of cost position that doesn't have anything to do with their income level or poverty level. we also know that they have a marked increase the risk of hospital readmission. when it comes to adults on medicated, what we know it is unfair outcomes are poor, the have a marked increase number of complications that is not related with their income status

or their poverty level. we also know that they have an increased hospital preadmission. what else do we now? banaa that 40 percent of the primary care physicians in this country won't see a medicaid patient in 65% of specialists want and we are proposing to put 20 million more americans in a program that has that kind of outcome data. rather than put those same 20 million people into an insurance program that is comparative and effective and equal to what everybody else in this country has. so what this amendment says -- the other thing i didn't mention, you put 20 million more people into medicated you are going to increase the cost shifting to about $2,100 and from $1,800 for every family in this country from medicaid to their private insurance bill.

because we don't pay and as we all heard the cbo said yesterday that their 500 billion doesn't include any increased score for increasing the payment rates under medicaid. that is without so the presumption has to be that our goal i think i would hope that our goal is to give the same kind of quality and access to everybody, tried to lacoste to try to allow individual choice when you exclude 40% of physicians to not allow any individual choice but eliminated the joys of 40 percent of them and that, in fact, we make health care sustainable. so what this amendment says to rest that medicaid not be expanded to 150 percent of the poverty level. because we can find a better way for the same amount of money to cover these people.

and you can buy them all the same amount of money, by and every one of them and health insurance policy that takes the medicare stamp on their forehead, and gives them access to 100 percent of physicians in this country in the sand and out comes a that everybody else gets and not give a loa outcome readmission rates that are higher, complications that are higher and higher death rate from similar complications. all of this is published data. so why would we put 20 million americans, seven. >> 5% of the population into a program and then say everyone else we will get a subsidy to do something better than that. why not give these people in subsidy if we are going to subsidize and put them into the same kind of level program that we have? why would we not do that? so the whole purpose behind this amendment is to save i know we are trying -- we all want to do the same thing, we all want access for everybody and affordable care. but i want to tell you denied

access is denied care and poor quality access is poor quality care. and the statistics are overwhelming. now that is not to say that lots of people who are caring for medicaid people in this country are doing a stellar job because they are the when you look at the gross numbers and the total numbers the outcome numbers are terrible. as compared to everybody else and as compared to medicare because when we study heart bypass surgery last as compared to medicare not private pay or not insurance play they still have to percent higher death rate. following heart bypass surgery. you go down the numbers on all these highly invasive procedures and see the poor outcome and those have been neutralized where living conditions and poverty rates. so the question i raise is if we are going to give and try to get everybody covered in this country which we admit that

we're going to have over 30 million people if we don't do this not covered, 37 million, why are we doing it this way? was give them real care. let's don't limit their care. let's don't put the program between an individual and a twist of position or choice of hospital. let's give them real care so israel straight forward and says we're not going to increase medicaid and will take the money that costs and try to figure out a different program. i can assure you that for $10,000 on average, actually $9,750 we can assure every minute in person in this country and not raise taxes on anybody. those numbers have been run several times, that does not include medicare, medicaid eligible, that except that group. so the whole purpose behind the

amendment is saying is let's don't get these 20 million americans and tell them like we tell the americans in this country we will give you health care except we're going to deny it and call of health care but since you can't get access unit don't really have health care and we are saying that on 40 percent of available positions in this country, let's not do that. let's give them real health care, let's give them the same thing everybody else has. let's not deny their access, let's not deny them the choice of their position and let's go back and work this over and the figure out a way to get this 20 million in a program and ensure programs so nobody ever knows they are on medicaid and if we still help them. in fact, they get better care of them what they would have gone with medicaid and out comes are better and ultimately their costs are lower because for every readmission that we have been you have a 20% higher readmission rate you're spending a ton more money.

so in essence you get what you pay for it. the other point i think about medicated, medicaid is worse than medicare as far as paying for prevention. and the lower incomes and our country have higher risk. we know the vmi is bigger, we know that a chronic diseases greater, some of that is live sell toys. oklahoma is smoking. but what we do know is that if an act we move this group of people with my proposal which we will get to hear about as an alternative two this title, it moves all of them to private insurance and does not raise taxes on anybody in america. so my question is why when we want to tell people we are going to give them access to a system that is less than what we have in terms of quality outcomes, availability of service and choice?

why shouldn't they have the same choice we have? why shouldn't they have available to them the same outcome, the same quality? the same low readmission rate. the same low complication rate. they should. the incentive that is they should. it tonight we are really sincere about what we want to accomplish so it is kind of an acute amendment, it is i am very serious with. i think we can do better for this 20 million people and i think we ought to consider how to do that. >> mr. chairman, let me just respond appear and i obviously would oppose an amendment based on my understanding of what our choices are. as i understood the cbo testimony, and was that it would be more expensive to cover this group of individuals to the private health insurance system and then it would do additions

to medicaid coming increase eligibility for a medicated. .. impression that there were -- there was at least some view that there are some individuals, low income individuals, who are more likely to obtain access if they have that access made available to them through medicaid than if they are required to go out and try to buy private insurance to obtain that coverage. i would just ask david if he could clarify whether my recollection of that testimony from cbo is accurate or not. >> that matches my recollection of their testimony, yes. >> so i think it's a question of, i mean, many of the

have been focused on the fact that we are putting too much money into providing low income, in tons or subsidies to low-income individuals and moderate income individuals. that was the thrust of a lot of testimony. i am told that the way the bill now stands, 43% of the money that is going into subsidies goes for this group between 150% and 200% of poverty. i assume, if you now say okay we are going to cover everyone below 150%, of medicaid or of the federal poverty line with private insurance also, you are talking about i don't know how many hundreds of millions of dollars initial cost in subsidies. i know they are going to be cost in medicaid expansion as well

and it will be dealt with in the finance committee, but, and they will decide whether there is eligibility increases go to 100% or 125 or 133 or 150. that is their jurisdiction obviously, but i would just say that i strongly believe we are going to wind up spending an lot more money trying to do it the way the senator from oklahoma is proposing to them the way the bill proposes to. >> mr. chairman? could i ask, if that is in fact a correct statement would it not be cheaper for us to put everybody 400% of poverty and the low under medicaid? >> i'm sorry? i'm not sure i fully understand the question. would it be cheaper than what? >> senator bingaman just made the statement for individuals

from 100 to 150% of poverty that it was his recollection that it was cheaper to put them under medicaid then it was under the subsidies stated in this bill. my question is this. would it then not be cheaper for us to put everybody under medicaid that we are subsidizing in this bill versus to subsidize them? >> i think if cost were only consideration than the answer to that question would be as but cost is the only consideration that is being applied to the 100 to 150% category because if we apply to any other standard quality of care access to physicians, then one openly has to admit that when you only allow medicaid beneficiaries to seek 60% of the medical providers you have restricted the ability for them to get the quality of care that they need. >> i mean, those statistics i

think have consensus, because there has not been a study that came out with anything different than 40% of the doctors, because the reimbursements are insufficient for them to stay in practice of doing that. >> mr. chairman the real question is, is, we are going to let everybody else have something better than we are going to have, at least 20 million people and we are going to say because it costs too much but we are not, if you happen to be at 150% or greater if your at 151% of poverty you get a whole different healthcare system. you get to choose your doctors, you get to choose what you have. you get better outcomes, you get better quality, you get less hospital readmissions, degette fewer deaths after heart bypass surgery and we have arbitrarily said because you make between

10150% of poverty you are stuck with the stamp on your forehead that ultimately as a group implies poor outcomes and poor care, and less no choice for 40% of the physicians in the country. my point is, is let's treat them the same. and, if it is money, if it is money, then let's take it from the 250% and above and given to these people so they get the same kind of care. rabid then say we are going to subsidize. remember 400% of poverty is $88,000 a year in this country. that is 80% of the people in this country aren't forager% of poverty or below so we have arbitrarily said that from 100 to 150 without any rate increases in medicaid over 6.5 years, we are going to spend at least $500 billion. that is what the cbo's antigens

senator gregg was. before we increase reimbursement rates that might change that dynamic. we are going to spend it. why can't we figure out a different way to do it? that is what i'm proposing why are we saying that this class of people get sick bush always then someone making 151% of poverty? choir we saying they get less access? why are we saying they get poor health outcomes? that is the problem and it kind of goes back to what senator sanders has already said. his single-payer argument. everybody gets treated the same under senator sanders argument. everybody. nobody gets an advantage but we are artificially putting an advantage, a disadvantage to somebody that is between 10150%. >> mr. chairman let me just clarify also. my impression is and i know there are differences in the outcome and i don't dispute those but my impression is that medicaid is different than

private insurance in other ways too. it is, it is tailored to meet the needs of low-income populations specifically. it has a richer benefit package then we, then you see in private insurance generally. it has minimal cost sharing. it does include benefits that are not in traditional private insurance policies, and those are all reasons why medicaid is appropriate for some of the folks that are receiving that care. >> then i would go back to senator burr. let's put everybody at 400% or belleau overmedicate. pull this country and see if people think medicaid benefit versus their own private health insurance is a better policy. i think he would probably win that 99.9.1. if i may finish. if in fact that is what senator

bingaman alleges is true, then let's put everybody on medicaid. the co-pays are nonexistent in some states because here is how a co-pay is. if you can afford it and pay it, but nobody can force you to pay a co-pay under medicaid so consequently nobody pays cophase, said there is no co-pay essentially. so, again, i would say we are arbitrarily taking 20 million people and saying here is the coverage you are going to get. we are going to limit your choice of doctor. we are going to limit your choice of options. we are going to limit your choice of facilities and we are doing that. we are going to make sure a percentage of you have the worst outcomes. and the bill that senator burr and i have proposed is it allows

all those people in medicate to have a private insurance policy with no medicaid stamp on their forehead, no discrimination as to their choice of doctor, no discrimination as to the choice of the facility, no discrimination as to the choice of them picking the procedures they want. without raising taxes in this country. so, i don't expect anything other than a 13-10 on this. i nakhchivan that that we have to answer this point. why are we saying that this group of people automatically gets shut down when we could do a subsidy by eliminating somebody from 66 to 88,000 give it to these people so they can have insurance? if this subsidy is a good deal why not these people? why not these people? >> i just would respond briefly that i now think eliminating the

subsidy above two lundrigan 50% of the federal poverty level begins to pay for what the senators guessing not to be done for low-income individuals. this subsidy above 250% of poverty accounts for 27% of the cost of this bill. and if you take 27% of that subsidy that cbo identified-- >> how much is that? [inaudible] >> 200 billion? you can't begin to provide-- >> that is $10,000 per individual. yes we can, yes we can. $10,000 per individual, a family of four, that's $40,000 do you can buy a health insurance policy for. >> well, the subsidy and the bill for the folks between 150

and 200% of poverty is 43% of that 723 right now. so, if you say everybody in the country below 150% of poverty will be added and get a similar subsidy-- >> what i said is not to take this group-- this amendment says don't increase from 100 to 150%. doan expand medicaid. we have plenty of money, 27% $700 billion or $600 billion is a ton of-- >> my impression is that the level of medicaid coverage today for adults is pretty darned low. what is that, david? do you know? >> it varies by states. eikenberry from a tiny percent of poverty do you know in some

states as low as nine, 10% of poverty for childless adults and so it varies by state and varies by category. if you take everybody from those levels up to 150% of poverty, which is what you were singing give them private insurance-- >> or give them subsidized insurance. >> essentially have the government pay for their coverage just as we are paying for their coverage from 152200% of poverty. i am just saying it is going to cost an awful lot more than who lopping off the group from 252 foreigner percent poverty. it will increase the cost of this bill very substantially. >> senator bing a mom that is my whole point. we have arbitrarily said if you make 151% of poverty you were going to get a subsidy and you are not going to fall into this group. that is my whole point and if in

fact we have $624 billion, is it? >> clarify the math, if 27% of the exchange subsidies in the bill would be 195 billion, assuming senator that is cbo response to senator gregg whether which i don't know the assumptions of, obviously a difference of 300 billion that you wouldn't have to make that expansion. >> here's my point if i can for a minute, and that may be wrong on my numbers. what is 20 cantu 19.5. i am probably wrong on my numbers but my point remains the same. somebody making $16,000 will get subsidized. somebody making 15,950 want and

they will get medicaid. and i am saying can we not work to figure out not to expand medicaid and to get these people in here and to give them a different level of care? that is my point. >> mr. chairman? i want to go at this just a little different direction, because if we expand medicaid, the 150% will increase the healthcare costs for all the rest of americans and will force millions of americans and to a worse healthcare program, which have been talking about and will drive states into bankruptcy. those three parts are all important when we are looking at what we will raise that to but to the first point if it is fine to raise the cost for all americans, there is a hidden cost year because medicaid routinely pays physicians and hospitals less than their actual

costs and those providers are then forced to shift those costs onto individuals with private health insurance. there is a cost shift so we are already all paying more for people on medicaid. now we want to expand its do we have a lot more for us to pay for medicaid because inadequate reimbursements by the programs such as medicaid and medicare are the annual cost of covering a family of four, increases the rest of our costs by $1,788 that is according to a report issued by an actuarial firm selwyn total under payments and programs like medicative minnick. actually increases healthcare costs for everyone else by $89 billion a year, so expanding medicaid means we are going to hide the cost, shift the cost and put it on the rest of the people, those with private health insurance and they are

not going to have a better plan. medicaid, i don't agree with anybody who says put me under medicaid because that is such a good plan. they know that 40% of the providers won't take medicaid people anymore, so they really are cheated out of getting the healthcare that they need. and the medical data shows that it isn't just a function of underlying medical problems. it is a direct consequence of program shortcomings. steady published in the journal of american cardiology found medications or 50% more likely to die after coronary artery bypass than patients with private coverage. firrea the report showed that medicaid patients presenting with heart attacks are unstable angina receive cardiac catheterization less often than medicare or private paying patients, so it does shift them into something different, and

then there's the part about the states. the states are required to pay a share of medicaid expense. the national average of that is 43%. i understand in the finance bill you have some way to release tie dead casa during the ten year window we are counting this week and hold that down to five funded billion dollars in additional costs but the state budgets are saying, senator alexander made quite a point out of that. he said the medicaid portion that keeps it brust off on the states, so unless we can find a way to keep spending down, cut costs on healthcare, the medicaid spending will double by 2017. that is an average growth rate of 8% a year and the fastest growing federal entitlement program that we have. that is that the current level, not that the 150% level. there's no reason to think we put anything here that would slow that growth curve down by including more people in it, so

we still have the initial problems that we have not solved, but we are talking about putting them in here which of course is the finance committee thing but we haven't followed that rule here anywhere, but that is the only way we get to the 97% coverage but we have to remember we are shifting cost to the other people when we are doing that. >> mr. chairman? >> senator casey. >> i just want to read a couple of things to the discussion. i know dr. coburn how much you are concerned about kids and you have demonstrated that over long period of time. the concern i have with any kind of limitations on the expansion of medicaid or the effect of this bill is not expanding medicaid coverage is my principal concern is kids. that come a eye which is handed

a report here that is actually in 1999 report the american academy of pediatrics says and i'm just reading, one sentence here but it says all do we need to say. and burling medicaid eligible underinsured children is a major priority of the academy and one of the things they point to win something i pointed to weeks ago in terms of our discussion here was when it comes to kids, the benefits they get in the early periodic screening diagnosis and treatment, which i know you are well familiar with her, there may be several things you can point to being problematic with medicaid, but i think it is irrefutable or is close to that is seeking get their kids do better when they get that kind of mandatory coverage entreatment under medicaid then they might in the private

market. or in a situation where because you have not expanded eligibility for expanded outreach that you are going to miss kids. bush children in my judgment and the evidence shows this, are better protected under medicaid so i can support the expansion of medicaid just based upon that. even though you might point to other-- >> my response to that would be, that it's in comparison to know care, not a comparison to private care because every milestone and every well child visit is paid for in every other insurance program out there. the two month, formants six month, the nine month, 15 month, 18 month and 24 month in nearly exams are paid for. >> but they are not getting the same mandatory coverage you would. >> sure they do. >> in the private market?

>> absolutely. we don't go short and kids on anything and i delivered 2,000 medicaid babies and i cared for over 1,000 delivered 2,000 non-medicaid baby sing cared for 1500 of those. there's no difference. was there occasionally somebody who had a high deductible plan but there was no difference in terms of the screening for the kids, the intervention when there's not a mandate. there's not a mandate in medicaid unless you bring, present the child to the doctor. that is the only mandate. if the child did not present, there is no mandate. [inaudible] >> the point is you need to look at what of this screening exams. there's no difference between that and what i do in caring for an infant or a toddler. there's no difference in what the screening is so i don't disagree that the system is good, but that is in comparison to them not having anything.

not its compared to giving private coverage. i recalculated the numbers. let's just look at the numbers, 20 million people, if you took the subsidies from the 66,000 which is three and a person of poverty and stop that right there and moved that money to these kids per person, 20 million people you get $9,750 per person. now, i don't know about you but in oklahoma we can insure a child for $3,000. in new jersey it costs about 6,000. if you take a family of four with two kids, that is $38,500, which is triple what we are spending on ourselves up here. i would tell you there's something wrong with the numbers, guys. something wrong with the numbers. no, the difference is, and let's go back and talk about what cbo

really said. there's only $500 billion worth of costs for 6.5 years under the assumption the federal government in the first three years will pay 100% of the cost to the states and then it is tapered off after that. but that does not mean there is not the cost. hedges men's after that we transfer the cost to the states and the reason we did that is so we wouldn't have as big a number. correct? i mean that is why we did it. we tapir but they are still going to be a cost. we are just going to transfer to pennsylvania and oklahoma and that is with no increase in payments in terms of the race, so by the time you make medicaid rate eligible to eliminate the disparity of choice of doctors, you are at about $1.4 trillion just on this portion of it. just on this portion of it. so, we can play with the numbers all we want but when you take

almost $200 billion in divided into these 20 million, you get more than enough, twice as much. as a matter of fact we could probably go to 30050%. mika probably go to phenergan 50% with a subsidy but we could, i would ask senator bingaman, would you have your people run those numbers at 350 down and see what the savings between 350 and 400 is and what we would get? >> i don't have any people that can run numbers but i am glad to have the committee staff try to run it down. >> if i might mr. chairman? if you had some information on these numbers. i think the may have given a misimpression when you do the math of 27% you are asking about the fraction of the over all exchange subsidies are the gateway subsidies that are in

the 250% plus range and it was mentioned that it was 27% so that is 27% of 723 which is 195 billion which translates to the divide that by 20 million people, as senator coburn said $9,760 but i just wanted to make sure i mentioned that was of course a ten year costello if you annualize that assuming an even distribution that is $976. >> okay, a big difference, so my numbers are in error. >> mr. chairman? mr. chairman? since we are on this point, with the medicaid versus private insurance, and we brought up the children's health insurance plan, wyoming insures their kids under a private plan and it saves money. and, the real advantage of doing that is the kids are covered all year and they are not just

covered while their parent doesn't have a job. they are covered the whole year, when you are at a time. they don't go to the hospital one day and go to the hospital the next day because there has been a change in their family circumstance they are not covered in the moreso that is the cost shifting point. that is one of the things the hospitals and wyoming have raised. is a lot of these people are medicaid eligible at one point but they aren't often when they come to the hospital, they aren't so we have to pick up the cost on that and of course hospital shift the cost off of it a number of different ways. so, the senator has a real bella pointed out talking about seeing what the difference would be of having this thing done through private insurance, and since we do do the kids already one of the waivers that wyoming has asked for is to be able to utilize the amount of money that is available for the kids as

part of family because to get family coverage cheaper than you get individual covered so there would be some advantages them of having a subsidy to the family if that schip money counted toward getting a family policy which would cover all of them for the whole year without the stigma overmedicate. there is a little bit of a stigma to medicaid, which we would just send people didn't have to have in in my opinion there's a lot of privacy violation just by having them say that they are. >> mr. chairman? >> senator standards. >> senator coburn numbered or wrong he made an important point, made a couple of important points in that i hope that is the committee and is the congress we don't want a two-tier healthcare system. we don't want a poor people's healthcare system and a system for everybody else but what think the solution is not to privatize our healthcare system as some do but i would hope that

at the very least, and senator alexander think made the same point yesterday that if we are going to add 20 million more people to lay stress system right now burgoine vermont we think 90% of the physicians take medicare and other states depend on state efforts but is a problem. i would hope that if we all add 20 million people to the medicaid program we take a hard look to the problems of medicaid and we address those problems and make sure we raise reimbursement rates and that medicaid can be a program in fact were people say this is a pretty good program. i do have a choice. will it cost more money to do that? it will but i think it's the end of the day what you will find this medicaid will provide healthcare, more cost effectively than the private sector but but we have to do is provide for funding that we need so that doctors to participate in that program.

>> i think of nothing else this discussion deshawn that medicaid is complicated program, it has been a great discussion. i am almost wanting to get involved in it myself, but it is not in our jurisdiction and we have got a lot of the amendments that really are in our jurisdiction that's legitimately, i'm not saying this is a legitimate but i am saying this is really the finance committee's jurisdiction and not ours. there has been a good discussion. >> let me add two more points and then i will quit mr. chairman. in this bill, as soon as you are above 150% you lose all of that screening. you are forced out. also, in this bill, there is an oft out provision to schip for medicaid. why do we allow the kids to opt

out of medicaid in schip? and what are we telling the kids that don't opt out? it is a two-tier system because we put more money into schip them we do medicare, right? we did, so we are allowing them to opt out but if your at 150% as soon as you go lot of that you are forced overmedicate and you may end up with a system that is much worse in terms of kids according to the senator or a system that has a higher deductible because there 20 go to a subsidy program. the one thing that does not end here, the one mandate that did not end here that should be is that the matter when insurance program you have, screening exams come with no detectable in no co-pay. that is what needs to be there. .

prevention section. i was going to add that one of the reasons the outcomes are so bad is because these are low wage people, they work, they're low wage, they don't have insurance, then they get out of a job and go on to medicaid. before that, they're not quite eligible. they have terrible outcomes. i hope the finance committee, tom, will put in there that whatever a & b from the preventive services task force, that that will be funded with no co-pays and no deductibles so that will begin to hopefully get more prevention and wellness to that for people. i didn't mean to get involved in this. i said i wasn't going to get involved in it. a roll-call vote on the the coburn number 205. >> mr. chairman, can i ask one question on this because i know you want to get there. a will be a short question to senator coburn. as i understand the way this

bill would operate is this would not become in effect until 2013 so in would be in effect for seven years and as i am understand when this bill they want the federal government to pay the difference over what is now for the states, right? but only for limited time. who is going to inherit the cost? with the states are going to inherit the cost? if they do that, what state can do that? i was looking at just "the new york times", i think it was a short while ago will statewide employees are having furloughs over the next two years, the equivalent of a 14% pay cut in idaho lawmakers reduced aid to public schools for the first time in recent memory forcing pay cuts for teachers in in california were 24 billion deficit is the nation's worst governor are will schwarzenegger has proposed leasing thousands of prisoners early in closing

200 state parks and meanwhile made it is adding a tax on candy, wisconsin on oil companies and kentucky and alcohol and cellphone bring tons the state revenues and a free fall and the economy by the worst recession in 60 years with the governors of proving program and laos to a smaller degree tax increases over previously. my point is who is going to inherit all these costs in the future? we can pay for them now. am i missing something here or is that right? >> what you're missing is i have the data for several states, maryland 13.1 billion, new mexico 3.9 billion, washington 8.8 billion, rhode island tubulin, vt. .5 billion, pennsylvania 15.4 million. >> what does that mean? >> that is their share of what will be paid for by the federal government's one him that we have a minute kids system that

isn't working well right now so this is just going to go worse and the only purpose for this is to pick up $500 billion so they can say that this bill doesn't cost well over a trillion dollars, is that right? just the title in the bill. there is something wrong here, i think according to governor barbara medicaid expansion to 150 percent of the federal poverty level would cost mississippi an additional 330 million per. would at least three and a thousand people to their medicaid rolls. they confirmed that also stated these numbers do not take in consideration the crowd out associated with expansion and what is crowd out? employers and individuals dropping private insurance to obtain cheaper government sponsored insurance. it goes on to say just in mississippi in addition is possible in large expansion in

the medicaid program requires states to increase their current reimbursement rates for a physician who participation, are those accurate assessments? i think the center brings up an apartment and our hope that we can all support him there a lot of other states have information on but i thought i would be short. i apologize for taking that long >> all those in favor?

[roll call] [roll call] will win will [roll call] [roll call] the amendment is defeated. and i also know that our staffs have been working to clear some

comments and i understand that we can except by unanimous consent enzi 243 and enzi 241. is that agreed to by unanimous consent? this is there any senator who has an amendment? >> i do madam chairman if it is an order. can i senator, why don't you offer your amendment and then after you i have an amendment caltech i will wait for you if you want to offer yours first because we had ours over here. >> well senator harkin is going you want to offer an amendment, i want to offer one on women's health one, are there other senators mw more offer amendments later? senator bingaman. anybody else who?

why don't i do mine, you will do yours and we'll go back to bingaman. does that sound like the way to go? >> thank you. >> i'm going to offer my women's health amendment. mr. chairman, i would like to call-up mikulski to one -- 201. donna and i ask unanimous consent that senator dodd to be asked -- added as a co-sponsor. without objection. i see a man in spain this dividend. i will go on and give a very brief description of my amendment and then can further amplified. this amendment is being offered on behalf of myself, senator harkin, kerrey, brown and don and it does two important things. first it ensures essential

community providers such as women's health clinics, community health clinics, hiv/aids clinics such as chase brass and who served low-income populations are included as providers the individuals can go to in any federal qualified health plan. second this provides coverage for women's preventive health care in screenings with no or limited cost-sharing therefore this would accomplish two of our major goals in health reform. and they should that individuals in particular women have access to the providers and they need in the communities and they come from an access to the services they need to remain healthy throughout their life span of. this amendment music and telling me and him and the onset of maryland we have the women who

use both women's health clinics and also the new clinics that offer a sense for hmd patients, the roman and distinguished james price and clinic the dust and outstanding job. these clinics are really the primary care providers for both women in in the sense of women's health clinics and for aids patients so if you're going to chase a paxton you don't simply, for your age cocktail and treatment for aids. is treating the whole person. at second with this amendment also does is eliminate cautionary preventive health services. we have found in studies like from the commonwealth foundation that copayments have been real the tournament for low-income women seeking preventive

services pieta mammogram screening are other very important screenings this is really very important. i would hope that we could adopt my amendment and move for is an option after other senators might wish to come. >> to we have any idea what kind of cost is being added on this? i think it is an important cost but i'm curious as to where we are trying to cut costs because i like to know how much we're adding in with a new a requirement. >> first of all, the option is no, this man as has not been scored. >> that is fine. contaminant has not been scored. kim balckout and may vote on it without having known how much it costs? >> i can tell you how much it will cost in terms of human life

now doing it. and tears of a rise of cervical cancer, the spread of sexually transmitted disease in the increased burden with an already stretched thin primary care system. >> i can tell you the cost we are placing on future generations of americans by expanding their dollars and increasing world itunes of dollars they're going to have to pay for. i think this committee has every right to know the cost of an amendment is if we're going to give the kind of judgment the taxpayers of americans deserve the matter how worthy the cause. i think the men and women in the military to serve the best equipment, best training and care but i don't propose amendments to them to help them unless i have a cost associated with it gimmicks senator, i appreciate those comments and then he said them at other times. we did send it to cbo so i have not been a laggard in that area,

but we have not yet approved the amount we have not gotten their score. we have approved other amendments yesterday with no score in and wheat approved some other republican amendments without scoring so i am trying to get a scored but with her hand amendments pending we thought we would move the amendment. when we got this court and it is astronomical believe me i would be one of the first to take a look. >> if i might say in response with all due respect maybe we ought to slow down and find what the cost of all this is before we move forward with it and afghanistan and that we have had hundreds of hours of hearings and debate and discussion but senator dodd told us that we would know the cost of this bill as we go through it and that was the statement made by the acting chairman. i expected that to be the case and we've adopted other eminence

that estimating the cost of it that, sure that justifies for the approval of eminence we don't know what the cost would be. i want to express my admiration and appreciation for the center for american her compassion and advocacy for those who most of all need our help, but the cost is something that at least the taxpayers ought to know who sent us here. >> will go ahead with that discussion because i have a different question. >> we do have a score on the underlying bill. we have pushed back in the market schedule an order to make sure we can get as much of an official cdl score as we could and i felt that ensuring we had cbo scores prior to marking up

the totals was urgent enough to of originally delayed the filing said that the allies and issues on these. senator dodd has done everything in terms of delaying the bill to get as much information as we could from cdl. cdl this done a chet good job of serving the committee as we offered each and every moment but right now we do know of that the cost of delay and cost of doing nothing will only already add to the cost of health care and other essential federal programs by not doing them. if someone is in the scoring. know that we know this for this court. i pledge this is i get it will be the first to tell you about it but of would like to see if we agree on the policy of them can go to the numbers.

>> if that is on the same line i would defer. >> did you want to comment on the policy or the scoring? >> i want to comment on your eminence 201. >> and then i guess my question because i was wondering if there is any limitation on what would be determined to be preventive service as opposed to other kinds of services the. >> would be the preventive services. >> is there a definition as preventive as opposed to other kinds of care? the reason i ask is because i have been making a point with everything that everybody regardless of to have some skin in the game on their regular care and that gets to be a little more careful with what they buy and to be involved in

their own care. >> preventive services are defined by a chart as a guide lines and i believe that their uniform and consistent and also there is a public health service task force and preventive services that provides definitions universally with except in. they eat it too early detection and screening. >> i knew would be thorough and i appreciate that. i0 is like to voice at this point that among people that have insurance on a 5 percent take advantage of what is in their policy but we have got to get people to use that they have been given. somehow we've got to get that up because it would save lives. it is an uncontested point so i hope we can get a lot of people above that level of abuse and

this would probably help do that. >> one of the things that you and i can really feel proud of about a half preventive service and that was not covered by health insurance is senior fall prevention program. i am pleased that we worked on that. the two major reasons seniors are admitted to hospitals and one dehydration auction bidding alone and forget all about some things and the other is false. when you fall usually break a bone, break a hip and it is enormously costly. we have worked on it will set of prevention's and a pass and am very proud of it. >> thank you very much, and when to stay quiet understanding in most cases this sort of early

screening and preventive care gravy reduces the chance of a disease in a well under way and causing great complications that have become very expensive to treat an aunt in general prevention and early detection screening is not only better for the quality of life for the individual but have great returns in terms of the cost of the health care systems? >> yes and for anyone who would like to learn more about it i commend it to the institute of women's health at gw university on women's health care reform. one of the major emphasis is early detection and screening pity if there is no further debate. >> i appreciate what you're trying to do and i have a lot of sympathy toward helping women in

distress. the author of the violence against women act along with senator biden and feel deeply about this but i wanted to ask on page two, page 59 between 96 and seven, include within health insurance plan that works when you are doing here those essential community providers were available to serve predominantly low-income medically underserved in the vigil such as health care providers etc.. >> could you repeat the lines you are looking at? >> is your language, page two d. just read down through the first five lines. would that include washington providers? it looks to be like you're expanding for like planned parenthood, would that put them in the system? >> it would include women's

health clinics that provide comprehensive services and under the definition of the women's health clinic it would include planned parenthood clinics. it does not in any way expand the service. in other words, it doesn't expand nor mandate and abortion service in. >> no, but it would provide for them. >> provide for any service deemed medically necessary or appropriate. >> i would have a rough time supporting on the basis but i just wanted to get that clarified, thank you. >> does that clarify it? >> any further debate. >> first of all, i want to commend you for your work on this. you and i had a discussion about the way in his written and i

don't believe this is the intense, it is too broad in the way it could be interpreted down the road might include something like abortion and am concerned about that. the threat of that and the scope of it and for that reason i will oppose it. i thank you know why record, i have been voting consistently for a title 10 finding and others family-planning, by i have had a good discussion about this and i am grateful for the time you took to talk to me about it, but i have to oppose an eminent. >> i appreciate that and i say to senator casey i would hope we could resolve the policy today as we move forward on the bill just as we said to senator mccain as we look at the scoring

and if you have a way of sharpening this in a way that we can mutually work with this. i want to thank you and senator hatch and for the advocacy for women. violence against women in many things we have worked on together and certainly your advocacy as well. this is for women's health, you have a legitimate issue of a personal philosophy which i think we all respect. >> madam chair, would you be willing to put some language in the sand out including abortion services, then you would have more support for. >> when we are doing here before we get into a picking which service or not service, and i would prefer to do is keep this to find, keep it as a women's health clinics that provide title 10 services which already providing tettleton services so, no, i would not do that at this

time. >> we have to have a recorded vote. >> if there is no further debate then the clerk will call the roll. this is the mikulski amendment and several co-sponsors. [roll call] [roll call] [roll call]

[roll call] the amendment is agreed to. >> madam chair, thank you so much and i appreciate the great courtesy they showed to all of us. you do very good job. i called the amendment number six. what this amendment is all about is to improve access to health care services and provide medical care by reducing the excessive burden liability on the delivery services by primary care physicians in rural and

medically underserved communities. what this amendment does basically is improve access to health care services and provides improved medical care in underserved communities. less is be honest about it, as someone who actually defended those cases, doctors, health care providers, i have to admit that once they changed the law from the standard of practice in the community if a document to the standard of practice in the community than that dr. willis of salt from liability and they

changed that long mainly to personal injury lawyers to where it became the doctrine of informed consent and from that point on every case with the slightest evidence as to a jury. even if the evidence is now a faulty. in the process we've had an upswing in medical liability cases throughout the country that have been devastating to the health care industry and especially to obstetrician gynecologist. and especially in rural areas. every case goes to the jury and if there is a bad result even though there was absolutely no negligence or fall on the part of a health care provider, whatever that may be, you can have runaway jury verdicts that basically run up the cost for everybody. consequently a lot of obstetricians and gynecologists

and them centering on that since we just passed that this u.s. senator from maryland amendment trying to take care of women's problems. we have had a lot of obstetrician gynecologist quit the practice and they are not going to do obstetrical services again. in some areas of the country that are not only woefully deficient, most areas are but some are so willfully the addition they have to travel for miles and miles to get any kind of health care treatment when they're in the process of delivering a baby and having other difficulties during pregnancy. with this amendment will do is help alleviate some of this because this amendment is aimed at eliminating needless to litigation costs of our health care system. and the use that every bit. when the doctor under an

informed consent became the rule that meant there was no way any doctor could ever fully inform the patient of all the problems and possibly had. you have to go to medical school to do that and even then the would-be doctors and say you never met that standard. we have a doctor in pittsburgh where i practice law to testify any dr.. the matter what. and he would make a case against the status and to go to the jury in or in my opinion frivolous and sometimes even fraudulent. and that has been replicated throughout the country and throughout the process when we told doctors was you are going to have to make sure that you have done everything he possibly can and have every possible procedure in your history and that patients of that if you do get sued, however frivolously it may be that you can then say how

i went way beyond the standard of care in the community. i have done everything i possibly could i have used every procedure and medical devices cetera. every drug, bingo, a bank of and in the process even then would not fully protect you doctors but at least you'd have a very good argument in court that you did everything that a great doctor would do under the circumstances and hopefully the jury is where recognize there are cases that with bad results because we're all different and where there wasn't any negligence and there should not be a jury verdict in those cases. i have to say that this is what we call unnecessary defensive medicine. having said that i think all of us would like to have unnecessary defensive medicine.

in other words, i just do the necessary procedures, the necessary approaches that art minimum to make sure that they have ruled out certain possibilities that could hurt you, but today they go way beyond that. secondly we all know there is another cat scans and mri in the medical devices. these are important devices, we can do without them but they are all realize and for many reasons one of which is medical liability. there are other reasons to. they can make a lot more money and pay for the machines and to a lot of things but the fact is most of these are trying to build that history and that record so they can show that if somebody has an and pleasant that result by the can at least argue that it wasn't because they failed to do something that should have been done. in the process i said 30 years

ago that i believe that unnecessary defensive medicine was in the neighborhood of $300 billion a. that was 30 years ago. the ama at that time in a recall correctly admitted to $60 billion to imagine what it would really be when the ama actually in knowledge that there was probably 60 billion. it was many times in that and they know it and i know it and anybody who has try these cases knows it. today is, then that and have become so dependent upon unnecessary defensive medicine that the costs have skyrocketed and what this particular amendment would do is it would impose limits on on the economic damages and be awarded against primary-care resistance at general and underserved areas. they would limit this amendment the ability to same occurrence

and finally they would raise the standard for the punitive damages in suits against the dodgers and facilities particularly will level for the costs associated with costs litigation. i am the first to say that there is negligence from time to time in the medical field and there are legitimate cases that are brought. i mentioned in the wrong leg, ron kilne -- we only have to of those and frankly those have to be settled for significant amounts of money and they were mistakes made by the best doctors in the country so there are legitimate medical liability cases, but the vast majority of them in my opinion are brought to get the defense cost somewhere between $250,000 and if the attorneys can get the defense cost they will make 40% in the contingent approach i don't begrudge them that if the cases are legitimate and that

amounts to an awful lot of cost of the whole of society. i'm very concerned and this amendment may not be everything i would do. for instance and i had my way establish health courts to resolve these problems and a fair and reasonable manner. if we could do with which to be non jury, of course i'm not sure that could be done but at least of it can we would move in that direction. secondly there might be other pressure points for you can determine whether doctors or negligent are not without indoor runaway jury verdicts and there may be a whole bunch of other things but what this does do is basically puts limits on non economic damages and was very important in and with limited not economic damages.

if you have punitive damages in would be the greater of to and 50,000 when 10 times the economic damages, but it would have unlimited economic damages. a matter what the cost would be able to recover them less than on economic damages of those limits. fibre all of us to work on something maybe even better but this is where we are right now and i believe is the right thing to do if we want to get health care costs under control. whenever they have done this type of legislation that have had a much greater success getting health care costs under control and limiting the explosion of a litigation that has occurred in our country and this is a that have done this have benefited and frankly i think it would resuscitate want the ability of committees

especially rural communities to get more obstetrician and gynecologist to top of the problems women go through and the problems of children in childbirth and otherwise. personally i think it is something we really need to do. i would be open to better ideas of somebody had them with but i think we need to set an example since we have got to bring costs under control and i contend that unnecessary defensive medicine is eating our country live. and frankly i don't blame the doctors for trying to build up their history is, their medical histories so they can and is try to protect themselves if they do get to court and that is what is happening at a think anybody can rebut that two really understand the situation. compared to when i was practicing law by have to admit

there were a lot of insurance companies to ensure from medical liability and there are very few today. it is getting more and more difficult to find companies that will ensure doctors for medical liability purposes in states where they have unlimited been on the economic damages in addition to the unlimited economic damages this amendment would provide. i know it is an unpleasant subject and those who are devoted to the american trial lawyers and i'm devoted to them when they are right, i'm just not devoted to them on this issue might feel otherwise but the tide is this time mr. getting this litigation and a control and this would help us to do that. >> madam chair. >> before the center from our

falun in response i just want to respond on to process points and then and of the senator, the content issue, that is correct on the process. first of all, it is my understanding, the center as a right to offer his amendment but it is my anger steny we are considering the title one which is the coverage and that that was going to be the scope of what we are going to do today two either expand coverage, and limit coverage, modify coverage and i'm not sure which title the hatch amendment is amending. i don't think it affects coverage. i'm certainly not going to prevent from offering this amendment but he did ask me to senator harkin who chaired before that we tried to keep to the coverage section because of the heart of what we're trying

to do that there are some and a good debates in medical malpractice earlier this month that i think we prefer this wasn't being discussed now and that we would stick to coverage and also as a senate an earlier debates this amendment is not germane to this committee and does belong in the judiciary committee and there is no fog the area of like in health care there is a condi area between us and finance, but i just wanted to put those to process points down. when we wrote the amendment we didn't have the bill or at least didn't have any idea of so we did put up for brit legislative language in because at the proper place started the following so it can be easily inserted in title one and

secondly i agree with the distinguished senator that should not prevent it i get this past and of the committee who wants a referral of this bill on this issue they certainly could demand it and i don't have any problem with that, but we're talking about a comprehensive health care bill which is called health care reform and i can't believe that we would have a comprehensive one without this but it is in his live economically without justification. i practice law as a trial lawyer, i am proud of that most travelers are very honest people, without them we wouldn't have justice in this country and i am the first to stand up for them but i go to admit this is a messy area that has gone way overboard and i don't care who you are, if you think is through he will say something is to be done in this is an attempt to

try and do something soon get the cost under control. we're talking over well over a trillion dollars by the time in the medicaid expansion and frankly people in this country are starting to catch on to this and starting to get really mad and least the ones talking to me are. this is one of the areas we have to face as attorneys, legislators and people who want to have things work right and as people who are interested in getting the best care him for women in our society. obstetrics and gynecology. and there are people that just won't go into it anymore because then no insurance is too expensive, it is tough to start out and then when they get into it they can be sued and the job of a hat for what is negligence and these of the type of things we've got to wake up to me and

say we don't i'm want to antagonize our trial lawyers who are funders of people in the senate and house but it is one of those things really need to face. >> i just wanted to make the point. >> you did and it is still valid to put an end. >> thank you madam chair. first let me express my very great respect and affection for this year senator from utah who vice versa has been obviously extremely distinguished member with. before that was not just in leader of the legal community in utah but nationally recognized lawyer of their great stature and so it is with some reservation that i regretfully

must disagree with them on this amendment and it concerns me that the insurance industry and will sold willingly turned its guns on the most severely injured victims of a catastrophic medical care in the medical arena is comprised of it is comprised of investment income and comprise and the experience and comprised of the cost of individual claims and in dealing with all of this the one place the insurance company chooses to turn its guns one is on high claims. high claims which are experienced by the people who senator the most devastating

injuries. the couple who have to come home with a damaged infants which is completely changed the lives with the rest of their lives they will be carrying a burden of care, their dreams for that town are completely changed, their whole lives are turned upside down by it. is on them that this places the burden. the person who comes home so disabled by a medical error that there damages exceed half a million dollars into that as a person who has to bear the burden on a this theory of insurance reform. if you look at the experience portion, let's just decided investment income and many have observed it relates more with promise and claims one of look at the experience part of it. it is now admitted established

by the institute of medicine found hundred thousand americans are killed every year by avoidable medical error swap and that the legal tip of the iceberg is part of a much with marginal -- larger iceberg of medical care and that is that the film. if it is 100,000 killed by medical errors, knows how big of those who are sorely injured who come home with no legs instead of one leg, because the wrong leg caught taken off and then i had to take off the other one. for all of that injury i think this bill and particularly the effort led by the senator from maryland are chairman barbara mikulski on policy reform will actually do a great deal to turn it around and reduce the body

count and reduced the butcher's bill from error in american medicine. i hope that we focus, because i think that as a humane and intelligent way to do with this problem of the cost of medical error, to have less medical care, not to take the re the rise of the people who on the most injured by the medical error. i think we find some support in this from cbo. just yesterday i believe it was yesterday and has become a blur of health care for a while. i sat next to not david budd died from cbo and he was asked by a distinguished member and of the committee and where the savings would be room door reform and insurance reform in an amendment like this and he said it is very small. negligible savings and he really can't pick out the offensive at madison because there are so

many reasons, the london senator from utah to sewage between the necessary resources necessary defensive medicine and as cbo said that the station can be drawn. for innumerable reasons my being careful with the patient to balance like having a friend within clinic where you want to keep sending people were, there is a lot of the offensive medicine practice and not of all of it is bad, some of it keeps america healthy and this type simply can't be in documented at least according to cbo who we customarily relied on. the last point is that they always try to head up the jury system work and we all know him that the jury system abandoned can be disruptive and uncomfortable with, but under our constitution is supposed to be weird is often the rastus --

last refuge of an individual and there are badly injured and the forces are raging against them and when they control the legislature or the executive. the timing of others were keenly aware of the vulnerability of goners and legislative assemblies and in both corruption and passing passion and what they trusted to remedy that was we can get before a jury of appears to have him our jury heard and to have a massive insurance industry now coming toward seeking to disable piece by piece that fundamental constitutional prerogative of america on three different times in the constitution and applied to the 14th amendment a fourth time i think is wrong and something we need to guard against so i would strongly urge my colleagues to vote against this amendment. >> i will be short,.

>> may i turn to senator isakson who hasn't spoken. >> thank you madam chair, i apologize, i had to be in a meeting with the secretary of the army. let me ask is this the sound of a thousand dollars cap on on economic and world pressure to run ob/gyn? document that is what it is. >> i appreciate was senator white house said but i'm not a lawyer and i have a child a terribly injured in an automobile accident as a passenger in a car, went to the windshield, double compound fracture to lower leg, and irrigation system and the hospital for six weeks in his leg to try to keep the bone marrow from getting infected, for operations so i know a little about what you're talking about and i appreciate the right of redress and i appreciate the jury, but i appreciate the other side. iran the company and here is

what i have voiced thought we ought to do and i don't think you're amendment does this but i felt like i was moved to say this. a judge can reduce a verdict that the judge feels light with is a bad verdict, is that correct? i think we ought to do is having on economic cap and have the power to lift the cap proven in court testifies lifting the cap because here is the thing you're not mentioning and i have no dog and my insurance company, and not talking about them and let me tell you what happens in the real world. there are those in the legal profession, not on lot but it doesn't take a lot who file cases strictly hoping to settle them and get some money within never going to court. if you have a cap that can only be lifted if the case proved in court gross negligence were, i don't know what the terms need to be the new and all of a sudden take away the attractiveness of filing the

suit in hopes of a recovery and instead if you filed a one thing you'd want to make sure that you have the tax on your side to win the case so as one who has had a child care of injured i don't want anybody to go to that and if they do i want them to be able to be confident, the child and i negotiated a structured settlement for my son because of the potential problems and it worked out fine and never went to court and filed suits. who but i want people to be ample to get that. the park in the middle on this thing which contributes a tremendous amount to cost are those that will take a situation and we did toward reform just by having from britain affidavit and by not another physician. in some kind of discipline to keep this unbridled filing of lawsuits in hopes of a settlement is one thing we need to work on and it would help accomplish what the president was to do which is reduced

because without jeopardize sing in injured individual or a parent who has it of one child or anybody that is a victim of negligence by a physician the judge would have the ability to lift that cap without evidence proving court so i want to put that in because there are two sides -- there are three sides to this order from story and i want to be able to project that so thinking madam chairman. >> to do want to wrap up? >> i agree with much of what she said if not all of it. i don't think this is insurance industry is driven thing to be honest with you. i tried cases on both sides, not on medical liability. i became a lawyer when we move to utah in i did both plaintiffs and defense worker as a partner,

all i can say is that we would have to do something here. whenever we've had a system like i'm talking about and the system works a lot better even though it appears event there could be some injustices', i don't disagree with the distinguished senator from georgia that there are cases worth more than $750,000 but hardly any of them are and the ones that are begin probably read some language that would accommodate us in clearly deserve more whether a judge alone can decide that has been questioned but certainly would be willing to look into it and we do provide for a limited economic damages here. that includes a lot of things and that includes a lot of money in some cases where there has been clear negligence. with a non economic damage we have limited in this amendment.

wherever they have done that they have been able to resuscitate with obstetricians and gynecologists from a man unable to get doctors to come back, unable to do a lot of things that proficient until who made that kind of determination. i really do respect my distinguished friend from the island and of foreign to working with him on how we can solve this problem. but in the meantime i think this is a step in the right direction to get us there and i would hope that my friends on the other side consider voting on that basis with the understanding i worked with my friend from on island to see if we can come up with a way that would work to make sure that people are treated well both ways. now with regard to him readily admitted not to know much about this and frankly in making his determination i can tell they don't all lot about it but for someone who has been in the

trenches and seen this year after year i can tell you right now that anybody with brains will come to the conclusion that these doctors are going to order a lot of tests that they really don't need. part of that will be to pay off their equipment and part is not right on that basis that they are going to do it because they want to make sure that that historical record, their record on those patients has every possible spot they can think of a social thing to happen to get sued the will be able to go to court and say i did everything i possibly could to help this person and the result was not bad and because of negligence. they will come up with i'm sure some reasons why it wasn't negligence and then go from there but unless we're willing to face this problem i don't see any real control of unwarranted runaway expenses in health care and more of corley even if is a

perception which is not it is a big perception and until the tops of checks and gynecology because people are choosing that profession anymore and in some areas they will practice, they cannot afford a 80 to $200,000 for insurance to take care of the liabilities that come. in that regard and pay a lot of tribute to our distinguished senator from oklahoma who has been doing this for years and helping women for years and years. has had the guts and the ability to do so but there are a lot of people who aren't going to put up with it, are going to pay those high costs and then also don't want to face a frivolous suits in the end just so attorneys can get the defense costs. usually between 50 and $200,000. what interest company will settle for someone rather than

take of a point to a runaway jury on a case that even though there is no reason to bring the case they just can't take the chance and these are driving costs sky-high and frankly dubois as good as he is is wrong. i have to say i have high regard for him. he has been honest and straightforward. he is a very good job in my eyes and the circumstances and beacon all agree and disagree on certain issues but i've got to say i think his approach to these things as honest as you can hear that all i can say is i've had experience in this area and i think what i am saying here is true but i'm prepared. i want to make a couple points on this issue whether of not the savings are used every are true

and we do have some fairly strong evidence there are very significant savings here. with 26 states have enacted limits on on economic damage, texas and active in women's and sell 31% increase in their rates. nevada enacted limits and they saw their rates go back significantly. the same situation in mississippi, california course is the best example and acted to a review thousand dollar limit. their rates rose less and rate of about one-third in the country and, of course, there are huge experience post a look at and cbo prior to them taking over the position to look at this issue and actually included in their december budget option an estimate almost identical to what senator hatch has proposed

would save $5.6 billion over 10 years which is a lot of money even though we're talking trillions and know that defensive medicine and medicare alone is costing summer between $31 billion a year so the potential here is huge, the experience of states is pretty determinative and there are significant savings and does have an impact on the rates for lawyers, the race for dr. said and as a result you get more doctors participating in underserved areas which is what this amendment is directed at >> madam chair? >> first, i want to thank senator gregg for his comments. i also want to thank him for his brevity. senator casey. >> senator