in the life or death situation to many americans. it is a trust that has been broken. today we will hear testimony from experts at think tanks and institutions. they will be on our second panel. we have concluded that the first panel should include three doctors who have actual life experience practicing with patients and realizing what can or cannot be done, what should or should not be done and direct experience of what is happening under the affordable care act -- not just to their practices which are businesses, but to their patients who are human beings in need of their care. testimony from these physicians will describe the most candid and personal terms exactly how the affordable care act, or obamacare, has effected the patients and the practices. will agree there were problems in the healthcare

care system that needed to be reformed. the fact is america had an imperfect system developed with a number of public and private forms of money, tremendous , and the like. crashing it into a wall is not a fixed system. with that, i recognize the gentleman from maryland for his opening statement. >> thank you for calling this hearing. this week, i had the tremendous honor and privilege of traveling to south africa. as part of our nation's delegation to honor the life of the late president nelson mandela. it was an inspirational trip, life altering because i have the opportunity to reflect on the amazing changes that one

individual, working with determination over a lifetime, can bring to millions of others. there will always be forces aligned against progress, against quality, against basic human dignity. but nelson mandela's life reminds us that our mission on earth is to transcend these district to forces and always pursue the betterment of our fellow man. atraveled back yesterday on 20 hour flight, and i began thinking about today's hearing and i was amazed again at the significance of what our nation accomplished with the affordable care act. lawre we pass this landmark , millions of our own citizens could not obtain health insurance because they had pre- existing conditions. we allowed insurance companies

to discriminate against them. premiumsged exorbitant that were prohibitively expensive. they attached writers that excluded care for these illnesses. and in many cases, they did not have access to health insurance altogether. we had an entire nation, a people without coverage. no insurance for doctor visits, , hospital care. it was a shameful and immoral for a nation is prosperous as ours. ,fter decades of inaction

congress passed the affordable care act. them from they owned discriminating against people with pre-existing conditions. we prohibited insurance companies from charging higher prices for women than for men. plans butted junk collect premiums but did not pay hospital bills when people got sick. that tens ofday is millions of people now have something they did not have a four we passed this law. abilityrtunity and the to afford and came quality health insurance that will safeguard their financial security and recognize their dignity as human beings. congress understood when we passed the affordable care act that these changes would tend to increase premiums for a subset of people who already had insurance under the old

discriminatory rules. put in place several measures to lower prices and control cost including subsidies to help people buy insurance, a requirement that insurance companies spend at least 80% of premiums on health care services or offer rebates to consumers and reviews of proposal by insurance companies to raise their rates by more than 10% in a year. that the actual premium rates have now been submitted by insurance companies and they have come in much lower than expected. in september, the department of health and human services issued the actualplaining premium rates now being offered under the affordable care act are 16% lower than projected. based on this actual premium data, the center for american issued this showing

that lower premiums will save the federal government 100 $90 billion over the next 10 years meaning 700,000 additional people will be able to obtain coverage. more broadly, the centers for medicare and medicaid services issued a report saying national health spending has slowed to only 3.9% in the last three years. this is the lowest rate since thegovernment began keeping statistics in 1960. i understand that we will consider two studies today that assert premiums are increasing for the majority of people in the exchanges. have veryts significant flaws. first, the heritage report completely disregards the subsidies provided by the affordable care act. completely. as a result it inaccurately inflates the actual cost of

coverage for consumers across the country. institute study is better because it includes subsidies but it still compares, and i quote, apples two avocados. it compares five plans under the affordable care act with the five cheapest plans offered before the law passed. the obvious problem is that the old plans offered the vastly inferior coverage. to me, the most significant problem with comparing premiums for and after the affordable care act is that it disregards the 50 million people who could not get insurance. if someone could not afford then the price of that prohibitively expensive plan is not considered. let me close by offering a final quote. one of the things that nelson mandela will always be remembered for is his push for

reconciliation. i respect the viewpoints of my colleagues on this committee as well as those of our witnesses and i understand that the affordable care act is not perfect. i have said that many times. in that spirit, i hope we can work together in a bipartisan way to approve the act rather than continuing to fight over its very existence. one of the things that the late president mandela said, and i quote this a lot because it's so true. he said it always seems impossible until it is done. it always seems impossible until it is done. no longer disregards experiences of 50 million members of our population. we can no longer ignore the pain, the frustration, and the fundamental inequality of this nation within a nation. with that, mr. chairman, i yield back. >> members may have seven days to submit opening statements and

other extraneous material for the record. we now welcome our first panel of witnesses. is notricia mclaughlin small at just in a private isctice and dr. eric novak an orthopedic surgeon with ortho-arizona in phoenix, arizona. i would like to recognize the gentleman from georgia, mr. woodall, to introduce his constituent, dr. english. >> i appreciate the courtesy. we have the great pleasure of having dr. jeffrey english with us. he got his bachelor of science and graduated from dartmouth medical school in 1995, served

as chiefy close by resident of neurology and university of maryland in 1999 and to the great pleasure has chosen to call norcross home where he is the director of clinical research at the multiple sclerosis center in atlanta and president of the of docs for patient care. it's with great pleasure that i welcome you today, dr. english. thank you for what you do not only on the committee but for back home. to committee rules, i ask all three of our witnesses to rise to take the oath. lease raise your right hand. do you solemnly swear or affirm the testimony you are about to give would be the truth, the whole truth and nothing but the truth? please be seated. let the record reflect that all witnesses answered in the affirmative. dr. english, you have time in your practice to watch c-span?

for all of you, i will give you the brief. ask, first of all, that all your opening statements in their entirety be placed in the record and in addition, any pertinent or extraneous material you would like to submit now or for the next seven days will be included in the record leaving you free to use the entire five minutes on the clock in front of you to say anything you'd like to say but i ask as it runs down that you try to wrap up. dr. english. >> mr. chair, members of the committee, thank you for inviting me to talk about how the affordable care act will affect my patients. practicing physicians who see who have read the law and understand the law have already predict did some of these outcomes that you mentioned earlier. and of what you are seeing are about to see is on for scene. the affordable care act problem is not a computer website.

mewould be common sense to that a program designed in washington, d.c., by people who don't take care of patients is his boat to affect people from maine to oregon in a top-down fashion with ancients being the variable will have a lot of unintended consequences, as you mentioned. unfortunately, those unintended consequences our patients, constituents, fellow americans. half of what i do is in a salaried position at the ms atlanta, nonprofit for the treatment of patients with ms. it's a disease of the brain and spinal cord and can be very disabling. it affect about half a million americans. patients are female. we had no medications and now we have 10. they are highly variable. patient's responses highly variable then they can have life-threatening side effects. require twice the number of staff and twice the

amount to take care of. they present as young teachers, working mothers who all of a sudden cannot walk, typical presentation. are able to move very quickly to therapy but it takes a lot of experience to know how to do that which is why we have about 5000 patients that come from 28 states and 118 of 150 nine counties in georgia. they look to us as it their primary care providers because they see us so often. we are now staffed with the health care plan looking at things like metrics that different physicians will be weighed against and i think my colleagues will touch on this also. they are set i people mostly in washington, d.c., who don't take care of patients. if you comply, there are bonuses. if you don't, there are penalties. section of the healthcare law state some of it includes removing physicians from government approved insurance. i will give you a few stories.

i don't know if i can finish but number one was a report i cms, center for medicaid and medicare services in 20 12 and said i was an over utilizer of the mri compared to my peers. it's what we used to look at brain injury and his protein for mass. not to do so can lead to disability so we obviously don't want to not do them. i said, first of all, who are my peers? other ms doctors? they also included orthopedic surgeons and i also said, are you aware that i am an ms dr. and this routine protocol? they said no. they did say that this would be on the medicare website in the future and people would look and see that i did not meet their .tandards again, that will be on the website. i heard earlier in opening testimony about united healthcare.

they dropped quite a few providers and according to "the wall street journal," this was in part due to managing the network with the five star meeting cost and quality. you're looking at a downgraded physician. i'm not off united healthcare but i'm downgraded because of, again, compared to my peers, fellow neurologists and they look at cost and quality. off thety was literally charts. a bell shaped curve. however, because of costs, i was also too-that is what downgraded me. two areas of cost were -- guess what? drugs and the mri. i have no control over that. my peers and send me the most comfort kidded patients that require these therapies so i reached out a few years ago with a question and i want to ask united healthcare. december 2ides the

deadline to repeal after three weeks of calling four weeks out we have not gotten them to appeal after the deadline. what i want to know is, as a provider, am i supposed to not take era of ms patients or take care of them but don't do what's required and limit my medications in order to meet metrics? is an example. physicians will be stuck with the way that the law is written now and we will be penalized for taking care of these complicated patients. testimony on the state exchanges. they will have as equally difficult a time as far as access to medication and providers in her how to care for certain types of patients. with that, i will close and i thank you for the opportunity. >> thank you, dr. english. morning, mr. chairman, and members of the committee. thank you for the invitation to be here and i welcome that opportunity. i have submitted testimony which

i hope you will all take the time to read. it is packed with details about of how these plans were designed an architecture with perhaps improper thoughts of the privates in the battlefield. those are the patients and the dock are. you are all generals and we respect hard work you have done to get the law passed. as mr. cummings said, even in my own family i can personally whent the fear that came my father passed away in my mother at 61 with terrible medical history lost her insurance because it was company-based with my father's company. for four years she was essentially uninsured. i have walked that road and they understand where you are coming from with wanting to do something for the citizens of this nation who have had such fears as well. ,owever, in taking care of that

unintentionally there were horrific events that are only starting to come to light which is the part that concerns me so much. in my society in ophthalmology, i am a third party liaison and i look at all things that insurance is due as a pattern of behavior and i report on them. that we take appropriate action if necessary and most time with good negotiations we can make rate strides. hard and imist that believe everything can be fixed. my former training in college and my graduate work was as an aerospace engineer and i had hoped to become an astronaut but because of my mother's health, my life took a vast change. , a divergentou comments, that the pay-for- performance structure we have now and medicare for bonus pay, to most physician colleagues, i think we can honestly say it should be scrapped. we are at trained to get our

best to our patients. supposedly to give our best to patients. we should not be doing metrics that have no bearing on the field that we do. in my field of ophthalmology, some of the pay-for-performance measures can include something as ridiculous as doing a body mass index. what does that have to do with the health of the ie or what it the eye?t -- health of nothing. you are spending medicare money for ridiculous measures. taking the time to document this for someone who is a statistician who wants to run numbers. this is not with the doctor- patient relationship is about. that is the only thing this is about. my comments have no bearing on politics or what brought us to this point. we are now at t -20 days and

counting. the doctors and the patients are going to be having extreme difficulties in accessing care. yes, mr. cummings, i agree that it's nice to carry a plastic insurance card to say you are insured but it's quite another to access that care. allowed the insurance companies to devise the current plans and how they are struck third in the affordable care act , and i might say affected small outside ofas well the affordable care act, leaves a lot to be desired. i'm glad that i was put in the middle of this because for everything bad, something good comes of it and that's why i'm here today. as a small business, i ensure my family in my two employees.

i have wonderful insurance. i was pleased with it. it was a small business plan. surprisingctual find how much in 2008, just as you said, those premiums raised ridiculous amounts every year. one year it was 26% for this great plan. i was in sticker shock. 2008 thatthe point in each individual in my small business plan to have a fully comprehensive land it would have cost $859. the math and i said i could not possibly afford it so i contacted my insurance broker and i asked what my options were. the consumer driven health plans. not familiar with them, leery about a new concept, i exploited and it took me two used to sign on. 2008that did in those

dollars was without the affordable care act the legislation, the insurance company took my premium of 800 $829 and dropped it down to $300. that was for the same plan. why? it did that because we had to assume a $2000 first pay deductible expense. put.is where the risk got they lowered the premium i increasing the dock will. deductiblehave a before for in network coverage. we had a very modernist deductible of $500 to go out of network. i was blessed with an out of network plan. i continued this plan for all those years and i was pleased. i was not pleased when i received a letter dated september 21 that my plan was

going to be canceled, that it was not in compliance with the aca. i'm no one to judge that. i have not read the 2000 page document. i'm assuming the insurance company is telling me the truth. plan would be replaced by something comparable and i trusted them for that. i've been with this company for years. i was a participating provider with them. just like patients have trust in their doctors, patients have trust in the insurance company and i was one of them. the new plan rolled out. it took away my out-of-network benefits, which i might say i might be able to live with because under the high deductible plans, the in network adoptable was $2000 for an individual but the out-of- network was $3500. i was less likely, i must say, even in my position and certainly my staff to go to an out-of-network physician because

the first dollar amounts would be hours to bear. being a responsible individual, you should take care of your bills. the new plan does not give out- of-network benefits to all small businesses. the affordable care act insurance does not allow for individuals out-of-network benefits. what a also noted when my new plan was developed was a very crafted a letter that implied even though i was going to have been in network plan presumably of the same level as my current plan, but only in network, it would now be called an epo. it would not have the same network of physicians that my current plan did. they have the same network. the hmo physicians or a smaller, different network. some doctors have the ability to

network, or the other but by some contracts they had to be in all products. what happened now was there was this term about how i needed to be careful as the administrator and i needed to inform my employees that they needed to check to be sure that all of their dark or is that they currently saw in network. mind you, the same insurance company makes this a bit ethical because you would assume if your doctor was in network before him a why would it not the in network afterwards yard or that was where the catch was. the new network was given a fancy name. it was calm halfway with variations. or just simply, passed away. of it beforeeard and i was a participating physician i just knew i took hmo, point of

service, but i did not understand the pathway. i went to the website and i look to the sub. what i saw was that these pathways were very restrict give. what we have now is an inability to refer patients as an ophthalmologist. if they are not in network, how patientng to give the with a sudden loss of site the ability to see a fine physician that i have sitting on my right? we have to fix this and we have to fix it now. we have no time to play with this. patient's lives are at stake. acute care situations need a .pecific doctor to refer it's not enough to send them to an emergency room. and by the way, many hospitals are not in network either. thank you so much for your time and i hope i can count on you to fix this. thank you.

>> thank you. mr. chairman, members of the committee, thanks for having me back again. when president obama made the case in 2009 that we needed to lower cost and improve access to healthcare, i agreed. on june 23, i told a house subcommittee that the system within which you are allowed to provide care is as important to delivery as the people providing it. if you're not willing to do the same level attention of detail into designing the system, it's doomed to fail. ring that same hearing, congressman dingell announced he would never presume to tell someone how to take out in appendix or replace a native but he does know something about drafting a law because he's been doing it for the years. since then, the healthcare law has failed to deliver on nearly every promise including if you like your dr. you can keep it. and failings certainly extend to medicaid. in february 2013, the obama

administration made clear their position about access to care for medicaid patients in the ninth circuit. there is no general mandate under medicaid to reimburse providers for all or substantially all costs. as children defense fund president, mary adelman said at the same hearing in june 2009, talking about a child with medicaid who died, his mother could not get the dentist to take him because of low reimbursement rates. andthan gruber's research others suggest between 50%-80% of all new medicaid enrollees will lose private insurance as it is crowded out by medicaid. in arizona according to a 2013 report, most hospitals receive 70% of medicare rates. that's unsustainable. some will benefit from the expansion, but the losers will

far outnumber the winners. to respond to congressman dingell, he may not be saying how the surgery gets done but he's impacting who will get it and when. the access problems do not end with medicaid. the healthcare exchanges are really just a variation of arizona's 100% had care managed system. it was expanded actually cost over four times what was predicted by supporters. the policies available through the exchanges, even with subsidies for many far more expensive than democrats and the president promised and many retired adoptable's, co-pays, coinsurance and very narrow providers, the group of over 70 musculoskeletal providers i meant did not have a single exchange contract by choice, one reason is the required 90 day grace. for policies. we can provide care thinking they have coverage and then we are on the hook for payment and they have no responsibility.

arizona is not alone. at least one major phoenix a singled not yet have exchange contract in large part because of the rates being offered are at or near medicaid rates. i recently spoke with a retired professor from an esteemed medical school. she feels obamacare is morally right but not of her personal doctors take medicare let alone medicaid. unwilling to make a moral stand and not go, the professor blames the doctors and the seeks to have government forced them in hospitals except butter payment they decide even if they go out of business doing so. i strongly suspect we will be hearing variations of this soon from the administration. defendho do not wish to the failures are quick to say, what is your solution? i know we are not focusing on alternatives but i want to mention three areas that should contribute to the larger proposals. arizona passed a first in the

nation price transparency law. i would add with significant bipartisan support. the law extends in the nation state constitutional rights to spend your own resources for else care services but it also and direct pay price discrimination based upon insurance stats. it goes into effect january 1. in 1994, inception they have focused on quality, utilization, and costs. we have shown repeatedly that physician accountability is reproducible and in effect give way -- and an effective way. a software company with whom i work for by the platform that takes automatically collect the data and provide analytics on that data combined with other sources of information getting better, more accurate, unbiased information in the hands of everyone from transporters in

the hospital to doctors, healthcare ceos to you, the policymakers in the country and it has never been more needed. ultimately, we must move the policies that ensure they maintain control of their health care decisions and that includes access to quality physicians. >> i thank all three of you. i recognize myself for a first round of questions. dr. english, you said very well in five minutes a position and i want to make sure i ask a question that makes it weird to all of us. under the affordable care act, what was often care -- called rationed care is occurring simply because you are being told that if you take an expensive practice you can be locked out? sends and casts off the types of people you deal with, a doctor or neurologist to

says anyone who gets ms i will dump them onto dr. english because he costs more and i'm going to keep my costs down by not having those patients, he or she wins and you lose under this rating system. is that pretty much a wrapup of what you are dealing with? >> that's my interpretation. could fix that. you provide a marginal care and do less mri costs and so on and you will be ok? did general neurology and stop working for the ms center, correct. >> you could not take these difficult haitians. i'm going to go on to practice wearing only deal with people up until the time they have a serious cancer events but after that i will dump that person. the really sick under the current system unless we change it find themselves undesirable either to get full care which or, quite frankly, to

go to the doctor out all. that's what you are dealing with unless we make these changes. >> yes. >> dr. novak novack, who walks in or writes a check for the service should not eat the advantage. what happens, and i support that , from the bottom of my heart i have find it hard to believe that your cash customer pays more that they do as in almost america because there is no transparency so they don't know. what would happen if everyone walks in and paid the medicaid reimbursement if that was the lowest rate? >> in my conversations with a variety of hospital systems see c suite people, they feel they need to be profitable at healthcare

medicaid rates. i can't speak to arizona where the average hospital medicaid reimbursement is 70% of medicare . for a total knee replacement the average commercial payment is $24,000. andcare pays $14,000 medicaid pays $8,000. there's no way that any of the hospitals in the phoenix area and the bulk of the ones around the country would stay open. it is not that unique a statement because if you look at the medicare actuary report, there is an expectation that up to 20 five percent of hospitals won't be able to survive the decade anyway. >> one thing we need to do is to figure out how to stop the cost shifting. anyone including the federal government mandating a rate less than what it takes for an entity to stand business unless we're willing to work with them to make sure that they can in fact live with that rate. >> its importance in on the issue of transparency, over 100

million americans get their insurance through a self-funded payer. in this same example of transparency, what we found is that again in arizona using hospital association data, commercial payment was $24,000 and in arizona if you pay cash, $19,000. as one of the executives of a privately held large company in the state said in exchange for doing everything right or our patients, our employees and their spouses, we are paying for00 extra for 20% more that knee replacement. when we look at the transparency law in arizona, it creates a mechanism where not only can we protect the uninsured but ultimately we protect those who are insured by hopefully lowering the difference between what they're going to pay. >> one quick question and i will respect the five-minute clock today. are all is that you

seeing something else, i believe and i would just like a yes or no. aderal reimbursement for particular event that a clinic or doctor's hospital is almost always less than in a hospital. right? >> yes. the interesting things is that if a doctor's hospital is more efficient -- the doctors offices and more efficient, we don't say we're going to try to get people to the most efficient rate i paying a fair rate to the dock or. instead we pay less to the doctor, more to the hospital, and it causes hospitals to build up the practices and is that correct the? >> yes. >> mr. cummings. yourank you all of you for testimony and i appreciate your passion and what you do. effective in be

what you do and it's so important. after english, you talk about you do witht multiple sclerosis patients and i'm very familiar with that area with johns hopkins smack dab in the middle of my district. we spend a lot of time dealing with that issue. you also discussed the costs associated as yang about $50,000 per year. is that right? that's a hefty price tag. multiple sclerosis is a terrible disease and i appreciate the work you do to treat those patients afflicted with it. i know you have concerns about the affordable care act but i have serious concerns about what happens to the 20-year-old woman or the 40-year-old woman who was diagnosed with all tuples grosses who does not have insurance. -- who was diagnosed with multiple sclerosis who does not have insurance.

i cannot hear you. up, everyonen agrees with the majority of your opening statement about the need to fix the healthcare care system and pre-existing conditions. >> do you agree that if an uninsured person with ms were seeking of care coverage in the individual market that the person would have been very unlikely to have gotten in sure and. thet least in my state, majority of my patients had a very good access to care. those who were uninsured, there were methods of getting them care. as congressman issa mentioned, i'm cheap. the medications are expensive and those are usually subsidized. >> part of the aca, insurance companies were allowed to discriminate against patients and pre-existing conditions that's a fact. do you think people with ms would have been able to get health insurance or would it have been so cost relative that

they would not have been able to afford it? >> i agree with your original statement that we need to handle pre-existing conditions. what i'm seeing is that they are getting a card that gets them access to nothing. i want to solve the problem you exactly stated and i'm on board 100%. hopkins has taken over the ms, you are right. university of maryland i was there. maryland?uated from >> wonderful. >> i have two children born in your district. >> fantastic. we needed to solve that problem. in my opinion, this did not solve the problem. we are going to see these unintended consequences and you're going to hear from your constituents. >> i could not help but think about the things you said about your mother not having insurance .

, member of my immediate family they found some precancerous cells with regards to the breast and could not get insurance. for four or five years. this is a young woman who could not get it. as i listen to you, i can see that you all seem to understand the problem here. on the one hand, we want to make sure that treatment that is provided is the appropriate treatment. we hear all of these complaints, and i know you have heard them, doctors giving too many tests and other same time, we want to get the results so that people can stay well or get well if they are sick. if they have to keep coming back to my it's only going to cost the system even more.

it andd the last thing, this is a written in the dna of every cell in my brain you said it -- i want you to fix it. that's what you said. sir.s, >> what suggestions do you have based upon the things you have talked about today that you would suggest about fixing it. >> i'm glad you asked. thank you so much. you see, the real problem, beside the networks that are so restrictive, i also got a letter dismissing me as a participating provider from the insurance that would cover patients on the aca. no one here intended that to happen, i'm sure, but that is what's happening to us as physicians, where we are being put on these panels without knowledge because the contract we signed 10 years ago that had clauses and you might assume, as someone who owns a business, but if you were paid x number of dollars by the insurance company

to be a participating provider currently, wouldn't you be offered the same feed just simply because were taking care of the new government law? it's not the case. they are coming in with fees that are sometimes 50% of medicare. as business, we cannot survive. the other problem here is these the dock the bulls. yes, there is some city but that is for people who qualify. not universal across the nation, but in a large city like new york, a studio apartment is $2000 a month. how is a person earning $50,000, which by most standards across this country is not a terribly small amount of money, but someone earning $50,000 in new york city paying $2000 rent for a hole in the wall cannot afford a $3000 deductible for a plan

that is being advertised as "affordable. plan in new york state for something like emblem after thatoinsurance patient reaches the $3000. the bull. what we have found when we went back to that 2008 level is that just simply having these high slowed downplans health care utilization because patients were afraid that they would have to pay the first of dock below amount. deductible amounts. cannot have a whole nation of patients and collections. we cannot have a whole nation of physicians offices and hospitals fighting the system to get paid. this is not fair to the patient. is rumoralk or there about a single-payer system, i think in my heart that the

quickest answer to help us in the next 20 days is to eliminate these networks. not everyone who signed up stay in those plans and those insurance companies must also be made to be transparent about what they will pay which, by the way, they have not at this point. i have colleagues who have no idea that they are even on these panels and no idea what they're going to be paid. notthe insurance companies, to hurt their business operations, we all want them to stay in business for the rest of us, let them pay that same as the access reference point and then allow a negotiated fee between the patient and any doctor they want for a value for that service. establish an competition between physicians to keep prices controlled unless

you want to have one of those often spoken about concierge that charge enrollment fees of $24,000 for a certain 1% -- often spoken about concierge practice. the doctors will be able to remain in private practice keeping them out of the facilities that are going to cost everyone more money. the patients will have the ability to see someone for a modest fee if available or they can negotiate another feed. that's the only fix right now, but please give it a networks and allow the doctors to stay in business at the same time. >> thank you. i now ask unanimous consent that the article today in "the wall street journal", or yesterday, entitled "chongqing the obamacare stats -- "junking the obama care stats."

>> thank you mr. chairman. a perfect lead-in putting that in the record. the title of this record is obamacare impact on premiums and provider networks. aboutfirst talk generally the impact on premiums and the people who have been affect and so far that we know about. in chairman just put this from the wall street journal. between 4 million and five and a half million have had their plans the created. liquidated. most of these people will now face a higher premium. r. english? actually, a higher premium and a higher deductible both. would that be your testament? >> there is so much variability. we want people to have --

collect these people have had existing plants and have now been notified that they are not getting them. with the new mandate in that, for example, i have been forced on no obamacare in my deductibles have doubled or 4-pled and i think that is 5.5 people have been seeing. >> i'm reading what you are reading. i just cannot give you personal experience. some of them don't know yet. they don't know what they're having. with more mandates, the cost of premiums are more so they have shafted as many as five and a half alien people with their premiums. any comments? likely that it will substantially outweigh. >> they have signed up a 364,0682.

>> the country is starting out so we negative number don't know who those people are, the 300,000 people. we don't know who those numbers are let alone whether or not they paid. >> let's jump to the impact on provider networks. here's another article from "the wall street journal" about the chairman talked about in his opening statement in my state which has many senior citizens residing in southwest florida. their primary oncologist hospital, hasitt been dropped. thousands of seniors now do not have box us to this critical care. is not the kind of impact you are seeing? again, this is on our seniors.

this does not involve obama care coverage. this is an existing medicare advantage of which 28% of all medicare people are on. this is an indirect result of inmacare and what's going on the marketplace. is that correct the? >> congressman issa mentioned talking about paying more to see on those plans and the state exchanges are set up. there are different exchanges. sure provider is in a different area, you cannot move out to see those people. >> we are seeing absolute turmoil in the marketplace. they are the most vulnerable in our society and probably need the most medical coverage. instead of getting coverage they are searching for a doctor to serve them as they have been thrown out in the cold. >> absolutely. in new york state, we are such a

large state. the behavior of the insurance company has been quite different upstate as opposed to downstate. in the downstate area, 2100 positions were dismissed from oxford united. >> not just florida. you're seeing it across the nation. >> there is a reason for that. the cms a budget to these managed care companies was decreased from 17% to believe about 8% to manage the medicare beneficiaries. with all due respect to the business operations of an insurance company, when they have a cut like that in their payments from the government to , they havee patients to do something to cut their cost. morally and ethically, none of us are happy with that but i can understand where that came about. >> you have mentioned the panels that are being set up and i hear these rumors that certain ages

and certain types of care will be cut off. do you envision that happening? i've heard rumors about 73, no cancer treatment. there's is a possibility of not getting transplants. what do you see. >> the gentleman's time has expired. i answer? a lot of that might be hearsay. we have heard the rumors about death panels but rationing care is something that has to be part of this to make it work. it's not the appropriate answer, however. i'm not quite sure what the some are about what age procedures will be limited but i would not dare say it may not come. if i could ask unanimous consent to follow up for 30 seconds on this? when the word "death panel" is

used, they have a real problem with it. dr. mclaughlin, you do agree medically sensible decisions about whether to use extreme healthcare options or not, in other words, decisions that are not always to do the most expensive than thoreau, do change with age and that they need to make those decisions. does not"death panel" mean that doctors make a decision but extraordinary measures are sometimes not appropriate for the elderly. andink the democrats republicans f just a yes or no if you can. >> the simple answer is most of us who are physicians will have a talk with the family and advise them what we feel is medically appropriate at that

time and we will do everything possible to sustain life where there is life and allow the family to make a just decision. we hope most will be advanced in a fish year he notices of the individual has the choice and takes the burden away. can do as anything we a society, we should be pushing them to make that decision. thank you. i did not want that to divide the panel because i think we are united on fixing health care. the gentlelady from illinois, ms. duckworth. that comment,or as someone being accused of being involved in death panels at the va where they certainly use outcomes-based analysis to deem what is appropriate for veterans, that's a very sensitive statement. dr. english, i just wanted to follow-up with you a little bit. the goal of giving america

access to quality, affordable, life-saving health care is critical. it's not only the moral thing to do to make sure getting sick in america does not leave bankruptcy but it is needed for our government's fiscal help. i personally think the affordable care act made the steps in that direction but as you mentioned, there have been problems with the need to be fixed and you spoke a little bit with cms, fores example, and your use of mri's and incorrectly compared your use to others. i understand how different types andherapies will differ associated diagnostic equipment you need to do to treat that. are you seeing in your testimony on howe cms decisions you are evaluated is specific to

the affordable care act or is trying topart of improve the medicare-medicaid system? measureieve outcomes part of the affordable care act is using models like that, somewhere predated with the stimulus package and it started ahead of the affordable care act but that's a big push. when we look at medicaid cuts for the future, out comes in of theans, that's part affordable care act. it's a combination. >> do you support outcomes-based physician decision-making with different treatments for your patience? this works better than others. i know you come from a very cutting-edge institution that is progressive and aggressive in treatment. if i had an mass, that's what i would want. do you support looking at outcomes? >> when they come from as far

is made, this really pushes coming from d.c. which was the wrong way. wereh specialty societies encouraged to come up with metrics to see what is appropriate care in ms, knee surgery, etc. it would have been a better way in my opinion. atnot so much looking outcomes is a bad thing but the way that cms is going about it using accountants to look at it versus relying on the healthcare practitioners to be the ones develop with the guidelines are. they should probably have some ms physicians who would inform that process of developing the guidelines so that your use of mri would be perfect in keeping with other physicians who treat like you'retitution

setting. >> the affordable care act is going to have these unintended consequences from the top down and not the ground up. ,hether you like the law or not these unintended consequences are going to happen. they are not unforeseen. >> i happen to agree that we need to fix the unintended consequences and i would love to be able to continue focusing on that. i don't know if repealing the long or defunding it is the way to go but there are many problems that need to be fixed. existing condition and i would assume someone with ms would be considered to have a pre-existing condition if they and to open the marketplace privatize now. have you had ideas -- have you had experience with ms haitians reaching lifetime caps for treatment? room has a in this pre-existing condition it's just

some of us don't know it yet. >> good point. had their own insurance and once they got sick, there's no such thing as pre-existing condition. in my practice, the answer is no. 13 years in atlanta, i've never been able to get the care to my patients through one way or another. even with gaps, there are ways to do it. about cap from insurance companies. you do a great job of raising to provideunds charity dollars. that's very different and i'm glad you can get the care to the patient but you're using other techniques and i think it would be better if the patient had insurance that would stay with them and cover to not rely on charity. i'm out of time, thank you. >> renowned go to the gentleman from michigan for his questions. to the gentleman

from michigan. >> thanks for the work you do. dr. nov >> what are your views on the independent patient advisory board? >> nobody has been nominated yet to my knowledge. they say it is not going to be involved and does not have the power to determine what care can notcannot be given, but only are the people on the panel with me saying, but in the context of the members imply can do isthe ipab determine how much you get paid for it. if the payment for something drops to a point where you cannot stay in business or keep your doors open if you continue to provide it, less will be available.

i think it is a bit of semantics and i think some of the words can cause division, but the ultimate reality, the ultimate goal of the independent payment advisory board if payment care expenditures go up faster than inflation is to reduce those costs. they're going to go with the money is. they're going to go to the andsive patients with mf say we're going to pay a lot less. they're going to say that centers like uris are going to not make services available. that that fromme what you say is negative to the health care system. the question is how do we get the best health care to the mom who brings her child to me. >> the best health care we deserve. >> trying to get patients and families involved on multiple levels and try to make the best

decision for them. ofmy world, taking care fractures in acute injuries, i don't have long-standing experience with patients and families. you need to get data so families can make the best decisions. >> to have any evidence that competition and choice is a better way to increase value and reduce costs in government bureaucracies? >> obviously that does exist in certain parts of medicine. we can look for an example in california more recently with what wellpoint has done with reference pricing for joint replacements. by changing the structure they have lowered the cost of joint replacements by 20% in less than two years. the idea of creating transparency and really -- you cannotle should provide high-quality care at a low quality cost -- at a low cost with overall better

patient satisfaction. >> to make sure it is clear where you stand, will obamacare limit your patience treatments? >> yes. >> in your testimony you mentioned 10 medications for ms patients. it will washington post article from two days ago said one way insurance plans under obamacare are keeping costs low is by not covering widely used ms drugs and requiring doctors to prescribe drugs in a certain order which would compel patients to take drugs more toxic to them potentially. have you found that to be the case. >> is is our major concern. i can't impress in your enough -- impress on you enough. my teacher who is paralyzed to i

know i can do something for who i know i can't. that is my concern. to take drugs that don't impact them positively, let alone produce the changes necessary. >> you stated obamacare punishes you because you care for the most vulnerable patients. how does it do that? if our center close down and i was looking for a job at a hospital and 5000 expensive patients are coming that i knew were going to bankrupt my hospital, which runs at up to take me on? i learned at the trauma center. that was incredible taking care of the sickest of the sick. i loved doing that. i don't see how under these payment models that any hospital system is incentivized by taking care of the sickest patients. they will be dis-incentivized

based on outcomes. >> what are looking at is to tears, those who can't afford specialist treatment -- we're tiers. at twotiers i thank all the panel for the participation. -- all the panelists for their participation. acauly believe that the really is important legislation and is by no means perfect. it really addresses some of the massive deficiencies in our nation's health care system such as covering pre-existing conditions and providing coverage to over 30 million americans that did not previously have coverage. while i do want to get to your

concerns and understand them in a deeper way, i would like to somea moment to highlight of the successes of the marketplace in my home state of new york. earlier this week the new york state of health reported that over 314,000 new yorkers had completed their applications for insurance and over 100,000 new yorkers have enrolled for ,overage starting on january 1 2014. i understand that 70,000 select anda private insurance plan one report stated that new york has the second-highest raw ,nrollment numbers of any state so there are some successes but i do and technology at always room for improvement. in massive new change something as complicated as health care is going to have to face many improvements and need to be willing to work together

on both sides of the aisle to correct deficiencies and challenges that we see during process. ientation asses would like to understand the concerns that your race today and understand completely your situation. you stated that you received notice last month from an insurance company stating that you would not be extended anticipating status on the new insurance plans in the pathway network, is that correct? >> yes, councilwoman. >> and what about other insurers? did you get similar letters? >> the way this works is the insurance companies can only thatach those physicians happen to be already networked with them under contract to them. in thetance, i am not emblem system so they cannot approach me or do anything to me

in voluntarily. that is important to understand. >> can you approach them? another insurance company, would you be willing to participate in any plan on the exchange? can you approach another plan? >> i am assuming that door may be open, however, what is clearly evident by the plans that i am already under contract , blue cross being the main one, they made a decision for whatever reason that they had enough participating physicians to form this pathway network, bych i might add just looking at the ophthalmologist serving manhattan in that list, came to less than 150 names, of which most of them were in solo toctices with no affiliation large group contracting forces. so these physicians happened to be under contract to that

company for the lowest fee reimbursement for the same service that another physician who is part of a faculty practice or large group tracked this would get. as insane as that sounds for doing the same work, physicians are paid differently in the current system depending on how large a group you belong to and what negotiating power comes with those numbers. have you appealed the decision? i know they are trying to save money and in fact the new york state testified or released a report saying that the people that had enrolled, 100,000, received premium rates that are as much as 53% lower than the rates in effect in 2013 for comparable coverage. that is great news for them, but they are looking for services that are more affordable. you can appeal these decisions, as you know. particularly in new york state

is being run by the state and state insurance is regulated by the state and you can appeal to the new york state insurance commissioner. i would be happy to work with you in setting up such meetings if you'd be so interested. have you appealed the decision? >> there was not an opportunity mentioned in that letter for appeal. it was a unilateral decision. there is no notice in there that i had a right to appeal. i must say that i had an amended contract to my united health care participating status and that also said that because i was not in an oxford liberty current network i would not be put onto the affordable care act insurances. .hat was an automatic opt out for those doctors that were in the oxford liberty current land, once they see their fee schedule they could opt out or it >> you could get a navigator to help

helpr a broker that would you with your appeal. i would be delighted to help you with an appeal. >> i think the gentlelady. we now go to the gentleman from oklahoma, mr. lankford. >> thank you all for what you do. you're going through a lot of paperwork and process right now. i can't imagine the incredible frustration with all the new rate legislation while you're trying to take care people and patience. i want you to know from us we appreciate what you are doing and how you're trying to focus on taking care of people. the problems are very real. thenumbers are out for first two months of enrollment and the aca in my state in up to just over 1600 people who have been able to sign up in my entire state here to give you a point of got ance, 1400 companies

letter two months ago that their insurance was canceled because they were in a small business group, just in oklahoma city. so just in one town in my district, 1400 companies received a letter on the same day that they had all been canceled because their association is no longer legal and they are out looking. we have had 1600 people in the entire state able to sign up. one of those was a small car dealership with 14 employees. aey now are having to select different insurance policy a different company. as the owner of the carla told me, we can either select a plan that is much more expensive than what we had last year but keep our doctors or pay the same as what we had last year but we all have to switch doctors. but we can't do both. we can't both keep our plan and our doctors or keep the pricing and our doctors.

we have to choose. it has been a very difficult process for them as a small business as it is for a lot of small businesses. you mentioned even with your own practice that is become a big issue. it is one of the many things out there. by one count, this law creates 159 new board's or agencies. research service to determine how many boards or agencies are created by this. they said it is not knowable at this point exactly how many. thementioned multiple times difficulty of decisions made in washington dc. i have direct family members that have them as worried i'm very familiar with the process and the drugs and what is going on. all these agencies are setting different rules and you get instructions about how to take every patience. what does it does that do for your day-to-day?

>> the me give you an example. for the first time in my career i have had haitians who are had patientshave coming into my office crying. they are afraid and don't know whether the medication will be covered. i have patients who are stable and medications that are no longer on the list. >> we're talking about people that are currently under medication doing better, stabilizing the process and instruction are coming down to say we may have to switch the regimen for treatment to a different drug or different treatment regimen when they're currently stabilized. co>> correct. >> at celtic summit in washington telling you how to take care of a patient and we are going to experiment with a different way to do this, with your patient. no indication of what

medications will be available. in the current system, there is a discouragement to take a more complicated patient. the more complex a case, the more that is discouraged financially and every other way from the federal government and the system, is a correct? >> the current system? testimonyussed him a to many things that will be discouraged. you mentioned before all the issues with medicaid based on the reimbursement rates. haveof the people that signed up for insurance nationwide are not signing up for private insurance, they are in state medicaid programs. issues that they will face in the days ahead? the crowd out issue is

something we can't discount. an architect of romney care and the aca, his own research that he does in the 90s and then repeated in 2007 showed that half the people on the government pogrom lost private care. from one ofstudy the boston-area university said that up to 80% of the people who will lose aess private insurance. we look at smaller networks and lower payment rates that discourage people to accept it or great long waiting list to , again, there will be a few winners but the number of losers will be greater. in arizona we see that access to certain equipment and therapy after an injury in terms of to certainess medications, all of those are severely restricted under medicaid relative to what was existing in the commercial

market. >> there's a tremendous difference between the hope and the reality. i yield back. to the gentleman from pennsylvania, mr. cartwright. thank you mr. chairman and thank you all the witnesses. i believe the aca is a landmark law. it is obviously by no means perfect and needs a lot of work. all of us need to roll up our sleeves and work together to make it better. i had planned to ask all of the witnesses questions about provider networks including dr. .eder unfortunately, the majority did not inform us, they decided to change the panel structure. it didn't inform him either. he was here and ready to testify at 930 and i would say that the fact that she is here and waiting for the second panel

while we are not including her now is disappointing. mclaughlin, i was interested in your testimony and would like to follow-up on some of the things that congresswoman maloney followed up with you. a is my understanding that large part of your testimony has surrounded the fact that you got dropped by empire blue cross and blue shield, right? >> as a participating provider in the new plans that they are developing for small businesses off the aca exchange as well as those serving the aca. >> not to put too fine a point on it, you're still waiting to hear about larger employers whether you will be included in that coverage heard >> no, i am completely in that. look into why these things happened. you got less than a full

explanation from empire blue cross and blue shield, am i correct? is on myd everyone who associated hospital staff had the same letter. letter,not an isolated this is across the board. >> right. if i am not mistaken, you got the empire blue cross blue shield letter on october 29 of this year, am i correct? >> yes. >> i want to talk about what efforts you have made in the couple of months since then to go over what the situation is and see what light you can help us shed on the situation. think you said you saw about 150 names of ophthalmologists who are included in the system, is that correct? >> did you make an effort to facts, different sets of for example compare your own

credentials with those of the other ophthalmologists who made the list? i assume you are board certified. that, we areed on all equal. with the bases is is the original fee schedule of the networks that the doctors are in. if you are a complete solo practitioner not part of a large group who negotiates a fee schedule with the insurance companies, you get what is called the standard rack rate from the insurance companies. those are preferentially doctors on this network. they are the lowest paid. that is clearly with the decision is. the don't mean to belabor point, but are you saying you haven't really engaged in a comparison of your own credentials with those of the other hundred 50? -- of the other 150. >> there's nothing to compare. we are all of equal rankings, do

the same work in the same exams. that is not what this is about. >> is about money and pricing. >> is clearly about money. >> let's take that. have you compare the pricing? have you compared how much it costs people to get treated by you and by the other people who got dropped versus the people who got accepted into the system? >> first of all i would have no way to compare that there are quite a bit of regulations on us as far as fee schedules. we have antitrust regulations and we are not allowed to elect differently negotiate, so in honesty i would have no idea to facts as to what someone is being paid compared to myself. >> obviously somebody engaged in a comparison heard that is why some people made the list and some didn't. >> is maybe for you to find out. -- that is maybe for you to find out.

>> another thing to mention was his idea and i had heard it before that if you want to protect yourself as a physician you want to join groups. the bigger group you're in the more protection you have as we enter the new age. you are a solo practitioner, am i correct? >> that is correct. >> so you have the least protection of anybody entering the new age and i want to ask , thatadn't you heard this you will protect yourself by joining medical groups? share this with you, i have been for eight years a full-time faculty member at a major hospital in new york and enjoyed my time there. i also saw the benefit of being able to be a physician, to make choices for the patient care in a way that i see fit in the

spirit i see fit for the patient that works for me and my patience. i don't want to give up that freedom by joining a larger group that has a nonphysician administrator telling me how fast i have to see patients and what i can and cannot do for them. as a choice today have in this country, thank god, and i want to keep it for my patients's sake. who are now go to someone who knows about patient care. novak, can you discuss for me the confusion your patients are feeling about >> also talk about about urban and rural. there's definitely a day economy going on here heard >> if there's one term that regardless of your political party preference that describes patientsroviders or are administrators or staff, it is confusion. no one really knows. i have 100 patients a week coming through, the bulk of home

will actually ask that question because i know i am involved in policy issues. the answer is we just don't know. they don't know what plans will be available or what services will be available, they don't know what medications will be covered and they don't know which hospital they will be allowed to go to. the issue here is basically abject confusion. onknows what will happen january 1. to say that that was an unforced error because of political islities, the great tragedy really the tens of millions of americans and hard-working american families that have been suffering emotionally because of the uncertainty that the law has created, because of work that was not done, the lack of transparency, the unwillingness to release regulations. i have patients who work for insurance companies and i was hearing from them throughout the portions, theyge

didn't even know the requirements that they would be forced to put into the software that they had to write. we hear that they're being required to be responsible for the data of the service but they are not allowed access to the service to be able to test integrity of the data that they are being held responsible for. at every single level, unfortunately the claims that were made to pass a law are not the reality. the losers, this is not about the three of us appear, it is not about the dentist, it is about the fact that we have -- we do need to do something about pre-existing conditions. that was a small amount of people. it was really intended for the people that have these chronic conditions. because of address that aired instead be a totally uprooted everybody. about the medicare advantage issue, there's nothing tangential to the change in it regardsvantage as

the aca. between, the aca has 130 and $150 billion of medicare advantage this decade. that is why you're seeing the cuts to the networks. >> so when you're talking about pre-existing conditions, let me ask you and dr. english, we just exchanged a prejudice to pre- existing conditions heard we traded one prejudice for another, would you three with that? >> correct. >> you have shifted care. >> on to applaud you. i have family members and your friends who have ms. we're talking about acute-care versus chronic conditions, writes dr. english? >> yes. >> we are handicapped when are talking about chronic care,

correct? >> yes. >> were asking to reduce your opportunity to individualize treatment modalities. i have a question for you. you see any tort reform in this bill? >> no sir. >> did you see any reform in this bill, dr. novak? >> no. >> have you ever heard about solving a problem without running everything on the table? >> excuse me? >> have you ever heard about solving a problem like this? >> no. >> is foreign to me. >> a language of the losses you may not do any demonstration program that includes any limits on noneconomic damages. the constraints were fairly significant. >> dr. mclaughlin, reducing time

for physicians to see their patients. we are reducing reimbursement rates and panels. all of this hurts a patient, would you agree with me? >> yes. >> you want to practice medicine your way and take your time as you see fit. >> yes or. >> how do you feel most patients would like your thoughtfulness? would be appreciated? >> absolutely. i would have patients returning gome out of network as they to some of these larger group practices where physician toenders are employed process patients literally through a quicker assembly line so that the facility can reap more benefits cost wise. they may actually only have two to three minutes of face to face physician time in that. are often told to

bring a companion with them because when you are the one that is seeking care, you're only observing half of the response from the other half, which is why most of us actually face umpteen phone calls after the fact because there is something they forgot to ask or they didn't understand. you can only imagine how that with only magnified two minutes of face-to-face time with the doctor. patients are nervous under those onditions. > >> and you're talking about what was in the act, you are talking about prohibition like they used to have in california in the 70s. overcompensation for actual loss, as is that correct? >> correct. back she says demonstration projects may not include any demonstrations that include limits on noneconomic amages.

this hearing is obamacare's impact on premiums and provider networks, but the majority of the opening testimony has largely focused on inadequate reimbursement from medicare and medicaid rates which private insurance companies use in large part to set their own rates. want the issues related to reimbursement rates under medicare and medicaid issues for the provider community before obamacare and the affordable care act were even law? yes or no? >> there's no question, but a think and i was speaker little bit, if the title is about provider and provider networks, we need to look at -- this is not about us, but this is about how we get the maximum number of people the best personalized health care we possibly can. the practical reality is, our

large group employs nearly 500 people -- >> with all due respect, my question was, are medicare and medicaid reimbursement issues issues at the provider community were dealing with prior to the obamacare affordable care act everett came into law, yes or no? >> yes. >> the rest of the panel? >> yes. >> yes. that, isn't the real issue you all as a provider community want this congress to focus on as many of the doctors in my district in nevada have talked to me about is the need to reform the reimbursement rate under medicare, specifically the sgr, isn't that the focus that would help to address a large part of his problem? >> i was big for myself. i don't think so. is isn't about creating a new

washington system to figuring out how to pay people to provide care. broadlya much more about how to establish policies to allow patients and families to remain in control of the health care decisions. bring up theu reimbursement rates under medicare and medicaid as one of the reasons why there is this lack of adequacy of network providers? reasons. of the >> if the congress could help address the reimbursement rate in the form sgr, with the help or hurt the process? >> i think it depends on how it is done. i would refer you back to the position of the administration that said in a court filing this year that there is no general mandate under medicaid to reimburse providers, including hospitals and that for all other

costs. the position of the --inistration appears to be >> you're giving me a reference is not my question. my question is on the sgr which is largely the basis for how reimbursement rates to doctors are established by the private insurance companies. things agreeat improved if there is not an annual uncertainty every year for us to say that on january 1, 2014 we are getting a 25% cut. we tell our patients under those conditions we cannot continue to see you so we have to decide over going to be willing to see medicare patients until congress refuses to fix a problem every year. >> of congress worked to fix the problem with the lack of reimbursement to cover the cost to the providers providing care under medicare and medicaid, that would help, not hurt,

correct? >> depending on how it was done, it might help, but there's a possibility that new policies could not be helpful. >> today we will be voting on a rulet deal that includes a on the sgr extension for another three months, at reforming it, not increasing the reimbursement rates like doctors in my state want us to do because they are not covering their costs, it is just extending it for another three months. i'd hoped at some point in the government reform part of this committee, we would work to bring forward those bills. i have signed letters with my colleagues on the other side in favor of these reforms. i am prepared to work on legislation to bring these needed reforms forward, but instead we are having these dog and pony show hearings that

don't get at any of the real reforms to make the law worked better or to address other issues that are unrelated to the law. medicare and medicaid reimbursement issues for doctors were problem before obamacare. before the aca was put into place. to somehow suggest that it is because of the obamacare that these issues are happening is to fail to recognize the history of the problems in the health-care care system to begin with. >> religion among yield? >> no. >> the jonas time is expired. recognize them children from tennessee. >> i would be happy to yield a minute to finish a thought. >> i was only going to say that i wasn't here 19 97 when they scored a big savings based on

the theoretical reduction in the cost of doing business. you want here. it is something i agree with the gentleman. we need to realize that simply paying doctors less and then reneging on agreeing to pay them less from the real cost savings to not occur because we never legislated or did anything to help drive down the cost of delivery, is in fact a very good point. i agree with the gentleman that that fundamental change which was scored before your night got here, is not about just paying doctors more, because we did say we're going to find ways to be more efficient in what drives their cost up. i look forward to working with the gentleman on that date it will come to our committee but i would certainly be happy to work with him to drive down the cost of doctors delivering quality health care. i think the german for yielding. justwill also add that we had a doctors caucus meeting this morning. there are markups pending in the

ways and means and energy in congress during with an sgr replacement. we are working with the 15 members of our gop doctors caucus as well as our dentists and nurses. we are going to try to find something that has a sensible approach to reimbursing physicians, unlike the sgr which over the past 15 years has yielded nothing but a 1.9% increase. i think most industries would have a hard time making that work with rising costs in other areas. put up a video if we could? >> we will keep his promise. to the american people. if you like your dr. you will be >> if youep your dr. uncovered from her doctor, a doctor you see in the past and want to, you can look and see if there's a plan in which that dr.

if you want in >> to pay more for an insurance company that covers your dr. you can do that. >> i'm sure this is something everyone in this room has seen or heard and maybe everyone across america. medicineg primary care for 20 years before coming to congress, i know that a lot of my patients who had insurance probably believed the president. he had an insurance plan and dr. you liked and you're given a clear assurance over and over to 2012 before the election, i'm sure a lot of you patients were secure that this law would not impact him. now they're finding out it is not the case. we can put on the line. what a patient's feeling when they realize they have been duped? because, there is fear they had an established relationship and patience will

follow their doctors. what is wrong about the last part of that video is that as i said if you are in a different part of georgia and your exchange does not have me and then you go into that exchange three hours away, not your primary doctors three hours away to. you can't just pay more to see us anymore. you are excluded if we are not on that list. you can still see me but you have to pay more because your dr. is being penalized because he takes care of sick people. are numb.ients that is all i can say. who had ae patients state subsidized plan in new york called healthy new york received letters of that plan would end and they would have to go into the new york marketplace. i approached many of those patients that were in my practice. he never bothered to open the mail. you didn't know that the plan terminated heard i was one that informed them.

these patients are numb, they're upset and as you know as a primary care doctor you don't work alone, you work with specialists. thatrahm emanuel said is you can pay more for a plan that has your dr., it may have your dr. but it may not have the four or five specialists that you see also. there's a discontinuation of care in a matter how you look at this. point bring up a great heard supporters of the health care law claim that 30 million people gain insurance. can you explain the difference between have a health insurance card for a government program and having access to care? i will preface that i came to tennessee in 93, the year before what was instituted came around . he mightn't work ver have to hire extra staff to stay on the line at night after

clinic hours trying to find a referral or someone that can accept it. what are your experiences with that? is it your idea to reform insurance based on the expansion medicaid? >> i don't think it is a good idea. .t's an unfortunate reality that thee seeing is plan that was supposedly whom he to help those wi the most, we're seeing rural areas with fewer doctors available and inner cities having closure of clinics and the moving out of primary care doctors, the near complete absence of specialist. unfortunately the groups said we really want to do things to help , but unfortunately the law, while well intended, is not doing what it said needed to be done. tinkering to make it better.

this needs a complete revamping to address the real problems. >> we now go to the general men from virginia. >> thank you, mr. chairman. thank you try three panelists. , looking be forgiven at this panel, and the theater frankly, if democrats had had the chance put together a panel of three doctors i guess we could ask you to wear your white coat and i guess we could find three doctors, i know we could, would praise the plan. doesn't innd this anyway disparage a value of opinion or your experience, but the idea that your experience is to be generalized as universal as false. and it false premise does a disservice in my opinion to this discussion.

none of you are policy experts and none of you universally speak to your profession. you are asked at one point by one of our colleagues how difficult it is to sign up. if we're going to go through anecdotal experience, i can tell you that i and my entire staff must go on the exchange on obamacare. all of us signed up and met the deadline. that was an accident. >> if you're under a certain age and my staff, the average premium cut ranges from 30 to 70%. there happy as clams. the deductibles are comparable or better, the co-pays are comparable or better. i can tell you in my district of small businesses who are crowing about the fact that when they

went on the exchange they had better choices than they have currently and they're going to who's- i talked to one going to save six to $7,000 a .ear it isn't an honest intellectual pursuit to liberally cherry pick facts and to deliberately put together a panel of critics of a piece of legislation that is admittedly complex. you were asked about tort reform. wasf tort reform dispositive on the cost of health care. it is not. it is a factor, but what the questioner didn't say as a prelude to his question was, on our side of the outcome a we to oppose itrii no matter what was in it. we didn't give it a chance.

and the fact that an entire party decided to take a powder on a major piece of legislation precisely meant tort reform would not be on the table in a meaningful way. of course not. we had a prominent republican senator in the other body you ,aid if we defeat health care this is before we even knew what was going to be in it, it didn't matter, it would be obama's waterloo. that is everything you need to know. it wasn't about health care him it wasn't about the quality of health care or the you are in the plan or being properly reimbursed, it was about a political game to try to make him a one term president. it didn't work. i hope someday we have a substantive hearing where we actually as republicans and democrats try to find out what is working and what isn't and make it better. that is the history of transformative legislation in this field. unfortunately it is not the issue here.

we spent 46 votes in this congress to simply repeal it, defund it or got it. not based on substantive analysis, not based on experience but based on a political predilection to oppose this bill and its president. even though there are elements in the bill that actually came from republican think tanks. the individual mandate being one of them, not aged democratic idea what it republican idea. i'm glad you're here. certainly enjoyed listening to testimony but i have to put it in a different context if you'll forgive me. it is too bad that the panel could not have been more balanced and it is too bad that dr. feder was kept waiting when she was under the impression as were we that she could join this panel to provide a different perspective. i yield back. i now ask consent that the

gentleman from virginia has a website. in 2010 the place in the record in which he says for the past years my constituents have told me we want health insurance reform but always have to meet certain tests. will it bring down premiums for families and small businesses? will it reduce the deficit and will it protect choice of plan and dr.? without objections ordered. >> could i inquire of the german? >> is it going to be the practice of this chairman to start to actually individually put members websites into the record? we would be glad to return the favor. was asked for it because it germane to your anecdotal statement.

said hey, youe used to be for what these people are testifying and we are not getting, that is all. >> i stand by the website. those are the three criteria used. >> we put it in because it was a historic peace. the requested individual from your side of the aisle is on the next panel along with all the other nonmedical doctors. that is the reason it was divided. are giving their anecdotal examples of what they see as practitioners, current practitioners and in the think be next.d will hopefully you will not disparage the think tank crowd for not being doctors heard >> know, there's no discouragement of doctors, just a cry of the heart that some democratic doctors not be on the panel heard >> if he suggested one we would've had one.

>> this is not a campaign. fact property of the house of representatives. am so concerned that we stay focused on this and not be distracted by certain angst. things. >> it was said on the floor of the house, it is on a government site, and it is pursuant to exactly why we chose his question, which is what is the , i know adoctors and couple of weeks ago when we were looking at failures of the website, something we are all working on reforms to fix, we had a discussion about the fundamentals of health care. mr. cummings, i will say something to you today.

you and i do not control, we are not the committee of jurisdiction for the aca. but the problems is doctors are talking about are what we have to take a leadership role in fixing. a lot of it began in the 90s when we thought we could simply a less from the federal docket in medicare and medicaid reimbursement. these are problems that are long-standing. the reason i'm having them here today is i agree with what you said to me in a sidebar, which is -- whenever going to start fixing the individual parts of it. the aca is not going away into a talented, but these doctors, and i take dr. english particularly, are telling us about a chronic problem which is our doctors being incentivize not to take the tough patients. , and mr.ases cartwright alluded to this, in some cases it is our government reimbursement.

in some cases it is how insurance companies are react. treat how the government acts and how insurance companies act the same in trying to get these doctors to be able to practice what they do and we can have a discussion about how much reimbursement comes out of tax dollars, but hopefully today, both in the first and second panel, we're dealing with what is happening currently so that we can fashion some legislation that has to be bipartisan if we're going to fix it. >> i just want to make sure we stand track. we keep going back to what dr. mcloughlin said. it can be fixed. by the way, i appreciate what you said to congressman course because we can help these doctors be efficient in what they do and help american society.

>> i thank you all for being here. my colleague from virginia u.s. obamacare critics. i would not do that. i would characterize you as patient advocates. that leads you to be critical of the obamacare legislation. and out what is working what is not an make it better. i wish that had been the council this congress and applied before the passage of the health care bill because each of you has made testimony about nations that you had, patients are receiving care, patients are getting the individual attention that they need who will no longer because of this new legislation. those folks were having problems, we created this problems. you are all in the caretaking business or than i am, but the stories you tell the touch me the most other tales of the

problems that we create, the uncertainty that you mentioned, dr. novak. there is no way to take those fears away. the spheres are real for the psalmist today. if six months from now those fears china to be and realize we still won't be able to take with thosein of frustrations families feel today. health care costs are rising too fast and many americans did not have reliable access to care. i thought he crafted the wrong solution to do that third think we can work together to solve those problems. we haveern is that created a whole new batch of problems. i want to ask you, dr. english, my good friend tom williamson is a neurologist. he told me the other day that here we are the largest county

in the southeastern united states, one of the fastest- growing, he has been in practice for more than 20 years and has not seen a new neurologist come into his county. the youngest in your practice? have you found some younger olives is coming in? -- have you found some younger neurologists coming in? >> i am not the youngest. another 50 million to obamacare navigators. the list goes on and on. bergen county record in new jersey. may 2 health care limbo as deadline nears. 398 alaskans pick a marketplace plan despite untold millions spent there.

oregon signs up 44 people for obamacare despite spending $300 million. happened if we spent that money on community i believe we can provide sliding scales. marty had such a mechanism in place. my colleague from virginia .alled this a pony show when the question came to you, dr. english, does obamacare ?imit your patients treatments and the answer came back yes. i don't know why that is not the end of the conversation. i do know why there are not 435 members of congress who say what we care about people having access to care only want to improve access to care for folks who don't have it. but you have access to care

today and you're doing things in his body that limit the medical professionals ability to treat her patients, why can't we all decide that is wrong and that we should go back and take another crack at that? the affordable care act is important legislation, i heard from one of my colleagues because it deals with pre- existing conditions and access to care. yount to ask you because characterize them as obamacare critics. is there one of you who does not believe that we should deal with pre-existing conditions and that we should improve access to care ? i was so with you, doctoring was. cracks of course we have to do . -- >> ofthings ver course we have to do all those things.

>> high deductibles that were imposed in these patients is nothing more than them not having insurance. can we understand that? my timehairman, i know is expired, but we have found that collection of ideas on which we can agree. we should begin working towards those goals and we should do that immediately. >> we now go to the german from massachusetts for five minutes. we now go tofor -- the gentleman from massachusetts for five minutes. i wanted to ask you whether thist when you're having discussion to patients who had their policies not reissued by insurance companies whether or not you looked and saw if those old policies had as part of

their coverage the following services and benefits -- ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance abuse, disorder services including behavioral health treatment, prescription drugs, rehabilitative services and devices, laboratory services , preventative and wellness services and chronic disease management, pediatric services including oral and vision care. did your patients have all of those benefits and services? >> sir, i can only speak of my small business plan. >> you give me information about your patients and their situations. i want to ask you before you reach a conclusion if you look at their policies to see whether or not they actually covered all those benefits and services? >> the policies i referred to as healthy new york which is state run and yes they had all those services.

so you're going to tell me that that policy had each and one of the services are cracks absolutely. >> did you look to see whether or not any of your patients had been advised by the insurance company that they could go to the exchange in new york and compare and contrast what they now are offered with whatever else might be on that exchange as an alternative? >> they receive notification, yes. >> to know whether they have gone and checked that out? whatcan't tell you patients do. >> to know whether you patients were eligible for a subsidy? over 400%re earning of poverty? what hen't know patients earnings are, but i can tell you from the careers that i >> did you ask them whether or not any of them qualified for a subsidy and if so how much? some checked.

to know which of them, give each and whether or not a covered all or some of what they thought was an increase in the policy? individualer than gets to the upper limits of what qualifies for that subsidy they were told they would only save about five dollars a month and the premium. the subsidy doesn't cover everything. it depends on how far away from the maximum that is covered. >> is the idea of a sliding scale. patientsalk with your about the medical ratio.