2250 positions were terminated from medicare in connecticut alone. most of the orthopedic surgeons in dayton ohio dropped. in florida, 250 physicians from one medical center dropped. in january mr. chairman i'm sure we will discover thousands if not tens of thousands of people to their dismay that they thought they signed up for the aca but because of the glitch in health care.gov did not. mr. chairman the web site itself is in question. a web site at that as the most personal intimate questions is not have the proper security protocols to ensure the personal medical data of our citizens that are safe and secure. obamacare created a panel of 15 unelected bureaucrats called the independent human advisory board to the power power to control attempts at treatment seniors

received through medicare and according to dr. jason fullman and mr. -- or dr. david rats are this unelected body will have the unprecedented ability to single-handedly change the allocation of health care resurgence should medicare spending exceed medical inflation which for the record it consistently does. dr. novack what are your views on those ipaa i believe it's called the independent payment advisory board? >> as i mentioned earlier it's a serious area of concern. for those of us and from those families creating another new layer of bureaucracy making determinations about accessibility suspect in the right direction. i would add i think there is fairly significant bipartisan opposition to the independent advisory lord because of the way it's structured.

their decisions effectively have the ability to bypass congress. >> do you have evidence that competition and choice is a better way to increase value and reduce costs and the government bureaucracy and experts? >> 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 earh 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 certification in spite of all the improvements, a real justification for spending five times as much on health care or have we built inefficiencies into the system and if so does the affordable care act attack any of those inefficiencies? >> increases the amount we will spend on health care and i do agree it would be nice to spend less. there are enormous amount to inefficiencies in the way we deliver and pay for health care and these of long standing problems. some things about the affordable care act may address but broadly speaking it does in the other direction. >> there are a couple questions. you were at the table during the affordable care act markup, were you not? i was at the heritage foundation. >> participating in the markup. >> i wasn't at the table but

when you watch the process, word there any ideas that came out of heritage, or conservative republican groups that use of being accepted as amendments from any source and particular me talk about medical malpractice reforms such as micro. >> no. on medical malpractice, we had a different opinion than our friends in congress who wanted a federal solution that should be made in the states. >> the affordable care act barred it. >> my observation is frankly the bipartisanship ended, i could look up the exact date, in july of 2009, the day they finish to the health committee markup in the senate and in that markup

the republicans made a number of substantive changes all of which were voted down on party lines and proposed technical changes, the worst draft of all the bills that were considered and accepted and announced they had a bipartisan bill and republicans walked away because i had been working and there were things they were drafting to submit but didn't submit them. it was clear there was not going to be any input. the interest in doing something bipartisan pretty much stopped in mid july from what i could tell because the demand for me to help people drafting evaporated. >> thank you. >> judith feder, some states, quote, have much stronger requirements, general providers and the essential community providers.

the strong requirements include the following. i am going to this because the people in the panel before blamed the affordable care act for the reasons they may not be on a provider network but these are state guidelines, reasons why at the requirements, provide recovered person ratio by primary care, geographic accessibility, waiting times for appointments with participating providers, hours of operation, technological services available to serve the needs of people who require advanced care. so if there are concerns with a state about adequacy of provider networks who can consumers go to and what actions can states take to address those concerns? >> you are right lee raising that the affordable care act actually establishes requirements for network adequacy and in many areas of

the lot it leaves it to the state to enforce those requirements and we need attention to them, legitimate requirements. does fall to the insurance commissioner in the state, states have different degrees of willingness and ability to address it and we are not seeing an active enough effort and need to attend to it. >> you have decades of experience of assessing the health care system and we hope to have you on the panel but here you are. one of the most critical features of the affordable care act is expansion of medicaid eligibility to millions of low-income adults. prior to the aca it was restricted to low-income children, parents, people with disabilities and seniors. in most states adults without dependent children were not eligible. according to a study on october 23rd by kaiser family

foundation, 30% of 4 non elderly adults have medicaid coverage in 2012. under the aca it can be expanded to cover all non elderly adults with incomes below 178% of the federal poverty level. the federal government would pay the state 100% of cost for the first three years and then phase down its match to 90% by 2020. is that right? >> it is correct. >> despite this level of federal assistance, 25 states decided not to be part of the expansion leaving literally millions of their own citizens without health care. >> absolutely true. >> what is your opinion of states that refuse to expand their medicaid programs? >> my opinion of the states, i am sad and disappointed for their citizens, citizens who need care and are contributing

to paying for care through their taxes in other states that do expand. the expansion research shows from commonwealth from urban institute how much in the interest of states this expansion is and i believe it is only political opposition to this log disk depriving these citizens have access to care and the state of needed revenue. >> by not participating there leading significant resources on the cable that could be used for their citizens. >> they sure are. >> a lot of these people are getting sick and sicker and some will die. >> the institute of medicine found lack of insurance kills. floor of protection is if you are not the parent of a dependent child or disabled or

old you are not eligible for coverage in most states. that hole is a vestige of an old-fashioned welfare system that assumes these people would get coverage through their jobs. they don't get coverage through their jobs. they are left out of employer sponsored coverage and leapt out of the public safety net and that is why we need to expand s 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. of hospital administrators came and >> this same study says by esti. choosing not to expand medicaid some states will lose billions c of dollars.billions i talked to senator cruise abouf this. it texas will forgo an estimated s $9.58 billion in federal funding in 2020 to taking into account federal taxes by texas 20 residents, costing taxpayers in the state will be more than by $9.2 billion. the decision not to participate will cost taxpayers $5 billion in 2020 to. i could go on. $5 billion what will this mean to sick people in those states? one of every four has insurance.

states? >> that is where the insurance is. those people are left without access to care and are more likely to suffer and die as a h. result. >> judith feder, a unit physician? >> no, sir.ou, gen >> is medicaid financially an? sustainable? >> i yes or no? sustainable? >> it is not -- it is about long-term care in large part, o medicaid costs are growing . slowly. many low-income people. >> based on reimbursement rates is unsustainable. >> i tholought you were talking about -- y >> financially and sustainable. >> would you agree with that?fiy >> i am not a physician but i did go to medical school. >> is medicaid sustainable? >> no. >> not in present form.

expanding, it is not be there. >> 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 chasi >> i recently published a book about medicare that details in 48 pages how the reimbursement structure of the program under pays physicians for care has led to poor access for those individuals and that is leading to poor health outcomes. the most definitive outcome was conducted in the state of oregon in new england journal of medicine by a panel of the scene

health economists that should medicaid compared to being uninsured showed no improvement in health outcomes. >> to get a card, does it mean something if you don't have providers? >> you heard in the earlier panel, the fact that you have health insurance is not the same as access to care and that is a distinction be affordable care act has not understood well. >> when reimbursing physicians below market rates but, for them to make a profit, we heard the gentlewoman make the comment is up to states to enforce proper panels so we will force physicians to take fees they can't even pay their own bills? >> in massachusetts under the most recent health reform bill they considered a provision that would have required all licensed physicians in the state to accept all forms of payment, that was not included in the law but we may see more overtime, effort to do that and that would

be problematic. >> next question you are familiar with the debt coming out of a school, physicians coming out of school law > the cost of medical school has skyrocketed, >> so reducing their fees is going to help them better pay that? >> it has discouraged new physicians from accepting medicaid patients and today the surveys and studies show the percentage of physicians willing to accept new medicaid patients is substantially lower than private insurance and medicare that is increasingly a problem. overtime as states expand their medicaid problem they will face further fiscal pressures. the only real mechanism states have to keep their budgets under control is to turn down the amount they paid physicians and hospitals to care for these patients so the problem will get worse over time. medicaid expansion will accelerate that.

>> we heard earlier in the panel and earlier panel talking about patient dumping, this is like federal patient dumping onto states that jurisdiction. >> in my experience physicians already caring for a patient of reluctant to let the patient go out of a humanitarian interest but are very reluctant to take on new patients, commit to new patients under the reimbursement structure. >> put them in a harmful situation because they can't abandon a patient because it is a litigation, very ethical problems here. understanding urban and rural dictations we are really skewing the benefits. i am from rural arizona and we are seeing catastrophic access issues. in the previous administration we look at federally qualified health centers which the gentlelady didn't bring up because they do not turn away

anybody. they can't turn anybody away. that was part of the safety net. i practiced for when are saw the patients they didn't want to see because they skewed the results, took medicaid and medicare patients and skewed them and took a service fee and insurance patients and took them at a regularly scheduled appointment, very skewed results. >> we should point out what the market price would bear would really be in a free market system for paying doctors and hospitals we don't know because we don't have a free market for health care because medicare and medicaid have so distorted what the prices are for a lot of services and evidence suggests in general price of the services are higher than in other countries. >> since i gave the gentleman extra time. >> one reason we don't have a lot of family care physicians is government has skewed the process and reimbursement rate so everybody goes to the specialty.

>> every physician will say they get paid for procedures, writing prescriptions, not their time. that is what a lot of physicians like about retainer practice, they are paid for their time and can spend more time with their patients. the evolution there of maybe 2 two tier system where you have doctors treating medicaid patients who don't spend time with those patients. >> we hear this downtick in expenditures for health care do to the aca. i think it has a lot to do with the economy. would you agree? >> yes. i have written about this. in general there has been a massive slowdown driven by the global economy. also a substantial of pollution in the united states for increase in high deductible plans with health savings accounts. >> i thank the gentleman. >> i would happily yield. >> why not give the president any credit?

any credit? i hear this over and over again that the cost of insurance is going down and you are trying to say president obama and his efforts with the affordable perfect had no effect? >> as you know, the bulk of the affordable care act does not been implemented so it is improbable the affordable care act is having a system wide effect on health spending. >> i think there are two challenges and we agree law on the power of the recession and bringing costs down, but what is missing from that picture is medicare, in the affordable care act, making medicare a more efficient effective payer in terms of reductions and overpayments there may be room to go. that made a big difference to spending and the thrust of the affordable care act on the cost containment side is to move to a more efficient delivery system in many of the ways that people

on both sides of the aisle would like to see it move. that has not had much effect yet although the administration does point to the reductions in readmission rates for hospitals as already showing an influence of those policies. >> edmund haislmaier, i will give you the opportunity -- >> this gets to the core of the debate over health care. the chairman was talking about percentage of gdp. we as a country spend more per capita than any other country in the world on health care and we are pretty much across the political spectrum not satisfied with the results. it is uneven, too many uninsured etc.. i do this in my general audience talks, make the observation that what we have is a value problem. the value is the relationship between what we are spending and what we are getting whether you are buying hamburger or health care. we are paying too much or not getting enough for what we are

paying. the central challenge in health care is how to improve value in the system. ideally what you would like to do is get more and pay less. we would all agree on that. there is no disagreement on that. the problem is how are you going to do it? there are a few points embodied in this legislation that we can do this by having better micromanagement of doctors and hospitals and insurers and all the rest. the other view the i hold and other colleagues told is the way you do this is to have government limit itself to what it is competent at doing which is taking money from a and giving it to be instead of trying to run the rest of it and if you want to give be a little more money than see that is fine too but move it to a patient centered system where people can pick and choose and seek value and be rewarded for providing value. i look at the system as to folks on the other side and say milk

at intermountain health or cleveland clinic, they provide better results at a lower price. i look at the system and say if that is true, why aren't they eating everybody else's lunch? why aren't other hospitals coming to their standard? thanks to my office i have a blackberry, but they are not so good. they have their lunch eaten by apple. why isn't that happening? we are propping them up with payments. the other side says we can go into mayo and study how to do it and write a bunch of rules and tell everybody else how to do it and come out with the affordable care act and the accountable care organization. is a difference how you go about it. >> thank you. i recognize the gentlelady from new mexico. >> thank you, mr. chairman. i appreciate the panels and this committee because i am not a doctor although i have maia j.d.

thank you for your graduate work. i will tell you that i think i can be qualified as a health care expert for free -- three reasons. i am a patient. every day all the time more than i want to be, try not to be, try to do everything right, i am a primary caregiver for chronically sick mother who is incredibly complicated and i don't care what system you put her in she is all by herself, navigating and doing concierge on medicare and medicaid and imaging care and you and them care, on her own, married to a dentist, doesn't matter. it is exhausting, so complex i could spend the rest of my life explaining it to her and she is a smart woman, gave birth to me. but can't do it. i have done health care in policymaking for 30 years. here is for me what is telling. you say there is an economic

downturn, the economy played a huge role in the reduction of health care costs. cbo says the opposite. we can work every day and get experts from everyplace to give us a different opinion. we have the most complicated convoluted system in the world and the affordable care act tries to levels that in many ways but i am one of those policymakers that think we need to go to a lot more and i spent 20 years before the affordable care act before state for figuring out medicaid waivers are making changes to medicare and i watched 8 m os and provider network shift and change every time there was a profit motive to do that. every single time. i dealt with patients left out, left under, left cold. no matter how much they were privately paying for their health care depends on who you are, where you live, what is going on and you are more likely to be chronically sick or not. are you living in an urban center or not? we have to do not

1-size-fits-all, many sizes all the time. this is a great experience about many people get better care as a result of the affordable care act and get access in new mexico, the lowest rate in the country because of the affordable care act. our problem is insurance regulatory oversight. i don't think we have enough insurance companies. never thought i would say that but it is true in this case regardless of my personal opinions. is true in this case. what i am interested in is using experts such as yourself and others to think about ways because we just cost shift in this country. and what you are proposing to some degree is more cost shifting. back to the state's cost shift back to the individual, cost shift back to business, cost shift back to veterans. we have 9, 10, 11 independent systems of care that no other country has, not very robust opportunity health system, those

are the real reasons health care doesn't work the way we wanted to and i hope all three of use a dedicated, help us navigate those critical next steps because i don't think the affordable care act is responsible for shifts and limited access. it will exacerbate that in some cases. i don't think coverage means access and it will improve it. we are wise and brave to use experts such as yourself, never mean to do these diatribes that there are no simple questions and certainly no simple answers. there are not. accept that. if we don't start leveling the playing field and we don't start focusing on consumers and we are not great enough to deal with the folks who still have significant problems before the affordable care act, with the affordable care act, i pay more because of the affordable care act.

that is because i am required to go to the d.c. exchange not because i am a consumer left to navigate through the affordable perfect in my own state. it depends on the real details of those issues. i am one of those folks who is complaining and i am really glad more people are helping me help you pay for my mother's chronic care procedures every day and she is more than happy to help pay for everybody's maternity care so all gets leveraged out and county commissioner. not just medicaid. medicaid gaps are paid for by local government which is paid for by taxpayers. it is all paid for by all of us every single day all the time. so my question, mr. chairman, thank you so very much, is there a way this committee can continue to work hard to get as much valid information about what we can do starting today?

my provider network changed because every time you do a reform we open a window for somebody to legally do adverse selection and cherry picking and that is not dealt with at the federal level at all and if i was a for profit insurance co. and it is legal why would i create a network that has the sickest patients? you cannot so you don't. that is not all of the reasons that occur but make no mistake there is no buddy here, any panel -- that is not part of the reason but it always happens. thanks for being here. thank you for my diatribe. i feel great today. i will get my pins out of my finger and try not to be one of the expense of high end users of health care no matter what i do. thank you, mr. chairman. >> i thank the lady from new mexico, hope you would sign on to the bill after listening to

you. one of the things you have to look at is the least common denominator. >> thank you. i want to go back briefly, not asking any questions, just giving a statement. september 9th, 2013, cbo director envision the paper to slow down health care spending. multiple sources, health care spending slowed dramatically across the country. slowdown in health care costs growth has been sufficiently broad and persistent to persuade us to make significant downward revisions to our projections of federal health care spending. goes on to say cbo found relative to a 2010 baseline projections through 2020,

medicare spending is 15% lower than projected, medicaid spending is 16% lower than projected. private health-insurance premiums are 9% lower than projected and goes on to say the paper made clear these reductions and listen to this are apparently not because of financial turmoil in recession but other factors affecting and this goes to what you said, the behavior of beneficiaries and providers and with that i say this. a witness said we have to fix it. chairman darrell issa talking to one of our colleagues from nevada said there are things we need to do to fix certain parts of this and we have to. we have to get this done and get it done in a way where there is a win/win/win/win and i do

believe that is possible land again coming from having travelled 20 hours on a plane to go to nelson mandela's memorial i got to tell you i left saying to myself we are so fortunate in this country to be where we are, we can accomplish anything, we just have to put our minds to it. someone once said it is not the people who don't know what to do. it is whether they have the will to do its at and again i want to thank you all for your testimony, extremely helpful and we are going to go forward. >> i thank the gentleman. i would like to ask the gentleman question. do you believe the actuary for centers for medicare and medicaid? >> give me a specific question. >> would you think they are spending under oversight of spending would be more deliberative and more accurate than cbo? >> one thing i do know --

>> the deal with it every day. this is their due diligence, actuarial deal with numbers? >> i quote what i just quoted. coming down according to cbo, the reason i got a little upset a few minutes ago, mr. chairman, i appreciate your question. it seems this president gets no credit for anything, nothing. over and over again, when everything goes well, must have been a fraud. it goes bad, it is his fault. the fact is there is a lot that can come out of this. we need the will to get this done and we will get it done. >> back to my question, the actuaries at the centers of medicare and medicaid services who do not answer to the white house said yesterday in journal health affairs that the cost of the economy, not obamacare,

would you agree with that? >> i would add i am an admirer of the president. of the affordable care act is successful in achieving its stated goals i will be absolutely thrilled. my concern is that it will not and my obligation to let the committee to pay the concerns that i have. >> i want to answer in fairness to you. dissenters -- they also said this the centers for medicaid and medicare and medicaid services, report finding that national health spending has slowed to 3.9% in the years -- this represents the lowest growth rate in health care spending since government began keeping these statistics in 1960. >> so i am fair about this i can tell you, dentistry didn't sell to the federal government for

the most part and there are problems but the problem is expendable money that you have at leisure, we have seen it go down. to buy increase care, or to invest in your health care. i personally, am powering patients, that is what nelson mandela would have wanted, and powering patients, not to make in cripples the to the entrepreneurs and cold on to their health care and demand the system benefit them. patient friendly, has to start and that is not what is included in obamacare. it is the government dictated centric relationship. i want to see the patient benefits and be empowered not to be a cripple. i want to comment, thank the witnesses -- we will adjourn this meeting. >> this weekend on newsmakers

appropriations committee chairman rep 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 thursday, the senate will vote on the deal next week. you can watch newsmakers that:00 a.m. and 6:00 eastern on c-span. >> let me be clear. this is a delicate diplomatic moment. we have a chance to address peacefully one of the most pressing national security concerns that the world faces today with gigantic implications of the potential of conflict. we are at a crossroads. we are at one of those hinge points in history. one path could leave and to an enduring resolution in

international concerns about iran's nuclear program. the other pets could lead to continued hostility and potentially lead to conflict and i don't have to tell you these are high stakes. >> this weekend on c-span secretary of state john kerry on why house members should not impose additional sanctions against iran. as talks continue freezing parts of iran's nuclear program. watch this morning at 10:00 eastern on c-span2's booktv, dick cheney and his longtime cardiologists talk about the former vice president's history with heart disease and recent events is in cardiology tonight at 11:00. and on c-span3's american history tv the free african american men and former slaves who fought for the union sunday at 11:00 eastern. >> i wish you both very happy christmas and a bright and prosperous new year.

>> up pleasure to be here and to have the sale that begins on thanksgiving day by this year. >> would you mind forecasting some of the christmas seals as a special favor for santa claus? >> of all time. >> one of the things that i do best. >> it is wonderful. >> yes indeed. >> my father, santa claus, gave it to me. >> some of the dog's heritage. >> first lady's influence and image season 2. next week edith roosevelt to grace coolidge, weeknights at 9:00 on c-span. >> next senate judiciary committee chair patrick leahy address human-rights and remarks

at the museum in washington d.c.. the speech coincided with the 65anniversary of the signing of the universal declaration of human rights which was adopted by the u.n. general assembly in 1948. this is 25 minutes. >> please come on in and make your way to your seats. one of the things you will learn about human rights at this summit is what an amazing board we are blessed with and it is my pleasure to introduce another of its members, james ziglar who has had four decades' experience in public policy, management, finance, law and academia. no stranger to historic moments. he started his law career as a clerk to supreme court justice harry blackman in the 1972 term. when he rode the landmark roe vs. wade decision.

30 years later president george w. bush appointed jim commissioner of the imf. that was weeks before the attacks on the timber eleventh. he served as assistant secretary of the interior in the reagan administration and as a sergeant in on that the united states senate. he was president and ceo of cross match technologies and currently a senior fellow at the migration policy institute where he focuses on u.s. immigration policy, border patrol and security initiatives. as a board member of human-rights first we have been incredibly blessed with his wisdom and expertise which have been invaluable to us in navigating complex political challenges. join me in welcoming board member james ziglar. [applause] >> thank you for that very kind and generous introduction.

it is -- excuse me -- a particular pleasure and honor for me today to introduce our keynote speaker, senator patrick leahy from the great state of vermont. it is a particular pleasure because i consider patrick leahy to be a good friend and for all of you out there who were doubting thomases it is possible for republicans and democrats to be friends in washington today. didn't say it was easy, i just said it is possible. but it is a special honor to introduce senator patrick leahy because he is a real honest to goodness champion of the cause that brings all of us here today and that is human rights for everyone everywhere and in fact without reservation, and i suspect everyone in this room will agree, there is no greater

champion for human rights in the u.s. congress and our friend patrick leahy. is determined, indeed, historic and heroic work to advance human rights is too expensive for me to detail and give him a chance to talk also. and i will talk about two or three of his large public accomplishments. before i do that i want to mention i had an opportunity on the personal level to see his work up close and as patrick leahy knows the sergeant in arms of the senate has to keep an eye on these guys. i observed him up close and i can tell you as commissioner of the i n s if you choose to ignore patrick leahy on an immigration issue you do at your own peril. i can tell you patrick leahy does a lot of things that are

below the radar screen that make a big difference in the lives of a lot of people who would otherwise fall through the cracks. he is not a show horse. he is a workhorse. patrick leahy as a longtime leader in the international campaign against land mines, 1992 he authored the first bill of any government anywhere to ban the export of these horrible weapons, spearheaded the effort in congress to aid victims of land mines by creating a special fund known as the patrick leahy war victims' fund and that fund has an on annual basis, $12 billion of aid to the victims of these horrible bombs. in 1997 he sponsored historic legislation appropriately known as the patrick leahy law which prohibits u.s. department of

state and department of defense from providing military aid to the foreign military and police forces that engage and violate human rights. it never stops on beating on an issue central to our mission at human-rights first and that is protection. he is the chief sponsor of the refugee protection act which would eliminate useless turtles that prevent persecuted refugees from receiving safe-haven. we have also teamed up with patrick leahy to fight for counter terrorism problems, counterterrorism policies that respect human rights. in 2009 he called for the creation of an independent commission to investigate our own government's use of torture in the post 9/11 era. that hasn't come to pass yet. patrick leahy has a strong record of success because he is

both a determined pragmatists and an idealist who is less interested in making a statement than in making change and frankly he is willing and able to work with republicans on human rights and a whole bunch of other issues. he and marco rubio are in the process of trying to get the reauthorization of the trafficking victims' protection act. i want to close by sharing a little secret with you. patrick leahy is now the longest serving u.s. senator and president pro tem of the senate. but don't tell him that. because he thinks, and i think all of us in this room know that it is true, that he is just getting started. ladies and gentlemen, i hope you will give a warm welcome to our

keynote speaker, the hon. patrick leahy. [applause] [applause] >> thank you walt, thank you all. thank you. thank you for that wonderful land not totally deserved introduction but i will accept it. james ziglar is one of the finest public servants i have known in either party and when he came in here when he was sergeant in arms of the senate, he set the gold standard and everybody else followed after that, the best interest of the senate, comparison what was best for the senate. it was great to see you.

we had a chance to get caught up not only in our connections to vermont, most people don't realize a name like patrick leahy, my mother was first-generation italian-american, we compare some of our relatives are from. and of course human-rights board members made all of this possible. what you are doing is so important, in some ways it is a convergence here, but i have long been an admirer of human rights first and the committee for human rights before that. what you do every day helps all of us. your research and advocacy has certainly been extremely important, some of the legislation i tried to pass, let me talk to a few topics, and encouraging you'd, don't stop,

keep doing what you are doing. it may seem obvious that this is central purpose of it, it needs to be said. we are here because each of us feels, each of us feels a responsibility to depend on fundamental freedoms and principles, what we regard as universal, which are often violated or denied by the very governments whose responsibility it is to protect them. we know in the history of the united states we have seen groundbreaking human-rights leadership, and tragic failures. the bill of rights, what a monumental achievement, inspired the universal declaration and the freedom that we find enshrined today in constitutions, the more recent events that we see in support of

people with disabilities, the l ddt community, immigrants, these are examples of what we can accomplish if we persevere against what is often longstanding prejudices. i am encouraged by recent efforts in congress to further support those who need help with improvements we made to the violence against women act, trafficking victims' protection act, and arrangements we accomplished so far in the senate in a comprehensive immigration reform. you might say in areas occupied by the senate, i am so pleased that you will be honoring my friend bob dole this evening. i was there when bob was republican leader in the senate, a man of integrity, his leadership and passage of the

americans with disabilities act morrison two decades ago, this would not have happened without bob dole's leadership, a great milestone in human rights history, and to see the ratify the rights of persons with disabilities, deserve our gratitude and raise. if we had more leaders like senator dole, leaders who are willing to put aside any kind of petty political differences and find common ground for the nation we would all be better off and frankly i miss leaders like that in the senate and house. we are complementing ourselves, let's not forget lot of examples for the united states fell short of the it as we saw in the declaration of independence, the internment of japanese citizens during world war ii, that is

really something in history. and was upheld by the u.s. supreme court. and the fact the we have been unable to close guantanamo or end mass incarceration. these are not the bright lights of our history. a few days go by when we are confronted by a significant challenges to our standing as a global leader on human rights. some of these are due to external forces. some unfortunately due to our own mistakes. 1997, i wrote what became known as the patrick leahy law. i had no idea what impact it might have. tried to explain, and i thought we will see. i did note -- provide training

and equipment to security forces and murder innocent civilians. you would think this was something we could easily all agree upon as americans. it happened many times where we had given aid to a country, to murder and torture their own citizens. that was wrong. it contradicted everything this country stands for but also undermined our standing as a global defender of human rights when people could say look what your age is doing in this country. under the patrick leahy law which would cut out that age, is the most effective tool we have for drawing a clear line between the united states and those who commit atrocities but also for providing an incentive for foreign governments to hold abuse of military and police officers accountable. what has been on the law for a

decade and a half, some officials in our embassies have not enforced them vigorously. and to explain the patrick leahy law is the patrick leahy law. it has to apply in every country where we give aid or turning our back on american ideals. let's start enforcing it everywhere. here we go. [applause] >> don't give me any excuse the we will make it the better if we give -- give aid to people using it to torture. that violates everything we stand for as americans. if you implement the patrick leahy law you need the sustained participation of a similar society here and around the world and everybody in this room. we should feel just as strongly

about defending human rights activists whether they are in egypt for russia or sri lanka or china war vietnam or any other country who are persecuted for peaceful expression or association, or religious beliefs. these are rights that we americans take for granted, writes in which we take great pride. we should hesitate to speak up when those rights are violated anywhere. our country or anywhere else. i have met some activists as many of you have who have been subjected to brutality, isolation, torture. i am awed by their courage. i am awed by the fact that they never give up. we have a responsibility to support them. when you are in prison, democrats and republicans set aside party labels, join together and work for their

release and here at home we have yet to fully recover from the effects of 9/11 attacks, we continue to mourn the horrific losses of innocent lives on that day. we do remain vigilant against the threat of future attacks. as americans, we should not ignore the damage done by some of the practices and policies put in place after 9/11. before 9/11, i doubt if any of us could have imagined the torture members of congress in both parties have condemned when used by repressive governments would be defended by top u.s. officials as a legitimate practice in the twenty-first century. we must never again allow torture by our country to be cloaked in euphemisms like

enhanced interrogation techniques, or justified by legal analyses that goes totally contrary to the moral core of our country. and we should put an end to the indefinite detention of suspected enemy combatants and the use of flawed military commissions and open ended global war on terrorism. we have spoken out so many times about the indeterminate detention in other countries how can we justify it in our own? frankly there is no justification. [applause] >> hi phil, i said this to various presidents, the indefinite detention of prisoners in guantanamo, contradict our most basic principles of justice, the great international standing as a

champion of human rights and rather than helping our national security it has harmed it. countries that respect the rule of law and human rights cannot law the way prisoners indefinitely without trial and without charge. we condemn the countries that do it, we should not authorize it in our own country so i am heartened by the incremental positive changes this year's defense authorization bill, we have to do more to ensure that guantanamo is closed. i greatly appreciate human-rights advocacy to close guantanamo. let's remove this blight. [applause] >> and continue your work on the

question of drones. drones can be used in armed conflict but only in accordance with international humanitarian law in. the united states free years conduct lethal operations using drones in pakistan, afghanistan, and yemen, some of which killed winded innocent civilians. i remain concerned about the lack of transparency concerning these operations. the use of signatures strikes, it raises a serious question whether drones comply with the international humanitarian law, and rejoined them as you continue this precedent for the rest of the world including other countries with terrible human rights records, we ought to be as transparent as possible about it and weather they are

used following international law. i would suggest here today, maybe it is time to look again at international law in this area and maybe it is time to have some kind in the of it and some changes. i did like to see that. sell -- so i never hesitate to criticize foreign governments that allow heinous crimes go unpunished or punish peaceful expression and other fundamental rights, so too i criticize my own government when it fails to live up to the standards we demand of other is and what the expect of us. let me use one area. i think of the international treaty banning land mines and i think of the continuing trend of innocent civilians becoming victims of war. the vast majority of people

harm, injury, killed by landmines are not combatants, they are innocent civilians, children, parents, mothers. the land mine treaty to ban the use, every nato country save one has signed it. and that one, the most powerful nation on earth, the united states. that is not the leadership by expect of my government. the clinton, george w. bush and obama administration have not blamed, they have isolated the united states on this issue. i asked what kind of message does this send the rest of the world, this lack of leadership? we ought to just sign it. we spent hundreds of millions of dollars removing land mines around the world, use the patrick leahy war victims' fund to help land mine victims around

world, what are we afraid of? another law says we cannot export land mines, show the courage, only take a little bit to go forward and sign the treaty like every one of our allies has done? is that so difficult? in conclusion let me tell you. on november 22nd we remember the great loss this country suffered 50 years ago when president kennedy was assassinated. drove down here and remembered my wife and i standing on this corner watching them go by, hundreds of thousands of people on the street. it was so silent, you could hear the drums and the cortege left whitehouse. you could hear the click in the street lights as they changed.

you could hear the horses and the drums as they came up pennsylvania avenue. thinking about that a lot in the last two days, we talked about it a lot and what it felt like as two youngsters standing there. one of the many markers president kennedy said for us in his memorable inaugural address, spoke of the unwillingness to recognize or permit the slow undoing of those human rights to which this nation has always been committed and to which we are committed today and around the world. john kennedy in his inaugural address, lost 53 years since then. i believe his words are even more relevant today. the most important things we can do for our country, asked us to

do back then, to continued to reaffirm, a poll that commitment, and doing so, help the rest of the world. frankly the american people have expected no less. my children and grandchildren expect no less. keep on working on this and i will be there to fight with you. thank you very much. [applause] >> this weekend on newsmakers appropriations committee chairman rep 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 the plan thursday and the senate is expected to vote on the deal next week. you can watch newsmakers at

10:00 a.m. and 6:00 eastern on c-span. >> you are watching c-span2 with politics and public affairs, weekdays featuring live coverage of the u.s. senate, weeknights watched the public policy events and every weekend the latest nonfiction authors and books on booktv. .. >> gigantic