to canada, mexico, thailand and taiwan for lower cost health care. thank you very much. >> thank you, ms. cheng. we're going to go now to doctor rod when, victor rodwin is a professor of health policy and management new york university's wagner school of public service. his work -- starting health care systems abroad with a special focus on france. professor rodwin held that a signature at the paris, in 2010. thanks for much for being with us. >> thank you, senator sanders, and distinguished members of the committee. good morning to all of you watching on c-span. my name is victor rodwin. iowa state on the french health care system. that system is a model of national health insurance that provides health care coverage to

all legal residents residing in france. it is not, i repeat, it is not an example of socialized medicine like cuba. it is also not a national health service as in the united states -- united kingdom. it is also not an instance of a government run health system like our excellent veterans health administration. french national health insurance in contrast is an example of public, social security, and private health care financing combined with a diverse public-private mix in the provision of health care services. the french health care system reflects three political values embraced by americans. liberalism in the sense of giving patients free choice of any doctor or any hospital they

care to go to, with no networks, no restrictions. second, pluralism. everybody has a diverse choice. they can go to fee-for-service, solo practitioners. they can go to group practices. they can go to outpatient health centers. the computer emergency risk, public or private hospital, consultations with specialists in public hospitals. the third valley this solidarity in the sense of having those with greater wealth and better health, finance services for those who are will less well off and in poor health. now, in terms of population health, the french outdo us, and i'm embarrassed to say that as an american, hands down. look at any indicator you like. life expectancy at birth, they do better than we do. infant mortality, they do better than we do. female life expectancy at 65. they outlive us. female life expectancy at 80, or male life expectancy at 80 where

medical care matters. they outdo us. disability adjusted life expectancy which takes into account measures a disability, they outdo us. figures of life lost, we have more years of life lost. this is not a republican or democratic debate. these are the facts. but that's not the way to judge a health care system entirely. surely a health care system reflects these indicators. but not just the health care system. my colleagues at nyu would still say that we have the best health care system in the world in spite of these indicators. they would argue that these indicators reflect the things for which they assume no responsibly. socialist or -- social services, inequality of income, family policies which are strong in france, maternal and child care programs, which is by a bit of population health and we do. so we have to look at other indicators. and one important indicator of health system performance is

called avoidable mortality. that is come into good health care system, women should not die in childbirth. people should not die of tuberculosis. people should not die of ischemic heart disease. people should not die of cancers that can be cured. and women look at bat, i'm embarrassed to say, that we come out in the united states as 19, and the french come out as number one. i repeat, number one. that is a fact that cannot be ignored. it must be addressed. it was written up in health affairs, a reputable journal. it was confirmed with different measures by the oecd, and it is not received, in my judgment, sufficient discussion. another indicator of how well a system is doing in a theme of this subcommittee that i know is dear to chairman sanders, is access to primary care. you can talk about primary care until you're blue in the face,

but let's look at the consequences of whether you receive primary care or not indifferent health care systems. we have a very established measure of primary care access. it's very direct. if people end up in the hospital for conditions for which you should not have access a patient's if you have access to primary care, that's called avoidable hospitalization. and on that criterion, avoidable hospitalization, the rates of avoidable hospitalization are twice as high in the united states as they are in france. that's an unfortunate statistic from the point of view of an american, but that's the way it is. lessons that we can draw. i believe that health systems cannot be transplanted from one country to another. but we can talk about some issues, and i'll just take them off. i'll go over 30 seconds if you allow me, mr. chairman. in france there's no choice of insurance plans.

everybody is in the same plan for the standardized benefits, but there's a complete choice of hospital or doctor. in france, all pensioners, and there are more than one, a the same price according to nationally set rates. you don't have a lower price for medicaid, a higher price for medicare, and an even higher price for commercial. in france there are no physician gatekeepers. everybody can go where they like. no one is telling them what network they can or cannot go in. they don't have to call the insurance company to get authorization. in france there's extensive to insurance, small, but there's a voluntary -- >> we're going to have to learn more about france in a few minutes. senator murphy, did you want to make a brief opening remarks? let's go to dr. yeh, if i'm pronouncing your name -- forgive me if i'm not. dr. yeh is a professor at the school of public health in taiwan. and we very much appreciate your

being with us today. just because into the microphone, tell us a little bit about what goes on in taiwan. >> chairman sanders, senator byrd and distinguished members of the committee, thank you for inviting me to testify here. my name is ching chuan yeh, professor at the university, but i was the founder ceo of our national health insurance administration in 1995-1998. that was 19 years ago, and i was the administer of health in taiwan. anti-want established the universal national health insurance in 1995. currently, 99.6% of our population enrolled in this program. the other .4%, they have citizenship, but state abroad. they are not covered.

taiwan's program is a single-payer system. and has a large single risk pool. before that we had 12 different social programs, strong and weak program, and we merged into one single pool. that enabled us to have caused some sedation -- among the well and the sick. sadly -- study show that the premium contribution compared to the health resources future rise are favorable to the low income. having a single-payer system is the main reason for our efficient services, and also how the low prices of our health care we can achieve. we have a private, not-for-profit oliver system. and very highly competitive providers enable us to have

efficient service. we contract 100% of the hospitals in taiwan, and 93.5% of the private petitioners enable us to ensure if they have the card, they can go anywhere, any hospital, any private practitioner for their advice. and that enable us very easy and equal access to the system. and single insurance administration have the benefit of very low administered cost, which is only 1.15% of the total spending. and people enjoy complete free choice of providers, and providers in taiwan must be mindful of their patients demands to stay competitive.

our section rate is implementation come it's always between 70-80%. we have a national free schedule, uniform free schedule. so because the hospital and the provider can only compete in quality instead of price and competition. patients carry the insurance card, can go to any provider if they are not satisfied with their quality of services. basically, there are no waiting lists at all, except for a few well-known medical institutes, or well-known doctors. and rationing is solved by provider competition and efficiency of our services.

in 2012, our life expectancy, infant mortality, maternal mortality and some key indicators, we are much better than u.s., although we spend only one-sixth of the u.s. dollar, if ppp adjusted, it is one-fourth of the u.s. dollar we spend. but we are doing better than the u.s. and that thing i wish to mention is it systems. health information system. everyone has this card, and we fix -- actually all our providers submit their data. so we are on the way to do

better. so we expect to accomplish a lifelong the record for everyone in the next few years. i think my time is up. thank you. spent thank you very much. senator robert, did you want to make a brief opening remark? >> no separate in interest of time i do have a question of the witnesses but i will wait. thank you, mr. chairman. >> thank you very much. senator burr, i think you have a witness you want to introduce. >> thank you, mr. chairman. and i thank my colleagues. i have the pleasure of introducing to you today the sally pipes, president and ceo and top fellow in health care studies of the pacific research institute, san francisco, california. sally, thanks for joining us today. to explore what we might learn from other countries around the

world to improve our health care system here at home. as a native canadian and naturalized american, she has a unique understanding of how single-payer systems actually operate. congratulations on becoming an american citizen. we are pleased to welcome and look forward to hearing about your personal expenses and professional analysis of single-payer systems. mic is yours, sally. >> thank you, chairman sanders and ranking member burr for inviting me to testify today. i'm sally pipes, president of the think tank based in san francisco that is dedicated to advancing opportunity for all through market-based solutions. i'm going to focus my remarks today on canada's single-payer medicare for all system, a system with which i'm extremely the mayor as i am, as senator burr said, a native of canada. many health reform advocates point to canada as a shining example of advantages of a state

run single-payer system. canada is, in fact, one of only a handful of countries with a bona fide single-payer system. government officials set the budget for what can be spent on health care every year. provinces administer their own insurance programs with additional funding from the federal government. private insurance is outlawed in many provinces. this is the sort of system that many are going for here in the united states. they want to abolish private insurance and leave government as the sole source of health coverage. but the canadian system is one that would not be suitable for america. officials severely restrict patient access to care, and those restrictions saddle patients and their families with massive monetary and nonmonetary costs. or to frame this in terms of a title of this hearing, if you're

looking for lessons from health care systems abroad, canada shows us exactly what not to do. let's start with wait time. in order to keep a lid on health care costs, canadian officials have to ration care. according to canada's fraser institute, the average canadian has to wait over 18 weeks from seeing a primary care doctor to getting treatment by a specialist. and wait times are only growing. the 18 week delay today plaguing canadians is 91% higher than it was in 1993. at any given time, 17% of the canadian population, 5 million out of 35 million, are on a waiting list to get primary care. there's also a sitter shortage of essential medical equipment. for instance, canada ranks 14th out of 23 oecd countries in mri machines per million

people, with an average weight time at just over eight weeks. these lengthy waits have profound consequences, not just for patients were suffering, but the rest of society. when people are not treated in a timely fashion, their conditions worsen and their health deteriorates. their productivity drops and then they have to stop working entirely. and they often end up requiring significantly more common expensive, and extensive treatments which are costly for the entire system. one estimate from the center for -- found that wait times were just for key procedures, mri scans and searchers for joint replacement, cataracts, and coronary artery bypass grafts cost canadian patients $14.8 billion every year in excess medical costs and lost productivity. once canadian patients finally receive medical treatment, it is

far from free. about 68 cents out of every dollar in government revenue goes to health care spending. but a typical canadian family spends about $11,300 in taxes every year just to finance the public system. technically every canadian has access to needed health care services. in 2005, madam chief justice beverly mclachlan of the canadian supreme court ruled in favor of overturning the ban on private health coverage in québec. she wrote that access to waiting list is not access to health care. those canadians who can afford to opt out often come to the united states, about 40,000 canadians come every year to this country to pay out of pocket. danny williams, former premier of newfoundland in 2010 flew to florida for heart valve surgery. when questioned by the press about that decision, he said it's my heart. it's my health. it's my choice.

i did not sign a waiver right to get the best possible health care for myself when it entered politics. brian day, an orthopedic surgeon who runs an illegal clinic in vancouver said, a person can get a heart -- a hip replacement for the dog in less than a week. for a canadian it's over two years. my own mother died from colon cancer because she had to wait. she could not get a colonoscopy. when she lost 35 pounds four months later terms you entered the hospital, had a colonoscopy, died two weeks later from metastasize colon cancer. how much longer could we've had my mother if she had had prompted treatment? there is an example in the u.s. of a single-payer system. it's the va and there's a lot of dissatisfaction with waiting list. i think this is no way for us to run a health care system, a single-payer system. we need a new way to inject genuine market competition and clinics and choice into our health care system. we need to scale back top gun

controls by government. thank you, an i do look forwardo your questions. >> thank you very much, ms. pipes. turns out we have another canadian with us as well. our fourth witness is dr. danielle martin, a primary care family physician actively involved in practice of women's college hospital in toronto canada where she also holds and administered leadership position, as vice president of medical affairs and health systems solutions. dr. martin, thank you for being with us. >> chairman sanders, ranking member burr, distinguished committee member, thank you for inviting me to address yo you today. minutest danielle martin. as a practicing physician and vice president medical affairs and health systems associate at women's college hospital i have daily firsthand experience with the canadian single-payer system. in addition to my clinical training i also hold a masters in public policy from university of toronto where i'm an assistant professor. i do not presume to claim today

that the canadian system is perfect or that we do not face significant challenges. the evidence is clear, the evidence is clear that those challenges do not stem from a single-payer nature of our system. quite the contrary, working within a public insurance structure helps us to better tackle many of the challenges shared by all developed nations in health care, including rising cost, variations in quality, and inequities of axis but i would like to highlight three major benefits of the canadian single-payer model. the first is equity. poll after poll has demonstrated a strong consensus among canadians that access to health care should be based on needs, not ability to pay. while of course we continue to struggle with an equity on other it is worth emphasizing that a substantial lower cost than in the u.s., all canadians have insurance that covers a doctor and hospital care. we do not have an uninsured resident we cannot have different qualities of insurance depending on a person's employment. we do not have an interest in

working to try to carve out different niches of the risk pool. this is a very important accomplishment and as we watch the debate unfold in the u.s. as about to address the challenges you face, we are reminded daily of its significance. one of the big challenges in a multitier system is the question of how to achieve policy reform with so many players in the game. in a single prayer -- single pair framer, it's government and providers identify significant challenge in health care system, they can work together at the bargaining table to align financial incentives to advance their shared policy objective. an example of him which elaborate in my written submission is the wind which ontario's government and physicians have worked together to increase the number of medical students choosing primary care as a career and choosing to work in rural underserved communities. finally, one cannot speak of a single-payer without addressing the issue of administrative costs. it has been estimated at the fewest administrative costs were curtailed to the love of those

in my home province of ontario, the total savings he would be $27.6 billion per year. indeed overall as you've heard we spent a much lower proportion of our gdp on health care in canada, 11.2% as compared to your 17.9%. this is not at the expense of quality. canadians enjoy the same or better health outcomes as americans. both of the level of life expectancy and infant mortality as you heard, and we'll look at outcomes for a range of acute and chronic illnesses. in fact, a recent scientific systematic review found that canada achieved health outcomes that are at least equal to those in the united states at two-thirds of the cost across a very wide range of diagnoses. the issue of wait times could -- is widely covered. when it comes to urgent and emergency or, canadians are not waiting substantially longer than our peers in other countries, including the united states.

unfortunately it is true that that has not been the case for elective medical care such as non-urgent diagnostic imaging and elective surgery. a great deal of work is underway to address this challenge. and, indeed, waits have been decreasing over the last decade for a variety of medical procedure. it's important to note that moving away from a single-payer model would likely exacerbate our wait time challenge rather than alleviating it by drawing critical health human resources out of the public system. this is borne out by international evidence from other jurisdictions such as australia. the canadian system is proof that public health insurance need not be provided federally in order to achieve the benefits of the single-payer model. in canada each province provides public health care insurance to its residents with minimum standards set at the federal level. furthermore, moving to single-payer insurance, as you heard, does not essential to me moving the direct provision of health care services by

government or socialized medicine. although our provincial health insurance plans in canada are financed publicly, almost all health care services are delivered by private entities. this includes our hospitals which are mostly independent not-for-profit entities, and also our providers most notably physicians who are not employees of the state but rather independent contractors who happen to build a public insurance plan for their services. i want to reiterate my thanks to the committee for giving me the opportunity to present to you today. i look forward to your questions and engaging in dialogue. >> dr. martin, thank you very much. senator burr, did you want to introduce your other guest? >> i'd like to introduce my colleagues, dr. david hallberg who is the health care policy analyst at the national center for public policy research here in washington, d.c. doctor holberg, thank you for joining us today. i look forward to your testimony and your thoughts as we examine the lessons learned from other

abroad countries were to strengthen our own health care system here at home. the mic is yours. >> chairman sanders, ranking member burr, members of the committee, thank you for this opportunity to testify before you. my name is david hogberg and on health care policy analyst with the national center for public policy research. i think the most important lesson we can learn from other nations is that we should avoid putting more and more of our health care system under the control of politicians. most politicians want to get reelected and that fact will have a substantial impact on health care policy. groups that have political clout, that can influence the politicians reelection chances are more likely to get good treatment under government run health care systems. groups that lack such clout will receive in for your care who are very ill usually lack such political clout. first, the very sick are relatively few in number which means the amount of very limited number of voters.

second, there to stick engaged in the type of political activities such as organizing them protesting and so forth that can bring about change in health care policy. alternately under a government system those with the most medical need are those most likely to have difficulty getting the care they need. both denmark and france provide good examples of this. health care system in denmark could be best described as single pair with a government financing over 85% of health care expenditures. health care in denmark is largely free of the point of consumption. this has consequences for how health care resources are allocated. if patients do nothing of the point of consumption, then patients will overuse health care putting strain on government budgets. health care systems -- health carcare must be rationed in anor minute. and like most single-payer system denmark crushed by using wait times for treatment of serious conditions. for example, gains most way the medium of 40 days to get her new disc repaired, 57 for a new

replacement, 81 days for cataract treatment. under the national standard for cancer treatment in denmark, a patient should not wait more than 28 days between the time he sees a physician for diagnosis to the time of treatment. however, a 2010 study found that less than half a danish patients diagnosed with head or neck cancer were treated within that national standard. this can have serious consequences for patients. analysis found that for every month treatment is delayed for head or neck cancer, the probability that the cancer will recur increases by the three about three points 7%. looking to the french system, the health care system in france is financed heavily through the government yet also has an extensive market of private insurance that covers co-payments and services the government does not cover. when a patient visits a physician in france he must be the cost directly. is then reimbursed by the government and the private ensure. patient must cover any cost that is not reimbursed. the method of payment and

extensive system of private finance is what allows friends to avoid using wait times to ration care. however, the health care portion of france's budget has been running a deficit since 1988. as a result the health care system in france has used other methods to ration care. one ration method is limiting investment in new medical technology. among industrialized nations, france is one of the most number of cat scans, pet scanners and mri machines per million publishing the rationing pharmaceuticals is another method. the french government author refuses to pay for drugs that are incremental improvements over existing drugs. such rationing has consequences. according to one study only about one quarter to one-third of alzheimer's patients in france are receiving state-of-the-art medication. rationing technology in medication or using waiting times falls hardest on people with serious illnesses. if these methods persist because they are politically tolerable. in general they do not cause

trouble for politicians since the people affected seldom are a significant political force. in summary i think the chief benefit of an examination of other nations health care systems is to discover what policies we should avoid. that said, it would be far more productive if we instead studied other markets rather than of the nation's pic that would include other markets for insurance such as life, homeowners and auto insurance and other markets for other vital products such as food and clothing. there you will find markets in which government tax policy hasn't distorted the purchase of goods or tax policy and regulation has not resulted in a three to system of insurance and where consumers are not prohibited from buying goods and services out of state. as a result these markets produce the cost of goods and services while also improving quality. it is in these markets we should look for guidance in reforming the u.s. health care system. thank you very much. >> thank you very much, dr. hogberg. our last but not least witness

is jacob l. burke. .. >> most patients in denmark are lid with a dp of their choice. all patient, all risks are free, and the use of specialized health services is free with a referral from the gp. patient can also choose group

two health insurance directly. but the group two patient will face a co-payment to visits to gp and specialists practicing outside the hospital. only about 1% of the population have chosen group two health insurance, and people are generally quite satisfied with the gp system. if referred to a hospital treatment, patient must choose between all hospitals offering the relevant treatment. all hospital treatment is free including all hospital drugs. patients may all choose among private hospitals in denmark or hospitals abroad if the waiting time exceeds one or two months depending on the severity of the condition. many patients prefer to stay with the local hospital, therefore, median wait can't be with longer than the waiting time guarantee, but it's a choice. if cancer is suspected, we offer a two week waiting time for examination and treatment. it had previously been a problem, as you mentioned.

to finance the health care system, the state collects the necessary revenue through general taxation. the state funds the regents, and today, on basis of objective criterias. this insures equal opportunities for the rejebts across -- regents across the country. the simplicity of the financing structure keeps the administrative costs low, only 4.3% of the total health spending is used for administration. the public sector finances about 85% of the total health expenditure. the 15% private expenditure mainly covers out of pocket payments for pharmaceuticals, dentistry and optical services like dallass and contact lenses -- glasses and contact lenses. about half of the population has supplemented to cover payments. there also are supplementary health insurances where you can access health care quicker than the four month -- one month or two month waiting time guarantee

or free access to physiotherapists, but the supplemental health insurance covers less than 1% of the total health care budget, but it's a choice. the -- [inaudible] service showed that 35% of the population perceived their own health status as comment or very good. life expectancy is an average of 80.1 years. historic high smoking rates is typically blamed for the relatively low life expectancy rate in denmark, not the system or the health system. the european consumer powerhouse ranks all the european systems, and the danish system ranks second. we score high on -- [inaudible] range of services provided and information. denmark scores relatively low in prevention and health outcomedies palins. health -- [inaudible]

slightly above oecd average when you look at thattists -- statistics. if these costs are reported if many line with the practice used in most other countries, the danish health expenditure is significantly below oecd average. to sum up, the danish health care system is an example of a transparent health care system that provides comprehensive and universal coverage and high level of patient satisfaction. the simplicity of the system keeps low cost and makes it easier for the patient to access health care. i would be happy to answer any questions you might have. thank you for the attentionment. >> thank you very much, mr. kjellberg. now we'll begin with questions and comments, and let me, let me begin. let me begin by asking all of our distinguished panelists a very simple question. in the united states today, we

are the only nation in the industrialized world that does not guarantee people health care as a right. and we still have, although numbers have gone down since the affordable care act, but we still have many, many millions of people with no health insurance at all, others have high co-payments or deductibles. so let me ask all of the panelists a very simple question. should health care be a right of all people regardless of income? yes, no, maybe? ms. cheng? should health care be a right of all people? >> i think it should. i think it should because it is, it is a sign, an expression of a civil society. >> okay. i ask for brief answers.

dr. yeh? >> access regardless of their job, their income is an inalienable right in our constitution. >> okay. ms. pipes? >> no. of we're entitle today life, liberty and the pursuit of happiness. how do you determine which right is worth more? do we have a right to housing, food, health care? how do you measure which is the appropriate level? so, no. >> okay, thank you. dr. martin? >> yes. access to health care is a human right, and i know that the vast majority of canadians in poll after poll feel the same way. >> mr. kjellberg? >> yes, i believe that access to health care should be a right. >> dr. hog beck. >> yes, i think it should be a right in the classical liberal notion of rights, that government should not interfere, congress should make no law and so forth. so, yes, everyone should have the right to health care this that sense -- in that sense. >> dr. rodwin. >> we have a right for health care in the united states, for

emergency care. i believe that should be extended to primary care as well. >> okay. let me stay on that point, maybe get to dr. hogberg. you indicated that you thought health care should be a right, but government should not be involved in that process. does that suggest that you would do away with the government-run medicare program? >> a moot -- it's a moot point. >> no, it's not. >> it's a very moot point because seniors vote at very, very high rates, and we're not getting rid of medicare. >> but i'm asking you as an academic. seniors, you're right, it's a popular program. but if you say government should not be involved in health care and medicare is a government health care program -- >> uh-huh. >> -- your judgment, in the best of your possible worlds, should the government vote to get rid of medicare? some people think we should. what do you think? >> i think it's a moot point.

it's here to stay. >> well, i think you didn't answer my question. ms. pipes, i would like to ask you that question. >> i believe that we are not going to get rid of medicare. medicare is a program for our seniors. i think we do have severe problems. the medicare trustees have said that medicare will be bankrupt by 2024, at a cost of -- >> i just wanted to ask you a simple question. >> it should be there -- >> government is -- medicare is a government-run program. >> right. >> as dr. hogberg anticipated, i think it's a popular program. we can disagree. my question is should we, in your judgment, abolish in this government-run program? >> not entirely. medicare should be there for those people that truly need it. >> truly need it. but not as it is right now. >> a lot of people are wealthy. congressman ryan, i think, has some very good ideas -- >> right. he would transform medicare into a voucher program.

dr. rodwin, let me ask you a question. despite the fact that our health care outcomes are not particularly good in terms of unpant mortality -- infant mortality, in terms of life expectancy, the united states ends up spending almost twice as much money per person on health care as any other nation. why is that? and i'm going to leave you -- and we'll give senator burr additional time as well. dr. rodwin, why is that? put your mic up. >> we spend more, senator sanders, for several reasons. first, our prices are higher than all other wealthy oecd nations. >> all right. if a woman has a birth in this country compared to france, how much more does it cost, or give me some examples. >> it can cost different prices here depending on who insures you. it can range from $5,000 to $27,000. the figures are in the excellent

paper from oecd for all to see. so price is one very, very important -- prices of drugs, prices -- >> how do drug prices compare in the united states compared to other countries? >> in the aggregate, her much higher. >> why is that? >> why is that? >> yeah. >> because we have no price control. >> so if i need a cancer drug in the united states, why is it much more expensive here tan it is in canada -- than it is in canada and france? >> in canada and france you have regulated prices for these drugs, and people have access to them -- >> that interferes with the free market system. is that a good idea? >> of course it's a good idea. the free market system doesn't exist anywhere in health care. i challenge anyone to give me an example of the free market system that operates and works. anyone to give me one cop crete example. -- concrete example. all the evidence suggests that it does not work. >> okay. senator burr. >> dr. martin, in your testimony you those that canadian doctors

exiting the public system for the private sector has had the effect of increasing waiting lists for patients seeking public health care. why are doctors exiting the public system in canada? >> thank you for your question, senator. i -- if i didn't express myself in a way that made myself understood, i apologize. there are no doctors exiting the public system this canada and, in fact, we see a net influx of physicians from the united states into the canadian system over the last number of years. what i did say was that the solution to the wait time challenge that we have in canada, which we do have a difficult time with waits for elective medical procedures, does not lie in moving away from our single-payer system towards a multi-payer system. and that's borne out by with the experience of australia. so australia used to have a single-tier system in the 1990s moved to a multiple payer system where private insurance was permitted. and a very well known study was

tracked, what took place in terms of wait times in australia as the multi-payer system was put in place. and what they found was in those areas of australia where private insurance was being taken up and utilized, waits in the public system became longer. >> what do you say to a an elected official who dose to florida and -- who goes to florida and not the canadian system to have a heart valve replaced? >> it's interesting because, in fact, the people who are pioneers of that particular surgery which premier williams had and had the best outcomes in the world for that surgery are in toronto at the cardiac center just down the street from where i work. sometimes people have a perception, and i believe that, actually, this is fueled in part by media discourse that going to where something, where you pay more for something, that that necessarily makes it better. but it's not actually bourne out by the evidence on outcomes -- >> one way or another people prefer their system because they

know consciously they pay more. no, i think it's because they judge quality and they judge innovation. ms. pipes, in your testimony you noted that more than 42,000 canadians come to the united states each year for health care. why is that? >> because they find that they're on a waiting list in canada for too long a period, and they feel that their health is at stake. so a lot of people in canada come to the u.s. for mris, ct scans, there are many examples of people in the be media of people like brian who came to the u.s. because he was told by his primary care doctor that he might have a brain tumor, but the wait for mri was too long. you will see advertisements in canadian newspapers for mris or -- >> pretty per till ground to market -- fertile ground to market in. >> right. >> dr. martin, in your testimony you state that the focus should be on reducing times in a way that's edge wit bl for all. what length of time do you

consider to be equitable when waiting for care? >> well, in fact, the wait time alliance in canada, sir, has established benchmarks across a variety of different diagnoses for what's a reasonable period to wait. and what we've found is that, actually, working within the single-payer system we can reorganize things. you know, i waited more than 30 minutes at the security line to get into this building today. and when i arrived in the lobby, i noticed across the hall that there was a second entry point with no line-up whatsoever. sometimes it's not about the amount of resources you have but, rather, about how you organize people in order to use your queues most effectively. we believe that when you try to address wait times, you should do it in a way that benefits everyone, not just people who can afford to pay. >> on average, how many decade yaps on a waiting list die each year? >> i don't know, sir, but i know there are 45,000 in america that die waiting because they don't have insurance at all. >> well, let me go back to

dr. rodwin's statement. the american system has access to health care for everybody. it's called the emergency room. now, we don't admit that clearly because we're lobbying for a particular angle. but every american can access health care. they can't access primary care, and, dr. rodwin, i would agree with you that we ought to make sure there's a medical home for practically everybody we can place. we don't do it in medicaid, we should. states should adopt it because primary care is an absolute necessity to wellness. but, mr. kjellberg, how many danish citizens have supplemental health insurance policies, and why has that number been increasing in recent years? >> about half the population got a co-payment insurance, and that has increased dramatically over the last year because the family were included, the children were included, and that brought up the numbers quite significantly. but the number of policyholders hasn't really changed much.

>> but half the population has supplemental insurance. >> co-payment insurance. and then many people in the labor market also as part of a benefit package offered health insurance so you can have faster access to elective care. >> so they can actually buy their way to faster access. >> oh, you can buy -- at private hospitals, you can buy any hospital services -- >> so they have of options. they have choices. >> they have choice, yeah. >> dr. rodwin, in your testimony you note that parliament sets health care expenditure targets each year. if a hospital or physician exceeds their target expenditure by billing for higher than projected volume of services, prices are negotiated downward for the following year. beyond volume or utilization of services, are there quality metrics that the french use to determine reimbursement for physicians or other providers in order to incentivize quality care for patients, for example, measuring health outcomes to insure patients are receiving quality care? >> this is a science that's not

well developed neither in our country, nor in france, but they are working on this very question which is very timely right now; that is, the negotiations focus certainly on volume, but now there's a program which will remunerate a physician's -- that's actually already in lace if they -- in place if they follow certain standards of preventive care. >> but tear penalized if they bill at a higher rate one year, they're permized the next year by a reduction -- >> every year, sir, there's a negotiation to set these rates. and if the volume goes up, the following year the -- the practice is -- >> thank you. thank you, doctor. thank you, mr. chairman. >> senator enzi. >> thank you, mr. chairman, and i want to thank the distinguished panel for all of the information that they've provided. it's a little different than a session that senator kennedy and i held several years ago. but first of all, i want to

thank ms. pipes for being here. she wrote a book in 2010 that predicted what was going to happen with our health care system as it is now. and then more recently she's written something called "the cure for obamacare," and it's not even copyrighted, but it's an outstanding book on what we could do to repair the damage that's been done on our present system. and i thank you for your effort on that and hope i can get a few more people to read them. i mentioned senator ken key and -- kennedy and i. when i was the chairman and he was the ranking member, we went to a system called a round table, and this is very similar except that at a round table we had, again, 8-10 people, and they were all practitioners of some sort in the health care area rather than people who were studying the health care system. and he and i would come up with the questions for the panel as well as total agreement on who

should serve on it as opposed to the way we do panels now which is the chairman gets to pick everybody, you know, four-fifths of every panel, and the ranking member gets to pick another one or two. and then we all come and beat up on the witnesses. [laughter] so at a round table, the senators really didn't speak much. but one of the questions we asked is will universal, single-pay health care work many america. and -- in america. and the first person was an engineer for hospitals, and he wasn't sure. but the other practitioners all said america won't settle for universal single-pay health care. at the end of that hearing, that round table, senator kennedy came to me, and he said i guess we better take a look at some of the things you have suggested like small business health plans and being able to sell across state lines, things like that. and i think one of the things that this panel points out, most

of you are talking about countries whose population is and size in some cases is relative to our states, each state. and in the united states, each state has health care plans, and they do it differently. and as the chairman mentioned, some of them have good ideas, and those spread to others. but what will work in canada with a smaller population or denmark with a smaller population or france with a smaller population might not work in the united states, especially under the form of government that we've got. i'm rate sure that the affordable health care initiative was designed to fail. that was predicted by senator graham about 15 years ago. and he thought that they would come up with a system that would fail, and then we could go to to

universal single-pay health care. i think that would have worked except for one thing; the debacle with the design of the exchange reminded people in america what happens when our federal government tries to handle everything for this vast united states with one plan. and, of course, i'm on the homeland security committee, too, and we're trying to work with another one of those government agencies called the post office. and that's another example that people use of what might be happen if we went to universal single-pay health care. i've been to some countries that have a lot of population like india, and they're very proud of their system. i asked how they took care of that vast of a population, and they said, well, our doctors see 200 patients a day. i don't think our doctors see 200 patient a day and wouldn't take that quick of action.

the question of medicare that was asked earlier, if people were given another option, i think they'd go with another option. too many people in america right now that are seniors at least know somebody that tried to see a doctor, and the doctor said i'm not seeing any medicare patients. so medicare is not the best example of how to get health care in america. and i've almost used up my time without asking a question. i'm the accountant on the panel. in fact, i'm one of three accountants in the united states senate. and so the questions that i have are really kind of technical and get down to some of the costs, and so i'll submit those in writing and would appreciate it if you'd answer the questions. thank you. thank you, mr. chairman. >> thank you very much, senator enzi. senator roberts. >> well, i, too, want to thank the panel and thank you, mr. chairman, for holding this hearing. seems to we that the entire question here has been summed up by the chairman; does the

government, if we have a government guarantee of health care as a right, he posed that question. and then with questions senator enzi and senator burr have pointed out is it a right to waiting list. actually, i think that is the statement by ms. pipes. and, ms. pipes, my deep regrets for the loss of your mother. how long did she have to wait? >> she went to her primary care doctor can, her general practitioner we call him in june, and she was admitted to the general hospital which is one of the largest hospitals in canada in late november. >> late november. and then you lost her after two weeks. did you say that you could get a hip replacement for a dog in a week, but you couldn't get a hip replacement for an individual for x number of -- >> yes. the wait for orthopedics is one of the longest waits in canada,

and my friend, dr. brian day, who is an orthopedic surgeon in vancouver, made that statement to "the new york times." dr. day, who runs the cambi clinic, is being sued by the british columbia government for operating a clinic which is considered illegal in british columbia. the interesting thing is he told me the other day they keep, the government keeps postponing the case, and i think it's because his practice so busy with people getting hip replacements, knee replacements that they're afraid of the backlash that will happen because of that. >> i have legislation that i call the repeal bill. i'm not going to get into the four rationing boards, ipab, cer, etc., etc., to address some of my concerns about the government controls and where we are with the affordable health care act. i'm trying to get ahead of that curve. by the way, i don't know dr. martin. does prime minister harper, does he change the rules and delay implementation of the system

every week like we see going on with the affordable health care act? >> i'm not sure that you, that you want me to answer that question, sir. i don't completely understand what you're saying. >> >> well, i'm saying that the prime minister of canada, i don't think, changes the national health care act that we have in place which i think is, basically, a first step towards single payer, and i think that was the intent of it. the president of the united states has changed the health care about every friday we have what we call a regulation dump, okay? a consortium of unions indicated that they would like a big change in the affordable health care act. he's going to have a carveout for them. on the other side of the fence, 27 members of the finance committee, some on this committee, the head of the centers of medicare and medicaid services to say, whoa, don't change the medicare d program that we have many this country,

a very popular program under budget used by a great number of our senior citizens. and if we hadn't written letter and if there hadn't been a real backlash from people to save medicare part d can, it wouldn't have happened. so we're just sort of writing this thing as we go along, except the president doesn't come to us and ask us to help him do that with each individual change. i'm just wondering with the problems you have up in canada, who makes the change if, in fact, there needs to be a change? >> well, i suppose the answer to your question comes in two parts. the first is in acknowledgment, i think, of what senator enzi was saying early earlier on which is like the united states, canada is a huge country, and our health insurance is actually not provided at the national or federal level, it's provided at the provincial level or the equivalent of your states. so the notion that something can begin in one subnational jurisdiction and then spread is exactly how we came to have 13 separate single-payer systems in

the 13 provinces and territories of canada. and so the first part of the answer to your question is, no, we don't see that kind of, those kinds of changes being made to health care legislation at the national level, but the second part of the answer to your question is that it is widely known in canada that the public commitment to our single-payer medicare system so strong that for a prime minister of any political stripe to try to alter that and undermine it in any way -- >> okay. i got, i got your message. dr. hogberg, you mentioned the fact we ought to, you know, keep the politicians out, and we have just had two changes, medicare part d and then also a carveout for the unions. is that an example of what we're talking about? and 33 other changes, by the way, and that's the last count that i have. >> well, i mean, they're very good examples of groups that have political clout can keep, you know, changes from happening that they don't want to see;

unions and seniors certainly have plenty of clout up here on capitol hill. and if i, would you mind if i were to just take a second to talk about some of the outcome measures here? >> well, i'm already over time. i'll ask the permission of the chairman if that would be possible. >> [inaudible] >> all right, thank you, sir. you've got 30 seconds. >> yeah. first of all, with regard to life expectancy and infant mortality, using those as measures to tell you something about a health care system is a bit like using batting average and on-base percentage to tell you something about football. life expectancy and infant mortality, there's so many factors that go into these outcomes that are not related to the health care system, the health care system has no control over, that they are really not good measures for telling you the quality of a health care system. one other problem is that many of these measures are not measured the same from country to country. infant mortality being -- >> well, thank you for that. the chairman's already gaveled,

hit the gavel. my main question is access to care and denial of that care and what other, what other alternative a person -- >> we're going to have -- >> a single-payer system. >> senator, we're going to have another round of questions. great panel. i think they're good questions. but let me pick up on a point that -- my turn now -- pick up on a point that dr. martin raised because i was going to ask the same question. i live one hour away from the canadian border. canadians watch american television, canadians are very familiar with our political system, probably foe more about -- know more about politics in america than americans know. is your prime minister a socialist? >> no, sir. our prime minister's quite conservative. >> conservative. oh. so, obviously, as a conservative he wants to implement the american health care system that the canadians are very aware of. i gather that was probably the first thing he did when he took power, is that right?

[laughter] >> not exactly. >> why not? >> support for a single-payer medicare in canada is, goes across all political stripes. quite famously, we had the leader of the most right-wing party in the canadian federal debate on television hold up a sign in the middle of the debate on which he'd written in marker no two tier as a means of trying to reassure the canadian public that, if elected, he would not dismantle -- >> in other words, you have a nation bordering on the united states, two nations that are probably as close together in so many respects as any two nations in the world, a conservative prime minister and yet there is no effort to move to an american health care system. i would say to my colleagues there's not a better example of maybe how people feel about two systems. they know the american system. they have a conservative prime minister. they can move this our -- in our direction, but for whatever reason, and i think sensible reasons, they understand that a

system that guarantees health care to all of their people in a cost effective way is the way that they want to stay. ms. pipes, let me ask you that question. why do the canadians not come to the more than health care system? >> well, as i mentioned in my testimony, about 42,000 canadians every year come to the u.s. and pay out of pocket -- >> that wasn't my question. >> no. i just wanted to make that point first. second, the canadian government and the provinces who administer the canadian health care system, this started in 1974. a lot of people in canada have no idea of an alternative system. >> oh, my goodness. they live an hour away from me this burlington, vermont, they watch american television, they read american newspapers, they have no idea of what goes on in the united states of america? that is a little bit hard for me to believe. >> well, i would say that canadian people are very, very nice people. they're not impatient like americans. [laughter] my mother said to me, i hope you're not becoming an impatient american. i am an impatient american. americans do not want to wait. canadians are very nice. and then -- >> well, i have a limited time.

>> yes. >> i think the answer is pretty clear. the canadians have seen the american system, they prefer their own. now, i want to say a word about access because -- and waiting lists. senator roberts raised that issue, and senator burr did. i want to focus on that picture over to there. i know it's hard to believe, and i mean this quite seriously, this is the united states of america. itthis is not a third world, developing country. this is a town called wise, virginia, and i don't mean to pick on virginia because i think the same story can be told all over america. so when we talk about access, what we're looking at here is that a number of times of year people, working class people wolf no health insurance at all, are given free health care, episodic care, volunteer doctors very kindly come and thousands of people line up because this is the health care they get. this takes place many a field in wise -- in a field in wise,

virginia. i think it's a stadium in los angeles where something similar takes place. now, if this is the kind of health care that we are proud of in the united states of america, well, some of us have some strong disagreements about that. dr. rodwin, i want to get back to another point which, to me, is very important. it is, and i'd like dr. martin to comment on this as well and maybe ms. cheng and dr. yeh. to get good health care, you need medicine very often. if i go into a french hospital, i leave the hospital is and i'm sick, how much do we, how much does my medicine cost? >> under french national health insurance, there's very high levels of pharmaceutical coverage. >> meaning what? my medicine is free or virtually free? >> virtually free. 90%, 80%, 70%. >> dr. martin? >> those prescription drugs are

cut because they're ineffective. >> dr. martin? >> interestingly, this is an area where we made a mistake in the design of our single-payer program in canada at the time. canadian medicare was designed in the 1950s, and '60s. medication was not a really big part of the way that we treated disease, and medicines were left out of coverage. so the single-payer program in canada does not include medication, and as a result, 1 in 10 canadians today fails to pill a prescription or take their medicine as prescribed because of concerns about cost. >> thank you. mr. kjellberg? what about prescription drugs in denmark? >> all hospital use at hospital are prix of charge. and if -- free of charge. and if prescription drugs are needed, you have a maximum co-payment a year about $600. >> okay. dr. yeh? in taiwan, how much do prescription drugs cost? >> it is covered by the -- [inaudible] but patient have to pay some co-payment up to about $10 u.s.

>> up to $10 u.s.? >> up to ten. and each year adds up to a -- [inaudible] the ceiling will be $1,000 u.s. >> ms. cheng, what's your view on prescription drugs? >> prescription drug use in the united states, in fact, is low compared to total health spending. relatively speaking, in europe as well as in taiwan percent of money spent on drugs in terms of total health spending is a much higher percentage. example, in the french system it's roughly 25%, in taiwan 25% of total health spending is on drugs. so they have much greater access the drugs, that's number one. number two, the reason why the drug price -- >> i apologize. my time has gone over. senator murphy has joined us, and, senator murphy, did you have some questions you wanted to ask? >> thank you very much, mr. chairman. thank you for this hearing and

for all of the witnesses, i'm sorry i had to step out for a few moments. i just sort of had one broad question for the panel because i think it's come up in some of the testimony, especially, i think, from ms. pipes and dr. martin. i'm always fascinated by thisser intersection between convenience and quality. and the extent to which metrics like wait times often don't automatically translate into differences in outcomes. often they do. i mean, les some services in which if you don't get it right away, it's going to have a pretty severe consequence on your health and on the amount of money you're going to spend later on. but there are parts of this country, for instance, that have enormous convenience that you can't drive more than a couple miles outside your door without finding an mri machine or a dialysis center. and, you know, there's health care all around you. and yet that doesn't seem to be adding to quality.

that seems to be adding to convenience. similarly, i hear all of the stories from canada that ms. pipes talked about in terms of wait times and yet when we sort of look at all the underlying data, it tells us, you know, in the end a lot of the diseases where you have wait times that might cause you to question the system, the outcomes in canada are fundamentally better than they are in the united states from heart disease to cancer. so that's not to say that we shouldn't sort of look at issues of veedges and issues of wait -- convenience and issues of wait times and your proximity either spatially or them porally to services. maybe asking others on the panel who have thoughts about this with your experience is to talk about how in other countries where there may be less easy access to health services, not

as much health care as we have in the united states -- we have tons of it -- as to whether that actually has a true relation all the time to the outcomes that we get. dr. martin, happy to have you start. >> thank you. it's a really thoughtful question, and i guess i might reframe it slightly by saying what you refer to as convenience, i would refer to as patient experience. and so when we talk about quality in health care, the so-called triple aim coined by don burr wick here, the notion of quality having three dimensions, one is population health outcomes on which single-payer countries like canada fare, in fact, quite well, another aspect of triple aim is cost per capita, and the third is patient experience. and, of course, patient experience is important. so i said that i wasn't here to be ap apologist for every single thing about the canadian health care system. we're working very hard on reducing wait times for elective surgeries because we believe that patient experience matters. but you're right that our

outcomes are very good. and i think it's critically important for the committee to understand that single payer does not equal wait times. we heard our colleagues from taiwan tell us quite clearly that they have a single payer system with virtually no wait times, with 99.6% coverage of the entire population. and so, of course, we should consider all aspects of the triple aim when we talk about quality. but we should not, we should avoid oversimplifying the message and equating a single payer model with wait times that simply is not the case. >> well, madam justice marie dechant who retired from the canadian supreme court in 2012 in that hearing in '05 said the idea of a single-payer health care system without waiting lists is an oxymoron. so even the canadian supreme court is not a conservative court by any stretch of the imagination. i think, you know -- >> do you dispute the characterization of the taiwan system?

>> well, the united states, i think as senator burr said, we have 315 million people here. we have such a diverse, we do not have a homogeneous society which is much more typical in many other countries around world. i did want to make a point about life expectancy and, you know, the world health organization often says united states ranks 37th out of 190 countries. well, as professor stephen wolf who was the lead author in the institute of medicine study which, you know, was really based on life expectancy and infant mortality rates, he said life expectancy and other noted health outcomes are determined by much more than health care. we have a huge obesity problems at a much higher per capita rate than any country in the world. so when you look at the numbers based on the work done, united states ranks number one in the world on 13 of the 16 most

popular cancers. so you have to be careful when you're doing statistics that you're comparing apples to apples. >> great. thank you very much. my time's expired, mr. chairman. >> senator burr. >> thank you, mr. chairman. let me say before i ask the second round of questions there's been a lot of reference to ped care and single-payer system. let me just remind everybody, medicare for life, working lifetime i pay into a system to finance part. there is a government share. when i become a senior and i go and get part b coverage which is the physician side, i pay a premium for that. when i go to get drug coverage, i pay a premium for that. you can't look at medicare and say this is like the single-payer system in taiwan where the government picks up the entire tab. now, health care's not free. we all know that. it comes out of general taxes. but there's a difference for seniors in america that they are personally invested into a system, and they even have choices. they can choose ped caravaning

which is a private -- medicare advantage which is a private sector coverage -- at least they could before obamacare, and now that's getting knocked out. and they can choose as a senior to buy mehdi gap insurance so they can buy their way out of skin in the game. the one thing i heard is that everybody -- except for possibly taiwan -- has some degree of co-pay. france does, canada doesn't, but they do as it relates to drugs because they're on their own for drugs. and what i want to talk about is drugs because, ms. cheng, dr. yeh, our friend from taiwan said in his testimony that patients in taiwan can experience delays in coverage for new drugs and new technologies from two to five years from adoption of the united states in that. and, ms. cheng, you touched on prescription drug prices in your testimony. almost all countries enjoy the benefits of america's medical research and development, but developed countries don't pay

their fair share for the immense expense involved in the development of innovative, life-saving therapies. these countries are free riders on the united states by enacting price controls on drugs and devices. how would sharing more of the financial burden that comes with research, development of life-saving drugs and devices affect comparison between the united states and the countries we're discussing today? that's to you, ms. cheng. >> thank you for this question. first of all, yes, we -- united states does fund whole hot of r&d -- whole lot of r&d in pharmaceutical and other device innovations. but in so doing, we are also helping to make the american health care system that much more expensive. in fact, so expensive that we're pricing people out of the mechanical together. so united states is, you know,

so in terms of r&d in single-payer systems, i think it is the governments of these systems can set aside specific r&d funds to end with r&d for innovations -- >> ms. cheng, in the u.s. system when we shifted from exclusively doing bypass surgery for heart blockage -- >> right, right. >> -- and we went to cater thization because innovation or technology allowed us to do catheterization, do you consider that a to be a cost saving to the united states or the expense of a new innovation? >> if it's done on the right patients at the right time, yes, it is a cost-saving innovation and application of that innovation. however, i think with the united states health care there's a very serious issue which has not been addressed which is overuse of services.

we have here in my testimony the -- >> isn't that the risk of letting the american people choose health care and having a marketplace versus having government dictate what, where, when and how much? >> it's not a, it's not a matter of letting people decide in the marketplace where to go or what to choose, what to have. >> we overprescribe grossly pharmaceuticals in the united states. why? because the american patient has the right to go in and ask their doctor, and payoff our -- because of our liability exposure, the doctor feels compelled to write the scrip in the united states. that's a lot of the health care, a lot of the drug costs. let me just move -- >> may i just say -- >> yes, ma'am. >> in the medicine book, in fact, i brought it, it says that this overuse of everything,

services, devices, drugs, it causes waste in the american health system. according to this book, about one-third of u.s. health care is waste. and $750 billion a year. and of that, unnecessary services accounts for $210 billion of the $750 -- >> i wouldn't disagree with conclusion. i have one last question, mr. chairman, and it's to dr. hogberg. in contrast to what i've just talked about with ms. cheng, price controls overseas don't reward innovation. if the united states were to have followed the price control model, what would happen to patients' access to innovative treatments here in america as well as overseas? >> in the long run, you'd see less access to new, innovative drugs. it'd be that simple. >> so if, in fact, we eliminated

innovation, and in many cases that innovation which takes somebody out of a hospital setting, puts them in an outpatient facility, they're treated, they no longer have the risk of infection, they no longer have the days in the hospital, that's not only been beneficial to the costs in health care, it's actually beneficial to the quality of outcome. >> well, sure. frank lichtenberg's looked at this extensively, and he's estimated that for about every dollar we put into pharmaceuticals, you save well over $3 in hospital costs by avoiding hospitalizations. the price controls can have one of two impacts. if you have price control that's lower than the market price, you'll see a shortage. if it's above the market price, you'll see a -- sorry, i'm losing my train of thought here. you'll see a surplus, and that's kind of, you know, what you're going to end up with, a system of price controls. >> i thank you. i thank our witnesses. i would ask the chairman for unanimous consent to allow us to

submit questions for all the witnesses for the purposes of the record. >> absolutely. and this has been, let me thank all of you for being here. and i want to apologize, i would like to stay for another round of questioning, but we have votes that are taking place right now. i think this has been a thought. and vigorous discussion, and i appreciate all of you very much for being here. thank you. this hearing is adjourned. [inaudible conversations]

[inaudible conversations] >> and a snowy day in washington, d.c. today where president obama spoke earlier about the ukraine after yesterday's referendum in crimea proved overwhelmingly in favor of seceding from ukraine to become with part of russia. here are the president's remarks to reporters from the white house briefing room. [inaudible conversations] >> good morning, even. good morning, everybody. in recent months the citizens of ukraine have made their voices heard. we have been guided by a fundamental principle, the future of ukraine must be decided by the people of ukraine. that means ukraine's sovereignty ander the to territorial integrt be respected, and international law must be upheld. and so russia's decision to send troops into crimea has rightly

drawn global condemnation. from the start the united states has mobilized the international community in support of ukraine to isolate russia for its actions and to reassure our allies and partners. we saw this international unity again over the weekend when russia stood alone in the u.n. security council e defending its actions in crimea. and as i told president putin yesterday, the referendum in crimea was a clear violation of ukrainian constitutions and international law. and it will not be recognized by the international community. today i'm announcing a series of measures that will continue to increase the costs on russia and on those responsible for what is happening in ukraine. first, as authorized by the executive order i signed two weeks ago, we are imposing sanctions on specific individuals responsible for undermining the sovereignty,

territorial integrity and government of ukraine. we're making it clear that there are consequences for their actions. second, i have signed a new executive order that expands the scope of our sanctions. as an initial step, i'm authorizing sanctions on russian officials, entities operating in the arms sector in russia and individuals who provide material support to senior officials of the russian government. and if russia continues to interfere in ukraine, we stand ready to impose further sanctions. third, we're continuing our close consultations with our european partners who today in brussels moved aheads with their own -- ahead with their own sanctions in the russia. tonight vice president biden departs for europe where he will meet with leaders of our nato allies, poland, latvia, estonia and lithuania. and i'll be traveling to europe next week. as nato allies, we have a solemn

commitment to our collective defense, and we will uphold this commitment. fourth, we'll continue to make clear to rush that that -- russia that further provocations will achieve nothing except to further isolate russia and diminish its place in the world. the international community will continue to stand together to oppose any violations of ukrainian sovereignty and territorial integrity, and continued russian military intervention in ukraine will only deepen russia's diplomatic isolation and exact a greater toll on the russian economy. going forward, we can l calibrate our response based on whether russia chooses to escalate or to deescalate the situation. now, i believe there's still a path to resolve this situation diplomatically in a way that dresses the enters of -- addresses the interests of both russia and ukraine. that includes the forces in crimea being pulled back to their bases, international monitors in ukraine and engaging

in dialogue with the ukrainian government which has indicated its openness to pursuing constitutional reform as they move forward towards elections this spring. but throughout this process we're going to stand firm in our unwavering support for ukraine. as i told prime minister yatsenyuk last week, the united states stands with the people of ukraine and their right to determine their own destiny. we're going to keep working with congress and our international partners to offer ukraine the economic support that it needs to weather this crisis and to improve the daily lives of the ukrainian people. and as we go forward, we'll continue to look at the range of ways we can help our ukrainian friends achieve their universal rights and the security, prosperity and dignity that they deserve. thanks very much, and, jay, i think, will be available for questions. thank you. [inaudible conversations] >> you surprised -- [inaudible] >> and president obama is

meeting with the president of the palestinian authority, mahmoud abbas, so talk about the middle east peace process. we'll bring you any updates on the c-span networks. both ukraine and the middle east are likely to be topics at today's white house briefing. you can watch the briefing live on our companion network, c-span. it's scheduled for 1:00 eastern time, that's about an hour and a half away. and you can also share your thoughts during the briefing via facebook and also twitter. >> we're focused on making sure that we can eliminate barriers to getting those networks in place, building out these networks is our priority. so sometimes there are local siting issues, sometimes there are federal rules that might affect how we deploy things or what the lighting might be or the impact on historic sites or the environment. we want to make sure that we are sensitive to those issues. at the same time, we want to make sure that we move forward on deployment because our

customers, those who use these devices every day in their lives, depend on having a good, strong connection, on getting the day-to-day -- the data they want when they want it wherever they want it. >> the wireless infrastructure, tonight on "the communicators" at 8 p.m. eastern on c-span2. >> last week the president's advisory council on financial capability for young americans held its first meeting. it was created to help young people better manage their money and handle financial decisions as they transition into adulthood. among the speakers, treasury secretary jack lew, education secretary arne duncan and the white house's valerie jarrett. >> the office of financial institutions here at treasury. it's great to have you all here with us for the first meeting of new president's advisory council on financial capability. also a warm welcome to the members of the council.

we're grateful that you've agreed to serve. the subject of financial capability is a priority for the administration, and so we look forward to the work of this council with great interest. in a few minutes, we'll hear remarks from secretary lew, secretary duncan, cecilia munoz and director rich cordray. before i turn it over to secretary lew, though, let me just make a couple of points about this, the work of this council. first, the mission of this council in many ways follows from the work of the previous president's advisory council on financial capability. that council submitted a report to the president in which it noted the importance, among other things, of financial education for our youth and of drawing on all resources, private and public, state, local and federal to advance this agenda. hence, the focus on youth with this particular council. second, while the previous

council worked on conceptualizing a path forward, this council's been constituted to discuss and share experiences on the actual implementation of ideas to promote financial capability. the members of this council have been leaders in achieving results in this area, and we look forward to hearing from them about how they're working to move the dial on youth financial capability. third, the members of this council come from both the public and private sectors, and we also have representation prosecute federal government -- from the federal government and from local government. work on financial capability is a collective endeavor. accordingly, we must do our best to figure out how the public and private sectors and the federal, state and local government can complement each other to achieve the results we all would like to see. and now i'm honored to present to you the secretary of the treasury, jack lew. >> thanks very much. thanks very much, cyrus.

and good morning, everyone, and welcome here to the department of treasury. i'm very pleased to have all the members of the new council here with us today, including director cordray and secretary duncan will be here shortly and cecilia munoz from the white house. i'm also pleased we have so many members of the public here this morning with us. president obama created this council and brought this group of talented, committed men and women together to advise him on the issue of profound importance to the future of our economy, the financial capability of america's young people. whether it's teenagers deciding how to spend their first paycheck, college students making crucial decisions about how to repay their student loans, or new parents trying to save for a child's education and their own retirement, helping young americans build a sound financial foundation is not only important for their futures, it can also strengthen our economy for generations to come. that's why the work that we do as members of this council could significantly impact how successful we are at growing the

middle class and increasing economic mobility and opportunity for all americans. fortunately, there's much we can do to improve financial capability, and i, like the president, call on this council to help us identify those opportunities. mastering the basics of financial decision making at an early age will equip young people for the first major financial decision many americans are likely to face, whether to pursue postsecondary education, and if so, how to pay for it. further, we need to make sure that work pays for all americans, not just those of who have earned a postbe second daughter degree. -- postsecondary degree. that's why the president has proposed an increase in the minimum wage, so that all americans who work hard will be able to be economically self-sufficient. but beyond growing jobs and expanding opportunity, there's more we can do to make american workers and their families financially secure. this council should call on employers of all kinds, large and small, in the private, nonfederalprofit and governments

to consider how they can help their employees become financially successful. many workers look to their employers for guidance on how important money management matters beyond retirement: employers play a critical role in providing workers with information and options to plan and save for retirement. these options include traditional retirement plans or new tools like treasury's myra, a safe, simple and affordable way to start saving for retirement geared towards workers who may not have access to an employer-sponsored plan. in addition to saving, we should also examine how other tools could improve financial outcomes. as we have worked in recent years to make our financial system more fair and more transparent and to protect against the worst bruises in our financial system -- abuses in our financial system, it's become clear that when it comes to protecting consumers, our best defense is a good offense. in the age of smartphones, mobile apps and big data, consumers are now empowered to

make smart financial decisions in realtime, allowing them to trade the financial emergency room for preventive care. technology has given us the ability to wholly rethink the definition of financial capability, and it gives us the ability to reshape and redefine what it means to be financially literate in the 21st century. be it employers, schools, government, private businesses, community-based organizations or families, there's a role for everyone to play in the effort to better prepare our youth to navigate a world full of consequential financial decisions. the administration has taken a number of steps over the last few years to advance financial capability and expand opportunity, but our work is not complete. i'm confident this council will continue to build on our efforts and make sure that we're working in concert with other sectors of our economy and society. i asked this council to show us what is working, who is leading and how we can work together to broaden impact because one approach will not suit all needs. i look forward to working with

my colleagues across the administration and our partners outside of government to identify the best new ideas in financial capability and put them to work for the next generation of americans. thank you. .. the rest o of the space growing up. i learned financial responsibility from my dad is still at 89 is a kind of guy who

could balance his checkbook every month. when i was about to ship my firstborn off to college he sickened and of all the conversations you worry that you can't have with them. one of them was i haven't taught you how to balance your checkbook yet. she looked at me with the patient look that they get right before they roll their eyes and said i don't have a checkbook. i have pieces of plastic. she does. she is constantly bombarded with credit and debit card offers, loans, other financial decisions on a daily basis that could and wanted a big impact on her life. these are things i couldn't have happened when i was at her age getting ready to go to school. young people are facing the same choices every day to the data indicates many of them are not well prepared to handle these challenges. they are less likely bank accounts and a significant percentage rely on riskier nontraditional borrowing. they are most likely have enough money to set aside to meet an emergency. this is particularly true for young people of color and for

those who haven't finished high school. this is our challenge. all young people no matter the background should be armed with the truth great a better future for themselves and that includes a national literacy skills. this goes hand-in-hand with the presidents agenda, we call it an opportunity agenda, to make sure we're increasing financial security to all americans. secretary duncan is a. he's engaged to make sure every student is able to go through and finish college, and with his leadership and ministry is working to make college more affordable and provide young people with clear information about the opportunities available. we also need to know to be sure that young people have the financial smarts to wait these options and make informed choices that affect their futures. this will increase the likelihood they will finish college and start their careers on a strong footing. and we talk about the presidents opportunity agenda as secretary lew pointed out, it also includes an issue that we are

deeply engaged in. like the affordable care act which is very much connects the financial security, and the effort to increase the minimum wage. but altar boy higher wages are the whole equation begin people need to know about and have access to some products that help them spend their money wisely and put so many a site for a rainy day. i hope the council will consider all of this and will also consider how it's worked, will coordinate with other initiatives across the administration, including my brothers keeper initiative which was announced by the president to provide more opportunity for boys of young color, and hope we get a line our work in the strategy together. what you're about to embark with his tremendous important. as i said at the start sometimes the earliest lessons are the ones that stay with the longest. one of the most basic financial lessons not only for money but for the present policies for young people, he make investment early and you watch them grow.

we thank you for your efforts and i look forward to your good work. >> thanks very much to say shealy. director cordray. nice to see you. >> so i finally the words that would really come to mind for me this morning is a man. we have many similar things to say i think this is what each of our own distinct advantage point i will -- i'm richard cordray, first director of the consumer financial protection bureau which did not exist when the council was first convened during the presidents first term. we're glad to be at be part at this point in time. over the years financial education has become a passion that i pursuit of the local, state and no federal levels. it's a privilege to be invited and to serve on this council. at the consumer bureau we are committed to helping consumers make sound financial choices. we're doing all we can to protect people by ensuring that consumer financial markets work

better for them, transparent, reliable and fair. we also recognize the best form of consumer protection is self protection which means helping people avoid problems in the first place and know how to address problems when they do occur. this is proven to be our problem in our society. although it's important for parents to talk to children about money from an early age, many find it difficult or uncomfortable to do so, leaving our young people starved for information. we need to begin by recognizing just how rarely families engage in these discussions. this is a fundamental problem for anyone cares about the direction o of this country begn people who lack the skills to make effective financial decision will find it hard to become productive and capable citizens. they will incur unnecessary debt, missed opportunities save money, and develop a poor credit history. these problems will block them from opportunities and resources to improve their futures. we are enrolling them in the school of hard knocks with no reason to think they will avoid

repeating the same mistakes others made before them. we have an opportunity with this council to see that america does better by its children to now more than ever as we emerge from the deepest financial and economic crisis of our lifetimes, people need new know how to manage the ways and means of the life. choices they face in the marketplace with instrument like mortgages, credit cards, auto loans, student loans, credit reporting and more our increasingly complex. many consumers used to tell your story future of our website to describe their lasting regret that they did not know more at the time they made an important financial decision. the most obvious way to greet him were financially capable mission is to assist another financial education in every one of our schools. in my opinion this is an imperative we cannot afford to ignore order for. last year we issued a report, the report presents five policy recommendations that squarely built on the great work already done by many of you and your

colleagues on this panel. let me briefly restate them. our first recommendation is that financial education begin at a young age, he made a part of students approach graduation from high school and continued to evolve to the very stages of adulthood. what we do not teach children about personal finance, managing household budgets, saving for the future are making informed decisions about larger investment in an education or home, whether or not includes balancing a checkbook in this day and age, we are failing them in their shameful and costly ways. we can do this with integrated curricula in our schools so that the benefits of competent interest are understood in math class, economic costs and risks are taught and english class may cover how we use money, how we protect our money or how we take control of our financial lives to achieve our goals. second, we recommended as part of you financial education students should practice financial management through extreme children. regardless of whether sending a bank instead, a computer game,

or fall in -- following the progress of the stock market they will learn more from the experience. thirdly, we must engage and support those teachers were instant in teaching personal financial management we need to ensure that teachers have the support they need. we want and have access to training and incentives to take part such as continued education credits in need-based travel stipend. we're developing teacher training resources through the bureau and partner with others to do more. fourth, in addition to equipping teachers with training they need to teach financial skills we are recommending integrating financial education concepts into standardized test. doing so would increase incentives for educators to teach these topics and present an opportunity measure and track the performance of students on financial education county. we been working on this issue with those in charge of writing the test. fifth, providing financial education in schools, that is critical, there are also numerous benefits when that education is present in the home. we need parents to be as

involved with their children and as their children are in learn to master the concept of personal financial management. parents help set expectations and researchers should a parent engage virtual by establishing a savings account for them, these children are seven times more likely to attend college than those without a savings account. affecting a families approach financial education will not be easy but the presentation of financial education in the schools will be a further stimulus to progress. i look forward to working with all of you to help our young people in the financial capability they need to control and shape their lives. thank you. >> thanks very much, rich. secretary duncan? >> thanks so much. i apologize for being a few minutes late. i'm thrilled to be under want to thank the council members. this is an extra in a group of people, very diverse. different backgrounds and i think what you can do for young people in the country going forward could have huge impact. i'm a big believer that

leadership matters a lot. this is a lifelong passion of his. i'll to you what you've done instances is nothing short of remarkable. if we have more local leaders with his passion, his commitment, we would be in a much better place right now as a nation to it's a great council with two amazing leaders and i look forward to doing whatever we can to partner with you to drive his agenda. i'm always looking for ways to try to bring people together and cut through the traditional battle. i think i could be wrong, i think this is an issue of no natural enemies. whether its union and management, teachers and principals, public and private sector, i think we can all unite behind the cause of putting our young people in a position to manage their lives and the finances in a much more thoughtful way than they do today. the huge need is out there. everyone here knows that. one quick story. i was back on in chicago, net

with students on the southside of chicago saturday night in a tough committee, about 40 kids. literally the last young man to speak was extraordinary. goes to a pretty good high school in chicago. he said, he's getting good grades, going to be successful but he just as he stood up, how come no one is helping me teaching me about finances? i'm going to get a good job at how am i going to manage my money when i get older? it was an unbelievably poignant question. i think far too many around, far too many children around the country today ask. today we don't have a great answer and our kids deserve better. they are asking for it. if we can take to scale what works, we can work together across sectors, across the traditional lines that divide us. i think we can do something pretty special for our kids in the country so i think all of you for your leadership and looking forward to working with you. >> thanks very much. and with that alternate over to the chairman of the council, john rogers.

>> thank you. it's great to be back again, to see so many people here, and we really do seem to have a lot of shared values. i wanted to pick up a little bit on what arne has talked about. when we grew up, we went to the same high school, and arne to eight years of german, went to germany one year. i took about four years of french. i've been to france three or four times. and if you think about it, values, the things we teach to our kids to get prepared for life, i think sometimes we have our priorities wrong. we've had to make sure that they have a robust financial is a program starting in grade school that builds over time the same way math skills, science skills, english skills built over time. so your true prepared to participate fully in our american democracy.

and i think that's something that is sometimes loss -- lost. i think it's why when arne was working, we working together 20 years or so ago, arne and sister sarah came over the idea of grading a small public school on the southside of chicago, and after a couple of years up and running, we decided we needed to have a robust financial literacy program for the kids who were coming from often very disadvantaged backgrounds. which this fits perfectly with the president's mandate when he talked about the importance of financial letters a and in particular in disadvantaged communities. we created a program that was sort of pattern after the program my father had for me as a child. my father had been at the tdm and. he came up in a tough way but he felt it was very important for me to get exposed to the stock market as a child. -- tuskegee airmen. every birthday and every

christmas after i was 12 i got stock certificates instead of toys. it was a fun going to the christmas tree and getting the envelope. [laughter] but eventually i became totally fascinated and loved the stock market and love interesting. so we did at the academy, every first grade class, we would get a 20,000 the class get. the kids would watch us manage it for the first six years, and then the kids would start to pick real stocks with real money in fifth, sixth, seventh and eighth grade. we work with our analyst on how to do research, come down for offices and children about financial services careers and what it's like to be an analyst and what it's like to work in a downtown office building. we thought that was something it would be really imported for them to have that exposure to the liberties that aniston was going on in the financial parts of our economy. and when the kids graduate in eighth grade they would take $20,000 give back to the next first grade class, take a

portion of the profits and create a philanthropic gift for the school or the community. teach the kids the importance of giving back because they had been given an opportunity. then the kids would have a chance at the end to keep a portion of the profits, if their money had gone over the years they've been investing it. every child to put money into a fight when a program we would match them with $1000 so the kids would learn the importance of matching. we all know today as more and more retirement plans disappear, traditional pension plans disappear, you have to do your own financial manager. and understand how to get involved with the buying contributions to prepare for your future. without that was very, very important. it was consistent with some of the research we've done with the report that melanie hobbs and the president led that showed when he looked up the combined constitution but often people of

color, african-americans, latinos and others, would often have half as much save for retirement as majority committee, even with the same educational opportunity even with the same job descriptions and job titles, literally would have passed judgment have as much for retirement because of all kinds of cultural reasons, past discrimination, lack of familiarity with the financial markets. so we thought this was so important for us to make sure kids learn the importance of how to get involved in becoming their own financial managers once they started their careers. finally, we think it's also important, some the things we talked about that if you want people to participate fully, in our democracy understand these issues around finance, it's incredibly important. we think that as time goes on it will help have a fully informed community to engage in all the kinds of dialogues and discussions that happen in washington, t.a.r.p., what have you.

and having this will help a lot. i think it's important we begin, coming back from the beginning we decided to focus on you. because last time, the last council we focus on a lot but now we realize if we can get financial literacy embedded in the core curriculum of public schools we will be able to make a difference for our young people. i'm excited for us to have this opportunity to be back to work hard on this important issue and i appreciate you get all of us and appreciate our exciting council for coming together today. thanks. >> thanks very much, john. and let me now introduce melissa koide who is the executive director of the council and also deputy assistant secretary of the treasury pro-consumer policies. >> thank you, cyrus. really just such appropriate and i think in many ways inspirational remarks we have heard so far. now we want to our children over

to the council members and hear from you, why are you here, what do you do with respect to financial capability and use, what do you want to get out of this council? that's the right way for us to start this discussion. so we can begin with ted. welcome back, ted. >> thank you. thanks, melissa. my name is ted beck, and ceo of the national endowment for financial education commonly known as -- i served as the chairman of the national jumpstart coalition. as background, we are based in denver, colorado. we fund research around financial capability. we also provide programs. we've been provided a high school program for over 30 years and have educated over 9 million students in the program. six years ago we launched a college program that is actually done very well. is now in over seven and campuses being used across the country. we also work with nonprofit partners bringing financial capability training to their communities.

one of the things i think we would like to contribute not only in nefe but the community i think we represent, first of all we will be publishing several research papers between now and the summer. actually three that are very focused on the financial capability of young people. i think that would be a strong support item for the council. i work in colleges i think has great potential. we are actually involved with over 250 community colleges and that's yielding a lot of information about how we can reach a very important group that we think is underserved and really represents a cross-section of the united states. also nefe in a group of like-minded or positions over the last few years have developed a teacher training program that we are now rolling across the country. we have found that america's teachers are not trained to teach personal finance, and we now have what we think is a very promising and effective program that we might be able to bring

to play for this community. finally i think is a major area of opportunity. if you look at our world, we really don't have all of the standards and any sort of hurdles that we are supposed to achieve if we're going to be rolling programs into school. i think the work of this council could really go to great things to help us set those sorts of guidelines and goals for us. as far as the council itself goes, this is a very important group. the nonprofit community looks to this council for leadership in helping identify what are the best standards, what's working out there. and you can really be spokespeople for what we need to be doing because the nonprofit community i think we'll follow this leadership. so i'm very pleased to be a member of the council again, and i look forward to working with you all. thank you. >> good morning, everyone.

it's an honor for me to be here. i work with the national congress of american indians. for those of you who don't know, it's a 70 year-old organization that works primarily with tribal governments across the united states and there are 567 federally recognized tribal governments. we work primarily to protect the rights of drives an american any, alaska native people in the united states. however, we do a variety of programs, and one of the programs i work on is the partnership for tribal governments, is really to tribal governments themselves build the capacity to provide services to their citizens. and through that we work with them on a variety of different areas, including financial education. ncai also ministers the native american educational coalition which is a coalition more than close to 15 years old and organizations, nonprofits,

for-profits, business, government, folks are very interested in improving the financial capability in native communities. so i'm very excited about that. we also have a youth commission. we are also working to set up his cabinets across the country. those would be cabinets at tribal governments themselves. we also worked very closely with the center for native american youth that is a d.c.-based organization working on native youth. i wanted to just share that 42% of our population is below the age of 25. so it's definitely a focus to really work with that generation, that population in a variety of different ways, and those of you making the front page of the "washington post" this morning know that we have substantial socioeconomic issues

remaining in indian country but it was an article about high suicide rate in native communities. and while there are economic successes happening in native communities can we need to do so much more to really promote those kinds of economic successes so that our youth, our children can really feel like they have a future in this country. i was on the previous council, and i feel that this is a second opportunity to really work to elevate the successes in indian country as well as we need for financial literacy. and one of the things i wanted to just end with is, really recognizing the role that president obama and the administration has really played in developing a nation to nation relationship with a tribal governments in this country. and really recognizing the roles

of tribal governments and the american family of government. and i think that's tribal governments are building the capacity, really looking at financial education and economic success is one of those key areas. so i thank you very much. we are honored to be here. >> good morning, everybody. good morning, mr. chairman and i want to thank you again for your leadership. i've been around for a minute. i was honored to play a role in the last you may be in the underserved where we stood up a commitment to 100 local financial there's a councils. it was nice to see this council's mission to go into the community. i believe that was certainly a passion of our committee. and had a role in bringing in a into -- i'm chairman of operation hope.

2 million clients, $2 billion in private capital, direct in underserved neighborhoods, 22000 volunteers, important for this council. we are in 4000 all urban inner-city low wealth schools. like chairman rogers, john, is personal to me. my mom and dad divorced when i was about five. i remember in arguing over money. number one cause of divorce in america is money. no one else it domestic abuse. it's money. that put a ceiling effect on my brain. when i was not on a banking coming to my classroom and teaching us financial literacy and pumped in california. i remember asking the bank it, what did you do for a living and how did you get rich legally? and i was dead serious. i never saw anybody with a suit

on before in my classroom. and he told me he finance on diverse. i said i don't know what an entrepreneur is, but i want to be one. and that kept me focused. it got my aspirations and got engaged. fast-forward i was homeless when i was, six possible lifeline is 18 but now that got me off track because i was refocused on my dreams. why is that relevant to today? i think the real challenge for our dropout crisis we have in america, which is a true crisis, is that we disconnected education from aspiration. kids are dropping out but they don't see a reason to stay in school, that moved their life for. so we are going to do something about it, hopefully working with this council but we're going to open 2000 business and the cabinet to i won't go into detail on what that is here, my opening remarks, but basically it emulates my life experience growing up.

to summarize, the experience of one of the kids. we were in inner-city in atlanta, young men were in a restaurant, one of my employees was there. the install was closed, young band kicks the door in, high school student. banca this mess, he said. welcome he didn't say bunk. this is a bs. he had lost -- you know we should have one. you know we should have one. his friend vincent yet, but butu know, the other group had matching uniforms. another guy said yet, but the other group, they prepared. they had prepared remarks. the first guy said that's all right, we're going to win this next time. in order to win next time you got to come back to school. and in short i see that's like the high school football you spirit for every kid. i think that's what we have to do with this group is to find ways to really connect to focus on financial literacy and financial capably with the reality that kids want a good job and a shot at economic

opportunity we've got to reconnect education with aspiration to its that simple. you do that with the lights on. we open 65 locations in 100 days. i'm on a tear to do this all across the country in the think we can do that and reshape america. >> good morning. i'm kerry doi with the consortium and employment better known as case in los angeles. i am really humbled to be asked to sit on this council, and it's a great honor, especially when i look around the table and take a look at everybody's bio. i don't know how much i have to contribute to