>> i think there's a fair amount of evidence that if we increase transparency and provide more information to patients a lot of patients will make better decisions and that's also trauma physician side. a lot of the solutions are simpler and cost less than the 2.5 to three chilean dollars we are spending on the affordable care act of the next 10 years. >> thank you and you think many people signing up for coverage don't know their doctor for their children's doctor will be in their network and still be able to visit their family doctor? >> i think the evidence of this panel is not only do the patients know but we don't know either. >> mr. chairman we are consistently hearing distortions of the poorly conceived law. dr. novack what do you anticipate will occur next year when people go to their doctor and find out they are no longer covered? >> congressman again it gets back to this uncertainty issue,

that already on the provider side we spend enormous amounts of time as you mentioned enormous phonecalls trying to sort through these complicated issues regarding health insurance and by the way this is not just for people in the private market and not just for people on medicaid. it's equally true for people on medicare in the 130,000 regulations that go along with medicare. this is only going to grow and so at least for our practice since we have no idea what the exchange will bring in this 90-day grace period issue is such an enormous issue for us that we don't feel we can actually see patients under these exchange contracts that we were pushed into without choice until this body or other bodies figures out what the rules are going to be so we can continue to provide service to be able to pay her staff. >> thank you very much. >> would the gentleman yield? dr. novack i just want to make it clear, under this 90-day plan if you have let's say a 2 billion-dollar practice that

you pay all your people and so one you could end up with one quarterback quarter of that, $500,000 were patients aren't covered in don't pay. this is the kind of exposure you could have paying all your people, paying out $500,000 getting back none of it. that's the uncertainty that was in the law. >> the concern is almost all insurance there is almost always a 30-day grace. things happen but under the law exchange plans have a 90-day grace period. for the 31st 30 days the patients or her to pay the bill but will be doing authorization on day 31 is going to look like a patient has insurance. the insurance companies going to hold payment and if the payment is not paid they will collect it from the patient. generally speaking talking to the hospital people as well your collection rate is one or 2 cents ,-com,-com ma dollar for that money. interestingly we had a

conversation with one of the newer insurers exchanges in the exchange in their zone and we said we would like some kind of protection against this exact problem. we didn't have an issue in terms of what the payment rate would be for services. we said we need some kind of protection and they were unwilling to provide us that protection so we walked away. >> at want to thank our witnesses today and i think we close on a good note. i think all the people on this side of the dies can agree on is we strictly need to make sure as if you are taking a visa or mastercard in you check it and it was good your expectation is that when you left the gas or product in your store that would be honored and not 60 or 90 days later you would find out retroactively you were going to be paid. as we look them in the albums represented by this first panel that's a good example of one that we look forward to working together to try to fix and fix

quickly. again doctors i think you for remaining in this industry, remaining in this industry in remaining in your practices and offering us some ideas of where we need to keep driving u.n. doctors like you out and i recognize that joan from maryland for a closing. >> at want to thank you all for what you do every day. you have very important jobs. you bring a quality of life to life and in many instances save lives. saving site. i want you to be paid for what you do. at the same time i also want people to have an attitude of staying well and if they get sick knowing that insurance card that they have mean something. i heard what you said

dr. mclaughlin about the various situations that you found yourself in. in some kind of way we have got to balance all of this. congressman tierney was so adamant. a lot of these things could've been solved when this was put together but there was a lot of give and take and a lot of things happened that i think we could have avoided a lot of what we have here now. there are a lot of problems that you are right, we have got to fix this and it's got to be a can-do attitude and not one where we just throw up our hands and say -- because do you know what? the people that suffer are the people you try to help every day. i thank you for all you do and i thank all of you for bringing the passion that you bring to your professions. we understand you are just trying to help people to get

them well and keep them well. we really appreciate you. thank you. >> thank you so much. >> thank you wall and again you will have seven days two and traditional statements or other material into the earth and we will now take a short resource resource -- recess for the second panel. if the witnesses could please be seated. i want to thank all of you for your patience. we welcome our second panel of witnesses. professor judith feder is a professor of public policy at the mccourt school of public policy at georgetown university and a fellow with dearborn institute. mr. edmund heiss of mire.

i do that every time. welcome back. a senior research fellow for health policy studies at the heritage foundation and doctorow a., m.d. is a senior fellow at the manhattan institute for policy research. eshoo saw on the first panel pursuant to the rules of the committee would you please rise and raise your right hand to take the oath? do you solemnly swear or affirm the testimony you're about to give us the truth the whole truth and nothing but the truth? please be seated in left the record reflect all answered in the affirmative. dr. roy. >> chairman issa ranking member coming seven members of the oversight committee thanks for inviting me to speak with you today about the affordable care act. my name is opec right i'm a senior fellow at the manhattan institute for policy research in which the capacity i said

conduct research on entitlement reform. i'm an advocate of market-based universal coverage. i believe the wealthiest country in the world can and should strive to protect every american from financial ruin due to injury or illness. furthermore i believe well-designed subsidize insurance marketplaces are among the most attractive vehicles for achieving these goals. it is for these reasons that i am deeply concerned about the way the aca insurance has been designed and implemented. most of all i'm concerned it will drive up the cost of health insurance especially for people who shop for coverage on their own. as you know the aca made substantial changes to the individual health insurance market. the law broadly bars insurers from charging different rates to the second helping requires insurers to raise rates on younger individuals nor to partially subsidize care for the old. the mandate should have insurers cover a broad range of services

that individuals might otherwise choose to purchase. the law taxes premiums pharmaceuticals and medical devices in a manner that has the net effect of increasing the cost of insurance. earlier this fall i into college for the manhattan institute did the most conference a study to date of individual marker premiums in 2014 relative to 2013. we examined the five least expensive plans available in the individual market for every county in united states. we average the premiums and adjusted the results to take into account those who had pre-existing conditions could not purchase insurance at those rates. we examined 27 to 40-year-old men and women. we then compare this race to the five cheapest plans on the aca exchange apples-to-apples. our analysis found that the average state will see a 41% increase in underlying premiums prior to the impact of subsidies. among the states seeing large

increases or nevada at 179% new mexico 142% north carolina 136% and georgia 92%. our analysis did find that eight states will see an average premium decrease in available including massachusetts negative 20% ohio negative 21% in new york negative 40%. of the six categories we studied 27-year-old men face the steepest increases with an average of 77%. 40 o'flynn will see the mildest increases with an average of 18%. we also study the impact of the lowest premium assistance payments on exchange premiums. our analysis found for individuals of average income taxpayer funded insurance subsidies primarily to flow to those near retirement because the elderly will still pay more for insurance on average than younger individuals and because subsidies are designed to fix the percentage of one's income devoted to paying health insurance premiums.

taking subsidies into account 64-year-old man will pay on average 19% less for insurance in the aca system or 27-year-old man would pay 41% more. the manhattan institute analysis indicates we are indeed likely to see a fair amount of adverse selection on the exchanges. people who consume above-average amount of health care services to such a sticker in older individuals have a compelling economic incentive to enroll in the marketplaces. healthier and younger individuals however have less of an incentive even when want takes into account the individual mandate. our analysis to the tree to which exchange has higher deductibles a narrower network's relative to plans available in 2013. there have been many anecdotal reports of people paying higher premiums for plans with higher deductibles and narrow networks and the plans they previously enjoyed. in particular prestigious

medical centers as specialists in the most complex cases and the wrist diseases tend to provide costlier care than the typical hospital. these facilities are mostly excluded from exchange network. it's not necessarily a bad thing to choose narrow networks if those choices allow americans to reduce monthly premiums and very bank urging price competition among providers. exchanges could insert the downward pressure on overall health costs. many individuals are reporting higher premiums for less attractive health coverage in a way that will increase the national health spending. millions of americans are likely to see less attractive coverage at a higher price and its goal of universal coverage will remain unfulfilled. >> thank you.

>> chairman issa ranking member coming to members of the committee i welcome the opportunity to speak with you about the affordable care act. my views are my own and not those of georgetown university where the urban institute where i have spent much of my career and over my career there and elsewhere i like you have reached the number of americans rising to 50 million people who go without care even as americans who have health insurance spend more to hold onto it. at long last the affordable care act enables us to assure americans access to affordable health care. we have a simple choice. effectively implement the law are resigned ourselves to be unacceptable status quo. the status quo that i believe is quite different from the rosy picture that we were left with in the last panel where everybody gets their care and their doctor and all is well. my own research has contributed to a substantial body of literature demonstrating that

insurance matters. americans without health insurance get less care get it later in the case of an in the room more likely to die with -- then americans without it. that care is paid for by those of us who have health insurance and your local state and federal taxes. who are the uninsured? they're mostly workers for families of workers that are not covered through their jobs. pre-aca they have few options to protect themselves. coverage in the individual market for pre-existing conditions and limited benefits and rescissions and nonrenewals simply does not work for people who get sick. far from living up to the promised the people who have this insurance can keep their doctor or their doctor is paid for mr. chairman as i heard you argue the limits on their annual payments as well as other limitations frequently leave them high and dry and that is what the evidence tells us. though medicaid provides an

invaluable safety net for people who are eligible it is far from an empty promise in research shows is it actually does give people access to care except in a few states medicaid excludes coverage of adult for not parents of dependent children and matter how poor they are. there are modest earners you can get coverage through their jobs and public protection. it is these giant holes in her health financing structure that the aca aims to fill. the aca requires insurance and discrimination based on pre-existing conditions gender and other factors to cover the range of services health professionals typically provide and to eliminate dollar caps on annual lifetime benefits. so that people don't wait until they get sick to enroll the aca companies requirements on individuals to purchase coverage or pay a penalty. to make that requirement feasible and coverage affordable the aca provides tax credits and

other protection to limit people's premiums and cost-sharing is a share of income. these policies together make it impossible to transform what is an empty individual market today into what insurance is supposed to be available adequately. the aca addresses the holes in medicaid by expanding its eligibility to people at incomes below 138% of the poverty level regardless of their family status. until 2017 that expansion was fully financed by the federal government with federal finance gradually dropping to 90% for 2020 in subsequent years. although states will ultimately pay 10% of knowledge just as the expansion will be better off by reducing the burden of uncompensated care what contributed to the overall health of the state economies. indeed research shows that because taxpayers of all states contribute to financing for the aca citizen states that choose

not to participate in medicaid will actually pay for benefits in other states without reaping any of the benefits themselves in additional federal funds. while the aca expand the coverage by improving the market outside employment it is important to emphasize that the law in the sponsored insurance is most of us depend on fundamentally as it is today. despite claims to the contrary analyses by a cbo ran to my colleagues at the urban institute show health insurance will remain the core of the system and essentially we have left 150 million people who rely on employer-sponsored insurance there coverage the same as it's been with some improvements and they were not the group that we were talking about this morning that is the coverage outside

employment. at the same time and i see my time going we are seeing this lowest cost growth we have seen in history in part a function of the aca's lamination of overpayments medicare and promotion of initiatives to support higher-quality care and that is affecting everyone. by filling the gaps in our current financing structure and the health care cost the aca has enormous potential to address the flaws in the health care system that all of us have. the biggest barrier i see to realizing the lost potential is the resistance to its implementation that too many states unwilling to establish their own marketplaces, despite the norms of managed to their own state. come january 1 millions of americans will for the first time have access to affordable insurance when they are sick. along with benefits people are already read in --

>> the gentlelady's entire statement will be put in record periods via i thought you said earlier that everyone will be able to finish their sentence. >> you may finish her sentence that you are one minute past and he said you were wrapping up. the gentlelady will finish the sentence. >> along with the benefits that we see people reaping we need to move forward to implement real promise of the aca standing in its way and for the unacceptable status quo. >> we now go to mr. heisler meyer. >> thank you mr. chairman and ranking member cummings for inviting me to testify today. i focus my testimony on the issue the committee asked to talk about of limited provider networks in exchange plaids under the affordable care act and i have a copy of my written testimony. i will simply summarize a few points.

obviously as you have heard on the panel before provider contracting is nothing new. it is a two-way street. it is up to both the insurers in the prior fighters to come to terms. there appears to be based on widespread news reports implied that i mean the different types. with that said nobody has at this point has a definitive provider networks are different from the ones that we see out there today. we just simply don't know in part because some of those networks are still being built

or those contract negotiations are still ongoing. what we do know though is in a number of cases the insurers are offering network coverage that is significantly less than what they offer in plants outside of the exchanges. the thing i would direct the committee's attention to as a policy matter is what i see driving at least some of this because the assumption has been that while the consumers will be price sensitive than the insurers are trying to keep prices down so they exclude providers but i think the design of a portion of the log drives is specifically referring to the cautioning subsidies. most of the attention has focused on premium subsidies but the law has a second set of car sharing subsidies it pays the ensure to reduce the cost-sharing for lower income enrollees. the problem with that is that because the cost-sharing for a significant portion of their expected enrollees is nominal,

the insurers have reason to expect that there'll be higher utilization and indeed hhs confirms that. hhs is adjusting the car sharing subsidies to reflect their higher utilization. essentially what is happening is the insurers will get paid that they are no longer able to use a tool of car sharing to steer patients to be more come prudent patience. that is one of the reasons we are seeing narrow networks in these plans. the other interesting thing that i found in the research that i did published at the beginning of the month and i think i'm the only one that has done the soap bar is i analyze all of the insurers who are participating in the exchanges and looked at them and their businesses in the state today and the insurers that are not as well to see what kind of patterns emerge. one of the interesting patterns

is 20% of the carriers who have gone into the exchange their principle business in the stage state when they went into the exchange is medicaid managed care and indeed we do find evidence that these plans recognize a structure meaning the patient faces very low premiums and only nominal cost-sharing for a generous benefit package that looks a lot like what they are dealing with in medicaid managed care and indeed i quote one of the ceos of the plan saying yeah it looks essentially the same. given that my expectation in how this plays out is the individuals at the lower end of the 104% of poverty that will be subsidized, 200% will probably gravitate towards the silver planned particularly if you have been uninsured. the trade-off of low premiums and low cost-sharing for limited access is not necessarily something you will be terribly upset about.

however somebody who is used to having insurance who makes more money and making three or 400% of poverty paying higher deductibles and co-pays for a limited provider network is not going to be attractive. i expect those individuals will move to the bronze plans were certainly above 3% of poverty. they might just look or coverage elsewhere. i think that's going to be the dynamic plays out. at this point it remains to be seen how many of these more limited networks we see in the coming days but i expect that were probably is fairly good. i and i would be happy to answer question. c. pison article in bloomberg in september of this year and the record is entitled per session

not health law may be responsible for cost occurrence. without objection so ordered. dr. roy you mention free market as a better way to get a working system and earlier on the first panel i asked all three doctors about the practice that the federal government in its reimbursement pays different rates for the identical treatment depending on where you have it. isn't that an example of an inherently flawed system in that it's a hip replacement done in a clinic that specializes in it therapeutic lee does an equally or better job with equal or better results and does it for a more efficient way whatever that term means most -- less less less overhead generally but by paying them less and paying the hospital more you're essentially driving up the cost of health care by subsidizing subsidizing hospitals even if they have higher overhead.

isn't that correct? >> is a distortion that medicare judges to the market and has gotten worse over time as congress tries to fat problem and makes it worse as well. >> in my own state of california we see hospitals buying up clinics and physician practices at a high rate paying them essentially as much, more than their practice is really worth not because they are generous to the doctors but because the anticipated revenue growth means the same doctor doing the same job in the same facility once they become part of a hospital pays more. therefore the hospital is doing this in order to increase its revenue. is that something in a small way we should be attacking is part of our reform? >> we should and in fact medpac has recommended modifying reimbursement structures as part b and priddy

paid the same so the arbitrage can't continue and i would also mention provider consolidation bradley is something the aca actually accelerates as a serious problem which is driving up market power and driving up prices in the commercial market. >> one last question for a couple of witnesses. in 1960 we spend 5% of gdp, then a smaller gdp on health care and we lived about 7.5 years less long than we do today. today we are spending roughly 18% of gdp. that's not just -- four times the amount that actually was gdp growth in constant dollars we spend about five times as much on health care as we spend then. i will start with you doctor come as a physician is very real justifications bite of all the improvements is there real justification for spending five times as much in real dollars on health care or have we

essentially dealt inefficiencies into the system and if so does the affordable care act attack any of those deficiencies? >> the affordable care act increases the amount we will spend on on health care unfortunately and i do agree it would be nice to spend less. there are enormous amounts of inefficiencies in the way we deliver and pay for health care and long-standing problems in with some things about the affordable care act may address we hope but broadly speaking it goes than in the other direction. >> here are a couple of questions. first of all you were at the table at heritage during the affordable care act markup, were you not? >> i was at the heritage foundation. i wasn't participating in the markup. >> i wasn't at the table either. when you watch that process were there any ideas that came out of heritage or other if you will

conservative republican groups that you saw being accepted as amendments and particularly i want to talk about medical malpractice reform. >> no. medical malpractice actually we had a different opinion than some of our friends in congress who wanted a federal solution and we thought it would should be made by the states. >> i'm just saying the affordable care act borrowed it. >> my observation is that frankly the bipartisanship and did and i could look up the exact date, it was july of 2009. it was the day they finished the help committee bark up in the senate and in that markup the republicans made a number of substantive changes all of which were voted down on the party line that propose a lot of technical changes to which in my opinion was the worst drafted

the fault of bills that were considered. and they accepted 100 of those and announced they had a bipartisan bill and i think at that point is when the republicans walked away. i had been working with members on things they would drafting to submit that this point they didn't submit them. it was clear that there was not going to be any meaningful input the interest in doing something bipartisan pretty much stopped right about mid-july from what i could tell. demands for me to help people track things just evaporated. >> thank you. >> dr. haislmaier, sums dates have much stronger requirements for general providers and community providers. ..

as in many areas of the law, it leaves it to the state for forces requirements.

and it does thought to the insurance commissioner of the state and the states have different degrees of willingness and ability to address that and we are not seeing that effort in that regard, and we need to attend to it. >> you have decades of experience in assessing the health care system, and we hope to have you on this panel and here you are. one of the most critical features of a portable correct is the expansion of medicaid eligibility to millions of low-income adults. prior to the aca, it was restricted primarily to the low income children and people with disabilities and seniors. most were not eligible according to a study by kaiser family foundation. and only about 30% of adults had this in 2012. under the aca, medicare eligibility was expanded to

cover all nonelderly adults, including 130% of the federal poverty level. and then face down this by 2020. >> that is correct. >> despite this, as many as 25 states have decided not to be a part of this expansion, leaving millions of their citizens without health care. >> that is absolutely true. what is your opinion of states that use this to expanded medicaid program? >> my opinion is that i'm sad and disappointed in this includes other states that do expand. the expansion research shows the urban institute and how much in

the interest of state this expansion is. i believe it is only political opposition to this law that is depriving these citizens have access to care in the states. >> by not participating, are they leaving for them at different resources that could be used for their citizens? >> they are. >> a lot of these citizens are getting sicker and sicker and sadly some of them will die early. >> we know that. that is essentially that the lack of insurance has been found to kill. >> wise expansion an important component of the affordable care act? >> well, we have a big hole in the process and this includes disabled order dependent individuals. in that hole is a vestige of an old-fashioned welfare system

that these people would get coverage through their jobs and they don't get coverage through their jobs. they are left out of employer-sponsored coverage and that is why we need to expanded. >> the commonwealth fund shows that we will gain us, such as reducing these claims. i remember reading about misery and a lot of administrators that you have to accept this because our hospitals are going to be in trouble if we don't provide for medicaid expansion. >> correct. although hospitals don't provide unlimited care and people don't get all they need, hospitals get stuck dealing with people who don't have insurance coverage it doesn't mean everything, but they are stuck and they don't get paid.

>> lamaze question. the same study says that by choosing not to expand medicaid, some states will lose billions of dollars in texas, for example, it is estimated at $9.850 billion federal aid in 2022, including taxis played by -- paid by texas residents. and it will cost more than $5 billion in 2022. so what will this mean with regard to sick people in the states? >> those people are left without access to care and they are more likely to suffer and die as a

result. and i thank you very much. >> and you, gentlemen. are you a physician? >> no, sir. >> is medicare financially sustainable? >> -- it's not -- >> yes or no. >> medicare costs are going very slowly and we have many low-income people. >> would you agree? >> it is financially in unsustainable. and i am not a physician and another medical school. >> okay. >> even expanding -- i'm sorry, i hit the wrong button. so it is not sustainable.

in the expansion will add to that in a number of ways. it could be if you informed it among the different lines. >> you heard the comments and what is your opinion in regards to this? are we not just chasing our tail at the expansion of medicaid? >> i recently talked about this. how the reimbursement under pays physician for care and has led to poor access for those individuals and this definitive study was conducted in the state of oregon by the new england journal of medicine that shows that no improvement in health outcomes occurred. >> is it means something when you have this?

>> heard in the earlier panel this morning, it is not the same thing as access to care and that is a distinction that i fear people will check has not understood well. >> when we are reimbursing below market rates, we just heard the gentlewomen basically make the comment that it's up to the panel. we'll force physicians to take these and they can even pay their own bills? >> under the most recent health reform bill passed in 202012, it is part of accepting all forms of payment and that was not included in the law and that is something that we may see over time in an effort to do that and that would be problematic. >> so you are very familiar with debt coming out of school and are they coming out of school as

physicians with less debt or more.? >> more debt, it's increased more so. >> reducing their fees is going to help them better pay that? >> it has discouraged a lot of new physicians from accepting medicaid patients. all of this shows that we are willing to accept new medicaid patients as lower than what it is for medicare and it's an increasing problem. i states expand medicaid programs, they will face further fiscal pressures on the only real mechanism to keep the budget controlled is determining the amount they pay with physicians and hospitals to care for these payments. and the medicaid expansion will get worse and expand over that. >> so we heard earlier with the earlier panel, patient dumping. this is like federal patient dumping on the state for that

jurisdiction? >> in my experience, those who are in the caring for patients are reluctant to let a lot of the humanitarian interests and they are reluctant to care for them under the structure. >> because it puts them in a harmful situation. they can't abandon the situation. >> yes, there are very big ethical problems here. >> understanding urban and rural dictations. we are really screwing the benefits of here. i am from rural arizona come and we are seeing catastrophic access issues. in the previous demonstration we try to look at this, which the gentlelady did not bring up. >> correct. >> they can turn anyone away. so that was part of the safety net. unfortunately, i saw the patients that they didn't want

to see and they skew the results to one percentage and then they took a fee-for-service pay as part of the regularly scheduled appointment. >> one thing we should point out is what the market price would really be in a free-market system for paying the doctors and hospitals. we don't know because we don't have a free-market health care system. it has distorted what the prices are in the evidence suggests that the prices for these services in the united states are higher here than they are in the other countries. >> that is one of the reasons i we don't have a lot of family care physicians. the government has skewed that process of the reimbursement rates that everyone can make a living. >> they get paid for procedures and writing prescriptions and that is what a lot of physicians like is that they are finally

paid for their time and unfortunately, the evolution thereof may lead to a two-tiered system we have the doctors treating medicaid patients who don't spend a lot of time with those patients. >> when we hear the downtick and expenditures due to the aca, and i don't agree with that, they have a lot to do with the economy. do you agree? >> yes, i have written about this. there has been a substantial revelation in the increased use of high deductible plans and that is also leading to a slowdown in spending. >> i thank the gentleman. >> thank you. >> why do we not want to give the president any credit? i mean, i hear this over and over again. the cost of insurance is going

down and you are saying that it had no effect. >> the bulk of the affordable care act has not been implemented as having a systemwide effect on how it is spent. >> i think that there are two challenges and i think we agree on bringing costs down, but what is missing from that is that medicare is making medicare a more official pair and there may be room to go. and that the whole thrust of the affordable care act is to move to a more efficient delivery system and many of the ways that people on both sides of the aisle like to see it move. that does not have much effect, although it does point to the

reductions in the admission rates to hospitals and is showing the influence of those possibilities. >> i would like to give you the opportunity. and this really gets to the core debate over health care and we all know that we spend more per capita than any country in the world and we are also across the board not satisfied with the results. and so i do admire this with the observation that what we have here is a value problem between what we are spending in what we are getting whether you're buying a hamburger or health care. and you are either paying too much we're not we are not getting enough for what we are paying. so the central challenge in health care is how do you improve value in the system and ideally what you would like to do is to get more and pay less i think we would all agree on

that. and the problem comes in on how you do it and as my colleague pointed out, there is a viewpoint. and we can do this by having micromanagement with insurers and all the rest. and the way you do this is to have government limit itself and stay out of trying to run the rest of it. and that is fine as well. we are just moving into a it to a patient centered system where people can pick and choose and the reward and i look at this, as the folks on the other side, we say look at this board dice in order cleveland clinic, they all provide better results at a lower price and i look at the system and i say, okay, if that is true, why are they not eating

everyone else's lunch and why it were they not possibly going out of business. so why isn't that happening? because we are propping them up with all of these payments. they see that we can go in we can write a bunch of rules and then come out with the affordable care act in the accountable care organizations and it's the difference of how you go about doing it. >> i recognize the gentlelady from new mexico. >> thank you, mr. chairman. i have to say that i really appreciate the panels and this committee because i am not a doctor and i think you for your work and i will tell you that i think that i can be a qualified expert for three reasons.

i'm impatient and every single day all of the time, i am a primary caregiver to a chronically sick mother and i don't care what system we put her in, she's by herself and she's navigating it she's on medicare and medicaid. and she's on her own and she's married to a dentist and it doesn't matter. it's exhausting and and complicated and complex i could spend the rest of my life explaining it to her, and she's a smart woman. but you can't do it. and i've done health care and policymaking for 30 years. you say there's been an economic downturn in the economy itself has played a huge role in the reduction of health care costs and the cbo says the opposite. we can work everyday and get

experts and we have the most convoluted system in the world and the affordable care act tries to level that in many ways. but i'm one of those policymakers who thinks we need to do a lot more. i spent 20 years before states are figuring out how to do medicaid waivers and we made changes and i watched it shift and change every time there was a profit motive to do that. every single time. and i dealt with patients who were left cold, no matter how much they were paying, who they are, where you live, whether you are more likely to be chronically sick or not. and so we are going to have to do not one-size-fits-all, but many sizes all the time and this is a great experience and many people get better care as a result of the oracle care act and we are at some of the lowest

rates in the country because of the affordable care act. i never thought i'd say this in my entire life. it happens to be true regardless of what my personal opinions are. it is true in this case. and so what i'm interested in using experts such as yourselves to start thinking about ways that we can cost shift in this country. and also what you are proposing to some people is more cost shifting. how shifting back to the individuals and cost shift -- what we have? nine or 10 or 11 independent systems of care? those are the real reasons that helped it is or can wait we wanted to and we hope that all three state dedicated to

navigate this critical next steps. because i don't think the affordable care act is responsible for the shifts and limited access. i think it would be exacerbated to think that in some ways. and i think that we are wise and brave enough here and there are no simple questions and certainly no simple answers. there are not. if we don't start leveling the playing field were focusing on consumers, and we are not dealing with the folks who have significant problems before the portal check in with the portable care and for the affordable care act. i pay more because of the affordable care act. that is because i'm required go to the washington dc exchange and not because i'm a consumer like to navigate before the affordable care act rules in my

own state. it depends on the details of those issues. so i can tell you that i'm one of those folks and on the other hand i can tell you that i'm really glad that more people are helping me help you pay for my mother's car care procedures every single day and she is more than happy to help to pay for everyone's maternity care so that it gets leveraged out. because it's not just medicaid. they are paid for by local government and taxpayers and it's paid for all of us by all of us every single day. so i guess my question is -- is there a way that is committee can work hard but is much valid information and what we can do starting today? my provider networks change because every time we do we reform, we open a window for

someone to do an adverse selection of cherry picking and that is not dealt with at the federal level at all. and if i was a for-profit insurance company, why would i create this? and that is not all of the reasons, but make no mistake, it's not part of the reason and so thank you for being here. i'm going to get my fingers atavism going to try to be not one of the high expense of individuals no matter what. thank you, mr. chairman. >> young lady from new mexico? and hope that she would sign onto my bill and i enjoy listening to you. one of the things you have to look at is the least common

denominator. >> on september 9 to 2013, the cbo director issued a paper entitled the slowdown in health care spending and it has slowed dramatically across the country. the slowdown has been sufficiently broad to persuade us to make downward revisions to federal health care spending. and medicare spending is 15% lower than projected. medicaid spending 16% lower than projected. and this is the cbo. and private health insurance

personally, 9% lower than projected. and we have also made clear that these reductions are apparently not because of a financial turmoil in the recession, but because of other factors affecting this in the behavior of beneficiaries and providers and this is one of the things we have to do try to fix parts of vets. and we have to. we have to get this done, and get it done where there is a win situation. and i do believe that that is possible. and again i say that traveling

from 20 hours on a plane to go to nelson mandela's memorial, i left saying that we are so fortunate to be where we are and we can accomplish anything. we just have to put our minds to it. someone said that it's not that people don't know what to do, it's whether or not they have the will to do it. i think you on your testimony has been extremely helpful and we are going to go forward. >> give me the specific question >> this is their due diligence and the actual aerials but dear with numbers. >> that's what i just quoted.

and the reason i got a little bit upset a few minutes ago, and i appreciate your question, but it seems that this president has no credit about anything. it must've been a fraud, some say. but the fact is that there is a lot that can come out of this and we just have to have the will to get this done. >> i just want to go back to my question. the actuaries at the center this do not answer to the white house and they said yesterday is not due to the cost but to obamacare. >> estimate that as the overwhelming evidence and i would just add that if the

formal character successful in achieving its goals, i will be absolutely thrilled and i think it is my obligation to alert you to these concerns. >> earlier this year, they also said this, they issued a report finding that national helipads load between 2009 to 2011 and represents the lowest birth rate in health care spending since the government began keeping tabs in 1960. >> being a dentist, i can fill your about guide. because there are problems. but the problem is expendable money. and we have seen it go down and

i personally believe in empowering patients and that is what nelson mandela would have wanted it. not to make them cripples, but to demand that the system benefit them. it has to be patient and family and that's not what was included before obamacare or after obamacare. i want to see the patient benefit and be empowered. so i want to thank the witnesses for coming forward and let you know that we appreciate it. and with that, we adjourn this meeting. [applause] >> the press secretary jay carney updated reporters on the implementation today the health care law and he spoke about the state of the union address in january. here is part of the briefing

today. >> first of all, i know a lot of you have been asking and i can confirm that we have asked the president delivered his to deliver the state of the union address on january 28. so that is one. second of all, he will be there and i want to relate to the implementation of the oracle care act. today we are highlighting the millions of uninsured americans because of the affordable care act and nearly six in 10 of uninsured americans will be eligible for coverage under cost of $100 per month or less. and if all expand medicaid programs, nearly eight in 10 would be able to purchase coverage for $100 or less per person in 2014. just yesterday i went joined a

growing number of states led by both republicans and democratic governors that have chosen to put policies and politics aside by expanding medicaid to reduce the rate of the uninsured and help states and hospitals and businesses save on uncompensated care costs. it's an example of how when both parties are flexible and work together, we can move the country forward for the greater good of all americans. and this stands in contrast to the congressional republicans are appealing plan. where every middle-class individual will see their premiums skyrocket and every medicaid expansion would be kicked out out of coverage. if they were there were ever a time for republicans to change course without obstruction and gain access to health insurance muslim month, it would be now. >> we will bring them on the health care law on sunday morning. health and human services

secretary kathleen sebelius testifies on the healthcare.gov website since it launched on october 1. you can watch the hearing at 10:35 a.m. eastern on c-span. >> on the next "washington journal", a roundtable discussion about federal gun policy. on the anniversary of the shooting of sandy hook elementary school. after speaking with our guests, we will talk about the two-year budget deal headed for the senate next week. we are joined by david lauter. "washington journal" is live every morning at 7:00 a.m. eastern on c-span. this weekend on newsmakers, the chairman harold rogers will talk about the recent budget deal negotiated between senator patty murray and representative paul

ryan, and what it means for federal spending. the house passed a plan on thursday in the senate is expected to vote on the deal next week. you can watch newsmakers at 10:00 a.m. and 6:00 p.m. eastern . >> let me be very clear that this is a delicate and diplomatic moment. we have a chance to address peacefully one of the most pressing national security concerns of the world faces today. with gigantic implications of the potential of conflict. we are at a crossroads and one of those hinge points in history. one path can lead to an enduring resolution and concerns about iran's nuclear program and the other path will lead to continued hostility delicate

conflict. i don't need to carry that these are high stakes. >> secretary john kerry on white house members should not impose sanctions against iran as talks continue on freezing the iran nuclear program. 10:00 a.m. eastern on c-span2's booktv. also, dick cheney and his longtime cardiologist talked about the former vice president's history with heart disease and recent advances in cardiology. saturday night, 11:00 p.m. and on american history tv on c-span3. a look at the former slaves who fought for the union. >> and his wife were in sarajevo and it was a bad day for him to come because it was a national holiday in the neighboring country was absolutely furious

that they had taken over bosnia. so the arch duke is one of the symbols of the oppression and they decided to kill him and they did. >> margaret miller on the war that ended peace. at 8:00 p.m. on c-span's q&a. >> policy experts discussed spending today and the proposals to slow down overall spending. including programs like medicare, hosted by the alliance for health care reform. this is one hour and 45 minutes.

[inaudible conversations] [inaudible conversations] >> hello, i am marilyn serafini on behalf of jay rockefeller and our board of directors come i would like to welcome everyone to a today's program. health care costs and emerging areas of consensus. i would like to thank our partners in the commonwealth fund. they have done a lot of work in this area. health care spending has moderated over the last two years and experts assure us that this is not the time to declare victory. u.s. spending on health care still expends spending in other countries and a percentage of

gdp and also per capita spending. it is worth noting that medicare consumed 15% of the total budget and in 2011 come the first of the baby boomers hit the medicare program. medicare spending is projected to double by 2022. and so while we typically talk about differences in this town come out today we will be talking about areas of consensus and health care costs consensus. there have been a number of major proposals in the area of health care costs and the commonwealth are part of this common ground.

rituals set the stage for us by framing areas identified by commonwealth. and this includes the cost containment proposals. >> thank you so much, maryland. thank you to the alliance for health care reform. and thank you for joining us to talk about health care costs. and as maryland said, we all understand the imperative at the federal and state level, as well as employers and households and other individuals go. health care costs are up to about $3 trillion in terms of national health expenditures and are expected to rise to $5 trillion by 2022. and just ordered some context, that is roughly 20% of the gdp. and as maryland mansion, it is starting to slow, but it is

still unclear as to whether or not that will continue with what is potentially driving the reductions. regardless, controlling the cost has been an issue for policymakers at the federal and state level, especially at the state level were balanced-budget exist in this includes individuals as well. so given the policy focus, as well is the as the belief that 2013 offered an unprecedented opportunity to ride out a policy resolution, and number of groups released a set of comprehensive proposals to control costs while improving the value that we received for our health care investment. several groups, including members and stakeholders expanded the continuum and while there were different coaches, there were also incredible amounts of agreement among them.

i think you would be wise that all of the stakeholders and groups are coming forward with comprehensive proposals at the same time and that sends an important message that stakeholders across the continuum agreed that much needs to be done control costs and reform the health delivery system. this helps to distinguish the approaches and serve as the policymaking process in this includes the link to the online tool that was developed this includes katie porter and her team so not just to medicare proposals, but a comprehensive proposal controlling health care

costs would transformation. and after careful analysis, we agreed on areas where action is needed and this is different on specific recommendations and there was enough commonality to just momentum and you see those here on the side. and this includes improving market competition and something that has been pretty controversial and i think that many of us were pretty surprised to see that in almost all of the proposals. and con considerable aosals. and considerable agreement when we look at this, it tends in the

bipartisan proposals as well. and that really was part of the goal, to see if this makes its way to the policymaking system. some of the common elements, there is more information available and all of them recommend this and this is apparent with many of the organizations. it also encourages insurance practices with value-based purchasing. in some of the areas where we saw the most consensus was the idea around the need for foreign measures and metrics and

alignment between public and private programs and there are efforts underway with these and others to move in that direction. and the strongest areas on the idea of price transparency. and the issue that we are hearing on both sides of the aisle in terms of the importance is shining light on the cost of care. as well as the prices paid. plus, all of the proposals

recommend spending targets and summer at the more global level. all of them really emphasize and encourage state-level innovation. and it gives you a quick glance at the online tool that we have available. and it also links to all of the individual proposals. so they encourage you to take a look at this and do some comparing and contrasting and then read more about the individual proposals. with that, i would like to again acknowledge our partners and i would like to thank everyone for their work on us, as well as the organizations they katie's team worked with. they did an extensive amount of analysis to make sure that we were really reflecting on those proposals accurately. so thank you to all of the organizations that participated. >> thank you, rachel. let me go through a couple of logistical points. first time you'll notice on the

screen behind me that if you are interested in tweeting coming you can use the hash tag if you would like to ask a question. if you'd like to ask a question for speakers and you are not in the room, send a question via twitter if you use the hash tag cost consensus. the last question when time comes. you can also send us a direct message on twitter at all health reform and we can also pick up your message that way. you can ask a question when the time comes in one of two ways. we have microphones and we also have the green card in your packet to write a question down and you will get the questions down to your speakers.

that packet has lots of great material for you and includes the powerpoint presentations for those speakers who have powerpoint today and this is a briefing that is live on c-span today and we will have this on monday and will be followed shortly after that i a transcript. one more point is we also have an evaluation form if you would be so good as to fill that out, we would be grateful. so let's move on to the rest of our program. and we are going to hear first

from an advocate of the system of health care change. [inaudible conversations] >> policy health care economist that has made it his group's business to know the trends in health care delivery across the country. paul has been analyzing cost containment proposals and we have asked him to discuss areas of consensus and the likelihood of moving forward, given the atmosphere. also to look at just how concrete these proposals really are in their ability to move us forward. >> thank you, maryland. as rachel said, there's a lot of activity in developing comprehensive strategies for developing cost containment for this year. many are motivated by the expectation that there would be substantial budget legislation that would include an opportunity to put many of these ideas forward. many of these entities are

ceding consensus and some of them have different stakeholders involved in the process and some have conservative and liberal policy experts and some are republicans and democrats and one is from the perspective of states. i would just like to mention that sheila and i served as advisers to the bipartisan policy center project was released in the month of april. the robert johnson foundation asked the need to sympathize with a lot of these reports. they have found that seven of the initiatives and added three others, one of which was the commonwealth report. so this is really about the synthesis. the invention across the reports is truly striking and i have used different words, which is diminishing the role of fee-for-service payments in medical care. and using other payment

approaches to promote coordination of care and management of populations and clinical immigration and they are seeking this as well as cost reduction. the goal is to achieve most of this transition by the end of the decade. and most of the reports, medicare payment policies are key in pushing the system forward. and there was one report mentioned called a state containment commission which was focusing on medicaid policies as the key level in the course that is parallel in this includes moving away from traditional policies this represents a portion of cost shifting, although some services were

identified if they thought the prices were too high and they were being paid by medicare and being called especially for processes to set the lower prices. we all recognize the large savings for medicare that were achievable only through the delivery system and improvements that affect all medical care. so the days of getting a lot of savings, we need to move past that. and most of these reports have had systemwide policies as well not include liability reform and the treatment of health insurance and wellness in the state initiative, we have talked about state reform guided by spending targets for each state. including the core of the affordable care act, although some propose changes in medicare payments, and other provisions

that are not part of the core of the affordable care act. none of the proposed medicare premium supports and this includes taking things on at this point. many of the reports did not offer concrete steps to achieve goals for fee-for-service and many other ports said we want 75% of payments to be from methods other than fee-for-service by the end of the decade. so how do you get that? those reports are silent. and so for those reports that we didn't specify did specify how to get there, they tended to be provider payment incentives and some talked about a permanent sgr fix, including some of the incentives for physicians to get into integrated and coordinated

delivery systems. in this includes the acl in medicare. and this includes shortcomings, which particularly in the absence of beneficiary engagements, this includes the second-generation ceos moving away for a fee for service. many talked about the redesign in medicare benefits. all of them talked about a unified benefit structure at least from the perspective of the beneficiaries. in this includes copayments for physician services and please be

politically realistic in the distinct financing for medicare part a and medicare part b alone. basically asking the actuaries to be created. including spending with a different trust funds. also remember the reports to discourage overly comprehensive supplemental coverage. and this includes the medicare eligibility. in this includes the process and this includes spending and

equality to go along with it and want to talk about the tax treatment of health insurance and a lot of people don't think too much about it and don't even realize that the tax that begins in 2018 is not a baseline. and we need to talk about changes from the baseline. in this includes more long-standing approach about having limits on the exclusion of employer contributions for employee compensation. and some of what we saw in these reports could be designed for greater proclivity than we had under the cadillac tax and the

other in advantages are capping tax benefits rather than capping premiums which the tax appears to be doing. and also the affordable care act which really starts later in the decade, it is seen as pushing providers forward and also i think the new reflections of federalism. we have had medicare block grants for a long time and now we seem to be thinking on both sides about using shared savings approaches for delivery reforms in medicaid programs.

and one of them is the rudimentary state of innovative payment approaches now and this is very early in the game. and there are concerns that a second generation may be needed soon. and also there is a lack of providers to succeed on the reform payment approaches. another obstacle is the importance of consistency by payers and this has some degree of coordination and it is a fast article that was written about a month ago and this includes the pioneering acl and this is a

demand-side approaches that is an obstacle in this includes the supply-side approaches as well. finally, the polarization. this includes a resolution of entitlement cuts in taxes, holding up action on health care costs. and we are optimistic now with this initiative where they are all working together to fix this. i think the fact that they are fixing this in isolation as part of a broad reform. and this includes much harder to be able to do it this way. and i think we will be much harder doing it now as part of

the broad process. even though there is a lot of agreement in the consensus in the concrete steps so thank you. >> thank you, pa. >> george directed the health policy program and at the office of management and budget under the clinton administration. >> i would say the proposals do tend to have a vision of where they want to go in this balsa,

they tend not to have a concrete roadmap and it is this roadmap, we need to construct it in ways that work for heterogeneous providers and are mostly private health care system. there are four groups in the u.s. health care system today. >> those that are trying to make the transition is part of fee for service. in this includes different reporting requirements and those

that are willing to make the transition don't have this where they are. ..they are worried about being left behind. they are worried about getting ahead of the payments, so they are sacrificing revenue without having new payment to make up the difference. finally, there are those that are opposed and will fight to hang on until they retire. job is to make -- help the good guys. frankly, it is not clear to me the new policy is required now. n re may be more noble --

nhattan hit geneproj use. charge, which there is no danger of happening, i would assemble a team of advisers to work out a map to give away as a public good. if you think about the medicare fee schedule, it is essentially a public good for every plan in this country. they all use it. we need a new way of playing -- pay. why not devote resources to that roadmap for us all? i love the are that so many -- there state employees that have a big chunk of buying power. states, all payer claims databases and some nimble antitrusts could be key tools. medicare must be. it is the biggest buyer.

it can only lead if the private sector will go where it wants to take it. there is a public and private ownership. shared savings with states are simpler. they are good ideas. it is heartening to see so much support for that across the spectrum. event, rewarding states for symbol metrics, like improving quality performance, is a good idea. the fix, as paul said, is a good idea and the challenge. in town see everyone agree, it is stupid to continue this policy. paying for it would have been a lot easier if we had been able to lease it in a bigger deal. one want a condition to fix a payment model. that will ultimately make

service was attractive overtired. if you think about it for five more seconds, that is not much different from what we're doing now. the trick is not the formula, but the willingness of congress to enforce the attractiveness over time. to make the transition to these alternative payment models, we must know what and how we want to pay the good guys. think hard about who are the good guys. are they the people who just adopt the alternative payment model and do not control cost or are they people who control cost i pointh the service? out that the vast majority of our patients are using this service. shared savings as key complements the payment. bundling, as much as i like it -- it cannot be done on much is spent at the moment. nor is it likely to be done anytime soon. the point is, it will be with us

for while. that is why we have to get the code relative to procedure codes right. we all know which stretch and then needs to move. i ask you this question. is the medical profession ready to do this? that policy,ld say if anything, has deferred too long to the ama dominated committee. we should blow that up and give the other group. giving medicare enrollees is a , they use networks should have been part of the original rollout. it is coming. that is financial incentives for a tighter network. look at these exchange products and how many are limited. it is definitely a portent of

things to come. so many proposals mentioned doing something about medsup. it is interesting to me that all thehose proposals restrict kind of policies that can be sold. rather than taxing the product. as an economist, i will tell you that you can structure taxes to drive people where you want them to go. without denying the right mutually desirable products. that is, by definition, being sold today. denying the right to sell my opinion is risky. in today's climate of hypersensitivity to freedom being taken away. the absence of the premium support and proposal is not shocking. it is too bad. that is clearly on the table and congress. represents is a

major strategic choice. we rely on health plans to enforce spending limits. the government separators are key. or depending on providers to respond to public and private payment reforms. in other words, do you want health plans to run our system or do you want providers? in my opinion, our country is large and diverse. each will lead in different parts of it. the question is, who will set and enforce the discipline of the target global cap rates over time? matters to me that no what, we need government and private affairs to incentivize providers to hit socially desirable growth rates with high risk payment mechanisms. i have always been confused by those who hate ipab and hate medicare vouchers. take a deep breath and step back. they are after the same thing.

holding health spending per capita to something close to gdp growth per capita. there is a dispute over the growth of level of benefits. there is a difference in who bears the risk of failure. beneficiaries -- but there are way more and comment than the antagonist have admitted. our debates would be more honest and more productive if we analysts could help them to see the essential similarities in the indications of their proposals. the cadillac tax simply taxes the exclusion. there are examples of where they were nonstarters before anyone had heard of the security act, much less the aca. i agree with paul. i spoke with self-insured firms last june. their ceo clients already directed them. make sure that we do not pay the cadillac tax.

six years before they come into being. that is a hugely perp -- and packed full provision. provision.ull judgedance can be fairly against objective standards. until then, we rest the same kind of -- it seems to me that the biggest political barrier is sustaining the lower cost growth. what will the savings be spent on? deficit reduction or coverage expansion? the aca answers the question in one way. they were not coupled with a long run fiscal balance agreement. a long-run fiscal balance agreement was resolved on its own, because we did not yet have an aca. now we do have an aca. it seems to me that the aca supporters ought to give firmly behind some credible version of

a long-term disco balance agreement. maybe this little, but important agreement that congressman ryan and senator murray have worked out is the first step toward that. is final point i would make that i was very intrigued by how many proposals talked about these taxes. what are these taxes? maybe this would relieve the split. conserver's hates sin. but they hate taxes. it has always been a good reason to do this. social economic status of smokers says it is a tax on the lower income. unless you give them access to effective ways to end addiction. it is that kind of trade-off. thank you very much. >> thank you, len. before we turn tour last figure,

i want to remind all of our viewers that you can submit questions that we will pose to our speakers through twitter. you can do that by sending us a .irect message on twitter also, if you are in the audience, you can use the microphone. if you want to get your questions ready now, you're welcome to write them on the green cards and our staff will pick them up. to the faculty of the harvard kennedy school of law -- government. she has a long list of credentials that you can find in your packet. she spent most of her time in washington working as chief for bob dole. she also worked on the staff of the senate finance committee and spent time as secretary of the senate. she is going to talk to us about

the accessibility of the major compliments of various proposals. sheila? >> thank you. really, my congratulations to the commonwealth unto others, who did a spectacular job of bringing folks together. paul essentially did an array of what it is that was out there in terms of per postal. he gave us an opportunity and a way to find where there are areas of consensus. there is an opportunity for us to build upon the work that was done in the past. kudos to commonwealth and others to purchase abated in that process. suggested, i am being asked to give you a sense of what i think the political realities are of what has been put before us. i would also note that the cbo has recently put out their ongoing health-related options for deficit reductions.

that is always an opportunity to look at how the look at these issues and think about the savings that would be accrued. there is certainly a host of proposals out there. i would like to step back, if i can, and reflect on the part that rachel mentioned and what paul has described as the building block for what i think we might see going forward. there might well be an opportunity for consensus. having been a staff member of the senate finance committee for a long. of time, and on the senate staff, i have to think of what occurred yesterday. very positive a way, not as a negative that they failed to do the paid -- i think what it showed, and what was le,,ioned by senator do who commented that it was nice to see bipartisanship.

what we saw in the finance committee, what we saw on the ways and means committee is the beginning of a conversation that began a number of years ago. we're coming back to it. that is refocusing on the programs. we're refocusing on the elements, which both sides of the aisle have the opportunity to look at and discuss. we have already found a number of common grounds. i think this will carry over into next year. what occurred in the ways and means committee is the number of -- beginning of that conversation. it will take us into the new year. we will be able to look in greater detail at what occurred to what has not been identified. the absence of that at this early work does suggest that there is a willingness to take on some of the hard challenges. i think that there is a very positive movement forward in

real looking at this program and the changes that could be made. i think that rachel, and some of her summary, and much of the work that paul did, did identify common themes. there are payment changes and moving away from the provider cuts. we have seen though so recently. there are broader questions too. issues around value. value versus volume. it is really a broader conversation about what we do with payment incentives and programs. a clear focus on quality. a clear focus on metrics and performance. again, something that has been coming for some. period of time. some are more ready than others to engage in that. somenk that engaging is reflection of that.

putting clinicians increasingly in charge, to one of lens points, there has been a long- term sense that much of what is occurring is up to the taxpayers. we drove it as public payers or private payers. there's a clear interest in figuring out how to incentivize physicians to become more actively engaged in the broader management of what is occurring in the systems. not simply in the silos that we have seen in the past. i think that timing is always an issue. the changesagine that we have seen in the aca that play out over a long. period of time. readiness that was pointed out is very variable. the opportunity to analyze data

and use it to drive change in behavior to try to drive a certain kind of behavior on the part of the clinician. the access to that information. how it is utilized and by whom. that clearly is an issue that varies across the country in terms of how organized systems are. some are more readily able to access that information. they utilize it in organizing their systems. there are those who are trying to make that transition. they want to access that kind of information. but it carries. certainly, bundling. it is limited to a limited number of circumstances. the concepts behind that is really about how we break out of the silos and begin to look at the full continuum of care. the opportunity to look at what happens pre-admission, during an admission, and post-admission. theink that traditionally, payment systems have encouraged

those silos to exist. now, through bundling and other efforts, what we're looking at is an interest in looking across the entire system. that obviously creates some real challenges. some of those relationships do not historically exist. whether in the postacute environment in nursing homes or other facilities, and home and community-based care -- but there is now a growing desire and need to understand how to help that patient manage. how do we create a payment system to do so? certainly, the movement, whether through acos or other organized systems of care, the problem is that there is not a single answer. we heard in yesterday's discussion that some of the unique problems that exist in rural communities -- you essentially do not have the number of providers available.

as we look at what has been ingested in the proposals before at, we have to look provider differences and has to be recognizing it it will not be one solution. there is an importance in the federal and state bishop, bipartisan,at is and that is the understanding of the value of the role of the state, how the state can incentivize behaviors. the state can have authority, orther in insurance regulatory environments. the adequacy of networks is something we need to look at, certainly with respect to workforce. the demand on primary care, the increasing number of people coming into the system will put pressure on it, so as we look at incentives to create more opportunities or more providers in those environments, near and dear to my heart is there a role of nurse tactician errs and whether they can practice to the nursextent of their --

practitioners and whether they can practice to the full extent of their education. also team-based care. how do we incentivize those kinds of things. there were a lot of allowance proposals we looked at and in the work that takes place that provide an opportunity to move forward, but there are take differences, and it would be foolish to ignore them. the budget and the concern about the deficit -- how we focus that on the health care programs, knowing they will be caught up in a broad conversation about taxes and the entitlement programs. the lack of readiness on the provider level. the, clearly wide, and i think both parties will approach that differently, depending on what they are hearing from constituencies. the opposition to demand side proposals, as paul noted. no question, resistance to increased exposure for

beneficiaries, but on the other side concern about how you get skin in the game, how you begin to have people pay more close attention. the issue around medigap coverage is one of the issues, how do you encourage to discourage the purchase that covers the first dollar, do you otherwise try to incentivize their behavior in terms of decisions and choices. the politics of these discussions inextricably inked to the tax discussion. in the did not see finance committee, we did not know anything about tax extenders, which will come out in the course of next year plus discussion on a broader tax debate which made back the broader entitlement debate. varying demands from payers and payer systems. the lack of consistency among payers and the way that providers have to respond. essentially require certain kinds of behaviors or do you leave the open market system as has been suggested? how do we incentivize the states?

one of the issues we have confronted in the medicaid, medicare discussions is how do you encourage states in the concepts of who is a little when the savings accrue at the federal government cause of the acute-care sign the program? how do you get states flexibility and ownership of those decisions, but essentially achieve a broader set of goals? the roadmap, as suggested, i think len is correct, there are those who are ready who have the are trying,ose that those that are willing to try, and then there are those who are , hell, no, not until i retire. the politics of the provider community, internal to the house and the senate and the discussions around the aca which have come located that will make some of these issues difficult, but i believe i have to say a glass half full because what happened yesterday gives us the basis on which we can move

forward and refocus on the programs and their future. i would say closing, the other thing we have not touched on to date, but i think we must touch on is the federal government is a purchaser in a variety of ways. medicare, and kate are not the only ways. whether the tri-care program, all the other systems, we have to move forward in a comprehensive and consistent way in terms of the way we organize finance and incentivize the haters on the parts of all our systems, and those systems which have their own politics have to be brought to the table as well. >> great, thank you, sheila. while folks are getting their questions ready, i will ask the first question. this has to do with the concrete nature of some of the proposals that are on the table right now. panel asike to ask the specifically about spending caps and targets. the way the proposals are set up, would they really come into play?

sense of the proposals is unlike an sgr, where the spending caps drives things, the approach that these proposals took the spending caps that they were a act up, and they were therefore cbo. what is different is they were laying out concrete policies, which, if they work out, should keep spending below the cap, and the cap is a act up. even as a backup, the notion would eat that if it is triggered, the response is not a mechanical reduction in payment rates, but a ramping up of some of the policies that were designed to lower spending. >> i think paul is exactly right. i think experience with the sgr has caused people to be concerned about the role of

cats, however they are constructed, how mechanical they are. we have seen in fact since the continuedof the sgr, pushback would occur. in designing any kind of a program like that, the question is how credible is it, what is the result of it, and in fact, it is a act up or mechanism that automatically comes into play, and how that decision is made? people has resulted in being cautious about how those are constructed. >> let's start here. please identify yourself. >> hi. the differentsed, proposals that have been presented today. i am interested in comments on which ones are most elliptically feasible and also would give us the biggest bang for the buck, if people could comment on two or three that you think would meet that kind of criteria.

i will take a first stab at that. i think -- and i would like to hear the comments from the other panelists, from the commonwealth fund's perspective, our take of looking at all these comprehensive proposals was to identify the areas where there was the most agreement and more common focus and similarities in approaches. i look at those as possible areas for a path forward. havethink, you know, we talked about many of those areas that we think and to be pretty promising. the movement from a way from paying for falling to paying for value, this widespread agreement, has the need for more consolidated and aligned quality measures. i think the directional movement

on price transparency from all those -- many of the areas change. that was really the goal of. the project is to identify the main areas of consensus so we could go a little bit deeper and that groups could work a little bit more closer to the ground. but other folks might want to talk specifically about individual proposals. not as a sympathizer of reports, but as an analyst of health care, i believe proprietor payment reform has some of the greatest potential to really move the dial. i think that is worthy of a lot of energy on the part of the congress. is thathe key things you have to have a link between andficiaries or enrollees the organizations such as the o. that is trying to

deliver more efficient care. without this link, that limits it. were part of the bipartisan policy center, and the formmended enrollment model beneficiaries, where they get incentives to enroll, and we did not call them aco's, we call the medicare networks, which i think paved the way for more success, prods,o used the the incentives of favoring the providers in that network. >> i would add that i would say none of them are going to pass as they are written. nothing ever does. what i would look to and is precisely the point of the exercise, look through what is common across them and there you see the things with traction. i would totally agree that payment reform or basic incentive realignment with

market-based tools like transparency and quality measurement and so forth, that has the most legs and i think the most potential for a bipartisan agreement going forward. >> i would agree with all my colleagues. i would add one element, and that is the question of workforce. i think there is not that growing understanding of the need for team-based care and a more collaborative environment rather than it being driven by in this case decisions, in most cases. but an investment in primary care, an investment in a essentially incentives that create these teams so that essentially when we approach a patient we look at them across a broad array of services. we increase access to services. i also think the emphasis on moving people out of an acute care setting into a home-based or community-based setting, the investments in essentially

developing those assets and people that can care for folks in those environments and making it again to a payment system that rewards essentially that kind of coordination. i think there is a fundamental agreement and understanding of that, and how that plays out state-by-state will be somewhat different, but i think there is commitment isng certainly do those things and that will change. >> if i could say one more thing price-- ritual brought up transparency. the point i want to make is -- ortransparency can be transparency in general, really, can be a very useful tool as an adjunct to something else. it is really as an adjunct to different types of benefit designs where there are are incentives concerning which provider you choose. be an adjunct to the front network type approaches. if you want the beneficiary of nrolle, to get a sense of what network they feel

most comfortable in. transparency on its own as a risk of snakes in its wheels, disappointing people unless is hitched up to the perhaps harder policy to pursue where it plays a supportive role. why don't we move over here, and if you could please give your name and affiliation, please. >> i'm a primary care physician. rathera brief comment than a question. you have presented here what the consensus is among a wide swath of the policy community, but it is not among everyone. the focus in these proposals is utilization, that the beneficiaries need to have to mature skin in the game. commonwealth just produced a report saying americans have more skin in the game than anybody else in any other developed c