but the president has always been involved in participating in that process. >> higgenbottom brooks also wrote in her letter, how many citizens walk in the door and can't pay? >> we -- first let me say that the district of district of columbia even before the affordable care act had a very high insurance rate among its citizens, i would say as high as 94 to 96%. so let's start with that. so the self-pay population still represents a small percentage of the entire population. the issue is that the rest of that population, we have about 70 to 80% of the patients who come to see us have medicare or medicaid types of insurance instruments. and the reimbursement rates from those are very low. so the difficulty that we have is that we provide a very high level of care that is costly with a very low reimbursement. so making that margin is difficult. the hospital is owned obviously by the university but it is a small hospital and therefore again when you look at things like supply chain, if i order ten hips for hip replacements versus part of a bigger system where i can order 10,000 hips, you ca