of extraordinarily good academic medical centers that are in urban areas, but it is not automatically the case that firm and hospitals outnumber rural hospitals. you also see gradients along a line that we do not understand. there appears to be some linkage of quality. i am thinking about highly effective care that is very cheap such as flu shots for elderly medicare beneficiaries and mammograms. if you look at those measures of quality, it appears to be the case that areas of the united states that have greater specialists relative to generalists, they do not have more specialists. it is just that the competition of the workforce is biased more toward specialists. those are the areas that do poorly in terms of delivering

high-quality care. that may or may not because all. you ask a question about how lines up. there is something about the position work force. it is possible that you have some fragmentation of care that arises when you have more specialist involved in the care process. that has not ever been formally tested. >> the key for coming. -- thank you for coming. i have become overtired so i am swimming underwater a little bit. i do have one remarque and one question. i guess they are both questions. -- i do have one remarque and one question -- i do have one comment and one question.

this is in the area of caper 12 education. there is a lot of chatter in the world of educational literature on whether the achievement is due to inadequate cultural confidence on the part of a lot of teachers. the record, here, is very clear. what determines educational outcomes is the quality of teachers by all the standard measures. what were their s.a.t. scores? where did they go to college? what do they know? to many of our teachers do not

know very much it has nothing to do with any thing one would call cultural competency or skin color. indeed, parents do not care. there have been a lot of this. people do not care what the color of their teacher is, they care about the quality of their teacher in terms of the lessons that are being delivered and the outcomes. the teacher -- does a fourth grade teacher know any math? the question is usually no. how are children learning any math? some of the best schools that i have looked at in places like

the south bronx in new york that is desperately poor and overwhelmingly minority. they are actually run by whites. these are charter schools. none of the parent's care. what they know about that school is that it is teaching kids. the entire question of cultural competency and how you define that, that is really troubling to me. i will go back to my broncs example. in terms of the differences of care delivered in different areas. the question was brought up by commissioner harriet. if you go back to my favorite school in the south bronx, there

is a sign in the hallway that says to never take a child to whatever the local hospital is in the south bronx. no teacher is to go to that hospital. this is in the same city. this is not rule versus urban, this is a huge difference in quality between hospitals that are 1 mile apart. i am not sure what the reason is that you get such a dysfunctional hospital in the south bronx of new york, but i do not have any doubt that that message with them at school has been well thought out. so, to questions, what do we

mean by cultural competency? are we really zeroing in on something that is ultimately a very important issue? the second question is, if you look at the bronx hospital, what is going on? >> first of all, i think that there is a whole lot of information and literature coming now that is looking at cultural competency. i would call your attention to a program in harvard -- >> and the definition of cultural competency is what? >> you can narrow it down to two things. number one is respect.

respect for culture. >> how do you measure that? >> you could measure rip by how you treat that patient and how you interact with the patients. how you interact with the patient. there are a number of things. one thing that you will have to do is to educate people on the role of cultural confidence. we have a large cities population in my part of the state. -- we have a large sudanese population in my part of the state. there is no question that language that simply writing a prescription and telling them what to do is going to have them follow through. you have to understand who to communicate with in the family structure in order for them to hear to that treatment. >> isn't that true of low-income whites as well?

i know a position that was running a clinic in a very low income white area and found exactly the same problem. >> that is why i go back to at least understanding those differences. >> that is a social class difference. >> i am not sure if it is social class difference. it is much more broadly to look at it. my point was that it needs to be given the whole issue of one's culture and cultural competency. unfortunately, recent reports show that less than half of health care academic institutions have mandatory courses on cultural competency. in fact, there has been a push in a couple of states to require some continuing education on cultural

competency it so that you can understand that a little bit better. i would like to >> can i interrupt just one second. if i could switch back to education, they are wife with ethnic and racial stereotyping. they are really a disaster, by and large. those courses were amy at. maybe it is not true in medicine. i know it is true in education. >> let me help answer that question. i think we're getting some good feedback. i would harkin this group and this commission to take a good look at why the institute of medicine is and what it does. they pulled together national experts. there were able to publish an unbiased, non partisan view.

one thing that it highlighted was confidence and health care. i certainly have a tremendous amount of respect for teachers. one of the other pieces of data that you can certainly read from is the report and the importance of concordance between groups in terms of understanding particular patients. here is where we get to the heart of cultural competency. understanding the patient and being able to understand the patient. that could be a hispanic patient or a russian patient. it is about understanding the cultural background of that patient. when we are talking about cultural compensate, i think we are focused on race and ethnicity.

this is about understanding that patient. as a position, really e. kgs are important. patients' care more when you care more about them. dr. sullivan spoke about the workforce data. it there is this idea that we train a workforce that is reflective of our nation and what our country represents. it is important not just in terms of the altruistic goals but in terms of some of the health outcomes. >> the doctor has had her head up for quite awhile. >> very quickly, that was not an arbitrarily chosen example. data suggests that process

analysis in emergency rooms and in cardiac catheter labs, it has shown that many of the steps have to do with indecision where data arises. reading in e cagy is extraordinarily important when you are making sure that if they get a heart attack, they get the same care. there are a lot of things i could rattle off. >> the commissioner is right. i think that i had an example here. this is mine numbingly vague. the distinction is that she made between linguistic competence and what i would call anthropological competence, especially when you work with

different populations, you want to know what kind of home remedies they use. at its worst, training has evolved into racial sensitivity training with the stereotypes and tact. i have always wondered how i am supposed to treat my white patients differently than my black ones. i have one case here that is revealing. he shows that this is about universal factors in dealing with other human beings. in this case, this is in the medical setting. it is a very short quotation where he says that an enlightened form of cultural confidence that has evolved from implementing the principles of patients centered care is on an individual basis. you say to respect that and all

individuals through this kind of group based keep those is hard to translate into a -- group based ito's is hard to translate into understanding. >> this is not simply racial or ethnic. it a good example of cultural competence is that half of the medical students are women. when i went to medical school, this was less than 5%. the presence of women in medicine has helped to improve women's health care because there are many efforts of communication, trust, compliance at sater road that women do feel much better having a woman physician. it does not mean that the male physician is incompetent, but if the patient is reticent in communicating, where the family does not communicate everything, it is a two-way street. cultural competence and clues

that kind of thing. i think we are much better off because we have women health professionals as well as men because they can, in many cases, when some women are reticent to share with me andnn they can get type of care. it has nothing to do with race or ethnicity. >> at this point i would like to thank you. this has been an informative exchange. >> commissioner taylor? >> i will be brief. i want to thank everyone for coming. first of all, i want to encourage the press to actually read the transcript and shy away from taking the blood instrument approach to this issue that i see it taken so often to label

disparity as the results of at the bias or discrimination because it is a more complex picture and i think that has been borne out today. i am concerned when i hear that minorities are clustered around a certain number of positions and that is what i hear tonight. i am not a position, but i come to this, in many ways, as a consumer. i want to know why there is not more discussion about this clustering and one black folks are not told that the outcome, in large part, depends on where you are going. we are all going to the same place with a bad outcome. why is it someone not telling us that. i have great concern about that. let's put it on a chart. i can tell my folks to go other places where the outcomes are better. i will leave on that point.

if nothing else comes out, i am thrilled that that came out today. >> there is nothing left for me to say of the van the thank you very much and let's take a five minute break and we will start with the second panel. >> [applause] >> this week, on america and the courts, justice ruth bader ginsberg. american and the courts, saturday at 7:00 p.m. eastern on c-span. >> there is still time to get your copy of the 2009 congressional directories with information on house and senate members, the supreme court justices and the nation's governors. it is $16.95 on line. or you can call 1-877-on-c span. >> we will hear from several of

dealers about the restructuring plans that include thousands of dealers closing. this is a little over four hours. >> as you can see, there is a lot of interest in this hearing today and i expect that members that are not on the hearing -- on the committee will be coming in and out. we will try to hold a tight rein on time and statements and questions. as i said, there is a lot of interest in this oversight hearing. this hearing is entitled "gm chrysler and dealership closures." other members of the subcommittee will be recognized with 3 minute statements. i will begin.

through their vehicle manufacturing and cat us suppliers and a vast dealer network, the automobile industry has created millions of jobs. with the recent global financial collapse, most of the auto industry has been brought to its knees. in 2008, general motors and chrysler lost money. in order to survive, they both filed for bankruptcy. bankruptcy process general motors has announced plans to close at roughly 1200 dealerships and chrysler announced plans to close 789 nationwide. the federal government has loaned billions to gm and chrysler in an effort to help stabilize them.

billions more have been committed to assist them while emerging from bankruptcy. today's hearing will focus on several issues associated with general motors and chrysr is decisions to close more than 2,000 dealerships across the country. among the questions to be answered r -- why did the manufacturers believe they need to close so many dealerships? what criteria were used to determine which dealerships to close practice how do gm and chrysler save money by closing these dealerships which are independently owned? why were chrysler dealers given a mere 26 days notice that their franchise would be pulled? why were dealerships that have been meeting or exceeding their expected sale requirements still ordered to close? cited chrysler effectively ordered dealers to buy more cars in january but now refuse to buy those cars back from dealers who are being forced to close? who made these decisions of which dealerships to close?

what are gm and chrysler doing to assist dealerships with selling their parts, cars and tools before they are put out of business? how well the dealerships closures and restructuring make gm and chrysler more competitive and profitable? from michigan and i want to see general motors survive. i think we all do but we have a saying in michigan that when the auto industry sneezes michigan catches a cold and out due to the global financial collapse entire nation is feeling the impact of a crippled domestic auto industry here and other than high gas prices or serious food an outbreak i can think of a few subjects that have brought a buyer of some money as they closed. i understand that general motors and chrysler new to improve their bottom line. i also understand that the import brands have far fewer dealerships with higher sales volume per dealership. what many of my colleagues and i do not fully understand is why there is a need to close some

many dealerships and why dealerships that. to be forming well are now being told to close their doors. we will hear from chrysler today, the average chrysler dealer sold 405 vehicles and lost $3,431 in 2008. we'll also hear from the komen dodge in tacoma, washington. tacoma dodge had a net sales exceeding $1.7 million last. was one of the top 100 dealers for sales of parts in 2008 and was the number one ranked dodge dealer in western washington during the month of april this year but still received a closure notice from chrysler. i look forward to asking mr. press how he reconciles this decision to close the, dodge spirit as i mentioned, i want to see gm and chrysler return to strong and private companies. i am however, concern that the time frame for dealership closers in the way in which dealers have been treated it may

actually damage the brands more than help them. i am also deeply concerned the closures will hurt rural communities disproportionately. in my pastoral number mission -- michigan district if a dealer closes down and can be a two hour drive to reach the next closest dealer and this will cause added expense and hardship for my constituents who need to have worn to work for a special service done and is certified dealership. in addition, when it comes to time to purchase a new vehicle many of my constituents will abandon gm or chrysler and go to whichever brand is locally sold by people they trust within our communities rather then traveling a long distance to future impersonal big box dealerships with a tone of the sales or the service staff. in closing, i want to thank general motors and chrysler executives for coming here. this committee understands how busy you are and greatly appreciates ticking time to work with our staff and attend today's hearing. in addition i want to thank the

dealers who have come from every region of the country to testify today. i know that in many instances many are facing the loss of your livelihood and to take the time and expense to travel to washington to be part of this hearing is appreciated by myself, the staff and everyone here. next i turned to the ranking member, mr. walden, for opening statement. >> thank you, i want to thank you and chairman waxman for concurring in the need for some committed to conduct oversight hearing an investigation to get answers regarding the termination of auto dealers franchises across our country. i want to recognize the dealers including constituent of organ second district, bob thomas of thomas chevrolet cadillac. at bob and the rest of the dealers have taken time and expense to travel to washington and provide us with their perspective on the issue and i welcome mr. press of chrysler and mr. henderson from general motors, we're honored to have you here today as well. we have hard questions and i appreciate your willingness to come here today and explain your

situation, your perspective with clear and straight answers. since american taxpayers on sister% of general motors we have a right to know just how the decisions affecting our constituents are made. we have a duty to make this process more accountable and trans parents were all concerned. so let's start with a look at the customer service. mr. henderson, you spend pretty large sum of money on newspaper ads recently and i'm sure you're familiar with their own ads proclaiming concern for greater transparency and customer service. yet you have dictated the closure of gm dealerships across organic and the country and it was specific in burns, organophosphate appear if you are a gm customer and the dealership in burns, oregon is closed, your nearest gm dealer is idaho 136 miles away. that is the equivalent of driving from philadelphia to washington d.c. to get service for your general motors vehicle. since we don't have the three

plus hours to take to drive their even in line of the new camaro is we're using the fastest plane on our air force, the f-15 eagle and to demonstrate their route all i talk to enact new brand of customer service, this will be in 3-d for your enjoyment. it will take a while. just about a month ago general motors and chrysler said what were effectively termination notices to about 2,000 auto dealerships nationwide. we're told these notices are to accelerate restructuring plans that are i must do step for the troubled automaker's and this is a chrysler and gm can emerge successfully from bankruptcy with stable financial support. many dealers in the communities they serve frankly feel blindsided. the mid-may notice is given the form of complex take-it-or-leave-it wind down contracts with weeks to make important and expense of life changing decisions about their own livelihoods. a few explanations, no real opportunity to negotiate corrections or even sell to another more favored dealer and

no clear rationale for why they ever chosen foreclosure. thousands more receive continuation contracts equally complex which force into 18 months of limbo giving up protections against abusive practices they would normally have been able to be protected against under state franchise laws. but they have no choice -- it was a take-it-or-leave-it. in the agreements require the dealers to say there were assigning underdress. really? was talk about transparency -- we have yet to get a clear answer on how the so-called rationalization of dealer network will save the automakers are taxpayers' money and rationalization seems like the 21st century version of we have to burn the village to save it. i want to hear this morning from gm about how cutting dealers' really will save $2 billion. the national auto dealers association argues that cost a little on the margin and provide necessary convenience outlets for consumer sales and even local connection the automaker is so sorely needed. dealers even small dealers make

sales and if the automakers money by what we can gather today, many affected are not bad apple operations and may be worth meeting amended its sales quotas but it is hard to see them as costs rise on a maker operations. they often are the mainstays of the local communities, they contribute substantial taxes, support local supports the community events and have good reputations. they are the established, hard working and struggling in a horrible economic environment and soon their employees will be out of work. by one estimate the termination notices may cost upwards of 190,000 well paying jobs. in the validity of the cost issue is a particular interest since the press reported yesterday the house majority leader said he has spoken to the white house auto task force and an acknowledged that the automakers will say no immediate cost savings from closing the dealerships. mr. henderson, you say gm is going to be more accountable, let's talk about accountability -- two mid the closure decisions, however, the maine,

where they may come amid the recent decisions to reverse closures of 41 dealerships. mr. anderson, you say gm will be focused on customers and less talk about customers -- how is it the mustard eliminated dealerships which compete with each other for price, quality and service. it has been set our domestic automakers on a rural america and you know how it is to serve rural america to limit the loan dealership in a place like burns, oregon. we're still not to idaho by the way it. we did past stinking water pass. in this alice-in-wonderland world of rationalization were up is down and less is more our customers are by less competition and higher prices while on the taxpayers a dime better served. in bend, oregon and the general motors terminated the only gm dealerships substantial service repair facilities servings -- servicing thousands of assisting thousand square mile radius and to the planners behind us understand the rural america really understand