better health. you can watch this entire national press club event at cspan.org. coming up on the next national journal, concerning the texas nurse who tested for ebola and calls for new standards to protect health care workers from the disease. then a look at the 2014 midterm elections, with tim phillips, president of americans for prosperity and his push to make the affordable care act the number one issue. you can join the conversation on facebook and twitter. cspan's 2015 student cam competition is under way, 150 prices totaling $100,000.

create ative to seven minute documentary on the three branchings and you, videos need to include cspan programs and must be submitted by january 20, 2015. go to student cam.org for more investigation and get started today. now a senate panel looks at universal health care systems in other countries, the discussion includes the high cost of pharmaceuticals in the u.s., compared to other industrialized nations. this subcommittee hearing is about an hour and 40 minutes. the chair is senator bernie sanders of vermont.

we want to thank cspan for covering this important hearing, and i especially want to thank our witnesses, some of whom have traveled from very long distances from around the world to be with us today, and we very much appreciate your being here. united states has i think a very effective form of government in the sense that we are a federalist system, which means that we have 50 separate states and it is very common that one state learns from one another state is doing. every day in california or north carolina or vermont, somebody is coming up with an idea or program and it works. other people steal those ideas and learn from those ideas and that's a pretty effective way of going forward. i do not believe that we utilize

that practice as much as we should internationally. the united states is not the only country on earth. there are other countries that are doing very positive interesting things and we should be learning from them. in a sense that's what this hearing is about. it's to see what we can learn from other countries around the world in terms of health care and in my view, in fact, we have a whole lot to learn. because at the end of the day, the united states spends far more per capita on health care, we spend almost twice as much per person on health care and yet we have many millions of people who are uninsured and our health care outcomes compared to many other countries are not particularly good. why is that?

and what can we learn from other countries who in many ways are doing better than we can? let me start off with a couple of basic facts about the american health care system. while it is absolutely true, some americans, often those with a lot of money, receive some of the best cutting edge health care in the world it is also true that for millions and low income americans, they have little and no access to even the most basic health care services. later on, maybe as part of the questions or answers, we're going to show a photograph that many of you have seen in virginia or california, people lining up in fields to get basic health care or to get their teeth, rotted teeth extracted,

photographs that would remind you of a third world country. and the reality is that today the united states is the only major country on earth that does not guarantee health care as a right. that is a basic debate we need to have. should all americans regardless of income have access to health care as a right or not? the united states is the only nation in the industrialized world that says you're not entitled to health care as a right. and in 2012, more than 15% of our population nearly 48 million americans were uninsured but that's only half the story. many people who had insurance also had high deductibles and high co-payments and those payments created situations where people hesitated to go to the doctor when they should. not to mention, other people leaving the hospital deeply in

debt and going bankrupt. is that something that we are proud of? here's another important point to be made. we talk about rationing and so forth of course in the united states health care is rationed but it is rationed by ability to pay. acourting to a harvard study published in health affairs 2009 and health affairs in 2014, some 45,000 americans die every year because of lack of access to health care. and i have talked to doctors, i don't know if my colleagues in their states have talked to doctors. i have talked to doctors who say yes, people walk in the door and they are now terminally ill and the doctors say why didn't you come in here six months ago or a year ago and people said, i didn't have any health insurance. i didn't want any charity, i thought i would get better. we're losing 45,000 people a year because they don't get to a

doctor when they should. there are furthermore communities around this country -- i know senator roberts of kansas mentioned this in a hearing we had a while back. there are no doctors and no doctors in the area at all. people do not have access to basic primary care. despite all of that, the united states as i mentioned a moment ago spends almost twice as much per capita on health care as does any other country. we are spending about 18% of the gross domestic product on health care compared to 11 to 12% in france, germany and denmark and canada. 9% in the u.k., australia and norway and less than 8% in taiwan. we're going to hear a representative from taiwan in a few minutes. in terms of efficiency, are we an efficient system?

compared to the huge amount of money we're spending, are we getting good value? in august of 2013, bloomberg a respected business source ranked the united states health care system 46th of 48 countries based on efficiency. now what about outcomes? if i'm spending $100,000 on a car and somebody is spending $20,000 on a car, we would assume thatmy car runs better. i'm getting better value, i'm getting value for what i pay for. the united states pays almost twice as much per person for health care but in terms of our health care outcomes we do not do particularly well compared to other countries around the world. among oecd countries, the united states ranks 26th in terms of life expectancy. residents of italy, and spain and france and norway and the list goes on will live two to three years longer than americans.

so in terms of our outcomes, they are not particularly good. what about prescription drugs? clearly when we go to the doctor's, very often the therapy is medicine. i recall talking to a doctor in northern vermont who told me that about 25% of the patients that she sees and she writes prescriptions for are unable to fill those prescriptions because they are just too expensive. the fact of the matter is the pharmaceutical industry in this country earns huge profits and charges other people the highest prices in the world for prescription drugs. there's a lot more to be sad but let me end my remarks with those comments and i look forward to hearing the testimony of our

esteemed panelists. senator burke? >> thank you, mr. chairman, thank you for calling this hearing. i truly thank our witnesses today for their knowledge and for their willingness to be here to share with us their information and about two weeks our nation will mark the fourth anniversary of the enactment of the affordable care act. better known to most as obama care. today's hearing will inform what direction we will next take health care in america by examining access to care and cost associated with health care systems overseas. as we examine single payer systems in other countries and what we can learn from their experiences, it seems fitting that we also take stock of where things stand in the american health care system today. at the time obama care was being debateded in this very committee, i warned it was the

wrong direction for our country. health care was broken before obama care but four years later, the american people are experiences firsthand how the new law has made things worse. that's why americans view the law unfavorably. and that's why they are understandably weary of still more government involvement in health care. the president promised if you like your plan, you get to keep it under obama care. the federal government mandates that americans -- that americans buy health care coverage and not just any coverage but the coverage that federal government says it good enough. sadly, millions of americans have lost their health care plans and health plans they liked and wanted to keep despite the promises and continued delays of the administration. obama care expanded medicare an unsustainable health entitlement

program on which 40% of physicians on average do not even agree to see medicaid patients. i believe the experiences of other countries will reinforce what many medicaid patients already know. their coverage does not always translate into timely access to care. today's hearing will also examine costs. while the president promised that obamacare would bring down premiums by $2500, premiums have actually gone up by an average of 41% in the individual market due to the law's mandates, how do they attempt to control costs? for starters it established the independent payment advisory board on unelected board of 15 bureaucrats empowered to make cuts to the medicare program most likely in the form of cuts to doctors, which will impact again, senior's access to care. today's hearing will be

informative as to the direction we take health care in this country. will we repeal obama kaur and replace it with reforms that lower health care costs and put our nation's entitlement programs on a sustainable path and empower patients in decision-making to find plans that best meet their individual needs? or will we continue on the current course of unprecedented government involvement in health care and unsustainable cost? what do we have to learn from a single payer system overseas and what have other countries reforms meant for their patients. what would such a course mean for our nation standing as a global leader in medical innovation and for american patients seeking access to quality and affordable coverage and care that meets their individual health care needs. i do want to thank chairman sanders for holding this hearing because it will inform many of us on these important questions. i think today's hearing

represents an important admission that obama care is not working, that such an admission takes place within the very committee that the act was written in is a huge step and i commend the committee in taking it. i look forward to listening to the witnesses today. i continue to work with my colleagues to advance patient centered reforms that will lower health care costs and increase access to quality affordable health care. i thank the chair. >> thank you, senator burr. did you want to make a statement? okay, thank you. we have seven very knowledgeable panelists and we look forward to their testimony. we're going to ask you to keep your remarks to five minutes and then we will follow-up with some questions. our first witness is may ching

a health policy research analyst at the woodrow wilson affairs in princeton university. she is adviser to the china national health development research center and we very much appreciate her being with us today. please speak right into the microphone so everybody can hear you -- >> it's already started counting. >> good morning, mr. chairman, senator sanders ranking member burr and senator enzee. my name is mae chang, research analyst at the woodrow wilson school of international affairs, princeton university. thank you for inviting me to testify. i have been asked to give an overview of single payer system and my written testimony into a few salient points. an overarching point in my testimony is that single payer

systems are notes same as socialized medicine or socialism so often assumed in this country. in socialized medicine, government owns and operates the health care delivery system and finances it. the health system americans reserve for their military veterans and va system is purely socialized medicine. single payer systems are typically just social insurance, like the social security system, under social health insurance, the government merely organizes the financing of health care but the health care delivery system typically is private and can include for profit entities. medicaid, for example, the social insurance, it is social insurance but not socialized medicine. the main characteristics of single payer systems are the following. they are ideal platform for equity and access to health care because everyone has the same

insurance coverage and providers are paid the same fees regardless of the social economic status of the patient. single payer systems typically are financed on the basis of ability to pay. rather than on pt basis of health status of the insured. single payer systems typically give patients free choice of doctors and hospitals. in single payer systems providers of care do not compete on price but they must compete on quality of care, including patient satisfaction. in a single payer health insurance system, health insurance is not tied to a job. instead it is fully portable from job to job when people lose their job and in a retirement. does not go away. therefore there's no job lock in these systems over health insurance. because all funds to providers of health care in a single payer

system flow from one payer, it is relatively easy to control total health spending in such systems. the international data i cite in my written testimony made that clear. now, some single payer systems like u.k. and canada, may put constraints on the physical capacity of their health system like number of hospitals and mri scanners as part of their effort to control total health spending including waste create by excess capacity. this constraint may lead to rationing by the queue. the alternative to rationing by search administrative measures is rationing by price and ability to pay. something that we see in the u.s. health care system, the argument that health care is not rationed in the u.s. is not supported by the data. a single payer system is an ideal platform for modern i.t. with common gnomen clay tour.

it can be done electronically and yields enormous savings in administrative costs. and because such i.t. system conveniently captures data and information on all health care transactions, these systems provide data base that can know spending in real time and is in the case of taiwan and it is a base for use for quality measurement monitoring and improvement. and public satisfaction of a single payer systems is generally high. denmark, for example, is ranked the number two highest in the european union in consumer satisfaction. in taiwan public satisfaction is also very high with a national health insurance program. ranging in the 70s to 80%. in canada, a 2013 international survey of 11 countries found

that 42% of canadian surveyed said that their health care system works well and need only minor changes compared to just 25% of americans who said that. 75% of americans said -- american health care system needs fundamental changes or completely rebuilt. lastly, survey research has shown that single payer medicare is very popular in the u.s. a final point is that every health system has its flaws which can be highlighted with anecdotes, therefore there's now a brisk medical tourism worldwide, for example, canadians come to the u.s. for health care but it is also true that americans go to canada, mexico and thailand and taiwan for lower cost health care. thank you very much. >> thank you. we're going to go to do rodwin, a professor of health professor of wagner school of public

service and work the his entire career on studying health care system as broad with a special focus on france. he head the fullbright distinguished chair at the university of paris in 2010. doctor, thanks very 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. i will speak 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 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 die verse 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 and no restrictions. second, pluralism, everybody has a die verse choice, they can go to fee for service or group practices or outpatient health centers or emergency rooms or go

to public hospitals or private hospitals or outpatient consultations with specialists in public hospitals. the third value is solidarity in the sense of having those with greater wealth and better tellth and finance services for those in poorer health. in terms of population health, the french outdo us and i'm embarrassed to say that, hands down. look at any indicator you like, life expectancy at birth, infant mortality, they better than we do. female life expectancy at 65. they outlive us. female life expectancy at 80 years of age where medical care matters, they outdo us. disabiblt adjusted life expectancy, they outdo us. years of life lost, we have more years of life lost.

this is not a re-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 we have the best health care system in the world in spite of these indicators and would argue these indicators reflect other things for which they assume no responsibility. social services, inequality of income, family policies which are very strong in france. maternal and child health programs which explain why they have better population health than we do. we have to look at other indicators and one important indicator of health system performance is called avoidable mortality. in a good health care system women should not die in childbirth. people should not tie of tuberculosis and not die of he schemic heart disease or cancers that can be cured.

when we look at that, i'm embarrassed to say 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, areputable journal and confirms with different measures by the oecd and not received in my judgment sufficient discussion. another indicator of how well a system is doing and 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 in different 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 as they are in france. that is an unfortunate statistic from the point of a view an american, but that is the way it is. lessons that we can draw. i believe that health systems cannot be transplanted from one country to another. we can talk about some issues, i will tick them off. i will go over 30 seconds, if you allow me mr. chairman. in france, there is no choice of insurance plan. everybody is in the same plan for the shootaroundized benefits, but there is a complete choice of hospital or doctor. all the insurers pay the same

price, according to nationally set price. in france, no physician gate keepers, anybody can go where they like. nobody is telling them what network, they don't have to call their insurance company to get authorization. co-insurance, there is a voluntary- -- we will have to learn more about france in a few minutes. >> okay. let's go to dr. -- for give me, dr. yeh is from the university ever taiwan. speak closely into that microphone. tell us what goes on in taiwan. >> distinguished members of the committee, thank you for inviting me to testify here.

i was the founding ceo of our national health insurance administration in 1995-1998. 19 years ago, i was the minister of health in taiwan. taiwan established the national insurance in 1995. 99.6% of the population enroll, the other .4% have citizenship but stay abroad. they are not covered. taiwan program is a single pay system, and has a large pool. before we that, we had 12 different social programs, and we merge into one single pool.

that enabled us to have subsiidation between the rich and poor, well and sick. studies show that premium contribution, compared to the house resources utilized are favorable to the low and middle income. having a single pay system is the main reason for our efficient services, and how, at the low prices of our health care, we can achieve. we have a private not for profit delivery system, and highly competitive providers enable us to have efficient service. we contract 100% of the hospitals in taiwan, 93.5% of the private practitioners enable

us, if they have the card, they can go anywhere, any hospital, any private practitioner, for advice. that is a level very easy and equal system. single insurance administration have the benefit of very low administrative cost, 1.15% of the total of spending. provider in taiwan must be mindful of their patients our rate is up to two years, it is always between 70 to 80%. we have a national fee schedule.

so, the cost, the hospital and the provider can only compete on quality instead of price competition. patients carry their insurance card, can go to any provider if they are not satisfied, with the quality of services. there are no waiting list at all. except for a few well known medical institute. provider competition and efficiency of our services. in 2012, our life expectancy, infant mortality, we are much

better than the u.s. although we spend one-sixth of the u.s. dollar, ppp adjusted it is one-fourth of the u.s. dollar that we spent. we are doing better than u.s. that thing i wish to mention is, our house information system. everyone has this card. a record in this card, actually, all our provider submit, so, we, on the way, we expect to accomplish an e-record for everyone in the next few years.

i think my time is up. thank you very much. >> did you want to make a brief opening remark. >> thank you for joining us for what we may learn to improve our health care system at home. single payer systems how they operate. congratulations on becoming an american citizen.

we are pleased to welcome you and look forward to hearing about your personal experiences, and professional analysis of single pair systems. the mike is yours, sally. >> thank you, chairman sanders, and ranking member, burr, i am sally pipes, president of the pacific research institute, a think tank, for opportunity for all. medicare for all system, a system i am familiar, as i am as senator burr said, a native of canada. many point to canada as a shining example of a state-run single payer system. one of 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 calling for here in the united states. they want to abolish private insurance, and leave government as the sole source of health coverage. 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 it in terms of the title of this hearing, if you are looking for i lessons from health care systems abroad, canada shows us exactly what not to do. let's start with wait times, in order to keep a lid on health care costs, canadian officials

have toeration care, according to the frazier institute, the average canadian has to wait 18 weeks to primary to 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, five million out of 35 million are on a waiting list to get primary care. there is a severe shortage of essential medical equipment. canada ranks 14th out of 23, oecd countries in mri machines per million, with an average wait time at over eight weeks. when people aren't treated in a

timely fashion, their conditions worsen and health deteriorates. their productivity drops and may have to stop work entirely. mri scans, surgeries for join replacement, catrackets, and bypass graphs, it is far from free. 68 cents out of every dollar in government revenue goes to health care spending, the typical canadian family spends $11,300 in tacks every year, just to finance the public

system. technically, every canadian has access to needed services, in 2005, madam chief justice mclaughlin ruled in favor of overturning private health coverage, she wrote that access to a waiting list is not access to a health care. those who can oept out often come to the united states, to pay out of pocket. danny williams, former premier, of newfoundland, flew to florida for heart valve surgery, he said, it is my heart, my health, it is my choice. i did not sign away the right to get the best health care for myself when i entered politics. a person can get a heart, a hip

relacement for their dog in less than a week for a canadian, it is over two years, my own mother died from colon cancer, she could not get a colon oftommy, she entered the hospital, died two weeks later, from metac taicized colon cancer. how much longer could we have had my mother, if she had prompt treatment there is an example of the u.s. of a single pay s it is the va, a lot of dissatisfaction with waiting lists. we need a way to inject competition and choice into our health care system. we need to scale back top down controls by government. thank you, i look forward to your questions. >> thank you very much. turns out with have another canadian with us as lmptd the

fourth witness, dr. danielle martin, a primary care physician, actively involved in practice in toronto canada, holds vice president of health solutions. thank you very much for being with us. >> distinguished committee members, thank you for inviting me, i am danielle martin. as a practicing facision, and health systems solution at women's college hospital, i have first hand experience with this system. i hold a masters in public policy from the university of toronto where i am current an assistant professor. i don't claim that the canadian system is perfect. the evidence is clear, that those challenges do not stem from the single pair nature of our system. quite the contrary, working within a public insurance

structure helps us to better tackle many challenges shared by many developed nation says, rising costs, variations in quality. three major benefits from the single payer model, the first is equity. a strong consensus among canadians, that should it be based on need, not ability to pay. of course, we continue to struggle on other fropths, at substantially lower cost than in the u.s., all canadians have insurance that covers doctor and hospital care. we don't have uninsured residents, we don't have different qualities, depending on a person's employment. we don't have an industry to carve out niches in the risk pool. this is an very important accomplishment. as we watch the debate that you face, we are reminded of the

significance. one of the challenges is how to achieve policy remove with so many players in the game. in a single payer framework, if government and providers identify a significant challenge in the health care system, they can work together at the bargaining table to align insens sensitives. in the way in which ontario's physicians work together, choosing to work in rural, underserviced communities. one cannot speak about single payer without addressing administrative cost, it has been estimate fd u.s. administrative costs were curtained to those of my home province, the estimated savings would be $27.6 billion a year. we spend a lower percentage, and

personalitily this is not at the expense of quality. canadians enjoy the same or better health outcomes as american, both at the level of life expectancy and mortality. and the range of acute and chronic illnesses. a review found that canada achieved outcomes equal to the u.s., at two-thirds of the cost, across a wide range of diagnoses. when it comes to urgent and emergent care, 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, dinostic imageing and elective surgery, a great deal of work is underway, and waits have been decreasing for a variety of ervegs lective

procedures, moving away from a single payer model would likely exacerbate our wait time challenge, drawing resources out of the public system this. is bourn out by other jurisdictions such as australia. in order to achieve the benefits of the single payer model, in canada, each province provides health care insurance to residents with minimum standards set at the federal level. moving to single payer insurance, does not necessarily mean moving to the direct provision of health care services by government or socialized medicine. although our provinceal plans in canada are financed publicly, all services are delivered by public entities.

physicians, not employees of the state, rather independent contractors who happen to bill a public insurance plan for their services, 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. mart in, thank you very much. >> i would like to introduce to my colleagues, dr. david hogberg, the analyst for the public policy research in washington, d.c., dr. holberg, thank you for joining us today. i look forward to your testimony and thoughts as we examine the lessons learned from other abroad countries in order to strengthen our own system, here at home. the mike is yours. >> chairman sanders, ranking member burr, members of the committee. thank you for the opportunity to testify before you.

i am david holberg, national center for public policy research. i think the most important lesson we can learn from other nations, most politicians want to get re-elected that fact will have a substantial impact on policy. groups with clout that can influence a politician's re-election chances are more likely to get good treatment under government-run health care systems. groups that lack such clout will receive inferrior care. people who are ill lack political clout. the very sick are few in number, too limited to have impact on elections, and political activities, protesting and so forth that can bring about change in health care policy. ultimately, under a government system, those with the most medical need are those most

likely to get the care they need. denmark and france provide good examples of this. the healthcare system in denmark is single payer, government financing 85% of health care expendittures it is largely free at the consumpg. if patients pay nothing at the point of consumption, patients overuse health care, putting strain on budgets. health care must be rationed in another manner, like most system, denmark rations with wait times of serious conditions. 48idate to get a herniated disk, 57 days for a knee replacement, and 81 days for catrackets treatment. under the national standard for cancer treatment, a patient shouldn't wait 28 days from the time he sees a fission to the time of treatment.

those will head and neck cancer, for every month treatment is delayed for head or neck cancer, the probability that cancer will reoccur raises 3.7%. extensive of market insurance, koe payment, and when a patient visits a physician, he must pay the cost, he must be reimbursed. the method of patient, and the expensive system of private finance is what allows france to avoid using wait times to ration care. france's budget has been running a deficit since 1988. the healthcare system in france

used other methods to ration care. one is limiting investment in new medical technology. among industrialized nations, the lowest members of mri machines per million,erational pharmaceutical system another method. they refuse to pay for drugs incremental improvements over existing drugs, according to one study, one quarter to one third of altimers patients are receiving state of the art medicatio medication. it falls hardest on people with serious illnesses, these mlths are exit because they are politically tolerable. the people affected are seldom a significant force. in summary, the chief benefit of an examination of other nation health care systems, is to discover what policiless to avoid.

it would be far more, study other markets, for insurance, life, homeowners and autoinsurance, and other markets for vital products such as food and clothing, there you will find marketings where it tax policy and regulation has not become a three tiered, as a result, these markets reduce the cost of goods and services while improving quality. it is in these markets we should look for guidance in reforming the u.s. health care system. thank you very much. >> our last but not least. >> the institute for local and regional government research.

mr. colbert, thank you very much for being with us. members of the committee. i would like to thank you for the opportunity. i have been asked to give an overview of the dannish health care system, it is an example of a health system providing universal coverage for all patients. spishts practicing outside of the hospital. only one percent of the

population have picked group two, and they are satisfied with the gp system. the patient may choose from all public hospitals, all hospital treatment is free, including all hospital drugs, patients may choose private hospitals 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, the wait can't be longer than the waiting time, it is a choice. if cancer is susspected, we aurve two weeks for waiting time and treatment. it has been a problem, as you mentioned. to finance a health care system, the state collects revenue from taxation, on the basis of objective criteria, this ensures equal opportunities for the

regions, the simplicity of the financing structure keeps the administrative costs low, 4.3% of the total cost is used for administration. the public sector 85% of the health expenditure, the 15%, covers out of pocket for pharmaceuticals, dentistry, glasses and contact lenses. half of the population has supplemental insurance to cover the out of pocket payments. there are supplementary, grnths or free access to -- it is eye choice.

the house in denmark, 85% of the population perceive their own health status as excellent or very good. the life expectancy is on average, 80.1 years, high smoking rates are blamed for the low life expectancy, not the health system. here, the dannish health care system ranks second in europe. high on patient rights, range and services provided and information. low in prevention and health in denmark, when you look at the statistics. however, denmark has a practice of reporting for social care as health expepdatures, if the costs were reported in line with most other countries, it is kig

santly below average. to sum up, the dannish health care system provides use a high level of patient satisfaction. it is low cost, and makes it easy for patients to access health care. i will be happy to answer any questions you might have. thank you very much for your attention. >> we begin with questions and comments, and let me begin by asking all of our distinguished panelists a 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. we still have all the numbers

have gone down since the affordable care act, we have millions of people with no health insurance at all. others have high copayments or deductibles. let me ask all of the pannists a simple question. should health care be a right of all people, regardless of income? yes, no, maybe? >> miss chang? >> i think it should. it is a sign and expression of a civil society. >> brief answers. >> dr. yeh? >> access to job and income, in unalienable right in our constitution. >> no, we are entired to life,

liberty, and pursuit of happiness, do we have a right to housing, a right to food, a right to health care, how do you measure which is the appreciate level. no. >> dr. martin? >> yes, it is a human right. i know the vast majority of canadians feel the same way. >> yes, i believe that access to health care should be a right. >> dr. hogberg? >> yes, i think it should be a right. in the classical liberal notion of rights, congress should make no law and so forth. yes, everyone should have a right to health care in that sense. >> dr. rogdon? >> we have a right for health care in the united states for emergency care, i believe it should be extended to primary care as well. >> let me stay on that point. maybe get dr. holberg. you indicate thad you thought

that health care should be a right. a government should not be involved in the process, does that suggest that you would do away with the government-run medicare program? >> it is a moot point. >> no, it is want. >> it is a moot point. seniors vote at high rate, we are not getting rid of medicare. >> i am asking you as an academic. it is a popular program, if you say that government should not be involved in health care, and medicare is a government health care program. >> in the best of your worlds, should we vote to get rid of medicare, some think we should? >> it is here to stay. >> i think you didn't answer my question. miss pipes, i would like to is ask you that question? >> i believe that we are not going to get rid of medicare, it is a program for our senior, i think we have severe problems,

the trustees said that medicare will be bankrupt by 2024. >> government, medicare is a government-run program. as dr. holberg, indicated it is a popular program. my question, in your judgment, we abolish this government-run medicare program? >> not entirely, medicare should be there for those who truly need it. >> not as it is right now. >> a lost people who are wealthy, can afford care. paul ryan -- congressman ryan has good ideas. >> he would transform medicare into a voucher program. dr. rogman, let me ask you a question. despite the fact that our health care outcomes are not particularly good, in terms of infant mortality, in terms of

life expectancy. the united states ends up spending twice as much money per person and health care than any other nation, why is that? i will give the senator additional time as well. why is that? >>. >> put your mike o we spend more for several reasons, our prices are higher than all other wealthy oecd nations. >> if a woman has this country, compared to france, how much more does it cost? give me examples? >> it can cost different prices, bepend og how ensures, 5,000 to 27,000. in the excellent paper from chen for all to see. price is one very, very important phenomenon. prices of drugs. >> how do drug prices in the united states, compared to other countries?

>> they are much higher. >> why is that? >> why is that? >> because we have no price control. >> fineed a cancer drug in the united states, why is it much more expensive here than in canada or france? >> in canada and france, you have regulated prices, and people have access to that. >> is that a good idea? >> the free market doesn't exist in health care, i challenge anyone to give me an example of that system that works, one concrete example, all the evidence suggests that it does not work. >> senator burr? >> dr. martin, in your testimony, you note that canadians doctors, exiting the public system for the private sector, increasing waiting list, why are doctors exiting the public system in canada? >> thank you for your question.

if i didn't express my way to make myself understood there, are no doctors exiting the public system in canada. in fact, we see a 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, doesn't lie in moving away from the single payer system toward a multipayer system. that is bourn out by the experience of australia. austral yau used to have that, and moved to a multiple payer system, and a very well known system was, what took place in terms of wait times in australia, as the system was put in place. what they found was, in those areas of australia, waitsed in

the public system became longer. >> what do you say to an elected official that goes to florida and not the canadian system to have a heart valve replaced. >> the people the pioneers, premier williams had, and had the best outcomes in the world for that surgery r in toronto. at the cardiac center down the street from where i work. >> sometimes people have a perception. i believe this is fuelled in part by media discourse, going to where you pay more for something, that that necessary makes it better it is not actually bourn out in outcomes on that surgery. >> when people know, consciously, they pay more, they judge quality and innovation. in your testimony, you noted 42,000 canadians come to the united states each year for health care, why is that?

>> because they find that they are on a waiting list for too long of a period, they feel their health is at stake. many in canada come to the u.s. for mri, c it scan, many examples of people like brian who came to the u.s., he was told by his primary care doctor, he may have a brain tumor, spent the $,000, paid out of pocket. you will see advertisements in canadian newspapers for mris. >> it is a fertile ground to market n in your testimony, dr. martin, you said that the reducing waiting time, what length of time do you consider to be equitable for care? >> in fact, the wait time alliance in canada, established bench marks for what a is a

reasonable period to wait. we found that working within the single payer system, we can reorganize. i waited 30 minutes to get into the building today. when i arrived in the building, there was a secondary entry with no lineup whatsoever. sometimes, it sent about the resources that you have, rather about how you organize people in order to use your qs most effectively. when you try to aaddress wait times, do it to benefit everybody. >> how many die on waiting lists this year? >> 45,000 waiting in america, die because they don't have insurance at all. >> going back to dr. rodwin's statement. the american system has access to healthcare for everybody. the emergency room. we don't admit that we are

lobbying for every american can access primary care, and doctor, i agree with you, there should be a medical home for everybody we can place. we don't do it in medicaid, states should adopt it. it is a necessity to wellness. in recent years? >> the population got a co-payment insurance. the number for policy holders changed most. and half the population has supplemental insurance. >> co-payment insurance, many peop people, to have faster access to

lective care. >> they can buy their way to faster access. >> can you buy any hospital services. >> they have options, choices? >> yes. >> dr. rodwin, in your testimony, you note that parliament sets health care expenditure targets, if a hospital exceeds it, prices are negotiated down ward for the following year. beyond volume or utilization, are quality metrics for physicians or other providers to incentiv incentive-ive. >> they well working on this very question, timely. right now. that is, the negotiation focus on volume. now there is a program that will

renumerate a physician, that is already in place f they follow standards of preventive care. >> they are pinlize fd they -- >> every year, there is an negotiation to set rates, if the volume goes up, then, the following year, the price, that is the practice health performance standard. >> thank you. >> thank you mr. chairman. i want to thank the distinguished panel for all of the information that they provided it is a little different than a session that senator kennedy and i held several years ago. i want to thank miss pipes for being here, she wrote a book in 2010 that predicted what would happen when our health care system as it is now. then, more recently, written

something called the cure for obama care. it is not even copyrighted, an outstanding book on what we can do for the damage that has been done on the present system. i thank you for your effort, hope i can get a few more people to read them. senator kennedy and i, when he was the chairman, i was the rank frpg number, we went to a round table. this is similar. at a round table, we had again, eight to ten people, and they were all practitioners of some sort in the health care area, rather than people who were studying the health care system. he and i would come up with the questions for the panel as well as total agreement on who should serve on it, opposed to the way we do panels, four fifths of every panel, and the ranking member gets to pick another wob

or two. then, we all come and beat up on the witnesses. so, at a round table, the senators didn't speak much. one of the questions that we asked is, will universal single pay health care work in america? and the first person was an engineer for hospitals, he wasn't sure. the other practitioners all said america won't settle for universal single pay health care, senator kennedy came to me and said, i guess we better take a look at some of the things you suggested like small business health plans, across state lines, one of the things that this panel points out, most of you are talking about countries. whose population is in size, in some cases, is relative to our states, each state.

in the united states, each state has health care plans. they do it differently, and as the chairman mentioned, some of them have good ideas, those spread to others, 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 have got. i am pretty sure that affordable health care initiative was designed to fail. that was predicted by senator graham 15 years ago. he thought that they would come up with a system that would fail, and we could go 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 am in the homeland security system too, we are trying to work with another one of those government agencies, called the post office. that is another example of what example people use, is what might happen with single pay health care. i have been to countries with a lot of population, like indian, proud of their system. i asked how they took care of that vast of a population, they said, well, our doctors see 200 patients a day. i don't think our pashlts see 200 patients a day. the question of medicare that was asked earlier, if people are given another option, i think they will go with another option. too many people in america right now, seniors, at least know somebody that tried to see a

doctor, and the doctor said, i am not seeing any medicare patients, medicare is not the best example of how to get health care in america. i have almost used up my time without asking a question. i am the account anlt. one of three accountants in the u.s. senate. my questions get down to some of the costs, i will submit those in writing, and appreciate it if you would answer the questions. >> senator roberts. it seems to me that the entire question here has been summed up bir 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

senators have pointed out, is it a right to a waiting list? actually, i think that is the at the same time by miss pipes, my deep regrets to the loss of your mother. how long did she have to wait? >> she went to her primary care, general practice fissioner in june, she was admitted to vancouver general hospital, one of the largest hospitals in canada, in late november. >> than you lost her after two weeks, did you say you could get a hip replacement for a dog in a week, you couldn't get a hip replacement for an individual. >> two years. yes, the wait for orthopedic system one of the longest waits in canada. my friend, brian day, an orthopedic surgery, made that statement to the new york time its, he is being sued by the

government for operating a clinic which is considered illegal in british columbia, the government keeps post-poning the case, because his practice is so busy, with people getting hip replacements, knee replacements, they are afraid of the back lash that will happen because of that. >> i have legislation, a repeal bill, to address some of my concerns about the government controls, where we are with the affordable health care act, i am trying to get ahead of that curve, by the way, i don't know dr. mart in does prime minister harper change the rules, and change it every week, like we see with the affordable health care act? >> i am not sure that you want me to answer that question, sir. i don't completely understand

what are you saying? >> 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 toward single payer, that was the intent of that. the president of the united states changed the health care, every friday we as well what we call a regulation dump. a consortium of unions kaelted they would like a big change in the affordable health care act. he will have a carve out for them. on the other side of the fence, 27 members of the finance committee, wrote to the head of the senators of medicaid and medicare services, don't change the medicare d, program that we have in this country. a popular program under budget, used by a great number of our senior citizens. if we hadn't written the letter f there hadn't been a back lash

to save medicare part b, if wouldn't have happened. we are writing it, the president doesn't come to us and ask us to do that with each change. with the problems that you have in canada, who makes the change, if there needs to be a change? >> in two parts, what the senator was saying earlier on. canada is a huge country. our health insurance is actually not provided at the national level, it is provided as your states. one jurisdiction, and spread, is exactly how we came to have 13 separate single payer systems, in the 13 provinces and territories of canada. so, the first part of the answer to your question is, no, we don't see that kind of changes being made to health care

legislation at the national lel level. the second part of the answer to your question is that it is widely known in canada, that it public commitment is so strong that for prime minister of any political stripe to try to alter that, and undermine it in any way would be political suicide. >> i got your message. >> keep the politicians out, we had two changes, medicare part d, and the carve out for the unions, is that an example of what we are talking about, and 33 other changes that is the last count, that i have. >> good examples of groups with political clout, to stop changes they don't want to see. they are clout on capitol hill. if would you mind if i take a second to talk about some of the outcome measures here. >> i am overtime.

i will ask the permission of the chairman if that would be possible. >> 30 seconds. >> thank you, you got 30 seconds. >> with regard to life expectancy and infant mortality. to use that to tell you about it is a bit like using batting average to tell you about football. life expensancy, and infant mortality, so much goes it that the health care system had has no control over, there a not good measures of telling you the quality of a health care system. many issues are not measured the same from country too country. infant mortality -- the chairman gavelled and hit the gavel. my main question is access to care. denial of that care. what other alternatives -- single pair system. >> senator, we will have another

round of questions. a great panel. good questions. let me pick up on a point that my turn now. i live one hour away from the canadian border. canadians watch american television, very familiar with our politics, probably more than most americans do. is your prime minister a socialist? >> no, sir t our prime minister is conservative. >> yes, sir, indeed. >> as a conservative, he wants to implement the american health care system that canadians are aware, that is what he did when he took power, is that right? >> not exactly. >> why not? >> support for single payer medicare in canada goes across all political stripes, famously, we had the leader of the most

right wing party in a federal debate on television, hold up a sign in the middle of the debate, which he he had written in marker, no two tier, a way to reassure the public that if elected -- >> two nations, probably as close together in so many respects as any two nations in the world. coservative prime minister, yes, there is no effort to move to an american health care system. i would say to my colleges there, support a better example of how people feel about two systems. they know the american system. they have a conservative prime minister. they can move in our direction, but for whatever reason, 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 they want to stay. miss pipes, why do the canadians not come to the u.s. system?

>> 42,000 come to the u.s. and pay out of pocket. >> that wasn't my question. >> i want fod make that point first. second, the canadian government, and the provinces that administer this system, it started in 1974. a lot of people in canada have no idea of an alternative system. >> they live an hour away from me in burrlington, vermont. they have no idea what goes on in the united states of america? that is hard for me to believe. >> i would say that canadian people are very, very nice people. they are not impatient. my mother said to me, i hope ru not becoming an impatient american, they don't want to wait. doctor said -- >> i have limited time. i think that the answer is pretty clear. the canadians have seen the american system, they prefer their own. >> i want to say a word about

waiting lists, i want to focus on that picture over there. this is the united states of america, not a third world count reach. i don't mean to pick on virginia. the think the same story can be told. we are looking at here working class people with no health insurance at all, are given free care, volunteer doctors come and thousands of people line up, because this is the health care they get. this takes place in a field in wise, virginia. i think it is 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, some of us have some strong

disagreements about that. doctor rodwin, i want to get back to another point to me that is very important it s i would like dr. martin to comment on this, and dr. yeh and miss chang. to get good health care, you need medicine. very often. if i go into a french hospital, i leave the hospital, i am sick. how much does my medicine cost. >> under french national health insurance, there is high levels of pharmaceutical coverage. >> my medicine is free? >> 90%. >> those drugs are cut because they are ineffective. >> so, interestingly, this san area where we made a mistake in the design of our single pair program, in canada, canadian medicare was dedesigned in the

1950s and 60s, medication was not a big way of treating, medicine was left out of coverage. the single payer program doesn't include medications, as a result, one in 10 canadians today fails to fill a prescription or take their medicine as prescribed because of cost. >> what about prescriptions in dannish. >> alm medicine at hospitals are free of charge. a maximum co-payment of $600. >> dr. yeh? taiwan, how much do prescription drugs cost? >> it is covered by the nhi. the payment has to pay a co-payment, up to $10 u.s. dollars, each year, it is up to be including hospitalization,

$1,000 u.s. dollar. >> prescription drug in the united states in fact, is low, compared to total spending. relatively speaking in europe, as well as in the percent of mo spent on drugs in terms of total health spending is a much higher percentage. for example, in the french system it's roughly 25%. 25% of the total health spending is on drugs. so they have much greater access to drugs. that's number one. number two, the reason why the drug price -- >> i apologize. my time has gone over. are senator murphy, do you have some questions to ask? >> thank you for this hearing, and to all of the witnesses. i'm sorry i had to step out for a few moments. i guess i just have one broad question for the panel. because i think it's come up in the testimony, especially in miss pipes and dr. martin. i'm always fascinated by this

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, there's some services in which if you don't get it quite away, it will have consequences on your health and the amount you will spend later on. there are parts of this country 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 miss pipes has talked about in terms of wait time, but the underlying data tells us in the end, on 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 convenience. and issues of wait times. and your proximity, either spatially or temporarily to services. but i wanted to kind of -- i mean, i'm specifically asking dr. martin and miss pipes about this, and the others on the panel with your experiences, 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.

i guess i might reframe mine slightly by what you refer to as convenience, i would refer to as patient experience. when we talk about quality in health care, the so-called triple aim, the notion of quality having three dimensions, one is population outcome, on which the single payer countries like canada fair fair quite well. another aspect of the triple aim is cost per capita, and the third is patient experience. patient experience is important, of course. i said i wasn't here to be an apologyist about the canadian health care system. we're working hard to reduce wait times for elective surgery, because we believe the patient experience matters. but you're right, 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 aaa when we talk about quality. but we should not -- we should oversimplifying the message, and equating a single payer model with wait time. that simply is not the case. >> well, madam justice marie dechant, in that hearing in '05, said the idea of a single payer health care system without waiting lists is an oxymoron. i wanted to make that point. and the canadian supreme court is not a conservative court by any stretch of the imagination. >> do you dispute the characterization of the taiwan system? >> well, the united states, we have 350 million people here. we have such a diverse -- we do not have a homogenous society, which is much more typical in many other countries around the world.

i did want to make a point about life expect answery, and the w.h.o. often says the united states ranked 37th out of 190 countries. as professor steven wolf in the institute of medicine study, which was really based on life expectancy, he said life expectancy and other noted health outcomes are determined by much more than health care. here in america, when you look at our lifestyle choices, we have a huge obesity problem. we have homicides and car accident deaths at a much higher per capita rate than any other country in the world. when you look at the numbers for five-year survival rates for cancer, the united states ranks number one in the world on 13 of the 16 most popular cancers. you have to compare apples to apples. >> thank you very much. my time is expired, mr. chairman. >> let me say before i ask the second round of questions,

there's been a lot of reference to medicare and single payer system. let me just remind everybody, medicare for a 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 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 a 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 medigap insurance. they can buy their way out of

skin in the game. the one thing that 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. what i want to talk about is drugs. because miss cheng, from taiwan, he said in his testimony that patients in taiwan can experience delays in drugs and technologies from two to five years, from adoption of the united states in that. and miss 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.

how about of the burden of life-saving drugs and devices come affect comparison between the united states and the countries we're discussing today? that's to you, miss cheng. >> thank you for this question. first of all, the -- yes, we -- the united states does fund a whole lot of r&d in pharmaceuticals, and other 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 health care. all together. so the 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 help with r & d innovations. >> when we shifted from exclusively to doing bypass surgery for heart blockage, and we went to catheterization, because innovation allowed us, or technology allowed us to do catheterization, do you consider that to be a cost savings to the united states? or the expense of a new innovation? >> if it is done on the right patient 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 is a very serious issue which has not been addressed, which is overuse of services. we have here in my testimony, the -- >> but in 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 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. >> yes. >> why? because the american patient has the right to go in and ask their doctor, and our liability exposure, the doctor feels compelled to write the script in the united states. and i would tell you that's a lot of the health care -- a lot of the drulg costs. >> right. may i say -- >> go ahead. >> 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 the institute of medicine 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 -- >> i would agree with the conclusion of that. i have one last question, mr. chairman, and it's to dr. hogberg. in contrast to what i've just talked about with miss cheng, price controls overseas don't reward innovation. if the united states were to follow 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 would see less access to new innovative drugs. it would be that simple. >> so if in fact we eliminated innovation, which takes somebody out of the hospital setting, puts them in an outpatient facility, they're treated, they no longer have the risk of infection because of inpatient, no longer the days in the hospital, that's not only been

beneficial to the cost in health care, it's actually beneficial to the quality of the outcome. >> well, sure. frank lictenberg looked at this extensively. he estimated every dollar we put into pharmaceuticals, you save over $3 in hospital costs by avoiding hospitalizations. now, the price controls can have one of two impacts. if you have price control, it's lower than the market price, you'll see a shortage, if it's above the market price, you'll see -- sorry, i'm losing my train of thought here. you'll see a surplus. and that's kind of what you're going to end up with in a system of price controls. >> i thank you. 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. so i think this has been a very

thoughtful and vigorous discussion. i appreciate all of you very much for being here. thank you. this hearing is adjourned.