in alaska we're at 170% of fpl with our schip program. you've got to draw a line somewhere with the cost and in terms of those who are covered, and i would suggest that 200% of federal poverty level gets us to the point where we are providing a level of screening and health risk appraisal for those who truly would not ever consider going in for one and setting the fpl at a lower level allows us to deal with the cost some what. i throw that out to the members. >> i'd say to my friend from alaska that that's the objective of the right choices program is to prevent, to prevent, disease in the first place. so if you limit it only to those who have a chronic disease, then you're not getting ahead of the game. the concept of the right choices was, okay, you've got people in medicaid and medicare, finance committee will provide certain things with that on co-pays and deductibles. then you have those who are insured. you've got that group this between that in five years or supposed to be on some kind of exchange. this idea is to get to that group

medicare, medicaid, tricare, schip. these are the plans that don't call doctors their cost to see patients. every year, more cost is shifted to those who are trying to buy private health insurance. these are the plans that are trillions of dollars in debt. these are the plans that offer americans no choice. if you're retired, on medicare, you don't have a choice. that's the end game of every government plan. the last thing we need to do now is expand those plans that are in debt, that are not paying doctors enough to see patients, and basically take away all your choice. there's a common sense solution. you look at those americans who are uninsured. and i'm talking about americans. i'm not talking about illegals. i'm not talking about the folks who are sign up for medicaid and sign up for schip. we're talking about 20 million -- maybe between 20 and 25 million americans who need help. we don't need a multitrillion-dollar government takeover to make this happen. what we can do is we can take the tarp money, we can reclai

of health care that is working very well or the government plans and care, medicaid, tricare come schip, these are the plans that don't pay doctors the cost to see patients. so every year or cost is shifted to those who try to buy private health insurance. these are the plans that are trillions of dollars in debt and these are the plans that offer americans no choice. if you're retired on medicare, you don't have a choice. and that's the end game of every government plan. the last thing we need to do now is expand those plants that are in debt not paying doctors enough to see patients and basically take away all of your torso read as a common sense solution you look at those americans who are uninsured and i'm talking about americans, i'm not talking about illegals, i'm not talking about the folks who can sign up for medicaid and don't or sign up for schip, we are talking about 20 million may be between 20 or 25 million americans who need help. we don't need a multi trillion dollar government takeover to make this happen. we could do is we could take t.a.r.p. mauney which is $700 billio

as has already been said, we believe that we need to reform medicaid, we need to reform schip, we believe that we should give people the right, the option, if they want to take the amount that we pay for medicaid and schip and get a private plan we would give them the premium assistance to do that. we believe we need to take appreciate off of medicaid by creating incentives for long-term health care so we have got some proposals that will do that. we believe people that work for small businesses that don't provide health care should be able to form associations and pooling arrangements either within like businesses, like associations, we even believe that states should be able to form regional pools across state lines so that people that work in areas that don't have health care provided for their business can be a part of a pool. we think that the federal government should provide premium assistance for those individuals. we believe in a refundable tax credit that will be under the jurisdiction of mr. camp in the ways and means committee. we believe that individuals can make the informed

we have seen this already in schip. how will we pay for this as a nation? have you accounted for the enrollment beyond just today's uninsured? further, public insurance accounts for about 40% of the health care coverage while private insurance covers about 60% of it. we know that the reimbursement rates are much lower than the actual cost when it comes to the public portion. in kansas the experiencing from 25% to 70% below cost on reimbursement rates and it's not one entity alone. its hospitals, clinics, and physicians. they try to make ends meet by shifting cost from the private insurance payments to cover the shortfalls and the public from the insurance. today in kansas one-third of the physicians will not take new medicare or medicaid patients because of this. if hhs can't find a way to meet senior health care cost, how will they be able to pay for the entire populace under government run health care? the only way this would be feasible is rationed health care system similar to what we find in other countries like canada, united kingdom, norway, any othe

we just modified schip and rejected a senate amendment that would have covered all of those kids and raised taxes at all. yet we've got 16 million kids out there today that are eligible for schip and medicaid and they're not on the roll. why? because we're not listening to the patient. we're not listening to what we're doing wrong and we're getting ready to make the same mistake again. 16 million of them. so why are e.r.s loaded with kids with an ear infection when they're already medicaid-eligible? because we haven't oversighted and neither have the states in terms of enrolling those people to where they have a primary care. and we have a medicare payment system that says, if you're a medical student you graduating in this country, you don't want to go into primary care because there's a 300% payment differential versus you spending another year or two in training, you'll make 300% more. so only the most altruistic of our physicians go into primary care. it's obviously not about money because they could be an engineer and make twice as much with less time and a lot less school debt.

we still have 100,000 children who are eligible for schip that are not signed up, so how do we encourage, how do we engage people to care and go sign up? and what happens -- to return them away at hospital emergency rooms because they do not have insurance of their own? what happens? how does it work? >> well, congressman, that is a great question. i think that one of my interests in the chip program is certainly taking some of the best practices of and roman -- of the enrollment and spreading those throughout the country, because there are some states that have done pretty creative work and have had great success in enrollment, and there are others that have not, and i think that that is one of the ways that our department, and that is a key building block for health reform, is actually getting folks to enroll and engage in programs that are currently eligible for and provide that coverage that congress and the administration has seen as a high priority, so outreach strategies, assisting with everything from presumptive and ii simplifying enrollment forms, not having the situation -- pr

for health care fraud established under this bill will focus also on fraud in medicare, medicaid and schip. my second amendment requires the senior adviser for health care fraud created under title five of this bill to report to congress on federal efforts regarding the detection and prevention of health care waste, fraud, and abuse. my third amendment requires school based health centers and those employed under or under contract to follow state law requiring the reporting of child abuse, child molestation, sexual abuse, rape and incest. funding authorized in title iii is discontinued and the provider of services fails to report this information in accordance with state law. n deferment program, also known as the 220 rule. this rule was eliminated in the college cost reduction and access act and has had a negative effect on the ability of medical residents to repay their student loans. we're going to increase the pot, we better increase the providers. my fifth amendment requires school based health center program to provide age appropriate care to children. my sixth amendment requires the

same thing with schip. a lot of small children that require that need to medical services. i want to ensure we cover them and we have the same aspirations as any other but we don't have the tools to do it. >> host: to that end to use part public option? >> guest: not necessarily. we believe as a government to take care of everybody. but if there is a private option that is working i shouldn't undo that private option. i believe that we should go out into the marketplace and provide in the case of border region between eight and 10% of my constituents are not covered by any insurance. we should provide for some sort of insurance for them. perhaps the state will have to pay part of the cover. perhaps they can put up some of the money depended on their income. the federal government could help in that process. but i believe we should do it by going to the marketplace. >> host: we are talking with governor luis fortuno border wikipedia if you want to call the republican line, it's 202-737-0001. on the democratic line its 202-737-0002. and of the independent mine, 202-628-0205.

and in fact, for schip program, a third of the uninsured charne that are currently eligible for schip, had been enrolled in a program within the past 12 months. they know how to get enrolled, and they found it of so little value that they didn't bother reenrolling, their parents didn't. if we don't listen to folks, and what they're telling us is that the cog that is out there is simply not attractive. they don't find value in it even when it's free. we should be listening to them and revising our insurance programs to suit that market instead of dictating to them. if we insist on dictating to them that they buy coverage that they don't value, we're basically telling working people, basically telling joe the plumber, that before he feeds his children, before he puts his gas this his car to get to work, he's got to pay for health insurance premiums, that that is the most important thing on earth, paying for your health insurance premiums. now, joe the plumber is not going to like that any more than the old folks that chased him down the streets of chicago. only joe the plumber carries a

how about schip? that's the bill the public plan that allows our children to be covered, our poor kids. why don't they come here and say, our children shouldn't be covered. let's repeal it? how about our military? they get free health care through the public domain. should we now cancel that? and contract out? look, i'm for a robust debate. i'm for a bipartisan bill. i want to work toward that, madam president, but let me tell you this: if we don't get 60 votes for something, we can't quit around here. we cannot allow a terrible crisis toward the end of life to bankrupt our families, and more than half of our families who file bankruptcy, file bankruptcy because of a crisis in their health. we can't afford it. and the fact is, we are on the verge of being able to do something, but not if the party of "no" comes here every day and bashes every idea. and starts frightening the american people. so they'll have their chance. but i hope we won't stop. we'll have to figure out a way to do it with a majority

from the signing of the lily ledbetter act or schip to tobacco regulation, this is what it means. standing there with the president when he assigning these, yesterday with him signing the memorandum on extending benefits in same-sex couples. people are in tears. people are impacted by this. this change is not abstract, it is real. the problems in national security are very difficult and people are working on them. some of this -- helpless and give us your ideas and stay with us as we work through them. >> i appreciate noel's candor although i am not so sure about the elected thing eight years ago. [applause] [laughter] >> i was trying not to use that word knowing the crowd i was in. >> not over it yet. look, i do think that it is hard to add to what was said about what president obama's presidency means. i will say that to see -- what this presidency means is change but change at a time when the nation so desperately needs to change. it is the combination of the man, the agenda, and the moment that are so powerful for me and so moving for me. why i am willing to get up early in th

the kind of things california would have to impose specifically on its participation of medicaid and schip which the president has identified as specific priorities of his administration, and the achievement of his administration? >> i don't know to what degree we have analyzed california's individualize cuts. obviously, we have had to make an states that had to make very difficult decisions. as it relates to our budget. and these aren't easy times for state. >> i want to follow up on john's question just to have it on the record. the president is still willing to talk to ahmadinejad about u.s. iranian issues even currently, is that correct? >> i'm sorry? >> the present is still willing to talk to ahmadinejad about the various u.s. issues and that has not been changed at all? >> the president is committed to direct engagement with the iranian government on issues of our national interests, including their pursuit of nuclear weapons and/or sponsorship or tear. >> this disputed election does not in any way change that. >> the disputed election is something for iranians. [inaudible] >> obviou

is -- and all of the evidence makes this clear -- that public programs like medicare, medicaid, the schip program, and veterans administration are administered for far less money than our private health insurance -- than are private health insurance companies. mr. president, in recent years, while we have experienced an acute shortage of primary health care doctors, nurses, and dentists, we are paying -- we are paying for a huge increase in health care bureaucrats and bill collectors. here's the insanity, the dysfunctionality of the current system. we don't have enough primary care dock turk we don't have enough dentists, we don't have enough nurses, we don't have enough medical personnel, don't have enough of those people. but over the last three decades, we have seen an explosion in the number of health care bureaucrats and people who are bill collectors. now, to my mind, i'd rather see somebody hired who can help somebody get well or prevent disease, not somebody on a telephone billing us or arguing about what we owe or don't owe. the fact of the matter is, though, over the last three

re from health reform than our children pete children ensured by medicaid and schip are covered under 50 different state programs and the d.c.'s coverage. 51 different programs. a child's access to health care coverage and health care should not vary by location in this country. so, the question is how does the federal government ensure that its most important investment, the investment in the health of its children, standardized in terms of uniform eligibility, national pediatric benefits and access to pediatrics specialists for medical necessary care. how can i work with you to make this a reality madame secretary? >> congressman, i would love to have a chance to work with you on that critical. as you know, there are some mandated benefits for young children in the medicare packages which all states must follow, but beyond that you correctly identified that eligibility rates vary from state to state for particularly the chip program and very -- in terms of the very earliest prenatal care. so the likelihood of having reducing low birthweight babies and bringing people into the system

there's a continuing supply of smokers to keep the revenue flowing, and the irony is compounded with schip, the state children's health insurance program being funded by smoking which is to say in order to fund this suppose it health care improvement we need to have a continually health damaging habit of smoking flourishing in the country. >> mr. will as much on his mind and we have opportunities to see and hear from him so we would like to open the phone lines for your calls, comments and questions 202-737-0001 for republicans, 202-737-0002 for democrats, and the line for independent, 202-628-0205. i am sure you have seen yesterday afternoon and in this morning's papers two new polls on the president's performance and popularity the cbs and also will street journal poll in a not shell both of them have similar results popular president and strong marks for his leadership and communication style rising concerns about the programmatic approaches to the financial crisis. you can either comment on the polls or tell people you think of his performance. >> first the retial once again the americ

we need to reform schip. we believe we should give people the right, the option, if they take the amount -- we would give them the premium assistance to do that. we believe we need to take pressure off of medicaid by creating incentives for long- term health care so we have got some proposals that will do that. . people should be able to put it -- a former -- form associations. we even believe that states should be able to form regional pools across state lines so that people who work in areas that do not have health care for their business can be part of a pool. we think the federal government should provide premium assistance for those individuals. we believe in a refundable tax credit. we believe that individuals can make informed choices if we have health care transparency. we will have proposals that will provide more transparency in the marketplace. we believe that doctors should be reimbursed adequately for their services. we will have a proposal that fixes the physician reimbursement problem. we're no

it appeared in the house schip bill. i guess it was a year or two ago. it's probably due today. and basically would involve a better process for updating physician work values because that process which is done by cms with advice with their relative value update kennedy called rvuc which because of productivity gains over time have become relatively overvalued or overvalued compared to the other services. there's also the need for much more accurate estimates of facilities costs. and their needs to be frequent updating some reflect declining costs associated with technology probably even considering projections of unit cost. but if you an example with problems of lack of data. for those that have followed this, cns assumes a piece of equipment and maybe this is specific to imaging is run 25 hours a week. when i asked what's the basis of that assumption well, we didn't have any data so we just chose that number presumably not to offend too many people. they've recently urged that number based on some data that they have reviewed the increase to 45 hours per week. just based on th

this is easy, it appeared in a -- in the house schip bill, i guess it was a year or two ago. it's probably doable today. and basically involves a better process for updating physician work values, because that process, which is done by cms, with advice from the relative value update committee, called the ruck, has not succeeded in identifying those services, which because of productivity gains over time have become relatively overvalued or overvalued compared to the other services. there's also a need for much more accurate estimates of facility. -- facility costs. and there needs to be frequent updating to reflect declining costs associated with technology, probably even considering projections of unit costs. let me give you an example of the problems with the lack of data. for those that have followed this, cms assumes that a piece of equipment, and maybe it's specific to imaging, is run 25 hours a week. when i asked, what's the basis of that assumption? well, we didn't have any data, so we just chose that number, presumably not to offend too many people. net pack has recen

and, of course, of the schip program so we have lost apprenticeship to attain a the same and between private insurers to get people covered so there is an example of how you get access and how you get people covered. we're working that already and we feel like we have got very good partnership with government to make that happen. the blue cross plan it that i belong to has just also launched a series of what we call instant care product in -- products so people injured for a brief time we have now wash products that are 30 days, 60 days and 90 day duration for somebody who knows the have a specified time of gap. we have made that available and is creating a lot of interest in the marketplace. i have touched a bit already on public-private partnerships and obviously we have those in medicaid and medicare within our state or working probably with government. probably no secret that i see this cooperative arrangement and this partnership as a way to go as opposed to having government as a competitor to u.s.. i think we have demonstrated we can have access and deliver quality and can add

we have another 4.3 million who are eligible for medicaid or schip or another government program, but they haven't signed up for it. we need to make more of an effort to get people to sign up for the programs they're eligible for. you've got about 9.3 who are noncitizens. many of those are illegal in the country and the taxpayer should not be paying for their health care. we've got about 10% who have incomes of 300% or more over poverty and they're just not buying health care. an i've had some of those work for me when i was in business. i would offer to pay -- most of oir insurance. i'd pay $500 a month and they would pay $50 and some people turn it down because they don't want to pay $50. some people don't want to buy insurance. we have some people between 18 and 34 years old who don't have insurance and 10.6 million who are uninsured. and if we look at this, at least half of these should not be subsidized by any type of government plan that are not already eligible for a plan or not citizens of our country. we could look at 20 million to 25 million. now, i want to make clear if the

i was really proud during my first few weeks here in washington in this chamber to vote for schip. this legislation provided critical health services for our nation's babies and just as importantly it provided crucial assistance for pregnant moms as well, the first time we have done that in this country. what a blessing it is we are finally taking care of the brand new precious babies and providing support for moms too. i strongly support this bill because of another personal story i have. when my second child was being born, when i was pregnant with number two gretchen we changed jobs in the middle of the pregnancy. my husband was carrying the insurance on his jobs and all of a sudden i had a preexisting condition. that preexisting condition was my pregnancy. and that child was born without myself having any health care coverage and luckily i had a very noneventful, natural birth, but you still have to go and have a doctor and make sure that your child's needs and your needs are taken care of. i would just like to say a child is not a preexisting condition. a child is precious and

medicaid, medicare, cobra and schip -- even though we pay taxes, we did not produce a big fully. when you come from a territory, things are different. we are willing to carry our burden fully, as any other state, but certainly want to partake in the process as well. host: in terms of health care, whether you advocating for? what does puerto rico need? guest: us governors one flexibility, but in terms of puerto rico specifically, i want to assure in terms of managing we participate fully. right now we are capped, recently 17% of the federal contribution where as the minimal states are 50% and four states with our demographics, it is 83%. so we are putting up for the rest at the state level. that affects the health care of my constituents. separately, on medicare, medical providers, both physicians, hospitals, and so on, are not treated equally in many ways. and i want to make sure that even though we are paying for medicare taxes, payroll taxes, that we get the same treatment. the same thing with s-chip -- small children that need medical services, and want to make sure that we co

one-third of all rural children in the country are covered by schip for medicated soap and we talk about cutting and talk about government programs i think we should remember a lot of real concern in that program. let me conclude with this story our constituency i should say. denise lewis. denise lives in pennsylvania, the middle of our said, i met her years ago when she wrote to our office recently but i did know her story before this. i met her in passing. denise and her husband, for children, most of whom are grown and the and this is 19. all during their children's growing up years to the center has been a struggle to be able to afford health care and made a little too much to qualify for public assistance but not enough to afford the kind of coverage they needed. we know this is all too common today. this is what she said -- there are many times that the medical care her children needed determined to the food, but the family with eight. one of the most poignant things he said was this and i quote. wondering whether you should go to the doctor earning a parent is completely different

now, i mean, on the signing of the lilly ledbetter pay act to banning torture designing stem cells, schip kenaf tobacco regulation. this is what it means. it needs standing there with the president when he is signing these, looking at them yesterday signed a memorandum on extending same-sex benefits and same-sex couples. people are in tears. these are real people, all of us are really impacted by this. and that's what it means. this change is not abstract. it is a very, very old and there will be a lot more of it. it's hard. especially in the arena, some are very, very difficult and people of real good faith are trying with a real belief in this comp petitions are working on them and some of this is, you know how but. give us your ideas and stay with us as we work through them. >> well, as i appreciate noel scanner but i'm not sure what the whole elected thing eight years ago. [applause] >> in my head i was trying not to use that had crowd i was with. >> not over it yet. [inaudible] >> i do think that, it's hard to add to the things spencer said about president obama's presidency means. b

butterfield: from the creation of medicare and medicaid in 1965 to the re-authorization of schip earlier this year, we have come a long way toward ensuring that every american has access to affordable quality health care. these programs, mr. speaker, ensure that our children and the disabled and elderly have access to health care. now it is time to get serious and to help those people in the middle who have been left out. family health care costs are increasing. families cannot afford the rising cost of health premiums and many employer-sponsored plans are providing less coverage and higher deductibles. and there are 45 million americans with no insurance. we must seize this opportunity to enact reforms that reduce cost, protect existing plans, preserve our choices and doctors, hospitals, and care and ensure affordable quality health care for all. i support president obama and the democratic leadership. we must act now. i yield back. the speaker pro tempore: for what purpose does the gentleman from texas rise? >> to address the house for one minute. the speaker pro tempore: the gentleman

dent: that's medicaid and schip. mr. kirk: that's right. as we found in the state of massachusetts, when a mandate that everyone has to buy health insurance is put forward, what they have generally found is that a technical and legal solution is not adequate. they thought by putting a health insurance signup machine at the entrance of every emergency room at the state would register and collect the required number of people who hadn't yet signed up for public assistance that they were eligible for. what they found is, for a small percentage of the most difficult parktes, either because of alcohol, drug abuse, or law enforcement problems, these patients were not registering under similar names, not registering under similar addresses and were failing to report for appointments and other preventive care. meaning for that small percentage of american we need to provide an open public clinic. it's the most more -- it's the much more appropriate health delivery system. for this small percentage of americans, we have different names, different ad

schip was mentioning, he was on a plane yesterday of the time of filing reports zero even though you follow the presidency he could and found his report but the present has been getting around both within the country and around the world. as far as i can determine if there was an attempt in the study and mention to ask whether coming hours coverage given to congress let alone how much was positive and i suspect on the latter question the experts was a statistically insignificant. so in the answer to the question is there in a balance of powers my response is an emphatic yes. it is so lopsided that i think the president is off the charts, every president has been even though sometimes presidents have been weaker and on popular but over all the presidency has been pretty powerful notwithstanding mr. cheney's assessment that somehow it was crippled after the nixon and ford administrations. the question should be well congress and the people demand restoration of balance of power between the branches as the founders intended? i think the answer to that will have to await another symposiu