think, and i'll speak a little bit, if, the title is, about provider and provider networks we need to look at, this is not about us, right? it is about how do we get the maximum number of people the best personalized health care we possibly can and the practical reality is our large group employs 500 people. >> with all due respect, my question was, are medicare and medicaid reimbursement issues issues that the provider community were dealing with prior to the obamacare affordable care act ever becoming law, yes or no? . .

>> this isn't about creating a new washington system to how to figure out how to pay people to provide care. this is much more broadly, about how do we establish policies to allow patients and families to remain in control of their health care and health care decisions. so -- >> so why did you guys bring up the reimbursement rates under medicare and medicaid as one of the reasons why there is this lack of adequacy of network -- >> i would say -- >> -- providers within some of the plans? >> i would say it is one of the reasons. >> okay. >> so it -- >> so if the congress could help address the reimbursement rates and reform sgr, would that help

or hurt the process? >> i think it all depends on how it's done. and, again, i'd refer you back to the position of the obama administration who said in a court filing this year saying there's to general mandate under medicaid to reimburse providers, including hospitals in that, for all or substantially all of their costs. so the position of the -- >> medicare, sgr is focused on medicare. >> but i'm just saying -- >> it's not the same thing. you're giving me a reference that's not my question. my question is on the sgr which is largely the basis for how reimbursement rates to doctors are established by the privacy insurance companies -- private insurance companies. >> i think that things would be improved if there was not an annual uncertainty every year for us to say that on january 1, 2014, we're getting a 25% cut. so we tell our patients that under those conditions we cannot continue to see you, so we have to decide if we're going to be

willing to see medicare patients until congress chooses to fix the problem every year. >> so if the congress worked to fix the problem with the lack of reimbursement to cover the cost to the providers providing care under medicare and medicaid, that would help, not hurt, correct? >> i think it would make -- it would, depending upon how it was done, it might help, but there's always a policy that new policy -- possibility that new policies could not be helpful. >> well, today, later today we will be voting on a budget deal that includes a rule on the sgr extension for another three months. not reforming it, not increasing the reimbursement rates like doctors in my state of nevada want us to do because they're not covering their costs, it's just extending it for another three months. so i would just hope that at some point in the government reform part of in this committee we would work to bring forward those bills.

i have signed letters with my colleagues on the other side in favor of these reforms. i'm prepared to work on legislation to bring these needed reforms forward. but instead we're having, you know, p kind of these dog and pony kind of show hearings that don't get at any of the real reforms to make the law work better or to the address other issues that are unrelated to the law. medicare and medicaid reimbursement issues for doctors were a problem before obamacare. before the affordable care act was put into place. and so to somehow suggest that it's because of the obamacare that these issues are happening is to fail to recognize the history of the problems in the health care system to begin with. >> would the gentleman yield? >> no, mr. chairman. i just want to conclude -- >> the gentleman's time has expired.

we now recognize the gentleman from tennessee. >> thank you, mr. chairman. i'd be happy to yield a minute to you to to finish your thought. >> thank you. i was only going to say that i wasn't here in 1997 when they scored a big savings based on a theoretical reduction in the cost of doing business. you weren't here. it is a, it is something that i agree with the gentleman, we need to realize that simply paying doctors less and then reneging on agreeing to pay them less when the real cost savings didn't occur because we never legislated or did anything to help drive down the cost of delivery is, in fact, a very good point. and i agree with the gentleman that that fundamental change which was scored before you and i got here is not about just paying doctors more. because we did say, well, we're going to find ways to be more efficient in what drives their cost up. so i look forward to working with the gentleman on that.

it won't come to our committee, but i certainly would be happy to work with the gentleman, try to drive down the cost of doctors delivering quality health care, and i thank the gentleman for yielding. >> certainly. and reclaiming my time, and i will also add that we just had a doctors' caucus meeting this morning. as you know, +markups pending in ways and means and energy and commerce dealing with an sgr replacement. there's going to be a three month patch, but we are working with the 15 members of our gop doctors' caucus as well as our dentists and our nurses, and we are going to try to find something that has a sensible approach to reimbursing physicians unlike the sgr which over the past 15 years has yielded nothing, i think, but a 1 .9% increase. and i think most industries would have a hard time making that work with the rising costs in other areas. i wanted to post a or put up a video, if we could? >> we will keep this promise to

the more than people -- to the american people. if you like your doctor, you will be able to keep your doctor, period. >> if you are looking for, if you want coverage from your doctor, a doctor that you've seen in the past and want that, you can look and see if there's a plan in which that doctor participates. >> have unlimited choice. >> it's a simple yes or no question. didn't he say if you like your doctor, you can keep your doctor? >> yes, but look, if you want to pay more for an insurance company that covers your doctor, you can do that. >> okay. i'm sure this is something most everyone in this room has seen or heard and maybe everyone across america, and practicing primary care medicine for the 20 years before coming to congress i know that, you know, a lot of my patients who had insurance probably believed the president. if you had an insurance plan that you liked and you had a doctor you liked and you were given that clear assurance over and over again right up through 2012 right before the election, i'm sure a lot of your patients were secured that maybe this health care law wasn't going to

impact them. well, now they're finding out that that's simply not the case, so i would ask you, we can just go down the line, what are your patients finding and feeling when they realize they've been duped? >> well, again, there's fear because they've had an established relationship, and, you know, patients are follow their doctors. what's wrong about the last part of that video is, as i said, if you're in a different part of georgia and your exchange does not have me but then you go into that exchange three hours away, now your primary care doctor's three hours away too. so you can't just pay more to see us anymore. you're excluded if you're not on that list. unitedhealthcare says i'm still on that list. your doctor's being penalized because he takes care of sick people. >> right. >> the patients are numb. i think that's about all i can say. >> okay. >> and many of the patients who had a state-subsidized plan in

new york called healthy new york received letters that that plan would end, and they would have to go into the new york marketplace. i actually approached many of those patients that were in my practice, they never bothered to open the mail. they didn't even know that their plan terminated. i was the one that informed them. so these patients are numb, they're upset, and as you know as a primary care doctor, you don't work alone. you work with specialists. so what rahm emanuel had said that you can pay more for a plan that has your doctor, well, it may have your doctor, one of them, but it may not have the four or five specialists that you see also. so there's a discontinuation of care no matter how you look at this. >> dr. novack, i'm going to finish because you bring up a great point. supporters claim 30 million people will gain insurance. can you explain the difference between having a health insurance card and having access to care? i'm just preface that that i came to tennessee in '93, a year before our care was instituted

which is a model for what we're experiencing now, and it didn't work. so i think you know very well that someone can come in with that card and they need maybe an orthopedic surgeon, and if you're in a rural area, they may have to go 100 miles or more to try to find that doctor, and you might have to hire extra staff just to stay on the line at night after clinic hours trying to find a referral or someone who would accept it. what are your experiences with it? do you think it's a good idea to reform health care based on the expansion of medicaidsome. >> i don't think the data suggests that's a particularly good idea, and i think it's the unfortunate reality and to touch on what you said, i know the congressman last time made that point exactly in his opening remarks that what we are seeing, unfortunately, is that a plan that was supposedly designed to help those who need the most, we're seeing rural areas there are fewer and fewer doctors available, and we're seeing in inner cities the closure of clinics, the moving out of primary care doctors, the near-complete absence of

specialists in cases. and so, unfortunately, the groups that we really do want to do things to be able to help, unfortunately, the law -- while well intended -- i just think we need to recognize it's not doing what it said needed to be done. so i would make -- this is beyond tinkering to make it better. this is it needs, essentially, a complete revamping and address the real problems. >> i thank the gentleman. we now go to the gentleman from virginia, mr. connolly. >> thank you, mr. chairman. and thank you to our three panelists. one might be forgiven looking at this panel and the theater of it, frankly, if democrats had had the chance to put together a panel of three doctors, i guess we could ask you to wear your white coat, and i guess we could find three doctors, i know we could, who would praise the plan. but the idea -- and this doesn't

in any way disparage the value of your opinion or your experience -- but the idea that your experience is to be generalized as universal is false. and it's a false premise, and it does a disservice, in my opinion, to this discussion. none of you are policy experts. and none of you universeally speak for your profession. you were asked at one point by one of our colleagues about how difficult it is to sign up. well, if we're going to go through anecdotal experience, i can tell you that i and my entire staff must go on the exchange, on obamacare. all of us signed up, met the deadline. i know that was an accident. if you're under a certain age this my staff, the average

premium cut ranges from 30-70%. they're happy as clams. the deductibles are comparable or better, the co-pays are comparable or better. i can tell you in my district those small businesses who are crowing about the fact that when they went on the exchange, they had better choices than they have currently, and they're going to save -- i talked to one the other day with four or five employees, he's going to save $6-$7,000 a year. it isn't an honest intellectual pursuit to deliberately cherry pick facts and to deliberately put together a panel of critics of a's of legislation -- of a piece of legislation that is admittedly complex. you were asked about tort reform. as if tort reform was dispositive on the cost of health care. it is not.

it is a factor, but, of course, what the questioner didn't say as a prelude to his question was, of course, on our side of the aisle we decided a priority to oppose it no matter what was in it. we didn't give it a chance. and the fact that an entire party decided to take a powder on a major piece of legislation precisely p meant tort reform wouldn't be at the table in a meaningful way, at least as determined by them. of course not. we had a permanent republican senator in the other body who said if we defeat health care -- this is before we even knew what was going to be in it, didn't matter -- it will be obama's waterloo. that tells you everything you need to know. it wasn't about health care, it wasn't about the quality of health care, it wasn't about whether you are in a plan or you're properly reimbursed, it was about a political game to try to make him a one-term

president, and it didn't work. i hope someday we have of a substantive or hearing where we actually as republicans and democrats try to find out what's working, what isn't and make it better. that is the history of transformative legislation in this field. unfortunately, it's not the history here. we've spent 46 votes in this congress to similarly repeal it, defund it or gut it. not based on substantive analysis, not based on experience, but based on a political predilection to oppose this bill and this president even though there are elements in the bill that actually came from republican think tanks, the individual mandate being one of them. not a democratic idea, a republican idea. and so i'm glad you're here, certainly have enjoyed listening to your testimony, but i have to, i have to put it in a different context. you will forgive me.

and and it's too bad that the panel couldn't have been more balanced, and it's too bad dr. feder is kept waiting when she was under the impression, as were we, that she could join this panel to provide a different perspective. i yield back. >> i now ask unanimous concept that the gentleman from virginia, mr. connolly's, web site -- which i'll put up there from 2010 be placed in the record. in can which he says for the past years my constituents have told me we want health insurance reform but only if it meets certain tests, connolly said. will it bring down premiums for families and small businesses? will it reduce the deficit and will it protect choice of of plan and doctor? without objection, so ordered. we now go to the gentleman from -- >> could i inquire of the chairman? >> yes. >> is it going to be the practice of this chairman to start to actually individually

put members' web sites into the record? because we'd be glad to return the favor on this side of the aisle. >> i have no problem at all. i asked for it because it was germane to your anecdotal statement of objection to their anecdotal statements, so it just seemed appropriate and good staffing as you know, gerry, somebody looked and said, heck, gerry used to be for what these people are testifying we're not getting. that's all. >> i stand by the web site. those were the three criteria i used, and that's why i supported the bill. happy to have it, i just wanted -- >> no, i thank the gentleman. we put it in because it was a historic piece. >> right. >> and candidly, the requested individual from your side of the aisle is on the next panel along with all the other nonmedical doctors, and that's the reason it was divided. medical doctors who were giving their anecdotal examples of what they see as practitioners, current practitioners, and then the think tank crowd will be

next. and hopefully, you will not disparage the think tank crowd for not being doctors. >> no, mr. chairman, absolutely not. >> thank you. >> there was no disparagement of doctors, just a cry of the heart that some democratic doctors -- >> if you'd suggested one, we might -- >> just for a second, mr. chairman, i would hope, mr. chairman, that we would not be engaged in putting members' campaign web site stuff up or whatever. >> this is not a campaign. we would not -- >> whatever. >> no, we would not put a campaign web site up. >> what was that? >> this is, in fact, an official -- this is property of the house of representatives. >> i just want to make sure. i'm just so concerned that we stay focused on this and not be distracted by serb things -- certain things, and i thought it was a web site, campaign -- and so, but thank you very much. >> no, no, and i appreciate it. the reason we chose this was that it was said on the floor of the house, it's on a government site, and it's pursuant to exactly why we chose this question which is what is the

impact to doctors and, you know, i know last -- a couple weeks ago when we were looking at failures of the web site, something we all are working on reforms to fix, we had a discussion about what about the fundamentals of the health care. mr. cummings, i will say something to you here today, you and i do not control, we were not the committee of jurisdiction for the affordable care act. but the exact problems that these doctors are talking about are what we have to take a leadership role in fixing, and mr. horsford has left, but a lot of it began in the '90s when we thought we could simply pay less from the federal docket in be medicare and medicaid reimbursement. these are problems that are longstanding. the reason i'm having them here today is i agree with what you said to me in a sidebar which is when are we going to start fixing some of the individual parts of it? the affordable care act is not going away in totality, but

these doctors -- and i take dr. english particularly -- are telling us about a chronic problem which is are doctors being incentivized not to take the tough patients? and in some cases, and mr. cart wright alluded to this, in some cases it's our government reimbursement. in some cases it's how insurance companies are reacting. and i will pledge to you today i will treat how the government acts and how insurance companies act the same in trying to get these doctors to be able to practice what they do, and we can have a discussion about how much reimbursement comes out of tax dollars. but hopefully today both in the first and second panel we're dealing with what's happening currently so that we can fashion some legislation that has to be bipartisan if we're going to fix it. >> thank you, mr. chairman. i just want to make sure we stay on track. i keep going back to what dr. mclaughlin said. she said fix it, and it can be

fixed. and by the way, mr. chairman, i appreciate what you said to congressman horsford be, because he did raise some very legitimate concerns, and i think we can work in a bipartisan way. we can help these doctors be efficient in what they do, and we can help the american society. thank you very much. >> thank you. gentleman from georgia. >> thank you, mr. chairman. i thank you all for being here. my colleague from virginia characterized you as obama care critics -- obamacare critics. i don't know how you would characterize yourself, i would characterize you as patient advocates. and if that leads you to be critical, then fair enough. but to the gentleman's point, i thought he was exactly right. find out what is working and what is not and make it better. i wish that had been the counsel this congress had applied before the passage because each of you has made testimony about patients that you had, patients that were receiving care, patients that were getting the

individual attention that they need who will no longer, because of this new legislation. those folks weren't having problems, we created those problems. and you all are in the caretaking business much more than i am. but the stories that you tell that touch me the most are the tales of the problems that we create, the uncertainty that you mentioned, mr. novack, dr. novack. there's no, there's no way to take those fears away. those fears are real for those families today. if six months from now those fears turn out to be unrealized, we still won't be able to take away the pain and frustration those families have experienced today. i tell everyone at town hall meetings that i thought the president identified exactly the right challenges, that health care costs were rising too fast and that many americans did not have reliable access to care. i thought he crafted exactly the wrong solution to do that. i think we can work together to solve those problems. the concern is that certainly from your testimony and from the

experience of my constituents, we've created a whole new batch of problems. i want to ask you, dr. english, you know my good friend todd williamson, dr. todd williamson, he's a neurologist as well. he told me the other day, he's just a little bit older than you are, that here we are the largest county in the southeastern united states, one of the fastest growing, he said he's been in practice for more than 20 years, he has not seen a new neurologist come into our county. i tried to look at the ages of folks in your practice. are you the youngest or have you found some young neurologists coming in? >> i'm not the youngest anymore. i wish i was. >> that is one of those challenges. i look at the dollars that we've poured into the president's health care bill just today the headlines, chicago tribune only 7,000 illinoisans enroll in obamacare plans in the first two months, hhs awards another 58 million to obamacare navigators. the list goes on and on.

burden county record in new jersey, many new jerseyans are in limbo as december 23rd deadline nears. alaskans pick marketplace plans despite untold millions spent there. oregon signs up just 44 people for obamacare despite spending $300 million. what would have happened if we'd spent those $3 million -- $300 million on community health centers? i happen to be a huge community health center advocate. i believe folks are entitled to a level of care, and i believe we can provide that. interesting, sliding scales, ability to pay. we already had such a mechanism in place. my colleague from virginia called in this a -- called this a pony show. when the question came to you, dr. english, does obamacare limit your patients' treatments and the answer came back, yes, i

don't know why that's not the end of the conversation. i don't know why there are not 435 members of congress who say, you know what? we care about people, and we care about people having access to care, and we want to improve the access to care for folks who don't have it. but if you have access to care today and we're doing things in this body that limit the medical professionals' ability to treat their patients, why can't we all decide that's wrong and that we should go back and take another crack at that? the affordable care act is important legislation, i heard from one of my colleagues, because it deals with pre-existing conditions and access to care. i want to ask you since you've been characterized as obamacare critics, is there one of you, is there even one of you who does not believe that we should deal with pre-existing conditions and that we should improve access to care? i'll start with you, dr. english.

>> of course we have to do all those things. >> have to do those things. have to do those things. dr. mclaughlin? >> sir, physicians have always given charity care, love of their heart to people who couldn't afford be it. always did. >> always did. >> and always will continue to do so. but what this has created, sir, is a roadblock of unsurmountable to organizations. the high deductibles that were imposed on these patients is nothing more than them not having insurance. can we understand that? >> dr. novack? >> the gentleman may answer, of course, doctor. >> i agree with you. >> mr. chairman, i know my time has expired, but we have found that collection of ideas on which we can agree, and i agree with my colleagues on the other side of the aisle, we should begin working towards those goals, and we should do that immediately. i yield back. >> i thank the gentleman. we now go to the gentleman from massachusetts for five minutes. >> well, thank you. thank you for your being here today. i wanted to ask, i think it was dr. mclaughlin who made a comment that her patients'

policies were -- the insurance companies did not renew her patients' policies, and as a result, that was an issue. i wanted to ask you whether or not when you were having this discussion with your patients who had their policies not reissued by their sthurks whether or not you looked and saw if those old policies had as part of their coverage the following services and benefits: ambulatory services, emergency services, hospitalization, maternity and newborn care, mental health and substance abuse disorder services including behavioral health treatment, prescription drugs, rehabilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, pediatric services including oral and vision care. did your patients in each case have all of those benefits and services? >> sir, i can only speak of my small business plan because -- >> well, let me ask you, you

gave me information about your patients and what you thought was their situation. >> right. >> so i'm asking you before you reached a conclusion or an opinion on that, did you look at their policies to see whether or not they actually covered all of those benefits and services? >> the policies i referred to were healthy new york, state-run and, yes, they had those -- >> all of those services were in those? >> but the reason -- >> no, i -- so you know, you're going to tell me that policy had each and every one of those services? >> absolutely. >> okay. and did you look to see whether or not any of your patients that you're talking about had been advised by their insurance company that they could go to the exchange in new york and compare and contrast what they now were offered with whatever else might be on that exchange as an alternative? >> they received notification of that, yes. >> okay. of and do you know whether or not they had gone and checked that out? >> i can't tell you what patients do. >> and do you know whether or not your patients were eligible for a subsidy? in other words, if they were earning less than over 400% of

poverty? >> again, some, obviously as a physician, we don't know what a patient's earnings are. but i can tell you from the careers that i see -- >> well, that wouldn't be fair. >> well, it would be fair. >> so did you check, ask them whether or not any of them qualified for a subsidy, and if so, how much? >> well, i can speak even of my own staff -- >> i just want to know about these patients that you were referring to. >> some checked. some had a subsidy, some did not. >> okay. and did you know which of them were which, how many of each and whether or not it covers all or some of what they thought was an increase in the policy? >> >> the closer that an individual, these patients, get to the upper limit of what qualifies for that subsidy, they were told that they would only save about $5 a month on the premium. so a subsidy doesn't cover everything. it depends on how far away from the maximum that is covered. >> that's the idea of a sliding scale subsidy, right?

>> correct. >> okay. can did you also talk with your patients about the medical loss ratio part of the affordable care act, that part that says insurance companies have to now use up to 80% of their poem yums for -- premiums for actual health services as opposed to to overhead, management and things of that nature? >> with all due respect to the patient population, sir, they don't understand a medical loss ratio. >> do you? >> i do. >> okay. so you're aware in 2012 consumers saved $3 .4 billion based on those new standards? >> my plan did not have that. i got no refund. >> my question to you, though, was if you are familiar with it, do you understand that in 2012 patients saved $3.4 billion -- >> i you said that, yes. >> and do you understand that companies that did not meet those standards issued $500 million in rebates? >> yes, i do. >> okay. do you know whether or not any of your patients were beneficiaries of those rebates? >> some of them were, yes. >> okay. i just want to close out, i'm not going to use all of my time

on this, but with respect to a comment that was made earlier from somebody on the panel here about the history of this bill and this was not a committee of jurisdiction, i was on one of the committees of jurisdiction, and my memory is that during the course of debate of this particular bill, the tremendous effort was made to try and have it be a bipartisan measure. and we reached out and asked for participation of both sides of the aisle. one side decided not to participate. and incredibly, even when certain provisions that people thought were generally good, bills that were drawn by republicans in that part were asked to be introduced, the republicans refused to introduce them, ask can even when some 12-15 of them were put in as amendments, those people who had drawn those amendments that were now amendments voted against them. so i think some indication of trying to have this be a joint effort of everybody working on this shows from the earliest parts of this whole exercise or whatever a concerted effort, i think, on one part just to not

even be involved in it and not participate in trying to make it the best project it could possibly be, and i think that's part of what we're seeing a continuation of here. >> would the gentleman yield? >> i'm afraid i'm out of time according to your strict standards, mr. chairman. >> okay, time is expired. the gentlelady, you were cut off several times because of limited time, but is there anything -- >> mr. chairman, is it your turn to question? be am i missing something? >> it is the requirement -- >> you just asked me to yield, so now you're just -- >> no, no, i'm not asking any questions. the prerogative of the chair under the rules is to make sure that there is a full and complete, clear answer. and to correct the record,necessary. >> that's not at all accurate. you're going to do it -- >> this is a longstanding practice under both republicans and democrats. the gentleman had limited time. the gentleman in his limited time cut you off several times. if if the doctor had anything that she felt was germane, i have always allowed witnesses to

continue answering even after time is expired. was there anything, doctor, that you felt you needed to fully answer that there was not time for? >> the purpose of this committee is to talk about the limited networks and whether premiums were, indeed, lowered or not. was it not? >> that's correct. >> and as i said to mr. cummings, we have 20 days to fix how we are going to provide care to patients with limited access, and there is no debating that. we talk about ms. i will talk about ophthalmology for a second. >> and i apologize, i'd love -- i just wanted to give you time on something that he had asked which included subsidies. he cut you off during your statement on occupations of your patients and so on. please, i'm only trying to make sure the record is full. if there's anything you wanted to say about your patients and so on, that was the line.

>> the cutoff -- >> mr. chairman, i would ask that you put -- if it's an answer to my question -- >> the gentleman is out of order. >> the reason the witness was asked to move to another question -- >> the gentleman is not in order. please. >> well, east is the chair, and i think we've got an issue here now you're going to shut the microphone off. >> yeah. >> [inaudible] >> thank you. please limit yourself to anything you felt was asked that you were unable to answer. i certainly want you to be germane. that's why i did ask you to stay to what the gentleman asked. >> $45,000, i believe, is the income ceiling in new york to obtain a subsidy. $45,000 living in new york barely makes it. so most of the people who are going to be getting these insurance plans will not receive a subsidy. and they are going to have a difficult time paying these

deductibles and paying their premiums. thank you. >> thank you. gentleman from georgia, mr. collins. >> thank you, mr. chairman. look, i'm not -- i just have a couple simple questions. i have a daughter who fits the special needs category. dr. english, i appreciate your being here from our home state as well as the rest here, and i'm just going to ask very broad sort of questions and give a relative personal experience note here. one, i've heard it said many times and, you know, there's a lot of things out there to fix. well, this is not one of the fixable laws, this is just one that is broken, and that's just a disagreement that both sides of the aisle are going to be, and we're going to deal with it. i don't believe it can, but there are things that can be done. reality is that as in the case of my daughter who has spy that biff da, early in life she had 0

major surgeries -- 30 major surgeries, eight of which went eight hours plus, a vast array of different things. she is 21 years old, and she actually rules the house and nothing else has been said. but doctors in her life, especially early on, were very important, and they still are. we're making the transition as i had a chance this morning to speak with dr. english about the transition from pediatric to adult, and that's hard for a father, so i'll just leave that at that. but she is a young woman. the problem i have here, and i want you to address, i'm going to stop here and just sort of open it up and then the you run -- if you don't have a lot to say, fine, we'll be done, and we'll move forward. this plan, the plans are hurting the very ones i believe they were intended to help. and especially with the zones and especially with the areas of access and especially on borders and especially those who need multidirectional or multi-physician care. could you speak to that?

not the politics of this thing, but speak to what happens a father who has a daughter named jordan who may not be at 21, they may be at 6, or they may be at 5, and they're trying to get everything that they can so that their daughter or son can move within the limitations of what you're now seeing. can you speak to that in just a minute? dr. english, you start, and anybody else who would like to pick up. >> the problem, as you said, this is the group of patients that we really need to provide for. i know your area, you're about an hour from us without traffic, depending upon the time of day -- [laughter] >> three and a half, four hours. >> so that's not a far place for someone to see a pediatric surgeon, going to boston from massachusetts is not a big deal. but if you're out of the exchange district, then you don't have access, and patients like your da will not -- daughter will not have access. not to mention we mentioned the mayo clinics and walter reeds and all of those places.

my concern is, again, you have that card, but because of where you live, that that's even going to restrict your access to the provider that you need. >> and just to clarify, that actually increases costs because you don't have the collaborative effort that you could do in, say, a clinic setting or something else at times, and i think maybe you had that experience, dr. mclaughlin? >> it is a team approach in illnesses. and the whole team has to be with us, because this was allowed to be created now as all in-network coverage. besides the high deductibles, all in-network coverage. that's not saying you can't go to see a specialist like dr. english, but you'd have to pay for it. and that won't go to satisfying your deductible or your out of pocket. so there are flaws in this, and i'm not against the affordable care act. but there are flaws in this that are increasing the costs to the patients, the very patients that you wanted to help. and this needs to be fixed.

be. >> dr. novack? >> and there will be some families who will see some improvement. but what we've changed with the law is really the set of who the winners and losers are and, again, certainly to date -- and there has been, frankly, not a shred of any real-life evidence that the number of losers -- that the number of winners are going to even come close to approaching the number of losers. >> right. and i think that's a concern we're seeing, that it was just a natural outflow of this, and there's things that have to be addressed. look, this is a passionate issue. it is not just for the folk on capitol hill. in fact, for the 535 of us on capitol hill, you know, we're just reflections of really the people in our districts who are dealing with this every day. the hearing's titled obamacare's impact on premiums and provider networks. frankly, i appreciate the differences on both sides, but i would have to just say that obamacare's impact on premium provider networks is a generic term for obamacare's impact on the lives of people and

families. and until we can -- if we ever disconnect our discussions of health care and insurance from the very people who need it, then we've made a mistake, and that's why this hearing is important because it actually is dealing with those who actually need the help and the doctors they need for day-to-day leaving. mr. chairman, i yield back. >> i thank you, sir. we now go to the gentleman from illinois, mr. davis. >> thank you very much, mr. chairman. and, you know, i'm leaded to report that -- pleased to report that i just came from a markup in ways and means where on a vote of 39-0 we voted to do a fix for three months of the sgr and kind of looking after the needs and concerns of doctors. i also want to take a moment to just associate myself with the comments of my friend from georgia, mr. woodall, who just spoke glowingly about community health centers and the

accessibility as well as impact that they've had. i happen to have worked for two of them in civilian life and also had the good fortune to be president of our national trade association at one time. and i certainly think that they are a tribute to what can happen in the development of ambulatory care. and so i just want to thank him for that comment. as we begin, i want to make sure that we don't lose sight of the fact that many of of these policies that we've talked about did not include basic services such as hospital care and prescription drugs. he were what many people call -- they were what many people call junk policies that provided bare bones coverage that would have resulted in catastrophic head call debt if policyholders -- medical debt if policyholders became seriously ill. back in september a young woman

requested to testify at a hearing before this committee, and although she ultimately did not testify, ranking member cummings read part of her statement into record. like millions of other members -- americans, ms. laurie had a pre-existing condition, a rare bloodies order. in 2005 she needed emergency gallbladder surgery and suffered complications due to her condition. although she had insurance at the time, her insurance company dropped her, refunded her premium and left her with a $50,000 hospital bill. although she spent years trying to appeal this decision, she was not successful. eventually, the hospital she was treated at decided to forgive the bill. my question to each of you, all of you are in the business of providing health care.

you clearly have all interacted with insurance companies and foe about insurance. and know about insurance. was this type of policy rescission common prior to the enactment of the reforms in the affordable care act, and what were your exb appearances -- experiences in each of your practices? and we could begin with you, dr. novack. >> sure. in my 13 years of practice and then five years of training before that up in the seattle area, i have not seen it, and i have taken well over a thousand days of on-call at multiple hospitals and, you know, seen over 50,000 patients. and most states actually have laws already that pre-existed the aca that prevented inappropriate rescissions. so that's a different issue that i think is being conflated sort of a little bit incorrectly. so laws against canceling people's policy because you get sick have been against the law in most states for a long time. and that is a different problem

that be this idea of -- than this idea of people's insurance not being renewed. now, the idea that people who have pre-existing conditions not being able to find affordable insurance, there is not a person i've ever come across in my 25 years of taking care of patients that doesn't feel like we need to do something or make policy changes to address that. the conclusion, however, is that the policies that are put forth through the affordable care act are actually making these problems worse and not better. >> dr. mclaughlin? >> it was illegal to cancel a policy because of increased ute hiization of it for -- utilization of it for a serious medical illness. this wholesale nonrenewal of policies is shocking. it has been reported that the insurance companies felt that small businesses were losing proposition to them economically, and this probably became a great opportunity to

just rewrite those policies which is why we are where we are today with so many small business policies being not renewed. hospitals, again, have always taken care of acute care conditions when somebody's uninsured, but we have to fix the problem that we're facing now as much as it is laudable to see that people who have pre-existing conditions can have insurance. thank you. >> dr. english? >> due to time, i don't really have much more to say than dr. novack. i mean, obviously, we agree that there are changes needed to occur, and, you know, we're just pointing out that, unfortunately, this plan is having huge amounts of unintended consequences. >> mr. chairman, with your indulgence, could i just simply ask the panel be they would agree that be many of these policies were, in fact, junk policies that we've been talking about? >> i don't think that there's any evidence to date that the five and a half million people who have had their policies canceled, i haven't seen exact

numbers as what percentage are, quote, junk policies. a lot of them didn't actually contain some of the new mandates in the law. >> no one in my practice had a junk policy. >> i've nothing else to add. >> thank you very much. >> i thank gentleman from illinois. like to recognize the gentleman from michigan, mr. bentivolio. >> thank you, will have. mr. chairman, we now know that you can't keep your insurance if even if you liked it, you can't keep your doctor even if you've been seeing him for the last 30 or 40 years, you can't keep your hospital. premiums are increasing, and we have eyer deductibles -- higher deductibles. obamacare rated 700 billion from medicare including 300 million from medicare advantage alone to pay for the aca. physicians were terminated in connecticut, most of the orthopedic surgeons in dayton, ohio, dropped. in florida 250 positions from

one medical center dropped. in january, mr. chairman, i'm sure we'll discover thousands if not tens of thousands of people to their dismay that they signed -- that they thought they signed up for the aca but because of a glitch this healthcare.gov did not. mr. chairman, the web site itself is in question, a web site that asks the most personal, intimate questions does not have the proper security protocols to insure the personal medical data of our citizens tar safe and secure. obamacare created a panel of 15 unelected bureaucrats called the independent payment advisory board who have the power to control the types of treatment seniors receive through medicare. and according to dr. jason fuldman and dr. david ratser in, this unelected body-the

unprecedented ability to single handedly change the allocation of health care resources should medicare spending exceed medical inflation which, for the record, it consistently does. dr. novack, what are your views on this ipab, i believe it's called, the independent payment advisory board? >> sure. as i mentioned earlier, i just think it's a serious area of concern. i don't think that for those of us -- and, actually, for most families -- that creating another new layer of bureaucracy that are making determinations about accessibility is a step in the right direction. i would add that i think there's actually fairly senate bipartisan opposition to the independent payment advisory board because of the way it's structured and how 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 than government bureaucracy in experts?

>> i think there's a fair amount of evidence that if we increase transparency, provide more information to patients that a lot of patients will make better decisions. that's also true on the physician side. and a lot of those solutions are a lot simpler and cost a lot less than the 2 .5 to $3 trillion we're p spending on the affordable care act over the next ten years. >> thank you. and dueck many people signing up for coverage don't know that their doctor or their children's doctor will still be in their network and they'll still be able to visit their. doctor, family doctor? >> i think the evidence is not only do the patients not know, but we don't know either. >> mr. chairman, we are consistently unearthing the lies, half truths and distortions of the poorly-conceived, this poorly-conceived law. and dr. no advantage, what do you -- novack, what do you anticipate are occur next year when people go to their doctor and find out they're no longer covered? >> well, congressman, i think, again, it gets back to this

uncertainty issue, that already on the provider side we spend enormous amounts of time, an enormous number of phone calls trying to sort through these very complicated issues regarding health insurance. and by the way, this is not just for people in the private market, people on medicaid, it's equally true for people with medicare and the 130,000 pages of 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 and this 90-day grace period issue is such an enormous issue for us that 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 oh bodies actually figures out what the rules are going to be so we can continue to provide services and be able to pay our staff. >> thank you very much. >> could the gentleman yield? >> yes. >> dr. novack, i just want to make it clear, under this 90-day plan if you have, let's say, a $2 million practice including

the pay you pay all your people and so on, you could end up with 90 days, one quarter of that, $500,000 of patients that aren't covered and don't pay. that's the kind of exposure you could have is paying all your people, paying out $500,000 and getting back none of it. that's the uncertainty that was in the law, is that correct? >> right. and the concern is almost all insurance, is my understanding, there's always a 30-day grace period because sometimes we forget to send a check in, but under the law there's a 90-day grace period. for the first 30 days, the they're required to pay the bill, but it's going to look like the insurance has insurance -- the patient has insurance. but the insurance company's going to hold payment, and if that premium's not paid, the insurance company says, well, it's not our problem, go collect it from the patient. generally speaking, your collection rate is about one or two cents on the dollar for that money. interestingly, we had a

conversation with one of the newer insurers that's going to be on the exchange in arizona, and we said we'd like some kind of protection against this exact problem. we didn't have an issue in terms of what the payment rate was boeing to be for services, we just said we need some kind of protection, and they were unwilling to provide us protection, to we walked away from that contract. >> i want to thank all our witnesses today. i certainly think that we closed on a good note, the fact that there's something that i think all people on this side of the dais can agree on that we certainly need to make sure just as if if you were taking a vis a vis or mastercard and you checked it and it was good, your expectation is that when you let the gas or the other product leave your store, that it would be honored and not that 60 or 90 days later you'd find out retroactively you weren't going to get paid. so as we look at the many problems we're presented here on this first panel, i think that's certainly a good example of one that we look forward to working together to try to fix and fix

quickly. again, doctors, i thank you for your remaining in this the industry. i -- well, remaining in this industry, remaining in your practices and offering us some ideas of where we need to keep from driving you and doctors like you out. and i recognize the gentleman from maryland for closing. >> thank you very much, mr. chairman. i want to thank all of you, too, for what you doer day. do every day. you have very, very important jobs. you bring a quality of of life to life and in instances save lives, saving sight. it's so important. i want you to be paid. 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 that insurance card that they have means something. and i heard what you said,

dr. mclaughlin, about these various situations with -- that you found yourself in with your mom. and so some kind of way we've got to balance all of this. and, you know, congressman tierney was so accurate. a lot of these things probably could have been resolved when the bill was doing being out together -- was being 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 problems, but you're right, we have got to fix this. and there's got to be a can-do attitude and not one to just throw out our hands and says, you know -- because you know what? the seem who suffer are the very people -- the people who suffer are the very people you try to help every day, so i thank you for what you do. and i also thank you, all of you, for bringing the passion that you bring to your professions. we understand. you're just trying to help

people, you know, to get them well and keep them well. and we really appreciate you. thank you. >> i thank you so much for this opportunity. >> thank you all. and, again, you'll have seven days be you want to put additional statements or other material in the record, and we'll now take a short recess for the second panel. if the witnesses could please be seated. i want to thank all of you for your patience. we'll now 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 the urban institute. mr. edmund haislmaier -- i do

that every time, welcome back -- is a senior research fellow at the heritage foundation. and dr. avik roy, m.d., is a senior fellow at the manhattan institute for policy research. as you saw on the first panel, pursuant to the rules of the committee, would you, please, rise, raise your right hands to take the oath. do you solemnly swear or affirm that the testimony you are about to give will be the truth, the whole truth and nothing but the truth? please be seated. let the record reflect all witnesses answered in the affirmative. dr. roy. >> chairman issa, ranking member cummings and members of the oversight committee, thanks for inviting me to speak with you today about the affordable care act. my name is avik roy, i'm a senior fellow at the manhattan institute for policy research in

which capacity i conduct research on health care and entitlement reform. i'm an advocate of market-based, universal coverage. i believe that 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 that well-designed, subsidized insurance marketplaces are among the most attractive vehicles for achieving these goals. it is more these reasons that i am deeply concerned about the way the aca's insurance exchanges have been designed and implemented. most of all, i'm concerned that the law 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 sick and the healthy and requires insurers to raise rates on younger individuals in order to partially subsidize care for the old. it mandates that insurers cover a broad range of services that

individuals might not otherwise choose to purchase. 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 and two colleagues from the manhattan institute completed the most comprehensive study to date of individual market premiums in 2014 relative to 2013. we examined the five least expensive plans available in the individual market for every county in the united states, averaged their premiums and adjusted the result to take into account those who, due to pre-existing conditions, could not purchase insurance at those rates. we examined premiums for 27, 40 and 64-year-old men and women. we then compared those rates to the five cheapest plans on the aca exchanges, an apples to apples compare soften. our analysis found that the average state will see a 41% increase in underlying premiums prior to the impact of sub is itys. among the states seeing large

increases are nevada, 179%; new mexico, 142%; north carolina, 136%; vermont, 117% and, georgia, 92%. our analysis did find eight states will see average premiums decrease under the law including montana, ohio and new york. of the six categories we studied, 27-year-old men faced the steepest increases with an average hike of 77%, 40-year-old women will see the mildest increases with an average of 18%. we also studied the impact of the law's premium assistance payments on exchange premiums. our analysis found that for individuals of average income, taxpayer-funded insurance subsidies primarily flow to those nearing retirement. this is because the elderly will still pay more for insurance on average than younger individuals and because the subsidies are designed to fix the percentage of one's income devoted to paying health insurance

premiums. taking subsidies into account, 64-year-old men will pay on average 19% less for insurance under the aca system whereas 27-year-old men will pay 41% more. we are, indeed, likely to see a fair amount of adverse selection on the exchanges. people who consume an above average amount of health care services such as sicker and older individuals have a compelling economic incentive to enroll in the aca marketplaces. healthier and younger individuals, however, have less of an incentive even when one takes into account the individual mandate. ..

it is not inherently a bad thing for individuals to choose plans with higher deductibles especially if they allow americans to reduce their monthly premiums in theory by encouraging price competition exchanges could exert a downward pressure on overall health costs. the problem is in the case of feith aca any way that all in all increase national health spending and would be one thing if they were forcing americans off the plan and offering more attractive plan at a lower price americans are less likely to see attractive coverage at the high price if they do the affordable care act will not live up to its name and its goal of universal coverage will remain unfulfilled. thank you.

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

demonstrating that insurance matters. americans get less care, get it later in the course of enrollment and are more likely to die than americans without and to the extent they get care it's paid for by those of us that have health insurance and our premiums and through the local, state and federal taxes. they are mostly workers and families of workers who are not offered coverage through their job the way most of us are. before aca they have few options to protect themselves. coverage in the individual market was denial of coverage for pre-existing conditions and limited benefits and monreal simply doesn't work for people when they get sick. far from looking at to the promise that people that have this insurance can keep their doctor or the doctor is paid for. as i heard you argue the law limits on the annual payments as well as other limitations leave them high and dry and that is what the evidence tells us.

medicaid provides a safety net for people who are eligible, it is far from an empty promise and research shows us it actually does get people access to care except in a few states with federal law medicate excludes coverage of the adults that are not parents of dependent children no matter how poor they are so they cannot get coverage through their job and cannot get public protection. it is the drying and holes in the structure that it aims to fill. the aca requires insurance to end discrimination based on the pre-existing condition and other factors to cover the service health professionals typically provide and to eliminate the caps on the annual lifetime benefits so that people don't wait until they get sick to enroll the requirements on the individuals to purchase coverage or pay a penalty and to make that requirement feasible and coverage affordable, they

provide tax credits and other production to limit the cost sharing as a share of income. these policies together make it possible to transform what is an empty card in the individual market today into what insurance is supposed to become available, adequate and affordable and the aca addresses medicate by expanding its eligibility to people with incomes below 138% of the poverty level regardless of the family status. until 2017, that expansion is fully financed by the federal government with federal financing gradually dropping to 90% for 2020 and subsequent years. now the states ultimately paid 10 percent and the analysis shows the will make state's financially better off by reducing the burden of the uncompensated care while contributing to the overall health of the state economy. research strows because the tax payers contribute to financing

for the aca, citizens that choose not to participate in medicaid will actually pay for benefits and other states without reaching any of the benefits for themselves in additional federal funds. while the achp expanded coverage by increasing the market outside employment, it is important to emphasize that bill all leaves the employer sponsored insurance that most of us depend on fundamentally as it is today. despite the claims to the contrary, the analysis by cbo and my colleagues at the urban institute showed that employers sponsor coffin gerrans would remain the core of the health insurance system. essentially we have left 150 million people who rely on employer sponsored insurance and their coverage is the same as it's been with some improvements and they were not the group that we were talking about this

morning. at the same time i see my time going. we have seen the slowest growth that we've seen in history as a function of the elimination of overpayments to medicare and initiative to support efficient high-quality care and that is affecting everyone. bye filling in gaps in the current structure and a slowing the growth in the health care cost, the aca has a potential to address the falls in the health care system that all of us. the biggest loss potential is the political resistance to its implementation with too many states on willing to establish their own market place is or expand medicaid despite the advantage to their own citizens. in january, millions of americans will for the first time have access to affordable insurance they can count on when they are sick along with the

benefits people are already reaping -- >> the entire statement will be placed in the record and we now go to the gentleman -- >> we have finished the sentence? i thought you said earlier everyone me finish their sentence. >> you may finish the sentence that you are one minute past and you said you were wrapping up. >> i would be glad to. along with the benefits that we see people already reaping we need to move forward to implement the real promise of the aca standing in its way and standing for the unacceptable status quo is wrong. we now go to the next witness. >> thank you mr. chairman and ranking member for inviting me to testify today. i focus my testimony on the issue the committee has to talk about on the limited provider networks in the exchange plans under the patient protection affordable care act. you have a copy of my written testimony and i will simply summarize a few of the planes.

obviously, as you've heard in the panel before the provider contracting is nothing new. it is a two-way street and it is up to both the insurers and providers to come to terms if one of them doesn't like the term and you don't have a contract that shouldn't surprise anyone. is their something significant or different about the contract thing and the networks in the plans and health insurance exchanges under the patient protection affordable care act? there appears to be based on the widespread news reports -- by that i mean all sectors of the country and involving all different types of providers. that said, nobody has at this point any definitive handle on the extent to which those provider networks are different from the ones that we see out there today. we simply don't know in part because some of the networks are still being built in the

contract negotiations are still ongoing. what we do know is that in a number of cases the and insurers are offering a network coverage that is significantly less than what they offer in the plans out side of the exchange's. 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 attwell the consumers will be price sensitive and the in jurors exclude providers but i think that the sign of the portion of the law drives this and i am specifically referring to the cost sharing subsidy spigot much of the attention has focused on the premium subsidies but the law has a second set of cost sharing subsidies that pays the insurer to reduce the cost sharing for the lower income enrollees. the problem with that is because the cost sharing for a

significant portion of their expected and will lease its nominal the insurers have reason to expect there will be high your utilization and hhs confirms they are adjusting the cost sharing subsidies to reflect their estimate of the higher utilization. essentially what is happening is the injures will get paid but they are no longer able to use the tool of cost sharing to steer the patient to be more prudent consumers they must rely on other tools and that is one of the reasons that we are seeing the narrow networks in these plans. the other interesting thing i found in the research i did that was published at the beginning of the month and i think i'm the only one that has done this so far is i analyze all of the insurers that are participating in the exchanges and looked at them and their businesses in the state today and the insurers that are not as well and to see what kind of patterns emerge.

20% of the carriers who have gone into the exchange, their principal business in the state where they went into the exchange is medicaid managed care and indeed we do find evidence that these plans recognizing structure meaning the patient faces very low premiums and only a nominal cost sharing for the generous benefit package that looks a lot like what they are dealing with a managed-care and i quote one of the ceos of the plan that says it looks essentially the same. given that, my expectation of how this plays out is the individuals at the lower end of the 100% of poverty that would be subsidized 100 to 200 percent would gravitate towards the silver plan particularly if you have been on injured the trade-off of low premiums and low cost sharing for the limited provider access isn't necessarily something that you

will be terribly upset about especially if you were coming from not having insurance. however somebody that is used to having entered into makes more money interest free or 400% of poverty paying higher deductibles for a limited provider network is not going to be attractive and so i expect those individuals who move to the plans certainly about 300% of poverty they are quite small and they might look for coverage elsewhere so i think that is going to be the dynamic that plays out and 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 that will probably be fairly prevalent. my time is about to expire. thank you and i would be happy to answer questions. >> i ask unanimous consent that an article in bloomberg in september of this year be placed on the record as entitled

recession responsible for the cost curves. without objection, so ordered. you mentioned free-market has a better way to get a working system and earlier on the first panel why ask all three doctors about the practice the federal government in its reimbursement pays different rates for the identical treatment depending upon where you have it. isn't that an example of a flawed system in that if a replacement done in the clinic that specializes does therapeutically an equally good or better job with equal or better results and does it for a more efficient way whenever that term means, less overhead generally, that by paying them less and paying the hospital more you are driving up the cost of health care by subsidizing hospitals even if they have

higher overhead isn't that correct? >> it's a distortion interest in the market that has gotten worse over time as congress tries to tweak that problem and make it better sometimes there are unintended consequences that may get worse. >> in my own state of california we are seeing hospitals buying at the clinics and physician practices at a high a rate paying them the essentially as much as or more than the practice is worth and 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've become part of a hospital pays more there for the hospital is doing this in order to increase its revenue. is that something in a small way we should be attacking as part of our reform? >> we should and met pac has recommended modifying the structure that they pay the same

rate in that instance so that the arbitrage can't continue and i would also mention that hospital consolidation broadly the provider consolidation something that the aca actually accelerate is a serious problem driving market power for the providers and prices in the commercial market. >> one last question for a couple of witnesses. in 1960 we spent 5% of gdp, smaller gdp on health care and about seven and a half years last longer than we do today. today we are spending roughly 18% of gdp. that's not just -- almost four times the amount but with gdp growth we spend about five times as much on health care as we spend them to get i will start with you as a physician is there a justification in spite of all of the improvements is there a justification for spending five times as much in real dollars on

health care or have we is centrally built inefficiencies into the system and if so, does the affordable care act detect any of those to efficiencies? >> the affordable care act increases the amount we are going to spend unfortunately and i do agree that there would be nice to spend less. there's enormous amount of inefficiency in the way the we deliver and pay for health care and these are long standing problems which some things of the affordable care act may address but broadly speaking it goes in the either direction putting it >> a couple of questions. you were at the table at heritage during the affordable care act market, were you not? >> at the heritage foundation, yes. >> but participating in the markup? >> i wasn't at the table, but when you watch that process were there any ideas that came out of

heritage or other if you will conservative republican groups that use all accepted as amendments from any source, and particularly i want to talk about medical malpractice reforms. on medical malpractice we had somewhat of a different opinion that some of our friends in congress who wanted a federal solution we thought should remain to the states. my observation is that frankly the bipartisanship ended and i could look up the exact date it was july of 29 when they finished the help committee markup in the senate and the republicans had made a number of substantive changes all of which were voted down on the party line and had been proposed a lot technical changes to which in my opinion and was the worst draft

of all of the bills that were considered and the accepted 100 of those and announced they had a bipartisan bill and i think at that point is when they walked away because i had been working with members and there were things that they were drafting to submit that at that point they didn't submit them. it was clear that there wasn't going to be any meaningful input. so the interest in doing something bipartisan pretty much stopped right about mid-july from a buy can tell because the demand to help people drafting just evaporated. >> dr. feder they have much stronger requirements but general providers and also essential community providers. some of the stronger state requirements include the following and the reason i'm going through this is the people on the panel before basically blamed the affordable care act for the reason they may not be

on the provider network. but these are some state guidelines, a provider covered person, primary care, geographic accessibility, waiting times for appointments with participating providers. the volume of technological and specialty services available to serve the needs of covered people who require advanced care. so, if there are concerns with any state about the adequacy of the provider networks who can the consumer is go to and what actions can the state to address those concerns? >> you are rightly raising that the affordable care act establishes requirements or calls for requirements for network adequacy and many areas of the law it leaves it to the state to enforce those and i think that we need attention to them. they are legitimate requirements. it does fall to the entrance

conditioner in the state and the different degrees and we are not seeing an active 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 the first panel but here you are. one of the most critical features is the expansion of medicaid eligibility to the millions of low-income adults. medicaid eligibility was restricted primarily to the low-income children, parents, people with disabilities and seniors. in most states adult without dependent children were not eligible. according to a study in october 31st by the kaiser family foundation only about 30% of the poor, elderly adults had medicaid coverage in 2012. medicaid eligibility can be expanded to cover all adults

with incomes below 100% of the federal poverty level that federal government would pay the state's 100% of the cost for the first three years and then phase down to about 90% by 2020. is that right? >> that is correct. >> now despite this huge level of assistance as many as 25 states have decided not to be part of the expansion meeting literally millions of their own citizens without health care is that right? >> that is true. >> what is your opinion of the states to expand the medicaid program? >> i am sad and disappointed for both of the citizens who need care and the citizens who are contributing to paying for care through their taxes and other states that do expand. the expansion research shows from the urban institute how

much in the interest of states this expansion is and i believe it is only political opposition to the law that is depriving the citizens of access to care and the states of needed revenue. >> by not participating on and the leading significant resources on the table that could be used for the citizens? and sadly a lot of these people are getting sick and some of them will die early. >> that is essentially the institute of medicine found that the lack of insurance kills some your statement is correct. >> why is the expansion an important component? >> we have had a big hole as you pointed out in the safety net program and that is if you are not the parent of a dependent child or disabled or old coming you really are not eligible for coverage in most states. that whole is a vestige of an old fashioned welfare system

that kind of assumes these people would get coverage through their jobs. they don't get coverage through the jobs. they are left out of the employer sponsored coverage and the public safety net and that's why we need to expand. >> there was a study showing states to expand medicaid will gain important benefits beyond covering the poor people such as reducing uncompensated claims. i remember reading something about missouri and a lot of the hospital administrators came and said you got to accept this because our hospitals are going to be in trouble if we don't accept the medicaid expansion to get can you explain that? >> hospitals although they don't provide unlimited care and people without insurance don't get all they need hospitals get stock dealing with people who don't have insurance coverage and they have to provide emergency care. with this created was the

opportunity they get paid for patients that hawken the door and they are counting on it. >> the same study says that by choosing not to expand medicaid some states will lose billions of dollars, and i talked to the senator about this the other day. texas for example will forgo an estimated 9.58 billion in 2020 to taking into account federal taxes paid by the residence and the net cost of the tax payers in the state and 2022 will be more than 9.2 billion similarly will cost taxpayers more than $5,000,000,000.2022 and i could go on. what will this mean with regards to the people in those states and by the we in texas one out of every poor person has no insurance. >> if that is where most of the entrance is, it's going to stay there and those people are left without access to care and does he said they are more likely to suffer and more likely to die as

a result. are you a physician? >> no sir. stan is medicaid financially sustainable? yes or no it's an easy one. >> it is not because it is about long-term care and medicaid costs are growing very slowly. >> based on reimbursement rates it is unsustainable. >> it is financially unsustainable. >> i don't agree. >> would you agree? >> i'm not a physician delighted to medical school. is medicaid sustainable financially? >> no not in the present form. even expanding it's not either. >> i'm sorry. i hit the wrong button. it's not sustainable and with

the expansion would simply add to that in a number of ways. it could be if you reform it along different lines but that's a different subject for a different day. >> you heard the comments that we saw. what is your opinion in regards to are we not just chasing our tails with the expansion of medicaid? >> i published a low book -- i published a book on how the reimbursement structure of the program now under pays physicians for care and has led to poor access for those individuals and that is leading to poor health outcomes so the most definitive study was conducted in the state of oregon and published in the journal of medicine by a panel of esteemed economists that showed that medicaid compared to be and not ventured shows no improvement in the outcomes. >> because you get a car does it

mean something if you don't have providers that see you? >> just having a card that says you have health insurance is not the same thing as access to care and that is a distinction i fear the affordable care act has not understood well to be a >> so does it work for them to even make a profit? we just heard the gentleman basically make the comment that it's up to the states to enforce so we are going to force physicians to take the fees' they can't even pay their own? >> in massachusetts under the most recent health reform bill they considered a provision that would have required all licensed physicians and the state to accept all forms of the payment and that wasn't included in the law but that is something we may see more of overtime in the effort to do that and it would be problematic if you are familiar with the debt coming out of the school or the physicians coming out of the school less debt or more debt?

>> cost of medical school has skyrocketed and its increased more than that of inflation. it has discouraged physicians from accepting medicaid patients and today the surveys and studies show that the percentage of the physicians who are willing to accept new medicaid patients are substantially lower than it is for private insurance in particular and medicare but increasingly a problem and overtime as the state's expand the medicaid program they will face further fiscal pressures and the only mechanism the states have to keep their budget under control is to turn down the amount paid from the physicians and hospitals to care for these patients so it's only going to get worse over time and the expansion will accelerate that. >> we heard earlier in the panel talking about the patient dumping services like federal patient dumping on the state's four that jurisdiction.

>> in my experience the patients are reluctant to let that patient go just out of the humanitarian interest but the are very reluctant to take on the new patients under that reimbursement structure. >> it puts them any harmful situation does it not because they can't abandon a patient because that is litigation. there are very ethical problems here. understanding urban and rural we are really skewing the benefits. i'm from rural arizona and we are seeing huge catastrophic access issues. in the previous administration we tried to look at the federally qualified centers which the gentlelady didn't bring up because they are not to turn away anybody. it's a sliding scale if i'm not mistaken, right? they can't turn anybody away so that was part of the safety net. unfortunately when i saw the patient they didn't want to see because the skew the results

that they did is took medicaid and medicare patients until one percentage and they took the fees for service patient at a regularly scheduled result. >> one thing we should point out is what the market price would be in the free-market system for paying the doctors and hospitals we don't know because we don't have a free-market because medicare in particular and also medicaid has distorted with the prices are for a lot of services and the evidence suggests that in general the price is higher than they are another country's biggest and i'm going to take the liberty that is one of the reasons why we don't have a lot of the family care physicians isn't that true if the government has skewed the process and reimburse the rate so everybody goes into the specialty because that is how you make a living. >> degette pay for procedures. that is what the physicians like about the retainer practices the

finally pay for their time and they can spend more time unfortunately the evolution thereof the doctors treating medicaid patients that don't spend a lot of time with those patients. >> we hear this downtick due to be aca. and i don't agree. i think it had a lot to do with the economy would you agree? >> i've written about this. across the developed world there has been a slowdown in the health expenditures driven by the global economy. also there's been a substantial evolution in the united states increase in the use of high deductible plans with health savings accounts and the employer market that is leading to a slowdown in spending. >> why don't we want to give the president any credit? i hear this over and over again the cost of insurance is going down and you are trying to say that president obama and his

efforts and the affordable care act had no effect? >> as you know the bulk of the affordable care act has not been implemented yet so it isn't probable that it's having a system might affect on health spending. >> there are two challenges. we agree on the cover of the recession and bringing the costs down but what is missing from that picture is that medicare and affordable care act by making medicare a more effective to a year in terms of the reductions and overpayments and there may be room to go that made a big difference to spending and the whole thrust of the affordable care act on the cost containment side is to move to a more efficient delivery system and many of the ways that people on both sides of the ogle would like to see it move. that doesn't have much effect

although the administration does point to the reductions as it's already showing influence in that policy. >> mr. haislamaier i would like to give you an opportunity. >> this really gets to the core of healthcare. the chairman was talking about the percentage of gdp and we know as a country we spend more per capita than any other country in the world and health care and it's in the political spectrum not satisfied with their results. it is running even come at too many uninsured etc. i make the observation of what we have here is a value problem. the value is the relationship on what we are spending and getting i don't care if you are buying a hamburger or health care we are either paying too much or we aren't getting enough for what we paid. the central challenge is how do you improve the value in the system? ideally what you would like to do is to get more and pay less.

we would all agree. there is no disagreement on that to the the the problem comes in on how are you going to do it and as my colleague pointed out, there is a viewpoint she holds in this legislation that we can do this by having better micromanagement of doctors and hospitals and insurers and all the rest beat the other view that michael and i call the colds is to have government limit itself to what it is doing which is pretty much in this case taking money and giving it to the rest and if you want to give a little more money that's fine, too but move it to a patient centered system where people can pick and choose and sikh volume and be reworded for providing value. i looked at the system has to focus on the other side and we say look at the award by senior or the cleveland clinic they all provide better results of the lower price and i look at the system and say if that's true

why aren't they eating everybody else's -- and why aren't other hospitals going out of business? thanks to my office i have a blackberry but they are getting their lunch eaten by apple. why isn't that happening? because we are propping them up with all of these payments etc.. the other side says we can study how the do it and then we are going to write a bunch of fools and then we come out in the affordable care act and the accountable care organization. it's the difference of how you go about doing it in that area. >> i now recognize the gentle lady from new mexico. >> thank you mr. chairman. i have to say i appreciate the panel's and this committee because i'm not a dr. mackall kawai at age 80 -- although i have a jd. i can be a qualified health care

expert for reasons. every single day all the time of more than i want to be and i try to do everything right but it doesn't matter. i'm a primary care giver for a chronically sick mother who's incredibly complicated and i don't care what system you put her and she is out by herself she's on medicare, medicaid, she's on her alone doesn't matter. it's exhausting and so complex i could spend the rest of my time explaining it to her and she's a smart woman who gave birth to me but can't do it. and i've done health care and policy-making for 30 years. you say there's been an economic downturn but the economy itself has played a role in the reduction of health care costs. cbo says the opposite. we can work every day and get

experts to give a different opinion. we have the most complicated system in the world and the affordable care act tries to levels that in many ways but i am one of the policy makers who thinks we need to allot more and i've spent years before the affordable care act and before we made changes and i've watched the provider networks shift and change every time there was a profit motive to do that. every single time. i dealt with patience that were left out no matter how much they were paying for their health care and what i mean by who you are are you living in an urban center or not so we have to do not one-size-fits-all we have to do many sizes of the time and this is a great experience about people get better care as a result and get access and we are

paying some of the lowest rates in the country because the affordable care act. insurance regulatory oversight we don't have enough. i never thought i would see that but it happens to be true in this case regardless of what my personal opinions are it is true in this case. what i'm interested in is using experts such as yourself because we just cost shift in this country and what you are proposing is more cost shifting. it shifts back to the states and individuals and back to business and veteran's, cost shift what we have, nine come ten cony 11 no other country has with a not very robust health system those are the reasons that health care doesn't quite work in the way we want it to and i hope all of you stay dedicated and help us navigate those next step because

i don't think the act is responsible for the shift and limited access to the i think that it would exacerbate that in some cases and i don't think that coverage means access and i think that will improve it and we are why is and the brave enough here and the committee used experts i never mean to use these diatribes but there are no simple questions and certainly no simple answers. there are not accept if we don't start leveling the playing field and we don't start focusing on consumers and we are not brave enough to deal with the folks that are still have significant problems before the affordable care act with the affordable care act i pay more because of the a4a global care act -- affordable care act but not because i'm a consumer to navigate through the affordable care act rules in my own state.

so it depends on the details of those issues. as a one the one hand i can tell you why one of those folks who is complaining 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 chronic care procedures of freezing all day and i will tell you that she is more than happy to help pay for everybody's maternity care so that it all gets leveraged out as the commissioner so it is not just medicaid. medicaid is paid for by local government which is paid for bye taxpayers. it's paid for by all of us every single day all the time. so i guess my question is and mr. chairman, thank you so 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 because my provider networks changed because every time you do we reform the open a window for somebody to legally do

adverse selection and cherry picking and that isn't dealt with at the federal level at all and if i was a for-profit insurance company why what i create a network that has the sickest patients? why would you do that? you can't so you don't. and that is not all the reasons that occurs but make no mistake in my opinion there isn't any panel that can convince me that isn't part of the reason that it's always haven't so thanks for being here dr. feder and all the others on the panel. i feel great today and i'm going to get the pans out of my finger and try not to be one of the expensive high end users of health care and you mr. chairman. >> the gentle lady from new mexico and i hope that he would sign on to my bill repealing after listening to you -- >> you know, one of the things you have to look at is getting to the least common denominator and i will talk about that in

the second. >> i will briefly closed. i want to go back 30 briefly to something you said and i'm not asking any questions i'm just getting a statement giving it september 9th the director of elmendorf issued a paper entitled the slow down on health care spending from the multiple sources of paper concluded health care spending has slowed dramatically across the country and the slowdown in health care costs growth has been sufficiently broad and persistent to persuade us to make significant downward revisions to the projections of the federal health care spending. he goes on to say specifically they found that relative to a 2010 baseline projection through 2020, medicare spending is 15% lower than projected and medicaid spending is 16% lower than projected. private health insurance

premiums per enrollee are 90% lower than projected and goes on to say it is also made clear by the way that these reductions come and listen to this, are apparently not because of the financial turmoil recession but because of other factors affecting and this goes to what you said the the fear of the beneficiaries and providers. and with that i would say a witness on the panel said we've got to get it right. chairman i set a few minutes ago talking to one of our colleagues from nevada said there are things we have to do to try to fix certain parts of this, and we have to. we have to get this done and get it done in a way there is a win-win. and i do believe that is possible. and again, i see that coming from having troubled some 20

hours on a plane to go to nelson mandela's memorial i left saying to myself we are so fortunate in this country to be where we are and we can accomplish anything we decide to put our mind to it and somebody once said it's not that people don't know what to do. it's whether they have the will to do it. so again i want to thank you all. your testimony has been helpful and we are going to go forward. >> i would like to ask the gentleman a question. do you believe the actuaries for the centers for medicaid and medicare? >> do you think that they are spending on the oversight of spending would be more the lubber tip and more accurate than cbo? >> i'm not sure but one thing i do know -- >> this is their due diligence, the actuarial steel with members. >> the fact is again what i just

quoted i do again the cost of coming down according to the cbo and the reason i got a little upset a few minutes ago mr. chairman and i appreciate your question, but it seems like this president gets no credit for anything. nothing. and over and over again when everything goes well it must have been a fraud. if it goes bad it's his fault. the fact is that there is a lot that can come out of this. we just have to find the will to get this done and we will. >> i want to go back and the actor reza the center of the medicaid and medicare services to do not the answer to the white house say yesterday in the journal health affairs that the cost because of the economy and not because of obamacare would you agree with that? >> yes that is the overwhelming evidence and i would add ayman ad meijer of the president and

if the affordable care act is successful in achieving the stated goal i would be absolutely thrilled. my concern is it will not and it's my obligation to alert the committee to the concerns. >> i just want to answer in fairness to you. earlier this year they also said the center for medicaid and medicare issued a report finding that national health spending has slowed to only 3.9% in the years between 29 to 2011. this represents the lowest rate in health care spending since the government began keeping these. >> just so that i'm fair about this i can tell you about that spending because there are problems don't get me wrong but the problem is expendable money and we have seen that go down.

there is nobody that has enough to buy increased care or to invest in your health care. there is none to be and i personally am an empowering patient. that is what nelson mandela would have wanted is empowering patient not to make them cripple's that to be an entrepreneur is and hold on to their health care and demand that system. patient centered and friendly. it has to start and that is and what was included before obamacare or in obamacare. it's a government dictated relationship. i want to see the patient benefit and empowered not to be a cripple so i want to comment and think the witnesses for coming forward. we appreciate it and with that we will adjourn this meeting.

the fcc provided the first country in the world to provide allocated spectrum for the medical not working. this is something that allows monitoring vital signs without having to have interested monitors. it can be a game changer in terms of tracking people. >> we are a remote wireless remote patient monitoring solution to be able to put devices and patients homes and to be able to monitor and keep them well and have better outcomes and keep them out of the hospital. this provides a regulation device to do readings and typically a patient would have to go to the doctor maybe once a week to get a reading and then the data can go to the service

center and nursing center where they could help monitor the patient if there is a problem they could alert the patient cardiologists. >> one of the things my office is working on is providing a model notice so for example when you go to buy a can of soup there is that consistent fda label that looks to the collapse you look at the things you are interested in. some people care about sodium or sugar or fat but similarly we are developing a tool and we've already done this for personal health records we are now extending it to address other mobile and mom mobile aspects this could help you say okay these do not resell my information or this is how they use it so began a consumer can help to kind of navigate this exploding field. the government's role in supporting the health care technology tonight on the communicators at 8 p.m. eastern on c-span2.

>> i wish you both a very happy christmas and a bright and prosperous new year. it's a pleasure to meet you which begins on thanksgiving day this year would you mind autographing some as a special favor to santa clause clucks >> it is one of the things i do best. [laughter] >> that is a good pen you have. >> my father gave it to me. [laughter]

i'm standing in front of the 1905 practical airplane and this was the third and final experimental airplane that they built and today it survived as the second oldest of their airplanes today. this was considered the world's first practical airplane that was constructed and flown in less than six years' time between the time that they built their kite and the success of this particular airplane. this is also a plan that was built less than two years after the first flight in north carolina december 17th 1903. what's interesting to think about is that the wright flyer flew just four times on one very historical day there were important flights and they very much for the proof of concept of power. but the airplane behind me, the

1905 was capable of repeated takeoff and landing, repeated flights not just for a few seconds of the time but upwards of 40 minutes by october of 1905. this airplane could fly circles, figure eight, it could turn and fly very much like a modern airplane flies. this is very much modern airplane capable of being controlled to three independent maxis of the flight. a look at the capitol where it appears that the budget deal now has enough votes to pass the

senate. "the washington post" reports a bipartisan agreement now appears to have sufficient support to survive the key procedural test vote in the chamber later this week. final passage of the bill with a simple majority of senators does not appear with the legislation was first in the procedural hurdle to and the formal debate on the measure and move the final passage. in order to end the debate at least 60 votes for the legislation. assuming all 55 members of the senate democratic caucus were to vote yes they would need at least five republicans to join them so according to "the washington post," the chamber does have those votes and the votes needed to advance the bill. the senate will gavel in in a few minutes and more work is expected on the executive nominations are around 5 p.m. eastern with votes at 5:30. we have a preview of the week ahead on today's washington journal. >> let's go to the roll calls on

the phone to talk about what we can expect on capitol hill thisp week. thanks for joining us. so this is the final week in session for the year. give a preview of what we can expect to see over the next couple of days. >> what's going to happen is the senate is coming back in sessiok at 3:00 this afternoon and they are expected to work through ado couple more nominations with votes at 5:30 as it is fairly normal on monday afternoon. we will see the confirmation ofe the assistant secretary of stat. as well as the confirmation of the more than likely have j johnson to be the secretary of homeland security. that will clear up to be able to move forward. tuesday with the all-important votes, cloture votes to limit the the date on the deal with the defense authorization

following after that a little bit later in the week. >> let's talk about those bills for the second. what you are hearing from the people on the hill does that have enough support to pass? >> it increasingly looks like it will. we heard just sunday from ron johnson who is like paul ryan ro helped negotiate the deal a republican from wisconsin who said he was going to support its we have heard a number ofrd a np republicans that have said at least would have signaled at least that they may go tot they foreclosure that is to say they would vote to break a potential filibuster which is the vote v n which the democrats will need their votes if they vote againse the measure itself. it would be tough to see at this point the deal not going through unless, and i will stress this because this has happened

before, though not in a couple of years there's been situations in the past where the minority leader mitch mcconnell of kentucky has pulled the conference away from agreements and what has happened is then there are no longer the votes for something that previously a lot of people thought would have the votes so boring that the situation should get through. >> talking with l lesniewski. also not just a policy is that likely to pass this week? >> the defense bill looks like it is probably going to be an easy ride at the end of the day partly because the defense authorization bill has been passed by congress every year for 52 years and it's one of these annual traditions is what people generally refer to it as and i think at the end of the

day that bill will get through before the end of the week although there will be some consternation and maybe some time stalling because of the way the bill came to the senate floor and didn't have any votes that were actually offered for amendments to speak of. any time that happens, you get a number of people that are not happy with what is going on that at the end of the day that will get through and most measures will be headed to president obama's desk before he leaves for the whole holiday and hawaii. >> the last time we spoke, senate majority leader harry reid was to change the senate procedural rules and a lot of lawmakers said they thought that would just increase what's already a very bitter partisan divide and conquer us. given your take has actually gotten worse? >> i think it has and i will

give two quick examples. the first one being of course last week's marathon session the senate was in session for more than 48 hours continuously as democrats look to push through a number of nominations taking advantage of the new procedural rules they set up for themselves much to the consternation of republicans. but i will also give you an anecdote which is myself and several other reporters were talking to john mccain of last week and he basically was saying -- and obviously he's one of the republicans the was a part of the deal making coalitions and he was saying late last week that a lot of that at least for now has fallen apart and a lot of the normal dealmaking that would be going on now will not happen. we will find out for sure when

the senate goes to leave for the year whether or not they are able to clear up this package that they normally do sort of late at night when very few people are watching which is largely like routine military promotions and routine appointments at the state department's and public health service. if all of that is up then we know we will have trouble as the senate moves in 2014. >> we have been chatting with niels lesniewski from roll call. thanks for being with us this morning. >> the senate is gaveling in to start the week and lawmakers will be giving speeches for the first couple hours before turning to nominations at five eastern. on the calendar today patterson to the assistant secretary of state for the near eastern affairs and jeanne johnson to