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tv   Medicare for All House Hearing  CSPAN  April 30, 2019 11:41am-4:05pm EDT

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finishing up our coverage for this budget hearing for the department of homeland security. if you missed any of our live presentation the hearing will be available shortly to view on-line at c-span.org. type mcaleenan in the search box. we'll continue with live coverage now, we'll go to the house rules committee. members are looking at a medicare for all bill. this got under way this morning at 10:00 eastern. live coverage here on c-span 3. >> we don't expect employers to provide their workers with education for their children or with fire insurance. there is no reason to tie health care to employment. it just exacerbates the negative impact of job loss and, frankly, it's a huge burden on employers. >> thank you. dr. brown?
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>> yes. i just am wanting to add in terms of people of color, the medicare and medicaid reimbursement cost is not the same across the board. our providers are already getting a lower rate. it's not likely that they're going to go out of business. and in terms of employers and the amount that's being paid, many of the smaller businesses go to part-time individuals so that they do not have to carry that cost. again, i think that for providers that we are concerned about, they're not going to walk out on taking care of their patients even though they're getting a lower rate. >> dr. knab. >> i assume you're asking the question from an implementation perspectivetive but as a physician we were ready for this not two years ago. i'm ready to stop seeing my patients not get good care because they can't afford things. >> and i'll answer the question
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as i'm answering every question from the federal cost perspective, when i did my study i was dealing with a bill that had a four-year transition and was not able, did not feel myself able to score the effects during that four-year transition period because very unpredictable factors like transition costs, voluntary buy-in rates, things like that. and so for simplicity sake, i assume that in that fourth year, everything just instantly sprang forth fully formed, instantly had administrative cost savings, instantly had a level shift downward in prescription drug costs and we instantly had the full implementation of these provider cuts. you could look at that and say those might be reasons why the lower bound estimate even assuming a four-year transition would be an understatement. if you had a two-year transition, obviously that increases the likelihood that lower bound estimate is a gross
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understatement because there's probably very, very little chance that we would be able to attain those instant admin traytive cost savings, those instant drug cost savings i'm assuming in the lower bound estimate. >> weighing in on the transition issue? >> let me let miss turner -- i have limited time left and then i will come back to you if i may. >> there's a really good piece in today's "washington post" about vermont's experience that i think is really instructive. amy goldstein took an in-depth look at the experience in trying to i a cleave a single payer health care system. green mountain care. they worked for four years and were unable to figure out how to structure it for the small state of vermont, to figure out how providers would be paid and the taxes would be collected, and the -- what they found was that
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the initial projections took what she calls a 36,000 foot view of what the korpcosts were going to be. when they got down to the hard wiring of implementation they found it was going to be so disruptive to the state's economy and the structure of health care system that they had to pull the plug on it. she said it was very difficult to disthe man al one health care system and replace it with another. >> may i? >> okay. >> please. >> here's what i know for sure. i needed medicare for all to be in effect yesterday. if the richest nation in the history of the world really decided to, we could guarantee health care as a right and we could probably do it more quickly than people think. but the problem is that right now, we're not even trying. too many people in the halls of this building are fine to accept the status quo that leaves people like me behind. >> thank you very much. thank you, mr. chairman.
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>> thank you very much. i just want to yield myself a minute here just to make a couple points to amplify the point, employer sponsored health care means the effects of job loss are amplified. it also puts a huge burden on employers. imagine if we expected employers to provide for fire insurance, police insurance, school funding for k through 12 and the paperwork that's all part of that. it's insane. just one other point here, i mean because i think what some of us are looking at this initiative from a different perspective. people aren't going to lose their health care with medicare for all. you would actually get to keep your doctors and go to your hospitals that you currently have. the only difference is you wouldn't have to deal with insurance companies. i don't know about you, but that's not my favorite thing to do when i get sick. i now yield to the -- my good friend. >> i just want to thank this
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pam, everybody. the professionalism in your testimony is very much appreciated by this congressman and i know the rules committee. mr. barkin, a couple questions for you. you know, you talked a lot about time. another guy in a chair like you, stephen hawkins wrote a number of essays on time. time is really a key piece to all of this and you talked about a number of things. you know, the effect of taking time and the waste of time on you personally. so i would like you to maybe expand on that a little bit and then you also said we could save enormous sums of money, i would like you to expand on that, and then you said, we could avoid immoral price gouging. i think those were your words. so i'm just putting those three things that you talked about, i
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would ask you to expand. now, to the economists i would like to just talk a little bit more about the money that's in the system in the health care system, is about -- is the biggest part of our economy in its own right. health care system, 19, 20, 21%, 18%, whatever it is, it's far bigger than anything else. so my first question, i guess, to you, dr. baker and dr. collins, is how does that percentage of our overall economy compared to the rest of the world, other countries, industrialized countries, and i guess to all of you, and you as well, the overall savings that we might expect from something like this. you know, there was an
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economist, bob poland, and sort of his approach to these things. because it is a massive change and why do we want to undergo a massive change if we're not going to save some money and have better outcomes. i'll get to you, doctors, you medical doctors, in a second, to talk about the outcomes and then miss turner, just so you know, i'm going to talk about colorado. i'll tee that up for you. >> okay. we spend about 18% of our gdp on health care and that's roughly twice the average from the oecd. you have a range. if you take a lower cost system like the uk we could finance that whole system from what we spend now on the public sector. that's how much we are out of line with everyone else. the point that i think is striking on the one hand we have huge admin traytive costs but the other point i was trying to emphasize in my comments and written testimony we pay twice as much for all the inputs. twice as much for the drugs, the medical equipment, for our doctors, on down the list.
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and again, that's not true of our cars. that's not true of our auto workers. you're sort of hard pressed to say why do we have to pay twice as much for drugs as everyone else, we don't pay twice as much for our cups much for our cups and cars. but we do. i think that speaks to the enormous potential savings. i understand, none of that is easy. you're the ones that have to fight with these people because that's income for people. if we just make the comparison, what does it look like u.s. compared to everyone else, we're paying twice as much on average. >> dr. collins? >> i would echo dr. baker's comments. there's a chart in my testimony that shows all the detail on the countries that pay so much less than we do. but i would also make the point that we also don't get commensurate outcomes for the spending that we're making. so we actually have worse outcomes in a number of areas than other countries that are spending far less. so the quality issue is a huge issue internationally as well. >> and i appreciated your
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testimony when mr. mcgovern was asking you some questions about, you know, ultimately it's kind of a push. maybe it's a little bit of a loss. maybe a little bit of a gain. this economist from university of massachusetts thinks that there's some big savings. do you have any comments on that? >> sure, if i could try to unpack it a little bit. >> sure. >> i want to build off some of the things dr. baker and dr. collins have said. it was well stated by dr. baker that most of the costs from the federal perspective are a shift. they're a shift from costs now being born by the private sector to the federal government. i would add to that, the government would also be assuming costs currently born by state and local governments. it's not just private. it's primarily a shift. that's the biggest piece of the federal cost. now there are other things that
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would increase the cost beyond that. i thought dr. collins said something earlier that was very useful where she said basically the total national cost increase would be less than the y utilization increase. in other words, the biggest part of this cost increase is an increase in service demand and utilization. now, maybe we can cut into some of that increase by savings on administrative costs, savings on drug prices, things like that. now, we wouldn't be able to offset that cost completely with those measures, and that's where the cuts to provider payments come in. the question is would we be able to cut provider payments enough to offset that additional cost. >> i think this was mentioned and it's in somebody else's papers, you know, that two out of five people don't take advantage of health care, their need for health care because of fear of expense. they walk back out. he gave some dramatic examples. so in effect, you know, there is a lot of demand that's not being
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met because people are afraid of the cost. so i was a bankruptcy lawyer before i was elected to congress. obviously one of the biggest areas of bankruptcy is because of health care costs. so i appreciate your comments when you said, yeah, i may convince somebody to stay there, but now have i saddled them with some debt that could cause a bankruptcy or something else. so there are all sorts of issues here. to dr. brown, if we were to go to this medicare for all or universal health care system, do you agree there would be more demand on the system? and can we -- could we, from a
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provider standpoint, manage that? >> thank you. yes, i think there would not necessarily be a demand on the system. i think you would practice medicine in a more appropriate, better way. the idea is that you're going to increase your educational components for your patients and practice prevention. if you put prevention into practice, you're not going to have many of those hospitalization visits that will end up in the intensive care units. so there's cost savings there. we have not practiced prevention, and we've been talking about it for years and years, and it's just going to the wayside. if we get people to come in and to do their immunizations and get those standard tests of screening -- so screening and early detection finds the diseases at an earlier stage. and again, you can then provide
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that care at a more cost effective, so the demand is not going to increase. we're practicing care in a more efficient, effective way. >> doctor? >> yeah, i'd like to echo that. i gave you a couple examples of people that came in, didn't get the care they needed, and ended up having more expensive care. there will be some people using more care, but we're going to be more efficient as well with primary care and other ways to utilize our health care system. as an er doctor, i see a lot of people come in with late-stage disease because they didn't get to go to their primary care doctor when they needed to, and we end up paying more for that. the reason is we have reagan era laws, the emergency medicine treatment labor act. it makes it such that anyone insured, uninsured, documented, undocumented, whoever they are, they can come to the er when they need to come to the er. we treat them, and if they can't foot the bill, the taxpayers foot the bill or the hospital does. i think if we expand coverage, we get these people utilizing care at the right places. they end up going to their
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primary car doctors, get their diabetes, high blood pressure, high cholesterol controlled so they don't have heart attacks and strokes. >> do you think a system like this would help you avoid some paperwork? >> most certainly. yes. >> ms. turner, i appreciated your testimony because you really kind of laid it out as to, you know, 70 years ago it was you paid out of your pocket or you got charity care. a lot of that charity care was underwritten by the churches, by charitable organizations. then kizer came along and said people are getting hurt, we have to do a war effort. so kizer steel and aluminum and all those guys, they started the employer system. so we are in this massive system. to change it is obviously a big
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undertaking. i agree with all of that. with respect to colorado -- so i'm from colorado. i support the legislation, and i support beefing up the affordable care act. i support -- there's an effort out there that says for anybody 50 and older, you can buy into the medicare system. so i think all are improvements over where we are today. but my question to you on vermont and on colorado, just as a voter on that thing, i voted against the legislation. because i didn't think colorado on its own could undertake a medicare for all system. that it was national in scope. that's why i went this way. but i'm happy to have you comment on it a little bit more. >> just briefly, you know much more about the debate in colorado than i do.
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in vermont, they were assuming much of the money that's currently flowing to the state through health care, whether it was employer contributions, whether it was aca funds, existing taxes, et cetera, all would be part of that. so they were assuming a much larger pot of money because there would additionally be federal funds coming in. they still couldn't make it work. i know in colorado that there were -- from my reading of it, and i did a couple debates in the state about the ballot initiative, the feedback that we continually got was people so nervous about the taxes that would be required to support it, and yes, there were arguments that the current money going to employer-based health insurance would go to the kitty, but that just wasn't enough. it would disrupt the economy. >> and i think you're right from a policy and a kind of political standpoint. it wasn't enough to overcome a number of the concerns and
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fears, but i think, you know, listening to the testimony of the economists and the doctors and just our own experience. my wife had a difficult surgery. initially denied. i can't tell you the panic that hits a family when something like that happens. you know, so there are all sorts of issues. i'm just pleased that mr. cole and mr. mcgovern were able to work out the details so we could actually have this hearing and get this ball rolling. i think it is a very important conversation for this nation to have. can you answer my questions, or are you ready for that? >> thanks very much for your questions. this health care system only works if you're a pharmaceutical or insurance industry executive who wants to maximize their own profit at the expense of people like me. it is simply unconscionable that i should have to pay $9,000 per month for life-saving medical
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care at a time when the insurance industry is raking in record profit. that's wrong, and it needs to stop. here's the thing. it's a huge stress to have to fight with insurance companies over what they'll cover. it's a huge financial strain. but most of all, i've come to realize that our time on earth is the most precious resource any of us have. i wish i didn't have to be here today. i think you are wonderful, congressman, but frankly, i'd rather be back at home, being with my wife and playing with my son instead of trying to wake the conscience of this nation's lawmakers. every day is precious for me. i don't have time on my side. americans who are dealing with the every day realities of their health care don't have time on their side. no one should have to fight to be treated with dignity again, and that's why i'm here today. >> thank you. i yield back. >> thank you very much. mr. woodall?
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>> thank you, mr. chairman. thank you for the holding of the hearing and the way you've conducted it so far. we have a tough time. it may not be obvious to you, with your reference to awakening the conscience of congress. it may be obvious to you that we don't always get a good healthy conversation on issues of this. i credit the young woman to your right there. i cannot support her legislation, but i absolutely support her. there's a way to have a conversation. there's a way to have that hearing. in fact, "the washington post," i don't know if you all saw the article on you all. "the washington post" did an article on this hearing. they said we're not going to make ourselves look crazy this morning, that was the quote they grabbed. "the washington post" observed there are lots of ways to start
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this conversation and that the chairman and the leadership of the house went out of their way to pick a group of folks who were going to start it on a healthy, productive measure. i hope you take your role in that with a great deal of pride as i take the chairman's role in that with a great deal of pride. i want to start with the numbers. i appreciate what you do, what you did as a trustee. i used to read your work regularly. i read it less now that you're in the think tank world. i read it more when you were in the government world. my understanding is that our payroll taxes, medicare and social security taxes, are largest tax that about 85% of american families pay. yet every time i read those reports from you, and they hbt got any better, is there's not enough money coming in to do the things we've promised to do. i can't believe that i read your testimony correctly, but i want to check it out with you.
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$32 trillion over ten years as the best-case scenario, not for the total cost of medicare for all, but just the add on to the current medicare program that is already there. am i reading that correctly? >> yes, that's a lower bound estimate of the additional federal obligations, above and beyond current federal health obligations. >> i sit on the budget committee, and we're not able to pass a budget out of the budget committee because we couldn't even agree as a committee on how to sort out our current challenges, much less future challenges. it was going to be about a $4.5 trillion budget, a little under that. best-case scenario, $ . -- $3.2 trillion annualized. but more appropriate is your nearly $40 trillion number, the worst-case scenario? >> i wouldn't say it's a worst-case scenario.
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basically, the cost estimate over ten years would be in the region of $40 trillion if you didn't assume any particular target of savings from medicare for all. of the different categories of potential savings from medicare for all, the relatively most likely is probably administrative cost savings, which would bring the total to about $38.8 trillion over ten years. depending on your assumptions for provider payment rates, drug costs, things like that, the additional cost would be somewhere between $36 trillion and $38 trillion. >> help me with that math. looking at your best-case scenario, everything goes right. what are we talking about in a per american cost? per person cost. >> well, this is very crude, but it's about $10,000 per capita, per person. 350 million americans, it's about 10,000 per person.
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>> that's real money. i was listening to your testimony, dr. collins. as you were going through some of those numbers and talking about after the affordable care act things that had gotten better. i want to stipulate i agree with everything you said about increased outcomes. what wasn't reflected there, though, is whether we got the best bang for our dollar. of course, if i spend a trillion new dollars on health care, subsidizing american families with their health care costs, when i run a poll that says are your health care costs easier to manage today than they were yesterday, folks are going to say yes. i don't think that's the right question, though. i think the question is we agreed to spend a trillion dollars. are we spending that trillion dollars in the way that helps the most families do the most for themselves, reduce those stresses that we've talked about. have you seen any data along those lines? not did we do better, but did we do the best we could do given
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the enormous resources we invested. >> we can actually do better. 17 states haven't expanded medicaid. that's one area we haven't fully implemented the law. there have been some changes to the cost-sharing reduction subsidies in the marketplaces that have bumped up premiums on silver plans, which has hurt some people but people's tax credits adjust. so actually, the federal government is paying a lot more because we're not paying these cost-sharing reduction subsidies. in term of implementation, there are areas we could do better. we could extend the subsidies to people just over that threshold for marketplace tax credits could afford their plans. i also want to say, i -- >> let me reclaim my time just for a second. i understand that if we wanted to improve the affordable care act in its current structure, there are lots of things folks would do. i suspect there are men and women around that table who would rather do that than the medicare for all plan. that wasn't the question i was
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asking. 41% of folks reported they didn't go to the er even though they thought they needed to. every er physician i talk to says, rob, we're in a conscious effort to keep people out of the er. people keep wanting to come to the er. we don't want them to come to the er. we want them to go to our urgent care center next door because when they come to see us if they don't really need to see us, we're wasting valuable resources on them in our environment because it's hyperexpensive. we could have served more people in more ways if we could have redirected them. that's what i'm thinking about. maximizing the dollar that we're spending. let's agree we're going to spend more money, but let's demand the very best of that money. i think about that in your case. how does the medicare for all plan, what incentive is there to do what all er physicians are telling me needs to be done? we got to keep folks out of the er, get them into urgent care instead. what's the skin in the game that keeps me out of your office?
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>> it doesn't need to be skin in the game. people want to go to their primary care doctor. they don't want to see me, and frankly, i don't want to see them. when a washpatient comes to me wants me to adjust their diabetes medication because i'm the only doctor they could access because i'm in the er. i feel totally comfortable indue baiting someone, doing chest compressions, cheating a stabbing or a gunshot. i don't feel comfortable treating someone's blood pressure medication or diabetes. >> your experience is overutilization in the er doesn't come from my misunderstanding as a consumer of what my needs are. it's that you're required to see me. >> patients often come to the er saying i took my blood pressure at a pharmacy. they had the machine there for free. it was through the roof, so i didn't know what to do, so i come to the er. i don't want them there. i want them to go to their primary care doctor. it'll be cheaper for them, better for them, cheaper for all of us, better for me. that's a win/win. i don't need to incentivize
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them. they already want to go there. they just can't get in. >> that is a win/win. i think about that, miss turner, and some of your testimony about your desire to do better. you've invested a lifetime in trying to move us in a better policy direction. i was visiting with a small town doc in georgia. we did not expand medicaid in georgia. he said, you hand out all the new medicaid cards you want to if it'll make you feel better, but i'm the only doc in five counties who still sees medicaid patients, and i can't fit anybody else in my waiting room. so we're not going to achieve that goal of providing more care. we'll just achieve a policy goal of feeling better about what we're doing in rural georgia as it sits today. what policy reason is there? if i want to achieve that goal of not seeing folks walk out the door because they can't pay for their care, i don't understand the policy reason to take away all of the dod health care system that my men and women in uniform tell me they love.
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i don't understand why we have to abolish every union health care system that my union members say back home, i've got the best health care on the planet. why, to achieve the goal of serving the underserved, is the policy solution to take everything away from people who already feel well served? >> i think that's really a crucial issue. what do we need to do to fix the current system rather than blowing it up? because there are a lot of systems and the employer community in tri-care, medicare, to provide this coordinated care, to provide better access for people, more humane, better coordinated care. if medicare fee for services usesed model, all that's blown up. and can we create a new system for better coordinated care in two years? extraordinarily difficult. i think we value what we have, build on that, and solve the problems we have but not destroy
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what's worked. >> even in the medicare system, in my jurisdiction, i live in a suburban area. so we have lots of providers. but more than 40% of my seniors have opted for medicare advantage. they've said, i don't want the traditional medicare system. i have a better option. i'm going to choose that. of course, that goes away too. i want to thank each one of you for your testimony. no one went out of their way to poison the well. again, you were chosen for a reason, to get this conversation started. i think we can achieve the goal of not having the underserved walk out on what ought to be an affordable procedure. though, i think we can do it without virtually doubling the federal budget. what i love about this is she
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doesn't hide from those numbers that you've laid out. she recognizes it's going to be a tremendous increase in tax burden for the country. you can't get to $40 trillion without that. and believes it's worth it. that's the conversation that we have to have. i want to ask -- i'll ask the good doctor who has more experience in the military system than most of us do. i don't hear frustrations from my servicemen and women about their quality of care. in fact, what i hear them say is, rob, because i'm deployed all over the planet, i have to have something different than what would be -- what would work in just metro atlanta in general. is it necessary to achieve the goals that you want for america and our health care system, to abolish that system we've promised our men and women in uniform, or could we keep that system while trying to achieve some other goals?
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>> i think you can keep that system and build on it. medicare for all or whatever label you put on it can be that system. that's what i'm saying. the government is paying for your health services, my health services, medicare, medicaid, va, dod already. you can duplicate that and label it whatever you want because you see the efficiencies there. and particularly when we talk about the goal that's being mentioned for the underserved, you have to have the educational component and address the social determinants of health. if you're in an area where there's a food desert and you can't get nutritious food, you can't exercise, you have to have a whole list of prescriptions when they come in to see you and they lay it out. if you can provide them with preventive care and education, they will become healthier and
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not need the bag of pills, not need to go to the emergency room, and also they have an assigned primary care provider that is going to keep them out of the emergency room. >> i'm glad you raised that. it is troubling to me, again, particularly given the trillions upon trillions that we're talking about investing here. we're only talking about treating people after something bad has happened. there's nothing in here that says what we ought to do is make sure that you're eating better before this happens. diabetes contributes over a quarter of our health care costs. nothing in here says we need to get to exercise ahead of time. it's all a response to crisis instead of intervening before the crisis. that's what health care professionals say. >> representative, may i -- >> i go on a bad day. let me ask this, and it goes to what was said. i think you said 10% of american families are grappling with someone who's disabled in their
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household. i do think it's outrageous that gofundme is what folks would call a successful health care system. i don't call that a successful health care system. but what i don't want to do is refocus america's resources away from your family and towards my family if i'm not in the 10% that's facing crisis. i want to focus the resources on the families that need them most. is it clear from your advocacy and your work that we have to change it for everybody instead of doubling down on those families that we know? there's not a man or woman who is not touched by your testimony and who doesn't want to do better for you, not just on this committee but in this entire congress. i worry that we're losing an opportunity to aglree on that b trying to take the conversation even broader.
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>> representative, may i please weigh in on the cost issue? >> please. >> one thing i can't help but think about today, congressman, is how we always seem to find the money for things like tax cuts for the wealthy and for corporate tax cuts. we never ask where the money will come from when we declare war. we always seem to just find the money. we only ask how we'll pay for it when it comes to our health. this is such a clear problem with such a straightforward solution. we can save taxpayers money. we can save money for families, and we can provide high-quality medical care for every american by doing what every industrialized nation on earth already has. >> if you'd indulge me just one moment, mr. chairman. i have to disagree with you. i do worry that kind of iffy one-liner makes it harder to get to where we need to go.
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it's not just health care we have this conversation. i live in a district that's a majority/minority district. 20% of my constituents are first-generation americans. we have the best education system in the country in our district. we pay for that, and it's hard to pay for it. our taxes are very high, but we make a decision every day. are we going to have the best education system or the second best or the bottom best? public housing in this country. that was referenced earlier, talking about some of our rights. we have people who live in desperately dangerous communities today, desperately unhealthy communities today, and we're not coming up with the money for those things either because money is in every conversation. i want to agree with you 100%. i support a war tax. i think it's absolutely immoral that we have taken the war off of the front page of the paper. and unless you have a family member who's at risk there, i know the chairman supports that as well and having that
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conversation, putting skin in the game. i would share with you most respectfully, i need you to believe that folks on every side of the aisle care as much about serving men and women in need as folks on any other side of the aisle. it's not a bunch of dollars and cents issue. it's a paying for those things we value. we value you, and we want to pay that tax. mr. chairman, you've been overly indulgent. i'm grate pful. >> i want to make sure he gets -- >> you said that you talked to the men and women in uniform. they're usually satisfied with their care. i work at a private hospital, a public hospital, and i also work at the va as well. that's been my experience too. i think you inadvertently made a great case. we provide excellent care. i've never had a patient at the va leave against medical advice because they're worried about
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the cost of their treatment. so i think that our men and women in uniform have great care, and it's a federally funded program where the doctors there are employees of the government. and we have a single form you lair and take care of patients in a great medical way and also a financially responsible way. so i think if it's good enough for our men and women in uniform, it's good enough for all americans. >> just so we don't confuse the issue -- of course, the va system stays under the medicare for all plan. i'm talking about the dod system. a very different conversation i have to veterans about the va system and dod families who are serving abroad. i take your point. thank you, mr. chairman. >> no, thank you. and because i'm the chairman and you're the ranking member, we have a little extra time. >> when did i get that? >> you do have that extra time. you just haven't used it. you can yield is back at the end if you want.
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just to the point about when it comes to certain things we don't question money and the cost. when it comes to health care, we do. that's just the fact. i know it's an uncomfortable fact, but it is. we passed a tax cut bill, which i know you guys supported. we didn't, i didn't support it. we didn't have a hearing on it in the committee. and it came right to the rules committee and went to the floor. we could argue whether that was a good idea or a bad idea. i think it was a bad idea. it's just the issue of how we're going to pay for it never really came up. and you and i have agreed on the issue of the need that when we're engaged in wars halfway around the world, we ought to pay for it, not just put it on the credit card. we don't do that. we make believe we don't have to. when it comes to health care, we do. i just want to -- i'll raise two important points. one was that medicaid rates are
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lower than private insurers. that's when they pay. but we know the private insurers don't always pay. and dr. collins, i just would appreciate it if you could explain this for us. also, would medicare for all pay the lowest rates? >> actually, medicaid rates would go up under medicare for all proposal. >> and the issue of -- i mean, insurance doesn't pay oftentimes. we do case work all the time in our districts where we have people who have issues. when it comes to paying for the bill, the insurance companies say no. that's a reality in this country, right? >> that's exactly right. and surprise medical bills are a huge issue right now. congress has taken up this issue. people are getting bills for services that they thought were covered. that continues. outside of the surprise billing issue, people have very high
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deductibles. people talked about how great employer-based coverage is. about 12% of people across the country, about 12% premiums and deductibles comprise about 12% of median income. so it's one of the largest sources of increase in the underinsured rates we're seeing. >> i've talked to a lot of hospitals. i have a lot of hospitals in my district and in massachusetts. we have some fine hospitals. they complain to me all the time about the fact they spend -- they invest so many man and woman hours into getting into filing, you know, claims with insurance companies to get them to get paid for what they've provided. sometimes they get to the point where it's not worth the time and just eat the cost. so that's another issue as well. i throw that out there to kind of, you know, make sure people appreciate that fact. i'm not happy -- i'm now happy
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yield to mr. raskin from maryland. >> i want to submit for the record a statement from the health care policy advocate for public citizen, which makes the important point that even americans who have insurance today are facing spiraling costs and that a medicare for all system will enable us to lower drug prices and restrain extraordinary growth in drug prices we've been seeing. i also want to recognize the presence today of the president of national nurses united, jean ross, who's the leader of an organization that has been heroically fighting for health care for all americans for many decades. i just wanted to recognize her. mr. chairman, thank you for calling this historic hearing, which is a breakthrough in the national dialogue about health care and what we're going to do to deliver health care to all of our people. i think not since senator
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kennedy had a hearing several decades about about health care have we had one that's this comprehensive, this detailed, and this serious. i want to thank colleagues on both sides of the aisle for participating. i especially want to thank you for your very lucid and poignant and compelling testimony today. and i wanted to start by saying that nine years ago i sat where you sit, met taphorically speaking. i was suffering from reflux symptoms and went to the doctor who recommended that i go in for an endoscopy. they said while we're at it, why don't we have a colonoscopy. we wouldn't normally do it this early. i think i was 47 at the time. but let's just go ahead and do it. when i woke up, nthey said, wel, we have good news and bad news. the endoscopy went find, but we found something in the
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colonoscopy. i had stage three colon cancer. it was off to the races. i did it all. i did radiation. i did chemotherapy. i had surgery twice. and i can't imagine any of my fellow citizens going through such a trauma, something of such an enormous emotional, psychological, and family strain as that and not know where they're going to get insurance. i was a state senator, and i was covered by maryland's health insurance plan. most state legislators don't make very much money. i think we were getting paid $40,000, $45,000, but we had a great health insurance plan and i was covered and able to deal with it. but it opened my eyes to the fact that this is a crisis in our country. there are tens of millions of
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people who don't know what they would do in the event they came down with a diagnosis like that. i decided that i was going to try to go through this personal crisis by staying at work and engaging with the things that i loved. one of the things i was working on was i was leading the floor fight in maryland for marriage equality. we adopted marriage equality. we became the first state in the union to do so without a judicial order compelling us to do so. all glory to massachusetts in all cases, but massachusetts did have that ju zisdicial order. in maryland, we didn't have that, but we passed it anyway. as the floor leader, you've got the opportunity when it's all over to make a little speech. i got up to thank my colleagues because i had been wearing a chemo belt to the debates and to session for several weeks. the guy who sat next to me, who's a great conservative
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democratic state senator from baltimore county, said that i just wore the chemo belt to try to get sympathy and votes for marriage equality, which is probably right. but we ended up pulling him over and changing his mine about it, so it worked, i guess. i got up and said, you know, that i had learned something in this process about the difference between misfortunate and injustice. if your life is going great, you've got not one but two jobs that you love and a wife you love. my wife is here today. and kids that you love and constituents you love. you go to the doctor and the doctor tells you, you got stage three cancer and you got a 50/50 chance of coming through it alive. that's a misfortunate. it's a terrible misfortunate. but it's just a misfortunate because it's built into the nature of our species, you know. any of us could be assigned such a verdict on any particular day. anybody could get such a
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diagnosis, but if you experience such a misfortunate and you get such a diagnosis and you can't get health care because you love the wrong person or you lost your job or you're not working or you're too poor, that's not a misfortunate. that's an injustice. because we can do something about that. and life is hard enough, mr. chairman. with all of the illness and accident and heartbreak, for a government to be compounding the misfortunates of life with the injustice of denialing peopying access to health care when they get sick. in the richest country in the history of our species, at its richest moment, not to advance forward to adopt a medicare for all system is to deny, i think, the common humanity of our fellow citizens.
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i read an essay during that period who said that everybody is born with two passports. one passport is to the lands of the healthy and the living. the other is to the passport of the sick and the dying. we all hope that we're just going to use one of our passports in life, but in truth, all of us are going to use both of those passports. and to me, it is an elementary question of democratic solidarity and equality whether we're willing to acknowledge that all of us are going to use those passports and we should make everybody's trip as easy as possible. so i'm a co-sponsor of this legislation. i'm not going to hide that fact. i'm not just a neutral objective questioner here. but i am fascinated about how we're going to get through this process and bring everybody aboard and come up with the system that makes sense to all americans. now, i want to ask a question that came up before about how we
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ended up tying in our society health care to people's employment. i read something, and i don't know whether it's true, but i read something which suggested it goes back to world war ii when there were wage and price controls and employers, in order to attract new talent, had to give them something better than higher wages. they offered them health insurance. and that began quite accidently, quite arbitrarily, the connection of employment and health care. i just wonder if everybody could illuminate that for me. perhaps mr. baker. >> that is, in fact, the history. of course, it spread, you know, to a wider range of employers so that the vast majority of people below medicare age are getting insurance through their employer. this has come up previously. i could speak now as a former employer. we hated having to deal with our health care insurance. just for obvious reasons. we're busy. we're trying to do lots of other
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things. >> and most small businesses hate it because they're not in the health care business. they're running a movie theater or a think tank or a farm. >> and we're trying to keep our workers happy, obviously. they have different needs. we're trying to find -- frankly, i don't know and i don't want to know what's the best insurance plan for my individual workers. but we had to pick -- talk about one size fits all. we had to pick one plan that was going to be better for some people, worse for others. we didn't want to be in the business. >> so a medicare for all system will liberate small business in america from the obligation of trying to figure out what's the best health care plan for their workers and from paying for it. >> that's right. i should also point out, we had insurance broker, an additional cost. we had someone who would go through the plans with us. this is a total waste. >> you described in your testimony how financing medicare for all starts by looking at how we're spending money today and then making it more efficient. in many ways, that description of how to finance it sounds remarkably similar to a study done by another witness here.
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in a piece for the american enterprise institute, he wrote the following. quote, medicare for all supporters are correct to observe that americans already pay for the vast majority of health spending that would occur under medicare for all and that most of the medicare for all costs are therefore not new to the national economy. do you agree on that point? >> absolutely. clearly there would be some increase in utilization. that's partially the point. i think that's limited for two reasons. one, the people who most heavily utilize care -- basically 10% of people account for 70% of the cost. most of those people are not limited by costs, strictly speaking. they're either on medicaid or they've hit their out of pocket maximum. so these are the -- where we might expect a big increase in costs. you have a lot of people that incur high costs because they're not getting the care they need at an earlier stage. so they go to the emergency room with expensive care when they
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could have had simple care if they'd had access to a primary care physician. >> the other industrialized countries on earth have arrived at national health care plans, the kind that's proven so elusive for us. i want to ask a couple questions about that. perhaps dr. collins, i can start with you. what's the principal value they're seeking there? is it justice for everybody? so that everybody gets health care. is it efficiency of the system? or is it the public health in general, to advance public health? what are the values they're seeking to vindicate? >> i would say certainly all three. i think having universal coverage enables people, everybody to get health care that they need. it definitely promotes a more efficiently run health care system. people have access to care that makes them productive. we have a big problem when we have 30 million people uninsured. so it reduces their overall productivity as well. so it's -- i would say it's all
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three of those things. >> okay. and dr. brown, do you agree with that, that all of those values are achieved? >> most certainly. and i think you also have to look at if you have a healthier work force, you're going to have cost savings in your employment business because the time that you lose for sick days and getting off and taking care of family and all of that would not be achieved because you're then fully working and staying healthy. so yes. >> thanks. i've received an increasing number of visits from doctors and nurses and people in the health care system who say that the current system we've got is not working for patients, and it is interfering with their ability to deliver quality health care to people for a whole host of reasons, including the ridiculous amount of time they have to spend on bureaucracy and fighting with insurance companies whose financial model is to not pay
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for people's health care. the question i want to ask you is this. i think it was ms. turner who said we should have just blown the whole system up. of course, some of my colleagues across the aisle voted 70 times to blow up the affordable care act. they wanted to take that system down. but i want to ask you a tough question about the transition from the affordable care act to one that covers everybody and tries to lower costs in the system, squeezing out the money we all pay for copays and deductibles and constantly escalating premiums. as i understand it, president obama said we want to reach across the aisle and we will go to the plan that was cooked up at the heritage foundation. now, that fact has been buried. but this was the heritage foundation plan, the affordable care act. it was the model for what governor romney did in massachusetts, right. so the idea was, let's take the
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republican plan of the individual mandate, which they came to revile and denounce, and put that at the heart of the system. they considered it an expression of individual responsibility. then what happened was it became politicized, and rather than that compromise working, they turned on it, they renamed it obamacare, and voted dozens of times to try to destroy it and not replace it but destroy it and leave nothing there despite the fact that tens of millions more people got health care because of the affordable care act. it was a giant step forward. and yet, we know of what its limitations are. now, is it going to be possible for us to move from the affordable care act with its limitations to a medicare for all system? is that going to be too complicated for us to accomplish? >> i don't think it's too complicated, and i also would say we need to do it. i think just expanding the affordable care act wouldn't cut it. and i gave three examples
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earlier of the 28-year-old female that had the urinary tract infection that tried to drink cranberry juice to solve it and the gentleman that stop the taking his anti-platelet medication and the lady with the depression medications. i don't know if i made this clear. they all had private insurance. it just wasn't cutting it for them. they ended up having these problems despite having private insurance. >> sometimes people think medicare for all is just for the 30 million people who have no health insurance. that, for me, probably would be enough. it's actually for the 45 million or 50 million americans who have a weak insurance plan where the premiums are always going up, the deductables are going up, and it doesn't work for them. what we're looking for is a system that's going to serve all americans. now, it's been suggested by our distinguished colleague that, well, we don't want to interfere with the plans they're working. the plans always cited in that question are single-payer plans like the va or military.
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they say don't mess with the people who have single-payer now because they love it. then the point of the political opposition is to try to scare everybody into thinking, well f we have single-payer for all americans, if we patriotically bring everybody in, then it's going to interrupt the single-payer provision we've got now, right? is it the case that we cannot afford a system that works for all americans without taking away health care for people who are getting it from the va or getting it from the military and so on? >> i'm not an economist, but as an er doctor, one of the first things you learn is when things are getting crazy, you need to stay cool, calm, collected. oftentimes when everyone around you is yelling, usually the problem is not that hard to deal with. so from a big step back perspective, i apply something that i call the look test to this. just look at what's out there and what makes sense. if someone is coming here and
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arguing that heavier than air flight is not possible, but i just point to an airplane, i say, but look, i see an airplane. i hear what you're saying, but that can't be true. so when everyone starts yelling and screaming that doctors are going to get paid so much less and these systems can't function, hospitals will have to close, i would point to other countries that are doing similar things and say, i hear you, but it seems to be working just fine. >> and do any of the economists want to weigh in on this point? in order to have a medicare for all system, do we have to -- >> i'm going to lend you two minutes of my time. >> oh, forgive me. i didn't know i was over. >> congressman, may i make a comment? >> mr. chair, i'll yield back. >> i get my two minutes back. >> congressman, may i make a comment? >> sure. >> congressman raskin, ten years ago just before you got sick, when i was in law school you
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came to speak to a student group. i was so inspired and amazed by the vision you laid out, and i decided that you were the kind of lawyer and public servant i wanted to become. and your comments today once again inspire me and give me hope for the future. thank you. >> thank you. >> thank you very much. before i yield, i want to ask unanimous consent to insert in the record an article that appeared in "the washington post" back in june of 2018 entitled "house gop plan would cut medicare, medicaid to balance budget." i do that not to break the spirit of camaraderie here, but simply to point out that when you complain about the lack of adequate reimbursement of medicaid and that providers don't want to oftentimes take medicaid and then you support a budget that cuts medicaid, it's a little bit kind of not
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consistent. i don't know. but anyway, i ask that be put in the record. i also want to acknowledge during the hearing, congressman adam schi iff came in. we are happy to have you. i'm now happy to yield to dr. burgess. >> thank you, mr. chairman. i take it under advisement you said you're happy to yield to me. so it's interesting. i used to be a student of milli medical irony. i'm a physician as well. we didn't have c.a.t. scans back in those days. you got operated on for appendicitis. it was probably a lot cheaper and more direct. however, i used to be a student of medical irony. now i've kind of branched out. policy irony is part of my realm as well. it's just, i find it ironic that we are here today criticizing
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employer-sponsored insurance that's so bad and yet the affordable care act that we debated in this room many, many years ago had an employer mandate built into the affordable care act. employer insurance is so good, we want to require one to have it. just a point of historical context. and it's not my goal to relitigate the affordable care act and how we got here. there are good books written on it. i think one of our witnesses has written a book. one of your committee members has written a book. i encourage you all to check on amazon. i'm sure they're still available. but i do have to say that as the affordable care act, president obama was elected. he was elected on a health care -- he saturday on a health care mandate. i reached out to the transition team. i said, along, i didn't give up a 25-year medical career to sit on the sidelines while you all do this. talk to me. there may be some places where we can work together. and they thanked me very much
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for my participation. that's the last i ever heard. same with the then-chairman. same discussion with chairman waxman. i didn't quit my day job to come up here and watch somebody else do health care reform. talk to me. there are perhaps places where we could work together. again, i never got a response. so my purpose was not to relitigate the affordable care act, but it's come up several times today. yeah, there were some missed opportunities. i say that having been part of -- and just for people watching at home, i don't want to say this committee is not normal, but normally health care policy would come through one of the committees of jurisdiction, what are called authorizing committees. mr. cole is an appropriator. he pays for everything we authorize very graciously. but one of the authorizing committees would have had this
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type of hearing and probably done it over several iterations. but this hearing in the rules committee is somewhat unusual. i mean, i haven't been on the rules committee more than eight years, but it's unusual in my experience. we had two primary hearings when republicans were in the majority, but they were on things that were outside of the normal realm of the authorizing committee. it's just -- i want you to know it's a little unusual to have this hearing, but it also indicates -- >> there's a new sheriff in town. that's why we're doing the hearing. >> what's that? >> there's a new sheriff in town. that's why we're doing the hearing. >> exactly the point. this issue is so important to the speaker of the house. this is the speaker's committee. this committee is not -- this committee is 9:00 to 4:00. mr. mcgovern is never going to lose a vote in this committee. if he does, he'll probably have to leave town.
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so this is the speaker's committee. the ratio was set up by a texan, s . he set up the ratio of the rules committee in 1961 to facilitate enacting the agenda of a young activist president john f. kennedy. the ratio has stood ever since. but it is unusual to have this hearing in the rules committee, but i make that point because this is the speaker's committee. the speaker has elevated this. this is what the speaker wants us to be talking about today, this week, this month, and so we shall. i do have a number of specific questions. i apologize for getting -- it's just hard. i devoted my time and experience to one of the authorizing committees that deals with health care, nih. our committee, energy and commerce committee, produced
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cures for the 21st century. we can argue about how we're going to pay for things, but if we ain't got the things to pay for, it's a crazy argument. and dr. brown, thank you so much for being here. thanks for jyour service to the national medical association. i will tell you, when we were doing cures and it had gone through all of the machinations that we could go through in the committee and the house had passed it, the senate drug their feet, and an election happened and decided they better get busy and pass cures because things weren't getting any better for them after the 2016 election, so they did. they passed a version of cures. we quickly got a conference committee together, worked out the differences, and mr. rush, bobby rush on our energy and commerce committee, came up to me and said, doc, we forgot sickle cell. we didn't really forget sickle cell. we were trying not to be disease specific. this was about funding for research in the broad perspective. but i got what he was saying because several months before
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we'd had a hearing in the energy and commerce committee in the summer of 2016, and we had a witness from the sickle cell disease association. she made the statement that it had been 40 years since a new sickle cell treatment had been approved by the fda. 40 years. that meant the stuff that i was using at parkland hospital in the 1970s, that was state of the art. i can probably go back to work tomorrow because it hadn't changed. that was an astounding statement that day. obviously we were at a point with the cures bill that nothing could be changed. the senate had agreed. the house had basically agreed. we were going to go to the floor for a vote. the president was going to sign it. i think it was the last bill signed by president obama. it's a great bill. in evidence of what the energy and commerce committee is capable of doing, if we take our time and do things correctly. i did make a commitment to mr. rush that i would work to get a new sickle cell authorization.
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it hadn't happened since 2004. that was tacked on to one of the bush tax cuts, so it wasn't a true sickle cell reauthorization. and the next month when i was chairman of the health subcommittee, we passed a sickle cell authorization bill, and it took the senate forever, as it always does. but in october they passed their version. we approved their version over here on the house floor. and the president signed it into law. the first major sickle cell authorization that had been passed in certainly over a decade. with no new therapy. then here's why this is important. because i normally don't watch "60 minutes." i don't think i watched it the night it was broadcast, but someone said you should go to youtube and look at this "60 minutes" broadcast on sickle cell. if i'm not violating copyright laws, i encourage people to do that. it was a fantastic discussion of what someone is doing at the nih with fixing the genetic defect that causes sickle cell.
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i mean, that's unheard of. it's a two-base error, and it seems like something that's just a spelling error. seems like spell check should have caught that, but it didn't. and this doctor has worked out a system where they're actually able to put that corrected dna into a patient's cells. i got to tell you, i'm an episcopalian, so i don't emote. when i saw that picture of the blood film on "60 minutes", the young woman they were treating and these were all normal red blood cells, i broke down and cried. that's incredible that child could have that blood film picture. doctor, you know from your time in the emergency room, they go into crisis. it's tough. not a lot you can do. people worry about prescribing opiates now, as we should be judicious, but at the same time, these are people who need pain relief. the old treatments of hydration, i suspect, is still one of the
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things you do. but this was a great step forward. again, i bring that because the authorizing committee did that. another bill that we did, i hated the sustainable growth rate formula. when you about medicare for all, there was one point the congress said, you know, we're just going to cut your medical reimbursement for doctors. not for hospitals, not for insurance companies, not for pharma, just for doctors 20% every year. oh, my god. it never goes away. it was written in a way that even if congress came back in and added some money, which we would do every money called the cost fix, it would still add on to what the congressional budget office scores, something called the updated cost factor. i don't know what it is but it was bad, i know that. 15 years it took me to reform
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the cost factor, but i did. we had 393 votes on the floor of the house, we had 92 votes on the floor of the senate, so that was a great example of bipartisan cooperation to correct a major problem that we had with the delivery of our health care. but you can't stop there, and this is one of the things i learned. when you finish a big bill like that and hand it off to the agency, with all due respect for anyone who might have worked at the agency at one time in their life -- when you hand off to the agency, things can happen to it. and you've got to keep your eye on it. as members of the authorizing committee, we've had multiple oversight hearings on the implementation of what's called medical access of the authorization act. this was a major medicare improvement that was agreed to in a bipartisan fashion, but, i mean, there's not a week that goes by that someone does not call my office with some concern
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about something that they're going to either not be able to do or be required to do because of something the agency said -- rule making that the agency makes. so i encourage people that when they read this medicare for all bill, it is a real bill and a real consideration. this is the speakers committee. we're considering this bill in the speakers committee. i worry about it because of the number of times that bill, we're talking secretary of health and human services. with all due respect to someone who might have been in health and human services at one time, that is a difficult one to involve because then it goes from the realm of the people's office to the agency. what was the statement that mr. raskin made? a ridiculous amount of time spent on bureaucracy. if you think that's going away, if you think the fine folks at
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the hubert humphrey building in charge of everything, if you think that bureaucracy is going away, it ain't. it will still be there in some form or fashion and could possibly be worse. i appreciate your indulgence, i just had a lot i wanted to get off my chest. ms. turner, let me ask you, because this comes up all the time, the issue of administrative cost and hhs and cms. i mean, administrative costs, that's a little misleading. if i want to go and start an insurance company -- i don't, but if i did, i would have to go borrow a lot of money, there would be a cost of capital that i would incur. cms does not have to account for the cost of capital, do they? >> no, dr. burgess. actually, marilyn matthews did a study with an economic consulting firm some time ago looking at the comparison of
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medicare administrative costs with private insurance. he said most of these comparisons are really apples to oranges. when you include not only the cost of capital but the federal government's ability to collect premiums and resources and the difference in the population of medicare versus those that are younger, it comes out pretty even. but i think the key point is that somebody is going to have to determine what benefits are allowed or not, who is going to be an authorized provider, how those providers are going to get paid, how the paperwork is going to get collected -- >> you turn all that over to the secretary with this medicare bill. >> someone is still going to have to do it, so i think all the processes of providing services that the taxpayers are going to be paying for and are part of this program are going to have to be documented. that's not going to go away. >> let me just take what time i have remaining, and i need to enter into the record -- we're
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limited to only have two witnesses on the republican side, so we're not able to have a patient. i wanted to bring this article that was printed this morning, cbd.ca. a mother in nova scotia with cancer is challenging steven to meet with her after a year of radiation. she said she went undiagnosed for two years because she couldn't access her family doctor. when she was diagnosed, her cancer had spread to stage 3. this is the face of health care in nova scotia. i cannot receive help for trauma i experienced because of the failed system until sometime in july. that's for the mental health she thinks she requires. doctors in nova scotia replied. tim holland, president of doctors for nova scotia says it's the first time he's heard this kind of story. this story has all the elements
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of problems nova scotia families are facing, lack of emergency care and knowing they aren't equipped to diagnose cancer, they are stretched thin. >> doctor, i think we must not ignore what we see in other countries. in canada, if you can't access a primary care physician, you can't get to see an oncologist. and the think tank spends a great deal of time tracking what is the average wait time. the average wait time is about five months for specialty care. we see in the u.k., we see ambulances that are driving around london for hours waiting for the emergency room to be able to let a patient in. when they get in, they're often warehoused in hallways. people die. there is a cite of example in my testimony. people dying in a hospital emergency room hallway waiting to get care. so we have to look at the experiences of other countries.
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that's how they rationalize lack of care. they rationalize waiting lines and the lack of access to new medicines. in the united states we have access to more than 95% of all new medicines. in france, half of them. so that sickle cell treatment may be available theoretically, but are you going to get it if the state has to pay for it. >> i need to yield back. i know i have more time later. >> first of all, i do want to say, dr. burgess, i'm always impressed with the way medicine was practiced back then and i'm always thankful for the luxuries our generation has in dealing with this. you said going through the protocols and taking time and making sure we do it right. if we go through something of this scale, we have to make sure we do it right. part of the reason i'm here, my patients are suffering and dying, so i want to advocate. we need just a little bit more
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sense of seizure generurgency. we have to go through the right channels and take our time, but we have to do it with a sense of seizure gener urgency that people are dying while we do this. at the end of the day, a lot of people have mentioned that this is the united states. we're the richest country in the world, but we're also the boldest, entrepreneurial country in the world. if we want to do something, we can do it. i'm a little worried that there is a lot of finding problems with the solution rather than finding solutions to the problem, as my dad would say. i think we need to invest more to try to start with the starting position that we can get this done and we need to get this done because people are dying and people are suffering. and then go through all the right channels, as you said, and do it the correct way. >> i just also would like some clarification here. we've heard that workers and everybody would lose their
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coverage under medicare for all, and all of us would lose our health care under medicare for all? how would that be better than today? >> everybody would move from the current coverage they have, for the most part, and into a new system of plans with more comprehensive benefits in many cases. it's not true that people would lose their insurance coverage. >> did you have a -- >> i did want to address the wait times in other countries and rationing care. insurers are rationing care right now, we are rationing care by leaving so many people uninsured, so it's all a matter of how you use that term. but also in other countries, we actually have wait times that are very consistent. in our surveys of international systems, we find that wait times for specialists are about the same as they are in the united states. in countries that have had wait time issues like the u.k., they have addressed those, so it doesn't mean that a single payer system there is going to be a
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single payer system here. there are ways to address wait times and certainly other countries have done that. >> i want to say to the rules committee, since it was brought up that it's unusual we're having a hearing with the rules committee. it's not unusual. actually, this is the oldest committee in the congress and we do big things. i'm proud of the fact we move the affordable care act and we ensured that 20 million people have health insurance. we did the affordable care act, the house held 79 bipartisan hearings and markups, and we had over 239 amendments. 121 amendments were accepted. this is an enormous undertaking. it's a perfect no. i contrast that to the way my republican friends handled the repeal bill. it basically bypassed the hearing process entirely. we just came right to the floor. so there is a contrast here. i don't think hearings should be viewed as unusual or undesirable. this is an opportunity for everybody to be able to say what's on their mind, pro and
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con, and that is not a bad thing. and -- dr. navi? >> i wanted to say we're already rationing with the uninsured, but we're also already rationing with the insured. when 41 mill dwrion americans f like they needed to go to the er in the past 12 months, there was still almost two-thirds of people unemployed. that's self-imposed rationing and that's part of the crisis. >> m mrm-r chairman, may i make comment? we know that systems in other countries have better outcomes than we do. >> i want to thank dr. burgess for the report of the sickle cell bill and how that has come about, and yes, we have one new drug that was just recently approved for the disease.
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and speaking to mr. raskin's comment, i want to say that even though i have a niece who, unfortunately, died from colon cancer, she was at the age of 48 so she could not get the screening test because her insurance did not cover it. she waited too late and she had advanced stage disease and died. so, again, having medicare for all, our universal health coverage would allow those individuals to get the kind of screening test that does not follow those guidelines, because at any age, if you're having symptoms, you need to be treated. >> thank you. >> thank you, chairman mcgovern, for the opportunity to participate in this hearing, to help us explore how we continue to try to make good on a commitment to accessible and affordable universal health care. i'm grateful for the expertise and effort that my colleagues,
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especially congresswoman jaia poll, and my congresswoman have put into handling this legislation. i have no question that health care is a human right and no family should go bankrupt or worry about putting food on the table due to medical costs, or have to create a gofundme page. i understand we have to find a way to address what my colleague mr. raskin called the injustice of being unable to afford medical care when hit with the misfortune of medical trauma. i've already supported measures that would try to lower prescription drug costs, allow americans over 50 to buy into a public option, but i'm trying to parse the best way forward from here, to protect the affordable care act and move to whatever our next step is. there are constituents in my district who believe that medicare for all is the best path forward. and there are others who are concerned about how it's going to work.
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and those concerns are multifacetted. they're rooted in fears of rising costs, change to their existing employer or union-based insurance, and for many, an impact on their jobs. it's my hope that i can get information from this panel to help get answers to these important questions that i can take back to my district as we have this critical conversation about what a just transmission to medicare for all would look like and how we achieve th that elusive coverage would have. when we talk about medicare for all, one of the things we talk about are the financial burdens of the current health care system to individuals. so whatever we do, how do we address the cost of rising premiums, prescription drugs, co-pays, deductibles. talk about the impact the medicare for all system would
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have on these premiums, co-pays and deductibles for individuals. dr. baker, please, first. >> if you did go to medicare for all, basically those all go away. we're taking money that we're paying for out of our pocket, or that employers are paying for, it would go into a tax credit for these services. it relieves that problem, r, how thood in a way that's. >> my colleague at the university of massachusetts made a pay plan, i think a reasonable one. it would really depend on how you decided to pay it.
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i emphasized this earlier, getting costs down. we could argue how much, but i think there is no doubt about it, we're getting rid of an insurance industry. we also get rid of the administrative expenses that hospitals, doctors' offices, other places have. that's a clear savings. how much will we save on drugs? i argue we would save a lot on drugs. drugs are cheap. we make them expensive. that seems stupid to me. same with medical equipment. i think our doctors' pay should be more in line with doctors elsewhere in the world. but those are all things up for debate. how much do you depress those costs? point of reference, we look at other countries. they pay about half as much per person on the average. there is some range there. there is no reason why we should be paying more than other countries. can we get as low as the average? will it take us five years, ten years? those are all very much up for grabs. it should mean a typical person will pay less in taxes than what they're paying now for their
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health care. >> dr. collins? >> i would add to that that there are -- in my testimony there are about ten other bills that provide smaller steps towards -- ultimately towards universal coverage. and there have been lots of different reform approaches thavthat have been modelled by the urban institute and approaches at the commonwealth fund has modelled. so there are lots of ways to improve people's cautionary to lower premiums, even in employer-based problems or policies moving more slowly. obviously there are tradeoffs. the affordable care act has been that we haven't seen any legislation to improve the affordable care act since it was passed, so there are definitely tradeoffs. i would also say for people with employer-based coverage, there are lots of hidden costs in
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employer-based coverage. people make wave concessions so they can have coverage. people p. so a movemently. taxes would rise nofrd to finance that, but for many people, depending on how you would structure the taxes, many people would probably see a net cost of health insurance go down, depending on their income. the controversy in vermont really did come down to legislatures not being able to explain this change to a financing from premiums to taxes to their constituents. >> if i could also just add quickly, in vermont, i think
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everyone agrees that at least a goal for medicare for all is putting downward pressure on things like drugs, like medical equipment, and something certainly a person here rather than someone with almost no bargaining power. >> they talked about long-term care being a big driver in cost and an issue we really need to struggle with, particularly with all the aging boomers coming into the system. how does medicare for all deal with that? >> well, the plan -- you know, the jab hole plan does cover long-term care, and that's a problem in the main system, mainly because it's not covered in general. however, you do have this in medicare. they could actually have nursing home care that is covered. the less desirable situation,
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rather than going into a nursing facility, but on top of that it's more expensive. we want to provide people with the care they need, not have them get care they do not need, but it's affordable because of the way we structured the payment system. >> i think, too, there's been talk about people losing their medicare, but actually, under the bills, medicare for all bills, medicare benefits would actually improve substantially especially with. >> that would be another area where there could shl savings. >>. some things are covered -- most important importantlily that's not good health care and it's an inkribl many.
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>> in terms of a just transition for those whose livelihoods are dependent on the current system, can you speak at all to how that would occur? >> it really depends on what you write into the law. if you have unemployment benefits in the system, they would lose out. i think that's something that's come up with climate change as well. what do we do with people in the fossil fuel industry if we move to solar wind energy? i think that's something for members of congress to look at. i know the gentleman who has support for that, but how you structure that, it really depends on what congress were to decide, and obviously it's a consideration that we don't want to see workers lose their jobs and suddenly be unemployed. is this situation worse than in other industries, because workers are always losing their job. i don't mean to be cryptic about that, i take it very, very
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seriously. i'm just saying we have to think about how does that fit in with our other systems. >> representatives, may i please weigh in on the cost issue. >> please. >> it is very important to emphasize the following point. these cost savings are only possible through a genuine medicare for all system. other proposals to increase health insurance coverage such as those that would make medicare compete with private insurance would not facilitate administrative and billing savings. >> okay. i actually was just going to speak to that subject. and what you saw as the pluses and minuses that would force the private insurance companies to compete. >> i actually am sympathetic to that as an interim measure. i would like to see us get to medicare for all, but i laid out, what would you do in a transition, and we have glaring
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inadequacies of the current medicare program. most obviously, there is no out of pocket cap. i'm embarrassed to say how long i was doing policy work before i realized that, because it's kind of like, why isn't there a policy cap? also we have a separate drug benefit. that makes no sense. you don't have separate drug benefits in the private sector, why did we think that made sense? representative woodall made the point that part of the people get the medicare advantage, well, we subsidize that. i think it's 50% more for people with medicare advantage, so would we pay for them in the traditional plan? those are the potential problems with the traditional plan. if you imagine a situation where we actually fix the medicare program, probably 80 or 90%, and then on top of that we let people buy into it, i think we're talking about a massive
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program at that point, and i think you would have providers saying, we don't want non-medicare people. this is a huge blind block. why do we want to pay with united health and -- the point is, why do we want to play with them when we have this huge block, we know what they're doing, it's standardized, we don't have to play games. i think there would be large administrative savings which is to say i don't want to not see us go to medicare for all, but there would be an intermediate step. >> i think there are very critical design issues, too, in medicare for all and where you set the provider rate. the bill is proposed at medicare rates, but clearly some of the analyses that have been done have looked at rates that are somewhat higher. that's a key design issue for a public plan, and going with a public plan option based on medicare, maybe rolling it out in certain parts of the country where there are very few insurance companies, would give
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us an opportunity to see how that would work, where you would set the price and what might work the best. so that would be an advantage of starting with a public plan based on medicare or medicaid. >> and that also relates back to the chairman's concern that if we keep slashing medicare and medicaid funding, then it becomes more difficult to get people on the provider's side to buy in. >> thank you very much. ms. lesko. >> thank you, mr. chairman. i think it's important to note that all of us, no matter what side of the aisle we are on, want to improve health care. >> kuwacan you wait just one se? i think what i'm being told is everybody needs a little bit of a break. if it's okay with you, can we take a break for votes and then come back? unless you can't come back, then we'll go right to you.
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>> can i come back? i think i'm back. >> we'll take a little bit of a bre break, and when votes are over with, we'll come back. we have a few more people to ask questions and then posing remarks and then we'll bring this to a conclusion. i thank the witnesses for their patience, but i think you're entitled to a rate mal. thank you.
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the house rules committee taking a break as members of the committee are heading over to the house chamber for a series of votes. members of the house today have been voting on bills considering financial literacy. those votes coming up in just a couple of moments. you can see live coverage of those votes on our companion network c-span. while this break is underway, we will take you back to the beginning of this hearing and hear some of the opening statements. i don't think we can squeeze anybody else in here. i think we're at that point right now. the rules committee will come to order. good morning, everybody, and i want to welcome our witnesses to the rules committee. thank you so much for being here. before i give my opening statement, i would like to outline kind of the time agreements that we reached before the majority -- between the majority and minority on this committee for the purposes of this hearing. in the rules committee we have no rules. we're going to have rules today a little bit.
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so while the rules committee -- while the rules of our committee provide members with five minutes to ask questions of the witnesses, that rule has not been followed for as long as i can ever remember. so i believe we've reached a fair agreement with our minority that respects the time of our expert witnesses and provides members of this committee with ample time to ask questions. so under the agreement, a chair and ranking member will provide an opening statement around five minutes. if other members of the committee have opening remarks, we ask that you submit those statements for the record. each witness will then have five minutes to provide an opening statement. if you go over a little bit, fine, but if you see that red light on, try to wind it up. after the committee receives testimony from our witnesses, each member of the committee will have about 15 minutes to ask questions of the witnesses. and if a member has a question for mr. barkin, please ask him your question at the beginning of your time and then proceed with the questions for the other
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witnesses to give mr. bark barkin time to type his responses. please leave questioning at the end for his responses. you can provide additional time to members during questioning. the minorities' additional time must end before the majorities begin their questioning. the ranking chair will have about five minutes to close, and the chair will close after, i'm sure, very eloquent closing remarks. i want to thank ranking member cole for his remarks, and i want to thank everyone for their participation in this hearing. before i begin, i just want to acknowledge some people here in the audience. you saw speaker pelosi was here a little bit earlier. we appreciate her coming by, and we have congresswoman katie porter is here from california. we are grateful that she is here in the audience.
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in addition, we have amir amira saquira from national nurses united, james ross from national nurses united, christy fogle from the progressive coalition, savannah lyons with the coalition. charlie was born prematurely, and before the age of three, she had suffered through more therapies and injections than most experience in a lifetime. as the bills pile up, the family faces tough choices for charlie's treatment, with the need for long-term care in this country. nate smith, audi's lifetime friend and caretaker, president of be a hero, which is audi's organization. elizar barkin, audi's father,
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he's here, and i'm sure you're very proud of your son today, as we all are. howey benkler, audi's cousin, is here, and audi's uncle. having said that, let me begin with my opening statement. i believe this is a historic day. today the rules committee is holding a hearing on the medicare for all act. and this marks the first time congress has ever held a hearing on medicare for all. and i want to thank, again, congresswoman jiapol, congresswoman debbie lincoln and her staff and for leading us through this hearing, but i particularly want to thank congresswoman j,iapol for her
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commitment to this situation. i have a sneaking suspicion we will have a lively debate. and that's a good thing. after nearly a decade of republicans talking only about how to rip health care away from people when they were in charge, this majority is here to discuss how to expand it and how to lower costs and improve outcomes in the process. i have long believed that health care is a right for all, not a privilege for the lucky few. and this congress is putting that belief into action. that's why i voted for the affordable care act. the lot to gave 20% for women and made sure it actually covered benefits. the aca saved lives, but we knew then it wouldn't be the last stop in health care reform, that
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we would always have to come back and build on those core values. that is what today is all about. because the work of reform isn't p done. 44 million people have coverage that stlint for them when they need it. we're not necessarily jacking up costs or deciding who gets care. it's still true today that for too many in america, you can go broke if you get cancer. you can lose your home if your kids get sick. that is not health care being delivered as a basic human right. that's health care that remains out of reach for too many. the medicare for all act would change that. the 20 million people who can't afford health care would get health care. the 49 million people would have peace finally knowing that their health care will be there for them when they need it. and see all of us, workers,
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health care, all of us, would know this is an important cost. people need services they need to live with dignity. the medicare for all act is a serious proposal. that's why more than 100 members of congress are co h-acts. not only should it be expanded, it deserves to move forward. congress should be a place where we tackle bigger problems. where we're not afraid to have heefrgz or new debates. . there are those who tried to sabotage their health care and looked at the commonwealth ily.
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we are sick and tired of the problems that are fundamental in our system today. so if my republican friends want to use a lot of scary words like government take. they tried that during the passage of the. this would be no different. and by now, we all know that the republican plan for health care can be summed umd. to the extent they had a health care plan, i think it could probably be summarized as take t two. this majority is taking a different route. we have fantastic witnesses who will talk about this bill today.
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some are somewhere in the middle and some are against. but i want to focus on one winner. with us today is audi barkin. audi is a father and a husband, an out of circumstance health care advocate. we have a picture of audi's beautiful family here today, and i'm sure your son is incredibly proud of you being here at the first ever medicare for all hearing. so we are so honored that you're here. if you recognize audi's name, it's because he's been fighting like hell for his life and for all of ours. he was diagnosed with als in 2016. since then he's been fighting medical companies just to get the help he needs. he has to battle to get care, battle to get services, battle
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to get lifesaving equipment. but nobody should have to fight a health care company while fighting for their lives. i cannot do audi's story justice. i will let him tell it. but i will leave my colleagues with this. if you think health care is just fine today, if you think we only need to nibble at the edges of reform, look at audi after what he has gone through and tell him that. audi, you are welcome to stay here as long as you want and take any breaks that you want, we are just honored that you're here. you literally put your life on the line to travel here from california and we are fortunate to be able to hear your story. let me just close with this. you know, in washington here, we talk a lot about national security. that's everybody's favorite topic. and i believe we need to expand the definition of national security which includes more than just the number of bombs we have. national security should also mean things like quality health care for every person in this country. we expect the federal government to defend us against enemies
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abroad. i don't think it's too much to expect the federal government to protect us against illnesses here at home. so we're going to have a spirited debate here. i'm looking forward to it. before i get started, i want to first recognize our distinguished ranking member from california, our good friend mr. cole. >> thank you very much, mr. chairman. i, too, want to thank you for holding the hearing and i want to thank all of our witnesses for coming and participating. i had the opportunity to read all of your testimony, and frankly, i found it very informative in all cases and quite moving, obviously, in a number. it's interesting for me to note, mr. chairman, that as you pointed out, there is a variety of perspective, as there should be, among our witnesses today. each and every one of them is interested in the best possible health care of the american people. they may disagree with how you get there, but it's a worthy goal for all who shared and dedicated a lifetime in pursuit of it. i'm grateful and i know every
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member on this panel is. today's hearing is quite extraordinary. we're here today to consider hr-1384, the medicare for all act of 2019. unlike our usual weekly hearings, today's hearing is a legislative hearing. out of the hundreds of pages of bill text, the rules committee has jurisdiction over precisely one of those pages. that's it, just one page. yet we're about to hold our first original jurisdiction legislative hearing in nearly three years on this bill. that's what makes this hearing extraordinary. i also think it's worth noting that speaker pelosi's personal committee is the one to take the first swing at this ball. when three other committees in the house can claim. they should conduct multiple hearings on this legislation as well.
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frankly, i'm sure ranking members of those committees will be requesting their chairs to take up this legislation and the relevant committees. i hope that happens. of course, there is a reason it's coming to rules first and that's because this bill, too, is an extraordinary bill. d what democrats are proposing today would completely change america's health care system, and not, in my view, for the better. medicare for all would require all americans to pay more in taxes, wait longer for care and receive potentially worse care. even worse, it would put our current medicare recipients at risk. as medicare instructor now, medicare advantage plan holders are by and large satisfied with the health care they receive. in particular, medicare advantage plans are extremely popular. however, this radical bill puts medicare itself at risk by enrolling millions of new recipients who have not paid into the program the way current
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recipients have. it would force longer wait times and ban medicare advantage entirely. for current medicare recipients, medicare for all really means medicare for none. indeed, this bill is a socialist proposal that threatens freedom of chase. private employee health insurance would lose their plan. even if you like your plan, you really can't keep it. more than 150 million people will lose health plans they like, plans that they bargained for, and in many cases, plans they've earned through years of hard work. medicare for all throws it all out the window in favor of a one size fits all government-run health plan. we will hear from one of our witnesses, ms. grace marie turner, on the impact this will
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have on employer-sponsored insurance and the method by which roughly half of americans of the health care. i think people need to be aware many. he reviewed medicare for all and told a very telling story on the topic. dr. blay has shown the previous basic version of medicare for all would cost at least $32 million for the next three years. the majority has not told us how much this massive new program will cost, how they will raise the money to pay for it, or whose taxes will have to go up to pay for it. on the last note, i can secure you that everyone's taxes will have to double to pay for this
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program. the majority need to be honest with us and with the american people to help out. the american health care bill leads to the funding of abortion. as many of you know, the funding for abortion has been limited for more than three decades. higher limits, taxpayer funds. the church amendment protects the conscious rights that are provided practitioners, and even though obamacare maintains protections. however, this bill provides none of it. . section 701 of the billy must ignore these federal laws dating back 33 years.
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mr. champl -- energy commerce and ways and means so that we can ensure that longstanding life protections are included as you move medicare for all to the floor for pay vote. mr. chairman, i'm looking forward to today's hearing. hope our witnesses can shed some light on these and other questions as we review this proposal that, if passed under law, would dramatically for everyone, and in my opinion, not for the better. >> let me just assure you that i hope all the. >> in my opening statement, a big contrast to the way my friends on the other side of the aisle conducted themselves when they tried to repeal the affordable care act. there were no hearings.
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hearings are a good thing. as far as how the rules with commence, i would like to think it's because of my chairman. we are ready to begin. my first witness is audi bong m bongyim. you helped design policy appraisals to help sick days, regulation of major retailers. >> as i said, mr. barkin, the floor is yours.
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>> chairman mcgovern and members of the committee, thank you for allowing me to testify today. my name is audi barkin. i'm 35 years old and i live with my beautiful wife rachel and our toddler carl. she is a professor at the university of california. sam and i are organizer for the center for democracy and the be a hero project. since i was a freshman on my high school debate team, i have been giving speeches and presentations on topics like health care reform and the federal budget. but never before have i given a speech without my natural voice. never before have i had to rely on a synthetic voice to lay out my arguments, convey my most passionately held beliefs, tell the details of my personal story. three years ago, rachel and i felt like we had reached mountaintop. we had fulfilling careers, a
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wonderful community of friends and family, and a smiling, chubby infant boy. we could see decades of happiness stretching out before us. the sun was shining and there was not a cloud in sight. and then, out of the clear blue sky, we were struck by lightning. als, a mysterious neurological disease with no cure and no good treatment, a life expectancy of three to four years. most of its victims are in their 50s and 60s. i was 32. every month since my diagnosis, my motor neurons have died out, my muscles have disintegrated and i have become increasingly paralyzed. i am speaking to you through this computer because my diaphragm and tongue are certainly not up to the task. although my story is tragic, it is not unique. inde indeed, in many ways, it is not so rare.
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jennifer statisan is sitting next to me. like me, her husband was struck by a neurological disease at a young age, multiple sclerosis. 10% of americans have a serious disability. every family is eventually confronted with serious illness or accidents on the day we are born and on the day we die and so many days in between, all of us need medical care, and yet in this country, the wealthiest in the history of human civilization, we do not have an effective or fair or rational system for delivering that care. i will not belabor the point because you and your constituents are well aware of the problem. high costs, bad outcomes, mind-boggling bureaucracies, bankruptcies, geographic inequities and profiteering. health care is not treated as a human right in the united states of america. this fact is outrageous and it
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is far past time that we change it. say it out loud for the people in the back. health care is a human right. for my family, although we have comparatively good private health insurance, als means paying out of pocket for almost 24-hour home care. this costs us $9,000 every month. the alternative is for me to go on medicare and move into a nursing home away from my wife and son, so we are cobbling together the money from family, friends and people all over the country. but this isn't a fairway to run the health care system. gofundme is a terrible substitute for smart congressional action. like so many others, rachel and i have had to fight with our insurer who has issued outrageous denials instead of covering the benefits we pay for. we have so little time left together, and yet our system forces us into ways of dealing
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with bureaucracy. that is why i am here with you today, to urge you to build a fair and effective system. i am here to urge you to enact medicare for all. there are three simple reasons why medicare for all is the right solution, the only solution to what ails the medical health care system. i summarize it here, but i urge you to watch the journal for more details. first, everyone in america deserves high quality care we deserve. medicare will deserve comprehensive care including dental and reproductive care. we will all be able to see the doctors and specialists we want. and, crucially, the program will provide for long-term services and supports that will allow people like me to stay in our homes and communities with the people we love. this will dramatically improve
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life for the tens of millions of people whose families include older or disabled people. second, medicare for all will save the american people enormous sums of money. under the program, there will be no premiums, no deductibles and no co-pays. that means we will no longer need to choose between paying the rent and filling a subscription. it means we will no longer delay necessary care until it is tragically late and tragically expensive. it means that we won't have to worry every year when our employer announces the new rates. it means that we can finally start to eliminate the atrocious racial and economic disparities that destroyed so many lives, that robbed our communities of so much dignity, that stripped us of all our common humanity. any proposal that continues to charge patients co-pays and deductibles will necessarily leave people out. any proposal that maintains the
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for-profit health insurance system will require that some people don't get the health care they need. without the generous support of my family and friends, this would include me. crucially, medicare for all is the only way to make our health care system more efficient. over the past three years, i have seen firsthand how the current system creates wasteful cost shipping, delays, billing disputes, rationing and worrying. administrative waste is costing us hundreds of billions of dollars every year. medicare for all will streamline the entire system, letting doctors and nurses focus on delivering care instead of on paperwork. as a single payer program, medicare for all will be able to eliminate enormous price gouging by pharmaceutical and device companies. the fundamental truth is that too many corporations make too much money off of our imnellnes
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and they are spending millions of dollars to stop us from building something better. it is very important to emphasize the following point. these cost savings are only possible through a genuine medicare for all system. other proposals to increase health insurance coverage such as those that would make medicare compete with private insurance would not facilitate administrative and billing savings. there are many other major benefits to medicare for all detailed in the written testimony submitted by the nurses and others. but my time to deliver this testimony is running out, and, in a much more profound sense, my time to deliver this message to the american people is running out as well. so i want to end on this third and final note. our time on this earth is the most precious resource we have. a medicare for all system will save all of us tremendous time. for doctors and nurses and providers, it will mean more time giving high quality care.
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and for patients and our families, it will mean less time dealing with a broken health care system and more time doing the things we love together. some people argue that although medicare for all is a great idea, we need to move slowly to get there. but i needed medicare for all yesterday. millions of people need it today. the time to pass this law is now. winning this reform will not be easy. they will do everything in their power to stop us, and yet despite these obstacles and despite the challenges i continue to face, i sit here a hopeful man, a hopeful husband and a hopeful father. i am hopeful because right now there is a mass movement of people from all over this country rising up. nurses, doctors, patients, caregivers, family members. we are all insisting tlhat ther is a better way to structure our
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society, a better way to care for one another, a better way to use our precious time together. so my closing message is not for the members of this committee, it is for the american people. join us in the struggle. be a hero for your family, your communities, your country. come give your passion and your energy and your precious time to this movement. it is a battle worth waging and a battle worth winning. for my son carl, for your children, and for our children's children, we have a once in a generation opportunity to win what we really deserve. no more half measures. no more health care for some. we can win medicare for all. this is our congress. this is our democracy. and this is our future for the making. >> thank you very much, mr. barkan. >> chairman mcgovern and members of the committee. thank you for inviting me to testify today. my name is ady barkan.
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>> thank you very much. i appreciate it. the entire committee is grateful for your testimony, and we're honored to have you here. let me yield to my colleague. >> thank you for your remarks. it's a great privilege to have you here at considerable sacrifice and risk to yourself. it's a testament to your courage, so we're very honored and happy to have you in this debate and this hearing today. thank you. my witness? okay. >> we'll go next to charles blayhouse. j. fish and william at the mercadis center, previously served as a public trustee for the social security and medicare programs and as deputy director of the national economic council under president george w. bush. >> thank you very much.
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chairman mcgovern -- it should be. is it on? chairman mcgovern, ranking member cole, all the members of the committee, i greatly appreciate this opportunity to appear before you to discuss the estimated federal budget costs of medicare for all. before i proceed to the estimates, just a few caveats. this is not an analysis to whether medicare for all is a good policy or bad policy, it is purely a cost projection. as i discuss the fact costs that play into the estimates, it's purely as a way they affect the numbers. my cost analysis is based on the medicare for all act of 2017 introduced by senator sanders in the last congress. obviously there are bills introduced by congressman jiapol, by senator sanders himself. these offer more care benefits but i have not the opportunity to analyze these bills. medicare for all would add
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between $6 trillion and $8 trillion in the first ten years. the first $6 trillion estimate is a lower estimate. it assumes every as possible. if instead things play out more statistically, the new federal costs would be closer to 38.8 trillion. obviously such enormous numbers are difficult to grasp. we're talking about 11% to 13% of our gdp in 2022, rising to 13%, and we simply do not have historical experience with permanent expansion of this size. the study notes that doubling all currently projected he he taxes would be insufficient to finance even the lower-bound estimate. to be clear, they would not be the total costs of medicare for all, but the federal government's net new costs above
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and beyond current obligation. total federal saves for the first ten year would be somewhere between 54.6 trillion and 60.7 trillion. the vast majority would arue from health spending that you now down by others, by private insurance, and by individuals in the payments out of pocket. other aspects of medicare for all would add to that existing health spending. still others are intended to bring costs down. the biggest factor increasing health spending would be the expansion and increased generosity of health insurance coverage. spending on behalf of the currently uninsured would rise, as one would expect and presumably intend. additional benefits would be provided that medicare currently doesn't, such as dental, vision and hearing services. programs most importantly, medicare for all would provide first dollar coverage of all americans' health experiences, no deductibles, no co-pays no
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other cost the federal government -- but a significantly increase demand. now, other provisions of medicare for all are expected or hoped to reduce costs. the study assumes substantial administrative cost savings from eliminating private health insurance and brackets a range of possible outcomes in efforts to negotiate lower drug prices. the big variable here is payment rates. the bill indicates that provider will be paid at medicare payment rates, much lower than those paid by private insurance they would grow even steeper over time. now, importantly these rue deuced payments rates would be,
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we do not know what would happen to the supply, timelyness or quality of health care services if we were to impose sudden provider payment cuts of this magnitude while simultaneously increasing demand. because of this, several other studies performed prior to the bill's introduction assumed higher rates. now, my stud,does not take sides on whether these provider payment cuts would be desirable, but purely from an analytical standpoint, you have to recognize they're much larger and more sudden that they've been historically abilitio been ilto implement when you adjust for the years being estimated as well as for alternative assumptions regarding administrative costs, prescription drug costs and provider payment rates. i hope this is useful, and i
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thank the opportunity to discuss they important aspects of medicare for all. >> thank you very, very much. dean baker is with us. his areas of research including housing macroeconomics, social security, medicare and european labor markets. he's the author of several books. sir, we are honored to have you here. >> thank you. i appreciate the opportunity to speak here. i also have to say it's a great honor. i knew ady from prior days when we were in the fed up coalition to pressure the fed to allow more full employment. that was an amazing effort he deserving enormous credit for.
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three main points, medicare for all is affordable, the bulk should be coming from shifting employer premiums to basically taxes. here we pay twice as much for everything as everyone else in the world. that doesn't make sense. the third point is that lower cost costs can be associated for better care. in terms of the affordability, the basic story is comparable that you're looking at incorporates 2021 to '30. i think those might be slightly
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different years, but incorporating the private payments into under the government budget, about 33.4 trillion by my calculations using cms numbers. first off, though, we know there will be a lot of administrative savings. there was an analysis done back in 2003 that compared our administrative costs with canadian administrative costs and most obviously the huge difference in what we pay up front for insurance, but in addition to that we have providers, they all have to have large number of staff to deal with different billing from different insurers. so using their figures, i calculate that we would get that tab down do 25 trillion still considerable. the second adjustment, we will see more utilization. we are somewhat shooting in the dark here, because we don't know
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what happens when we in essence make more health carefree or cheap for people, but the important point to keep in mind. 70% of our health care costs come from roughly 10% of the population. the point about that is those 10% are ed on medicaid or they have hit their out-of-pocket limits. they're already not constrained. i assume 10% in the calculation. there's some research for that. also there will be some out-of-pocket, houf you have, i assume 1 march of gdp. after we account for the 11.6 trillion in employers payments, we're left with 13.6 trillion. still a substantial bill. but what about input costs? i won't go into these in great detail, but if we look at our input costs, if we look through medical equipment, prescription drugs, physicians payments, dentists, we pay twice as much as everyone else in the world.
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will we get down to other levels? that's an open question. there's no obvious reason we should by paying twice as much for our drugs, we don't pay twice as much for cars, it's not clear why we should pay twice as much for health care 6.6 trillion is estimated to be spent on prescription drugs. the assumption in the bill and most people have analyzed we can get that down. we're not talking about making them cheap. the problem is we make prescription drugs expensive. doctors would be cheap if we didn't give government-granted patent monopolies. i understand there's a rationale, but the point is we could fund the research alternative ways, and they would be cheap. s ady and his family shouldn't have to pay for stress. that has to be a negative in
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terms of care for someone, a cancer victim, someone else suffering from a serious dise e disease. they're drugs we helped create that problem by granting patent monopolies. last point on the transition, i would be cautious how you do it. first off, fix medicare. it's absurd we don't have an out-of-pocket limit on traditional medicare. we need that. secondly, not incorporating the drug benefit, we don't have stand-alone plans, why do we have that some medicare? it raises costs. and we overpay the medicare advantage plans. a recent analysis found we overpay by roughly 13%. no reason for that. secondly, in a transition, i would say allow a buy-in, have a competitive medicare plan,
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reduce input prices how about lowers the medicare age to 64? a great down payment. we have to be careful on how we get there. >> thank you very much. thank you. she's are instrumental in developing and promotings she speaking add rites --
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>> thank you, chairman, members of the committee. let me begin by saying i believe there are important shared goals for health reform. everyone should be able to get health coverage for access the care they need. it should be affordable. people should be able to see the doctors they choose. we must guard quality of care, and we must protect the most vulnerable with a strong safety net. millions of merges are frustr e frustrat frustrated. many are simply priced out of the marg. those on who can -- a people are hurting and they feel powerless
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as cogs in the health sector with little power to impact choices or costs. in a country that values diversity, with one list of benefits and one set the of es rules work for everyone? nfc gallery the night the house passed the affordable care act in 2010 and heard member after member talk about the importance of passing the bill in order to finally clef university coverage. nine years later in calling this hearing today, you acknowledged the growing interest in this bold proposal.
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what happened recently in colorado and vermont when they tried and failed i think it's important to study. i believe the growing presence of government in the it a significant contributor to its dysfunction, government officials not consumers, increase get decide how much will be covered, how much to be paid who is eligible to receive the third-party payments lead to significant disruptions. insurers and others must respond to government rules and regulation, shoving consumers to the bottom of the health care totem pole. we need to look at they problems and targets appropriate solutions that empower consumers and build on what works. medicare for all, is virtually
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unprecedented, and it is difficult to anticipated impact of this new system the bill implies -- by global -- paying doctors and hospitals at medicare rates would force many to close or significantly cut back on services, and would worsen the existings physician shortage. we do know from the experience of other countries that global budgets and centrally determined benefit structures lead to rationing, waiting lines and lower quality of care, as i describe in my testimony. tragically, it is often the most vulnerable that are left behind. many americans would see it as severely disruptive to lose their current coverage, as well as job-based health insurance would be shut do you think. 173 million americans go ahead
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health coverage through the workplace, a highly valued benefit. my college badger says this is a center pillar. it produces nearly 3 to 1 ratio in value to tax expenditures, employer plans also pay doctors and hospitals more than medicare and medicaid do, providing the margins that most need. employers also have more flex independent to 25i8or insurance to the need of their workforce, to advocate for them and provide education and incent irving about good health. i describe in my testimony targeted solutions already until way to give more, not fewer choices. i also describe work by the health poole consensus group, which i facilitate, in developing a plan to reduce the
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costs while protecting the poor and sick, including those with preexisting conditions. finally, americans want more now fewer choices in health coverage, yesterday medicare for all would put them on a single government program. when government officials are making decisions about what services to be covered as the legislation explicitly says, how much providers will be paid how much citizens must pay, consumer will have even fewer choices than they do today. it would reduce access to new technologies, stifle innovation and result in the near doubling of the at the tax burden. i would welcome the opportunity to achieve the goals for better access and better protection for the vulnerable. thank you for the opportunity to testify. >> thank you very much. dr. sarah collins is vice president for health care coverage and access to the commonwealth fund. she writes the program's -- she's led several surveys on
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health insurance and numerous reports, issued briefs and journal articles on health reform and the affordable care act. earlier in her career she was associate editor at -- dr. collins holds an ab and ph.d. in economics from george washington university. thank you for being here. >> thank you, mr. chairman and members of this committee for the invitation to testify. my comments are going to focus on gains in health insurance since the passage of the afford kabul care act, the problems people kin to report, and the potential of recent congressional bills to address these problems. the aca brought sweeping change and expanding comprehensive coverage to millions of americans in making it possible for anyone with health problems
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to get coverage by banning insurers or chargesing more because of the preexisting conditions, the number of uninsured people has fallen by nearly half since the aca became law. there's been decline in the share of people reporting problems paying medical bill on people's -- he remains he he 44 million people with insurance, and they have not -- with just over the eligibility threshold
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and medicaid have reduced potential enrollment. and a major factor underlying trends in both uninsured and underinsured rates is growth in health care costs. there's also evidence that these prices explain the wide spending gap between the u.s. and other wealthy countries. there's also evident that the greatest price growth is occurring in private insurance. he several bills have been introduced to address these problems. they all propose to expands the public dimension of our private
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and public health system and may be grouped into three categories -- bills with more public plans to private insurance such as enhancing and reinsurance, bills that give people a choice of public plans lookside private plans, such as plans based on medicare or medicaid. bills that made public plans a prime year source of coverage such as medicare for all bills. these bills are an amalgam of provisions that individually or collectively have the potential to make the follow changes, improve the affordability, benefit and cost protection of insurance. slow cost growth prescription drugs and administration, reduce the number of uninsured and underinsured people. some notable estimates of the provisions include lifting the top income eligibility threshold for marketplace tax credits could ensure nearly 2 million more people, and lower silver
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plans at a net cost of $10 billion. allows hhs to negotiate prices could lower drug prices by 4% to 40%. a medicare for all approach could lower administrative costs from a current 14% of spending to anywhere from 6% to 3.5% of all spending. the estimated effects of an medicare for all approach range from a decline of 10% to an increase of 17%. what has captured the most attention in the debate most shift most financial responsibility to the federal epps, in -- what is notable about the range of national health expenditures estimates under a medicare for all approach is that the increase in
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expenditures is often less than the increase in demand for health care induced by providing comprehensive coverage to everyone. these spending estimates vary widely because of assumptions about the degree of change in provider prices, and administrative costs, but the mechanisms to slowing cost growth cook considered refined and applied not only in single-payer approaches, but other health reform as well. in the absence of congressional absence on improving coverage, many states have stepped up and implemented policies such as reinsurance programs, but improving coverage for everyone will ultimately require federal legislation. expanding coverage, limiting families' costs and slowing cost growthing are achievable goals, and they bills provide mechanisms. i look forward to your questions. thank you. thank you.
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dr. doris brown rye tired, she managed the breast cancer chemo prevent portfolio. she was a wood row wilson public policy scholar, where he research focused on breast cancer health disparities. before i yield, i just want to ask you -- assent to assert boo the report. thee encountered some unforeseen problems leaving the country, so she can't be here, i should say -- as far as i know she's a strong advocate for universal health care. ly yield again. >> thank you, and i hope rep torrez comes back soon.
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hopefully she's not being held against her will or something. >> i think members on both sides of the aisle we do believe there's problems in the health care right now, and then if improvements can be made, but i think we should do this in a bipartisan fashion, because i think really big issues like this need to be done in a bipartisan fashion. when i was in the state legislature, in the state senate, i actually worked on legislation to address surprise medical bills, which have been brought up before. it was controversial, but we got it done. i think we should get things done, even though we disagree on certain issues. i do believe it can be worked
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out. however, this bill is not bipartisan. this is a very partisan bill i'm sure you know most, if not all republicans in the house will vote against it if it gets up for a vote. certainly the senate is not going to hear it, so, you know, i don't know why we're doing this, but here we are. as we have had discussed. several studies have put the extra price tack to the government of a one size fits all health care system is north of 30 trillion with a t over ten years. some states have already tried to implement government-controlled health care, but the price tag is too high. in vermont, as was stated, they want no, because it said that the payroll taxes were going to
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increase by 11.5%. i think it's unclear that this new bill will so much enough our problems, and it's question how any of it will even be paid for. this bill would take it all away. all medicare advantage plans would be gone, and so medicare
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advantage enrollment has almost tripled from about 7 million people in 1999 glue the 2018 annual report of the medicare trustee's release indicates that 37% of medicare beneficiaries are currently in a medicare advantage plan and that this percentage is expected to rise to 40% over the next ten years. also, according to the kaiser family foundation, 88% of medicare advantage enrollees have plans, which include prescription drug coverage and about half of these beneficiaries pay no premium at all, which is the case of my mother. my mother is on a medicare advantage plan, she loves it, she doesn't pay anything extra for drugs, and i can tell you that if we took this away from
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her, she would not be happy. if we forced her into another plan, she would be confused, because it's difficult. as you all know, to navigate this whole health care system. so i wanted to point out -- i got some numbers of how many people are members here that are here present today have their constituents on medicare advantage and that would lose it under this bill. so the first one, the one that has the most people under medicare advantages actually representative morelli 98,360 of your constituents, or 66% 4% of all medicare population has medicare advantage in your district. ms. shalala, 63%.
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i come in third, 75,887 of my constituents are currently on medicare advantage, which is 44% of all of the people on medicare in my district. i can go on and on, but my point is medicare for all would take away all of this from everyone. so my question is -- to ms. turner, what do you think about that? do you think senioring will be happy that their medicare advantage plans are taken away? >> the medicare advantage allows seniors to voluntarily, as you said, enroll in these plans that provide coordinated care, integrated care, so they can have one plan with their physician coverage, their hospital coverage, their drug coverage, they obvious provide additional benefit, yes, i think seniors are gravitating to these
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ambulance, because they give them more resources to deal with an evermore complex health care system. they highly value it. now about 20 million seniors overall are on medicare advantage. as you say, the number grows because it provides coordinated, integrated benefit. >> and my next question really has to do with how the bureaucracy would work until this program. i would take to take a few minutes to walk through what i understand the process of hospital would need to go through to fix a leaking roof under this bill. so let's start off with a simple example, and what happens under the current system. the room is leak eggs, the hospital administer or maintenance division calls somebody out to inspect it. maybe they get a couple bids, decide on a contractor, and the
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leak gets fixed. pretty simple, but what ha has since the hospital has a provider agreement, it needs to be funds from the government capital expenditure budget to fix its roof. they have to submit an application to the regional director. once they submit the application, they have to wait, wait until the regional administrator decides to review the application. how long will that take? what happens to the roof in the meantime? but that's not the end of the process. after it goes through the regional director, the secretary of health and human services has to review the application and decide whether to approve the application, and how much money should be provided. now, i'm sure that the secretary of the health and human services has many more important things to do than go through applications for fundsing of a leaking roof. so how long does that take? who nose? this bill doesn't set any limits
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on either of these two review processes, so a hospital could be sitting for months in line, waiting for their application to be reviewed. we all know how painful it can be going to dmv, the department of motor vehicles, sitting in that line, waiting for your number to be called. imagine having to go to a federal department of motor vehicle for every little thing you need. you need a new x-ray machine, new application and wait. need to buy the software upgrade for your electric health records system? new application and wait. and every single medicare for all provider across the country will be forced through this one system we need less bureaucracy in the system, not more. so that is a problem i see. also, ms. turner. you have spoken about wait times
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in your testimony in other countries who have government-run health care. is there anything in this bill to protect the american people from astronomical wait times? >> there's not. i do believe the promises being made evokes for me that your health insurance premiums will go down by 2500 a year for a typically family. everybody can keep their doctor and keep their plan. it's easy to say these things, but when you wind up with a system that's promising free access to the system without any checks, it is impossible to imagine the current system being ability to meet that demand without having ever-lengthening queues, that of course is what we see in other countries, and why the phrasier institute keeps track and why in the uk people can be waiting for a year for
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surgery, in canada, the hospital may -- the region may run out of money. if you had a surgery canceled in late november, sorry the hospital is not doing any more surgery this is year, get back in line. speaking of wait times, you know, it wasn't that long ago that phoenix's v.a. medical center was in the news and the spotlight because of really long wait times for our veterans at the hospital some of the claims were that vet raj died while they were waiting. so one of the solution that has been worked on and was supported by our late senator john mccain was that there be more freedom of choice for the veterans outside of the government-run health care plan, so that they could go see a private doctor if the wait time was too long.
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now, to me, ms. turner, does this seem like the opposite approach? we're going to more government-run health care instead of allowing patient choice? this plan is more comprehensive in bringing everybody and virtually all systems undered federal government as control. even in the uk you can buy private insurance. in canada you can come to the u.s. the mayo clinic in rochester has a lot of patients that are canadians coming to the united states. so the fact that people would have a difficult time finding a private option in this country i think would concern a lot of people. >> thank you. it certainly concerns me. >> congresswoman, may i make a comment about medicare advantage? >> can i ask dr. blahaus about a question first? and then if you have time,
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certainly. >> will this provide free health care for illegal immigrants? >> well, the bill i analyzed indicates that it would be -- the benefits would be provided for every resident of the united states and it's left to the secretary of hhs to basically promulgate regulations that define a resident. there's nothing in the legislation that excludes the undocumented immigrants from receiving benefits. my working assumption is they would be eligible for benefits. thank you. as you already know, i come from a district where the number one, the number one concern is border security and illegal immigration. i know we all come from different districts. i can tell you that my constituents, and i would guess the majority of citizens in the united states, would not feel happy that they are going to be forced to pay for illegals that
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aren't citizen free health care. so with that, i am done with my questions. sir, you had a comment. >> medicare for all would deliver all of the benefits currently provided for with medicare advantage. seniors wouldn't lose the joys every paying for medicare advantage. they would receive better coverage for no cost. >> thank you. and thank you for your comment. i can tell you firsthand experience, my mother is on medicare advantage. it took quite? time to figure out which program was the correct one for her, and now she likes the doctors that she has, she's happy with that, she doesn't like changes, and my understanding is that this bill would take away that program and require everyone, everyone, no matter what they are on, if they're on medicare advantage or not, they would all have to take
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this government-run program, and i just find that unacceptable. it's not choice, it's government-run, mandated health care. thank you. i used back my time. >> i no the doctor was being recognized. >> i'll be real quick. one thing that is worth pointing out is regarding undocumented immigrants, we're already providing care for them for free in the most expensive way possible. they're coming to the e.r. because of that 1986 law signed by ronald reagan, and they're getting care, and no one can stop them. it's the most expensive place to get it. medicare for all would provide such patients getting medicare, but in a more fiscally responsible way. >> thank you, mr. chair. sir, i thank you for your testimony. but most people in the united states are not going to voluntarily want to be paying for illegal immigrants free health care.
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so there's a difference between people coming here illegally and showing up in the e.r. -- and by the way, we have a huge crisis at the border, and i hope i'm going to introduce several pieces of legislation, and i hope that republicans and democrats will get on board and realize we have a crisis at the border, and we have to mitigate it, but i can tell you, i go to a lot of different meetings in my district, and quite frankly throughout the state, and there's not going to be anybody happy about paying their taxes for free health care for illegal immigrants. >> it's not good ideology. we're already doing that. the on difference is we would save money. >> well, we can debate this. obviously we disagree, but i've heard loud and clear from people consistently they do not want their taxes to pay for free health care for illegal immigrants. thank you.
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i have a couple requests. first, without objection. i boo like to insert a letter from the washington community action network, with 44,000 members. i'd like to insert a her from the labor campaign, with, eight-state labor federation, and i'd like to insert a letter from the social security works, an organization which seeks to improve the economic -- a letter from dr. john adis, a dr. in west virginia. and a letter from charlie, was born premature by before the age of 3. she had suffered through more surgeries, physical therapists and injections that most of es deal with. her medical costs added up
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convictionly. much of that was paid for out of pocket. the financial devastate that forced her family to make he tough choices highlights the need for adequate long-term care in this country. in the story she says, long-term support and services included in this bill are crucial to families like mine. the bill would provide mandatory coverage of community-based services that people with disability need and want. . i want that in the record as well. dr. blahaus thank you, it's a personal thing for me, about you when talking about the issue of -- to this group of people as undocumented immigrants, i much prefer to them. it's just a personal thing with me. i i don't think anybody in this world is illegal.
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i would just say to ms. lesko why are we doing this hear? we're doing it because many of us i think are concerned about the fact we have 29 million people who do not have insurance, over 40 million people underslurred or afraid to get sick, and we need to do better. the system we have this place is deeply flawed, and hugely expensive. we all think we can do better. i think medicare for all is the way to go. that is why we're here. i would love to come up with a bipartisan solution here, but i will remind mea colleague, i've been in the minority for eight years, and every time there was a bill to repeal the affordable care act, i don't ever recall being asked you have to a discussion before we move forward. i know mr. barkin had an
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additional -- >> you said you're not sure why we are doing this hearing giving that the republican-controlled senate won't pasch medicare for all. first of all, if you don't remember, i want to remind you we last ran into each other in arizona during your election. at that time when i asked you about paul ryan's plans to cut social security, you had no idea what i was talking about. well, it seems you have chosen to not get your facts straight today either. why are we having this hearing? to keep people alive. >> thank you. >> thank you. mr. chairman, if i could respond. thank you. you know, the reason that i said that statement is because we're going through the rules committee, first of all. this bill is not being heard in a regular commit year -- >> we, we are -- >> also, i would like -- this is
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a -- this is a big issue, and i do believe we need to have high-quality health care at a reasonable cost for patients. i concede that we can definitely improve on our health care system, but something this big? my point was something this big, this major, i think both parties need to work together. we're not going to agree on everything. i already know this. i did pension reform in my state. i did surprise medical bills. i did contentious things, but we worked through it. i know that, you know representative cole has said that in the past here, he has worked on big issues and by partisan fashion. that's what i think we should do. you must concede that you don't think this is going to pass, because you didn't ask for ink put from republicans.
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even though we're in the minority here, the senate is still republican, and you still have a republican president. so that was my comment, why i said that, because we -- i would hope that we would work on something that is actually going to pass. >> thank you. again, we're the rules committee, the oldest committee in the congress, one of the committees to which this bill was referred. i hope all the other committees do hearings, until like whether my colleagues were in charge, there were no hearings on these issues. in terms of input, everybody is offering suggestions, we have witnesses who have all kinds of opinions. this is what you're supposed to do. this is a deliberative process, right? so i just -- i mean, i think this discussion has been good. i don't agree with most of my
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colleagues, but i think it's been a good discussion, and we are going to continue beyond the committee. having said that's correct i notice yield to mr. morelli. >> thank you, mr. chairman. first of all, thank you for organizer this. i think this is the appropriate place to begin the conversation around health care. i would congratulate congresswoman jiapal for introducing an ambitious piece of legislation. this is an important discussion about america's patients and to ensure quality and affordable health care for all of our citizens. tomorrow i should be celebrating my daughter's 31st birthday from breast cancer. while it's a personal tragedy for my family and myself, we are
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hardly unique. i don't think there's a member that this room, in this body that hasn't been percentagely touched by tragedy as it relates to health care. after making what i consider significant progress, we're backlieding now toe end of 2018, the percentage of u.s. adults reached a four-year high. more than 1 million people have lost coverage since 2016, almost 14% of americans are without health insurance today. those are numbers we haven't seen since the enactment of the affordable care act. this is part because of the actions by the president.
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and repeated attack, and essential family planning services. the fact is donald trump does not have a plan to address health care unless you consider dismantling and stripping away protections in people, unlie the present members of this house, who believe it's critical we address this crisis head-on, whether it's this plan or others. he improved patient experience and ensures every person in our nation has coverage. i think the american public has
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been clear. they want properties in and a lifetime -- based on preexisting conditions. the instants even prepared to -- which i consider reprehensible at the very least. our system has sdersz shortcomings and concerns, and i think this hearing is entirely appropriate. having said that, there are a number of concerns i have, a number of questions i have about financing this system. health care cost trendlines, cost containment measures, some of which have been talked about, provider reimbursements, so i would like to talk, perhaps -- i
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would ask anyone to feel free to respond, but i note that dr. collins, you have talked a bit about this, but dr. baker as well. currently as i look at it, we spend, according to cms 3.5 trillion a year, and that you will all payers, private insurance, pbs insurers, and my back of the envelope, which is not very good, but even if you assume that 3.5% increase in the cpi and health care, which is pretty low, but let's for argument's sake, we would be 4.75 trillion over the next ten years. most of that goes to health care spent in hospitals and physicians. i'm trying to understand medicare payroll is about $289
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million out of what is a 3.5 trillion spent. so as i think about it. i was trying to figure out how this works, we saw today in numbs number of times, some corporations are paying zero taxes, some getting rebates, how we make this work -- i apologize for a long question. i recognize people are paying premiums now. those premiums would presumably go to pay -- there's clearly a movement of those, but there are disparities as well. some businesses pay for health insurance right now, coverage for their employees, others do not. it's not as though it's going to be a smooth transition. if you could talk about how the financing would work in some detail, and if you have thoughts about income taxes, payroll taxes, other forms of taxes or premiums to meet that spend.
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>> i'll take a stab at that. first off, you know, we'll talked about this. there are clearly large administrative savings. most immediately we know the private -- spends probably about 25% what to pays out in benefits, with regards the medicare -- traditional medicare sum is less that 2%. you know, so that allows for very large savings. >> i apologize, but private insurance is about a third of the medicaid or health care spent, about 1.2 trillion right now if the estimate 18% savings, translate to about 214 bim on, so i'll give you that. but i want to talk about the tax.
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so i'll give you that. s. >> there's also administrative costs incurred by hospitals, by doctors' offices, other provides which would largely go away. i also -- i talked about this in both my written testimony we do have to reduce our payments to providers. i think we have to get thor closer in line with the rest of the world. how do you get the rest of myomine? i think a payroll tax has to be a very big part of the picture.
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>> just as we've had other mandates on employers then i think you would have to -- a payroll tax would be equivalent. senator warren running for president, i think that's -- i think we can get more taxes. >> does anyone have anything to add to that? >> as -- as providing prices and private insurance, that's a key
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growth push. >> as i sort of thing about it, and this is --, in my district and around new york city, essential it's. >> are too low by proirs. so, yes, the literature on the cost shift, which is a cost schiff from lower payments, and
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found that the higher marges, that providers were getting, the higher prices providers were getting were going towards more administrative costs, higher margins, buildings, other things like that. and there's an enormous amount of literature. so is it your argument we had not substantial family the quality of providers or not impact their ability to provide service? >> so a key thing about the health care market that is so different from every other market is that prices drive cost s so they are a fair reflects
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shun. so we know there's a huge amount of evidence right now that the major growth in health care costs is occurring in what we pay providers and provider insurance. one of to start focusing on that issue. what these bills have done is bring this issue up. >> some of you have looked at plld be a comparison of what a surgeonen of that kind would be compensated for?
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it would be considerably lower. you know, i had arguments with dreg about their compensation, because they all thing they get too little. to my view that's not closely offsetting, but that is a point to keep in mind. you see it is important to insurance we have a clear way we paid for par more expensive thing lice wars of choice. we can afford to do this. we just need to decide to makes it happen. >> i appreciate that. i agreed with you, this is ultimately about what people are
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willing to do. if we didn't go into it with a clear-headed view, i think we're doing a severe disservice. a it relates to cost containment, i was involved in a practice transformation grand i chaired back in rochester to drive down -- chronically injured or chronically ill -- we had some success. i'm not sure where i see the precious to do that in this seasonal. from my mind, unless you have a different view, this is essential a fee for service.
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i'm not sure how you get dirt a the plan and the comprehensiveness of the services that you're going to provide, it behooves the plan to have those coordinators that are part of it that's going to go out, and whether it is community health workers in cancer -- of course, we call them navigators, that's going to make the patients understand how to utilize the system in a more appropriate way. so you are talking about a patient/provider partnership. and you're going to bring about better care. you're looking at -- whether you're providing them nutrition and food services, exercise programs -- >> well, and i don't mean to cut you off. i think those are all great. i agree with you. the goal here ought to be to try to reduce the health care spend or at least bring the cost curve
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down. and you can do that with some of those things. i'm not sure i see in a fee for service system that this essentially moves to where the incentives are to do that. i'm not sure who provides that kind of coordination. because i don't see incentive in this. i just see fee for service. i'm really afraid of that, because i think it blows out potentially the long-term health care trend lines in terms of cost. >> well, i'm looking at it sort of in a prepaid way. so you have incentives built in the program. if you are basing it on the kinds of system that we have in tricare, or you're looking at -- and, again, that's a large, integrated health system. or even some of the services that's provided under the v.a. so you're focused more on the preventive aspect of it. you want to keep and tricare and all services want to keep our patients out of emergency rooms. and so you build in emergency care facilities, you then expand your hours. you get those people to practice
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prevention. and, again, that's not utilizing the cost that's there and then they can get an incentive for keeping people well and healthy. >> well, and i completely agree. if there's a system that allows us to do that, and i'm not sure this entirely sets up the incentives -- >> local billing is exact -- global billing is exactly how we bend the curve. no more fee for service. >> well, i agree. i'm just not sure that this proposal contains that. but -- and if it does, what do you do in a metro region. i apologize, mr. chairman. i know i exceeded my time. i appreciate your thoughts on it. >> do you want to finish -- >> one more thing. medicare has been a leader in innovative payment practices for providers. and care organizations. there is no reason why those kinds of innovations could be brought into a bill like this. >> haven't those largely been
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done by the -- some of the private insurers that create the programs around medicare? because you use private insurance right now to do it. i'd love to talk to you maybe offline, mr. chairman. >> i yield to mr. cole. he has some unused time. >> thank you very much. i appreciate that, mr. chairman. i only be hahave a couple minut. i'm going move along rapidly. committees are primary health care jurisdiction are moving legislation that would make fixes to the aca. and some of that legislation literally could be here in the next few weeks in front of this committee. so my question is this. and if you can, give me a yes or no, i would appreciate it. and i'll start with you, ms. turner. do you support abandoning the -- these committee efforts to reform the aca in favor of medicare for all? >> the trump administration is trying to do a lot of things to give people more choices who felt shut out of the market. some are short-term limited duration plans. >> i've got to ask for a yes or
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no or i'm not going get through. >> so should they -- >> should they abandon those efforts and focus on medicare for all or keep moving with efforts to fix the aca? >> i think we should do what we can to fix the aca through administrative and legislative authority. >> i agree. >> i think that's a false choice. i think we could do both. >> it's really not a false choice. there's only so much time up here. and there's only so much bandwidth to move something to become law. we have debated a lot of legislation this year that is not going to become law. we have a chance, i think, to make some fixes we would probably all agree on in a bipartisan sense. so thshould they continue to prioritize that? >> if you need more bandwidth, i'm happy to help. a lot of citizens will sign up for this. >> i appreciate that. but i don't think that's quite within your power legislatively. >> universal health coverage is one way to fix it. >> i think there are a lot of good ideas on the table.
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and many bills that would move the system towards universal coverage and even small little fixes could help millions of people. >> both, please. thanks very much. >> if you could do fixes that would move the situation forward, do that. but i just don't see this coming. >> i'm out of time. can i ask one quick question? >> absolutely. >> usual very kind, mr. chairman. let me ask this. is medicare going broke now? >> the medicare hospital insurance trust fund is projected to be insolvent in 2026. that's less than half of medicare. the other half of medicare, by definition, cannot go insolvent, because it's statutorily constructed so that you always give it enough money. but it also has financial strains going forward. so both sides of medicare are in trouble. >> let's fix what we've got first before we launch into a new system. i mean, i think there's a lot of risk involved in this.
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we have a system that millions of americans depend on that's going broke right now under the current financing mechanism we have. >> for the affordable care act, it's projected to go broke in 2019. this year. >> it suggests to me we should be working on that, not medicare for all. >> another two minutes for mr. woodall. >> if you're offering, mr. chairman, i accept. and if i could ask unanimous consent to mr. chairman, i've got a letter from the partnership for employer-sponsored coverage. >> without objection. >> as you would imagine, they supported employer-sponsored coverage. and dr. collins, i just wanted to clarify. i think in response to a question the chairman asked you about plans going away. your response was, it is not true that anyone would lose their insurance coverage. i think we so often conflate insurance coverage and health care access. i think what is actually true is everyone would lose their insurance coverage, because health insurance would no longer exist in america.
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health care would exist in america. am i misunderstanding the dynamics? >> well, this is a single payer insurance plan. so people would -- have access to a set of benefits, and that would give them access to health care. i guess i'm not understanding your question. >> let me go to one of our actuaries. the reason the trust fund is going to be insolvent isn't that we're planning to stop providing care to people. it's that we're -- we prefunded it through payroll taxes. there is no insurance out there. we just have a pot of money and we're using that pot of money to pay for every claim that comes through the door. we're no longer insuring against risk. we're indemocrnifying folks. >> medicare for all. you're basically providing first-dollar provision for the entirety of people's health care. so in a sense, you're not ensuring them against the risk
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of a large future health expense or unforeseen event. you're basically providing payment for every service. routine and large. >> and i wasn't trying to wordsmith. i'm just saying, there is a different set of challenges to fix the insurance system than to to fix i'm sick and can't get access to care system. i haven't heard mr. navi care two hoots about that. tell me from a financing perspective -- i appreciate mr. morelli's perspective. we serve on the budget committee together. we're not paying for the promises we make today. we're not paying for the wars we're in, we're not paying for the health care promises we make. i've got $3 trillion in revenue, $4.5 trillion in expenditures. i'm happy to suspend pend my chs money. this is an issue important to all of us. what is the order of magnitude that your numbers suggest we would have to increase our individual citizen contribution to pay for medicare for all?
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>> again, this is on the national level. we're talking somewhere between 32, $38 trillion in additional funds provided to the government. on a per capita basis, $10,000 per head. to your other point, we have a very substantial financing shortfall in our current medicare system and have not figured out how we're going to finance that yet. that is a much more manageable problem than trying to finance what is called medicare for all. it's actually sort of a national single payer system that differs from medicare in many ways. but that is several orders of magnitude more difficult than financing current medicare, which we have not yet figured out how we're going to do. >> that shortfall is not a republican or democratic shortfall. that's just an american shortfall. when you're talking about your numbers, these aren't republican or democratic numbers. there are conservative groups who are computing those scores and liberal groups computing the same order of magnitude? >> the estimates are remarkably consistent, regardless of who
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makes them. i provided a table that shows if you adjust for the years being estimated and particular assumptions for administrative costs or drug costs or provider payments, you can basically get a lot of these different estimates to line up. and they're pretty much all in the same ballpark. >> i'm afraid i'm out of time. i would welcome my chairman's indu indulgence -- >> we would let you go on for two minutes. >> i thought i had abused it already. >> let me, before i yield, let me just say one thing. first of all, two things. dr. baker is going to have to leave at 3:10. so i don't know if there is anybody who has an urgent question for dr. baker. he's going to have to leave. a hard stop. so thank you. let me just say one other thing. the idea of, you know, should we fix the affordable care act or should we do medicare for all or single comprehensive, i believe we can do great things here if we want to. right? we can walk and chew gum at the same time. so you can -- if you have a fix ready to go tomorrow that would
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help more people, we should just do it. doesn't mean you can't do this. i mean, we ought to be able to go on both. that's kind of -- you know, i just -- always refuse to believe we are incapable of doing great things. medicare is a great thing, right? social security is a great thing. so it doesn't -- i mean, we don't have to be picking and choosing. we ought to be doing both. and just to my colleague, mr. woodall, i think i know what he's trying to do. he's trying to get a sound bite to say that people are going to lose their health insurance. you know, to add to the -- >> mr. chairman, i don't believe you're suggesting that my goal here is to get a sound bite on an issue as important as this one. >> well, i -- you know, i hope i'm wrong. but it just seems to me that, you know, the difference between, you know -- getting provided -- well, anyway. i shouldn't go down there. this is a mistake. i won't do that. i'm just simply saying that i think what is motivating us here is the fact that the system we
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have right now is deeply flawed. and that we have 29 million americans without insurance, over 40 million americans underinsured. people are afraid to get sick, afraid to take their doctors' advice. there is something terribly wrong. and we need to fix it. and i know this is politically a hazardous topic to go down the road on. but we have to do it. and i believe that the -- this is -- this is a political condition, what we're faced with right now. we can fix this. and we have the resources to fix it. we have everything we need to fix it. it's whether we have the political will to fix it. and we'll see. i hope we do. that's why i think we can do small fixes and we can do a larger piece here. but anyway, let me yield to ms. s shalala. >> thank you, mr. chairman. i actually think this has been a smart hearing with very smart people and very good questions. i want to thank all of my
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colleagues. the truth is, if any of us had a chance to sit down and establish a health care system from scratch, none of us would have designed the system that we have. it's a system in which we've cobbled together over the last half century or so a number of programs to fill gaps. some people may call them incremental. but i don't consider medicare and medicaid or the children's health insurance plan or the passage of medicare part d in the mid 2000s or the passage of the affordable care act small steps. we americans are not afraid of giant steps. and certainly congress has demonstrated over and over again that they have the backbone to take on big problems, put their arms around it. and try to find a solution. in fact, that affordable care act actually extended the medicare -- the h-i fund by
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eight years once we established it. because it offset a lot of costs that would have otherwise been there. i want to see more changes in the health care system. i want to get to the place where a family does not have to pay $9,000 a month to allow him to live at home with his wife and child and where parents are not walking out of dr. navi's emergency room with treatable conditions. we need that kind of health care system. i'm for universal care. we have spent a lifetime filling in the blanks where the private sector couldn't fill in the blanks. government has stepped up for the working -- for working folks, for the poor, for senior citizens, time and time again. but now what we've got is a system in which we thought the employer-based system was going to be the core of health care forever in this country. we adopted it after world war ii. the unions bought into it.
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but it's deteriorating. and anyone that has talked to employers or has looked at the statistics sees a deterioration of the employer-based system. i know that. i've been an employer. i've sat on corporate boards. ceos are struggling with trying to predict their health care costs for the future. and what have they done? most of us have shifted more costs to our employees, increased the deductibles. in fact, high deductibles have become the norm here in this country, as we've tried to contain health care costs with very crude -- with very crude instance. throughout all of that, medicare in many places -- in many ways has been a star. because it's been better at reforming costs, at trying different kinds of reforms. but more importantly, from my point of view, at containing costs. but in many -- i'm perfectly willing to debate the cost issue
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and how we're going to pay for it. but we're here because the employee system is deteriorating in front of our eyes. as our companies have changed and as we have moved to a big economy. smaller and smaller companies have lost their leverage. and because we want better outcomes because we pay twice as much as anyone else in the world for our health care. i'm far more interested in focusing on outcomes and how we get to outcomes and how we get an integrated system. but i'm for universal care. i think medicare for all is one way of getting there. and looking at the v.a. and its integrated care system, at tricare, at the military health care system, we've got lots of experience. and i'm not afraid of transferring our system if that's what we decide to do, because we've got platforms. we've got lots of experience in taking large-scale problems and integrating.
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we've got lots of platforms, medicare happens to be one of the platforms that we could do it. i could build the system. i don't think i could do it in two years, but certainly our experience in the public system of taking advantage of platforms and extending it to more and more people is certainly possible. dr. collins, i'd really like to start with you, though. i have some questions. private insurers have been less effective at controlling costs than medicare itself. in fact, private sector costs have gone up faster. you've talked about that a little bit. but you haven't explained the reasons for it. is it because they're a smaller part of the market, the medicare? could you talk us through the reasons why the private sector -- before we laud the private sector, let's talk a little about the deterioration as well as the failure of the private sector to be able to control costs themselves. >> great question. one of the main reasons that
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we're seeing the price increases that we're seeing across the country and private insurance is the fact that prices are set through private negotiations with -- between providers, hospitals and insurers. and so insure -- providers, particularly in concentrated markets, have a lot of leverage to increase prices. >> this is the complaints that hospitals have with -- they don't have enough docs to negotiate with, right? >> or they don't -- >> they don't have options. >> right. so insurers want a hospital in their networks, because it makes their networks more valuable. so then they -- that cost then gets shifted to the employers. so the employers have a higher premium than they might otherwise have. and they share those costs, they try to lower those costs, premium costs, by increasing deductibles for employees. employees are already making wage concessions, but they're
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having to have benefits with higher deductibles that actually give them less coverage. that's really kind of a simple way of looking at how prices are determined and how that kind of filters through the system, and hurts employees. particularly employees at the mid range of the income distribution. >> doctor, do you have anything to add to that in terms of why the private sector has more trouble negotiating cost containment? >> i really don't. i'll be brutally honest. perhaps not that informative. but when i was doing the research for my paper, i found this area bewildering. and i think dr. collins has a clearer view of the literature than i do. but obviously, you know, i became informed in the course of the research of the paper about the discrepancies and payment rates between medicare pays and what the private sector pays. and i ran into a lot of conflicting explanations as to what was going on, why it was going on and what would be the
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consequences of making various changes. i ultimately concluded that it would be a fool's errand on my part to venture too far into there and try to explain what was going on. so instead i simply flagged the issue. i noted where the payment rates are relative to hospital costs, where medicares are. i flagged the issue, identified it. and noted some of the conflicting interpretations out there. but i fell well short of being able to explain it. >> do you -- any of you, do you know very much about -- i sat on the corporate boards. and it -- one of the things that was apparent to me, particularly on health care boards, is they're following the medicare decisions on payment. that it's not the private sector setting up their own group to decide how much to pay. they're actually watching medicare very carefully. and in many casways, medicare i driving that cost. is that your experience as well?
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>> i'll just sum it up really quickly. i think it goes to congressman morelli's question about medicare and how it could lead in innovation and payment. bundled payment, all kinds of different ways of lowering health care costs. so it has been a leader. the medicaid program has been a leader in lowering health care costs. there's not a lot of fat in the medicaid program or the medicare program. in fact, what's really driving both those programs is enrollment, rather than prices in the private -- in the commercial sector. >> do you know a way in which -- without an integrated system, we can get better outcomes? is there any experience in this country in getting better outcomes without an integrated system? it seems to me the v.a. has better outcomes. tricare has struggled with outcomes, but have done a pretty good job, as has the military health care system. >> but both of those are sort of integrated systems, so i don't
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think there is one that is not an integrated system. and i do want to add the comment, in terms of the medicare costs, particularly for mr. cole, when you set -- and i'll just use the drive-by mastectomies they had for a while where patients had to stay in the hospital for a short time, get this procedure and go, so you could lower the cost for those hospitals. the outcomes have been very different. they send patients home when they have congestive heart failure and the plans are penalized, because within a certain time period, those patients are coming back to the hospital. it's really not a cost savings under that program. you have to, again, practice better health care if you're going to lower those costs. and that is an integrated system. >> there's no question that medicare advantage has provided some integration, depending on the plan. and certainly in florida, in my
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district, over 60% are in medicare advantage plans. they feel like it. but we're paying more for it. we're paying at least 13% more for medicare advantage to get some integration much but it's still pretty fragmented when it comes to referrals for specialists. and that's -- it seems to me, where the system breaks down. because medicare advantage, often the hmos come together. but they're mostly providing primary care. and then they're contracting for the specialty care. and contracting with as low costs as they possibly can for the specialty care. but i haven't seen the outcomes research on medicare advantage. have any of you seen that outcomes research on medicare -- as far as i know, the research has not -- even though we're paying more and people may be happier because they're going to one place, i would argue that medicare advantage is as close
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to medicare for all as we're going to see. medicare for all as we're going to see. but we don't know very much about the outcomes yet. and i assume that that is your experience, as well. and finally, let me give mr. barkann a chance to talk a little about, again, about this fragmented health care system. how many -- how many interactions have you had to have with your private health insurance system in a month? can you give us a feel for some of that? >> maybe five or ten.
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>> you must be the best friend of your insurance company. these are all appeals, i assume, for them to cover more quickly? >> i cost too much. >> mr. barkann, of all the people i've met on this earth, you are the last person i would use that for. thank you. >> congresswoman, i want to say how important your voice is in this debate. as chairman mcgovern said, this is a question of political will. many democrats are going to follow your lead on this. so i just want to plead with you to summon all the courage you can and help lead our country to a more rational, just and humane system. >> mr. barkann, i'll try. i'll try. thank you, very much. i yield back my time.
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>> thank you very much. and yield back to mr. cole. >> thank you, mr. chairman. one second please. as i was -- mr. chairman, as i was thinking about this, i thought of the different, like, fire, police, teacher unions and associations that negotiate their health plans. and sometimes it takes them years to get what they want. and they often trade better health plans in lieu of higher wages. or salaries and other things. and so ms. turner, would this bill take away the current health care plans negotiated by, let's say, the teachers' unions?
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>> yes, it would. and i think one of the issues that would be on the table is, what about the compensation that they have foregone in order to get those benefits? i think that's going to be something that could be very, very disruptive and something that would be of particular concern. because they make considerable sacrifices in their take-home pay in order to get these generous health benefits. >> thank you, ms. turner. and members, i'm just actually a little surprised that some of my colleagues would, you know -- understanding these different unions, fire, police, teachers, negotiate a lot. and i know they do, because they came to me when i was in the state legislature. and take away that and replace it with a one-size-fits-all government-run plan. thank you. i yield back. >> and if i could just acknowledge congressman chewy garcia from illinois who is
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here. and we want to thank him for coming by. >> thank you, mr. chairman. let's talk a little bit about global budgeting and what it means. so if you have a budget and you have more expenditures than your budget, what happens? >> well, then you're going to have to cut something. you're going to have to cut the excess or restrict what you're paying. >> so could you envision a system where that would perhaps result in the rationing of care? >> well, yes. and if i might elaborate a little bit. >> please. >> there's been some discussion here about the effects of medicare for all upon the demand for services. the economic literature is actually very, very clear and unanimous on this point. people do use or demand more health services when their insurance covers more. there is a very famous rand insurance study several decades ago that demonstrated that when there's no cost-sharing, people
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utilize more services. there was a more recent study by coveralls and mahoney about what happens when medicare beneficiaries cover gap insurance that has first-dollar coverage. costs of the benefits they claim goes up by about 22%. so these are very real, very well-documented effects. so we would expect to see a very significant increase above and beyond currently projected health services under medicare for all. so i'm sorry, but just to quickly wrap-up. at the same time we're going to have various constraints upon supply because of provider payment productions. the urban institute found some insufficiency of supply to meet demand. clearly, something would have to give. >> something would have to give. i agree. and i'm going to assume that the medicare supplementals have to go away under this bill we're discussing today. they would be duplicative and by
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law unavailable to people. it's not clear what the punishment would be for violating the law. i get that. so let me just ask you, on the innovation side, new products, new drugs, new treatments, new devices come to market. i've got to tell you, i deal a lot with people who are affected by coverage determinations by cms. so what happens to a patient? do they have to just wait until the next budget cycle if there is one of these new therapies or new sickle cell therapy? they just have to wait until the next budget? >> that's what we see in europe. we see that access to the most innovative and oftentimes the most effective medicines are absolutely restricted. as i said earlier, the -- we have access to about 96% of new medicines over the last 11 years
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in the united states. in france, they only have access to about half. in singapore, only 18%. so they do provide chemotherapy, for example. but it is not likely to be the newest and best chemotherapy drugs. and then the innovation is crippled, because -- and we see in europe it used to have a robust pharmaceutical medical development, medical device industry. has shrunk because of payment policies in europe. we are now the medicine chest of the world. most new drugs come from the united states, because we continue to pay for them. we pay for the planet. people object to that. but those new medicines are available, because of thein sin testifi incentives the companies have to continue to produce those new medicines. and without that, i think we would find we have nothing but old drugs and leaky hospitals.
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>> right. and we're in the 21st century. congress should be proud of their work. ms. turner, our current medicare and hospital provider rates are mandatory rates set for all health services. that's going to have an impact on patient access, correct? >> actually, the cms actuary said it would cause many hospitals to either cut back dramatically on services -- hospital operations, services offered. and some would have to close. physicians' offices, many would start operating in the red. so, yes, they would be -- they would have -- this is not us. this is the cms actuary looking at the impact. they simply couldn't keep their doors open. >> true story, personal experience. if you're losing money on every patient, you can't make it up in volume. i learned that in the 1980s.
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so doctor, you've made some assumptions regarding provider cuts, is that correct? >> yes. i've examined what was in the text of the bill. yes. so just -- someone asked a question about provider rates in other countries. i -- here's an op-ed from a new york post and i'm going to ask to put it in the record. >> without objection. >> in cuba, doctors make the equivalent of 25 cents an hour. teachers, 21 cents an hour and pharmacists, 8 cents an hour, for your reading pleasure. so ms. turner, britain's national health service cancelled 25,000 surgeries. is this a problem for a one-size-fits-all system? >> it's a problem when you have a strict global budget, and hospitals make decisions about cancelling or delaying surgeries, and people do have -- are impacted. and once again, they get access to fewer of the new treatments.
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if you're in the private system, you do have access to more of the new treatments that are surgeons. if you're in the public system, you may not even know it, but you will have fewer options. >> and i do have to bring up the issue of -- we talked about this offline a little bit. patient autonomy. i've got a paper, mr. chairman, i would like to ask noanonymous consent to put in the record. >> without objection. >> the story of charlie gaard, the sad story where the determination was made by the hospital not to acquiesce to the parents' request to bring that child to the united states where they thought they had a treatment for his mitochondrial disorder. i would ask that be made part of the record. so the 25,000 surgeries. is that isolated in government-run systems, or does that -- does that seem to be pervasive in government-run systems? >> well, there's no one
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government-run system, obviously. and some do better than others at being able to -- >> i've got to interrupt you there. >> yeah. >> the director -- no thought for my personal safety. i attended the commonwealth funds health care weekend. thank you, commonwealth fund, for putting that on. i was the only republican there. the director of the national health service was there. and he did point out to me that there is no single european health service. there is england, there is france, there is germany. canada, i believe, is structured provincially the provinces run. so this thing that we're building, and with no cost benefit analysis, with no double blind control randomized study, no toxicity study. this thing we're building has never -- no one has ever seen a system that is this big. our medicaid system currently is larger than the national health service, i believe that is correct. but this medicare for all bill that we have under consideration
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in the speaker's committee, the speaker's desire to have this bill heard today, that is going to be gargantuan. is that a fair statement? >> a fair statement. and you have to worry about access to care. in the u.k., a commission that helps determine benefits available decided that cataract surgery was not a high priority. and so cataract surgery was significantly limited. if you're -- if you have cataracts and you can't see, that should not be an optional visit. but when you have centralized government bureaucracies deciding what services are available, i just don't think that's something that americans are going to tolerate. >> so as a practical matter, and i don't understand from my reading of the bill, and i've read through it a couple of times. and it is a frightening bill to read for me. but if you can't get your cataracts surgery, and there's an ophthalmologist down the street saying i'm doing these in
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my kitchen, what's to prevent that from happening? and what's to prevent a cottage industry of health care that then develops a black market of health care, if you will? >> or offshore. or indian reservations. they have american reservations, enclaves where you could get private care. >> and so the cataracts are an interesting case study, because during the bush administration, the variable lens that could be replaced during cataracts surgery and do away with bifocals, medicare said, hey, wait a minute, we don't pay for refractive services. so you only get a one-size lens. so medicare patients were then -- it was a pretty uncomfortable position for the bush administration. we're going to deny the best treatment available to medicare patients. and so they had to actually make a -- i remember when dr. mcclellin did it. and i was jubilant. i thought, oh, man, here's a
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balanced billing example we can use. patients were allowed to bring their own money to the transaction to get the state of the art lens so they could read their sunday paper without their readers. i mean, it was -- i thought going to herald a new era of insight in the medicare system. but i was wrong. so -- but i did repeal the sgr. thank you very much. thank you, chairman. i yield back. >> okay. but i want to -- some other people want to say -- i'll use remaining time. let me say a couple things before i yield to dr. navi and who else -- dr. collins. i know, dr. burgess, you said you read the bill many times and then you referred to the global budget. the bill says in the reading i read, there will be a quarterly review of the global budget so we can choose to make sure there are enough funds if there is any problem. that's actually written into the bill. and i know -- i mean, people like to speak in alarmist terms.
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we talk about the affordable care act, we talk about -- my friends talking about death panels, but that wasn't true. it wasn't true then, wasn't true now. >> mr. chairman, we don't have a budget for this year, where are we going to get this budget? >> thank you. and then you also raised the issue of u.k. and canada and said they can't get the latest, greatest services. i'm not saying we should be like the u.k. or canada. i would like to think we could do even better. let me ask mr. collins on this point. does that mean that the u.k. and canada have worse outcomes than we do? >> that's a really good point. and i was actually going to raise that. why is it -- such a gloomy picture was painted of the u.k. where, in fact, their outcomes and those in other industrialized countries with universal health systems are better than ours with less money spent. i also think, congressman burgess, at the conference, the director of the national health service did say they were
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covering car t service, because they made a determination that it was highly effective as a curative therapy. and so they made a decision to cover it. so there's a different metric that's applied i think than we often do. >> i did relate to him that at m.d. anderson hospital in houston, they have come up with a therapy that is as effective but less expensive and can be administered as an outpatient. >> thank you. dr. navi. >> dr. burgess, i did just want to respectfully point out that if we're going to be talking about a hypothetical future where there might be rationing, we need to make sure we don't forget we have rationing right here today. and it's not for the most expensive and the newest drugs or not only for the most expensive or newest drugs, but patients that can't get antibiotics or anti platelet medications. we have that russiationing here today. and in regards to we would be the first country doing this, that's kind of what america is good at. doing things that no one else has done before. >> dr. brown. >> thank you. and mr. burgess, just wanting to
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add to the point that we are really not talking about one-size-fits-all. because we are talking about a universal coverage, but we've moved into decision medicine, where we're trying to give the therapy that is specific for those individuals, and when we take in the social determinants that are very important for those individuals, we know the kind of care. and so it's equity that we're talking about. not equality. >> and i know -- i have someone who just showed me a report that appeared in "the hill" magazine, because she was curious. i said the ways and means committee will doing a hearing on this very bill. so she doesn't have to worry we'll be the only one. i now yield to mr. de sannier. >> thank you, mr. chairman. you're almost done. if you're on this end of the podium -- the panel, i should
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say. you're almost done. but i want to thank you all for your patience. your ability to articulate your thoughts and your professional experience. and i obviously want to thank mr. barkann for your tenacity and your being here and your good demeanor, in spite of difficult personal lauds. so thank you all for being here. i am a little bit flummoxed. not unlike the hearing yesterday, with all due respect to my colleagues. the united states is number one in cost as a percentage of gdp. and as a cost per capita. almost twice of other developed countries -- per capita for cost of health care. but our outcomes are the opposite of what you would expect. 28th in life and mortality. i think close to 30th in infant mortality. so for me, it just strikes me, not unlike the conversation yesterday, about the energy economy and the environment. we're arguing about status quo
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versus a world that's already changing and how are we going to adjust to that. i'm a coauthor of the bill. i appreciate the author. and i think this is a discussion we have to have. as a former small business person, i remember owning restaurants and fortunately, where i live in the bay area, kaiser and the east bay is very dominant. it started in the east bay, so the closed system in kaiser is over half the population of the two counties. where i live, 3.5 million people. and they have been able in that closed system to provide a pretty good quality of care versus cost. when i started in the restaurant business 30 years ago, i could pay easily for kaiser. and pay a portion and then after someone worked for me for six months in full. but then towards the end, i had employees coming to me in tears, one manager in particular, where she couldn't pay the co-pay. so i came out of pocket as an employer. which goes to the statistics about -- ms. shalala talked
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about a little bit, the number of employees -- employers, i should say, paying 100 me% or a portion. and i don't know what the numbers are for small businesses but i would imagine it's staggering with small businesses and the cost of staying in business just not being able to pay at all. my memory from reading is in 2000 or 2001, almost 30% of employers paid 100 percent% of their health care costs. so this model to me clearly doesn't work. so it's a question of what we're going to do about it. like mr. asken, i'm a survivor of cancer. four years ago, i was diagnosed with stage 4 chronic lympho sattic leukemia. i took a pill that keeps me alive. senator durbin said to me recently because he knows of my health struggles, he said how is your health. and i said fine, dick, i have a pill in my pocket i take every day and it keeps me alive. and he said how much does it
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cost? and he said $400 and he said that's outrageous and i said not to me, it keeps me alive. my oncologist said 15 years ago somebody who came in with the same diagnosis and we would sprinkle some water on your forehead and say good luck. now the live expectancy is 85 merz if you can get through the first five years and i'm almost there. and a lot of this as i've become familiar with it and gone to nih actually was developed with taxpayer dollars. a doctor who worked for the army for years and is now at ohio state, that dr. moynihan, the key person. and most of his research was taxpayer-funded. much of the deployment. i went over to nih and met with these young people making 60, $65,000 a year that went to hopkins and stanford and harvard. and they're working at nih, because that's what they want to do. so one of the things to me is apples and oranges. i'm sorry that one of the
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panelists had to leave, because this is directed at him. but i want to direct it to dr. navi, because it will lead into this. what are the real costs to the average consumer? so if we know the numbers about individual costs and outcomes and the gdp, it's a huge disadvantage to us, because if we weren't at 18% and if we were like the japanese at 12% with better outcomes, that money could be going to more productive uses. not that health care -- keeping people alive isn't important. but we could be prioritizing. so the reason why i've been able to afford this, and there's an interesting story in the "wall street journal" i would ask everyone to read about people who are wealthy with my condition and having a challenge paying through private health insurance. i was lucky enough to get elected to be a county supervisor. i chose to take my health care through what was the first county public option of the
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united states when the contra costa health plan was approved, the hmo. and they paid. i'm here alive today because of that. if not, i would have stayed -- a restaurant owner, would have made more money. but now when i look back at hindsight, i wouldn't have nearly the service versus what the out-of-pocket costs would be. so doctor, i have an example from my experience as an elected official. in california, we delegate public health and delivery of services to the urban counties. contra costa, where i governed was. our biggest challenge, whether it's los angeles or all urban counties, is the cost of the clinics and hospitals who do most of the indigent care. so one of the things we did when we rebuilt our county hospital, i was a swing vote. l.a. at the time, their general fund contributions with five hospitals and with an increasing indigent care population was up to 23, 24%. ours was going in the same direction. so we have tried in california to help the counties and say you've got to cap your cost, be
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more efficient. my point is, when we get down to 10%, that extra 15% we spend on libraries, sheriff's department, economic development. so that's sort of the color of money. in your experience as a point of sale person, in different emergency rooms, you see people coming in the door, but their costs are all absorbed differently. but the consequences for who pays and subsidizes those costs are also different. could you speak to that on a personal level and then i'd ask ms. collins to also talk to that. >> sure. i think that if you go to different hospitals, people will be paying differently. and the interesting thing about new york, we have a lot of hospitals that are right next door to each other that accept different types of insurance and different types of payments. so there's two hospitals that i work at that are right next door to each other. if someone comes in and they have insurance, they'll be taken care of, and if they don't, they often get referred next door to the public hospital where they
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end up receiving care and the hospital does not get reimbursed for it. and that contributes to the challenges of that hospital not having enough money, and it creates the cycle. i think one of the good things about medicare for all is that in those hospitals that primarily serve the indigent population, they will be able to make more money, because they'll be reimbursed higher than medicaid payments and no one effectively will be uninsured. every patient will be a paying patient. >> before we leave you, this is another -- so the behavioral health costs. in los angeles, we see we're -- they have been pushed out of the hospital. i know in my county, i was on joint conference committee. we would look at indigent care in the psych ward. and we were stabilizing them and pushing them out. but they would go into the emergency room first. i think the statistic on people who commit suicide, 60 me% go t see a primary care physician within 60 days. so that's another aspect i don't think we're talking about.
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we understand the neuro science and the amazing research we're having on helping on behavioral health. but then the acuity of people going through the current system for medical conditions and then accruing greater liabilities, both real and financial on that side -- and you saw that, i assume, in your experience. >> yes, i do. and the people that end up in the e.r. that can't be reimbursed, we end up all paying for that. i'm not sure if that answers your question. >> yeah, it does. ms. collins? >> yes, it is, i think on the benefits, the way we're designing benefits and the way employers are being forced to grapple with their higher costs, are giving patients incentives or people incentives that goes goes their own health interests. so people are making decisions based on their deductibles about whether or not to fill a prescription. whether or not to keep their -- to skip doses of the prescriptions because they're afraid of the cost. and it just really does run
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counter to how we would like people to think about their health care and getting better. >> and i don't know if others have had this experience, but i know the rotary clubs in my area take me out to their clinics where they have pro bono physicians and others who come. and especially in the disadvantaged communities. most of them who come to the rotary clinics once a month won't go to the county hospital. they won't go because they're afraid of the cost. and they're -- and some of it, i'm sure, is part of white smock disease -- dr. burgess would remember that. i have that. my blood pressure is usually off -- i don't know why i don't trust doctors, doctor. but i do know, because they have kept me alive. but the rotary care stuff is really fascinating, because people will go to the rotary clinics and it's the same doctor. but the environment is different. i just -- i guess i'm really appreciative. i didn't fully anticipate this hearing. i think it was good and
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constructive and largely positive. i hope that we go on from here. and i think the genesis of this in the bill -- i remember madison said -- not that this is going to happen. he said, just because a member of congress doesn't think their bill will happen immediately shouldn't inhibit them from introducing it. and i think this is at the very least has restarted an important conversation in this country. so with that, mr. barkann, do you have anything to add to my -- whatever is left of my 15 minutes? or is mr. mcgovern going to take it all? >> no, no, no. >> as long as it's not ed. >> thank you so much to members of this committee for having me. this has not been an easy trip to make, and it's a big risk for me. but i came here today because this is one of the most pressing crises facing our society. every day i feel the weight of the moment. every moment feels urgent, and i feel acutely my time running
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out. i hope that sense of urgency is pressed on everyone here, as we think about how to build a more fair and just society for all. we are at a crossroads as a nation. we can either become a society where care is rationed to those only with immense means to pay the most exorbitant, exploitive health care bills imaginable, or we can transform our society, alleviate families of the enormous financial burdens that come with a for-profit health care system and live with more dignity and joy. i sit before you today hopeful, because i believe we will make the right choice. i believe the number of people demanding justice across the country will only grow, and i believe that we will win. thank you again for having me. >> with all our pleasure. thank you for being here. >> so everybody has asked their questions. so at this point, i will yield to mr. cole for his closing
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remarks and then i'll make closing remarks and we will let you all go home. >> i want to begin, mr. chairman, for thanking you. i want to thank you for the manner in which you have conducted the hearing. you have been exceptionally generous of time and kept us focused skp focus and very civil. you can be very proud of your performance here and we're all very proud of you. and i want to thank all of our witnesses as well. each of you have brought insight, knowledge, professionalism. you have all contributed to helping us grapple with what's -- you know, a challenge at the societal level. and obviously we heard a great deal today about the majority's highest priority in congress. in my view, putting everyone in a one-size-fits-all government-run health plan that will double everybody's taxes, eliminate choice and put medicare at risk. it will take plans away from 173 million americans, and give them
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something they may or may not want and something they may or may not be willing to pay for. as we heard from dr. playhouse, medicare for all would cost a staggering amount, $32 trillion over ten years. worth thinking about that. the current federal budget annually is about $4.5 trillion. this would make it immediately $7.7 trillion. the legislation has not proposed any way to pay for that. but dr. blayhouse told us if you doubled the corporate tax rate, it still wouldn't cover these costs. and as my friend, mr. woodall pointed out, we're not paying for all the health care we're getting now. we're putting an awful lot of it on the national credit card. dr. baker offered up several ways to pay for this in his testimony. but many of those involve what euphemistically are called input costs or what everybody in the health care industry would call
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more than a 40% cut in their compensation. i can't imagine that an entire industry would accept that level of reduction. and i would also note that such cuts would put everybody's health care at risk. indeed, ms. turner testified that many hospitals would simply close if they had to take 40% pay cuts as envisioned in this bill. if such cuts become law, the medicare for all truly would become nothing more than a program that provided minimal care in exchange for astronomically high taxes and much longer wait times. most disturbing me to me, i think today's clearing made clear that the medicare for all would put the current medicare system at risk. we force doctors and hospitals to take lower payments. we run the risk of pushing them out of the industry entirely. thus making it impossible for current medicare beneficiaries who have paid into this program for a lifetime to receive health care. in my home district, rural hospitals rely on higher
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reimbursement rates from private insurance to offset the lower reimbursement rates from medicare patients. if these hospitals were to only be reimbursed at medicare rates, most of them, quite frankly, would close. if nothing else, today's hearing shows jurisdictions need to consider this bill, as well. and i'm proud that you have both called on that, mr. chairman, and announced that at least one of those are going to take it up. you know, i particularly hope my friend, mr. burgess, gets another crack at this in the energy and commerce subcommittee and the ways and means committee and the education committee and labor committee, as well. all of them, frankly, have significantly more jurisdiction in this area than we have here, and to be uncharacteristically humble for our committee and ourselves, they probably have more expertise than we have here. because they have both the staff and -- >> i don't know about that.
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>> well -- i'll let you argue that with mr. neil and his counterpart. so you guys -- and mr. pallone. because, frankly, they do. they just focus on these things. guess what, i probably know more on indian health than some of these things, because i focus on it. we don't have hearings up here, this is an unusual moment for us and a good one. i'm not complaining about that. i'm glad you're going to have the opportunity for these issues to be discussed in front of the committees of jurisdiction. though i think the democratic medicare for all proposal is an extreme one, i would remind the majority that republicans are, as ms. lessko said, committed to working together to improve the system we currently have and to build on and improve what works and ensure that every american gets the quality of care that they deserve. and while it's always fashionable to want to do a once and for all total comprehensive bill, we went through that with
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the aca. and with all due respect to my friends, i heard phrases like, "if you like the doctor you have, you can keep it." "if you like the plan you have, you can keep it." and finally, "your insurance plans are going to decline by $2500." none of those things happened. so count me as skeptical that a new one-size-fits-all system will achieve what advocates have laid out with optimism and such hope, and, you know, again, it's worth discussing for sure. i would hope, in the meantime, though, we do what everybody here agreed we ought to do. in addition to looking at this, which i have no objection to, we actually focus on smaller steps that we know can become law. that we know can actually happen. i look forward to working with my good friends on the other side of the aisle. certainly with you, mr. chairman. to make sure we can do something that matters in the weeks and months ahead and make some big difference.
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so with that, mr. chairman, again, thank you for the hearing. thank you for the manner in which it's been conducted. i yield back my time. >> well, thank you. and let me also thank my ranking member, mr. cole, for his participation in this hearing and for his courtesies and for all -- and for his questions, quite frankly. i want to thank my republican colleagues, as well. i don't agree with you on a lot of what you said. but, you know, i appreciate that this was -- this hearing, which is on a serious topic, was treated in a very serious manner. and i was recounting to some of you that some members of the press and some colleagues who have been watching this on c-span are kind of surprised that this has been such a civilized and in-depth hearing. and some of those people are on the committees of jurisdiction. and so i -- so i will tell mr. neil that, you know -- who is chair of the ways and means committee, the second-oldest committee, he should follow our
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example. and i want to thank the staff on the majority and minority side as well for their -- all their work in this. and i want to thank congresswoman's staff and congresswoman dingell's staff and others who have been very helpful. working with us, with this hearing. i want to thank the panelists. this -- you've been here since 10:00 this morning. and nonstop. with a short break. and i think everybody here was excellent. and we may have some differences of opinion, but i think everybody did an excellent job. so i want to thank, again, all of our witnesses for their time today. so as this hearing comes to a close, let's remember why we're all here. we're here because 29 million americans are still without health coverage. 44 million people are underinsured. and many more are paying ridiculous, out-of-pocket costs for health care that just isn't there when they need it the
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most. you know, there is no -- there's no health care system like what we have in america. and i don't mean that necessarily positively. you know, people are forced to go without care. those with coverage have to wonder whether their insurance provider will play games with their coverage when they need it most. and all of us up here know exactly what i'm talking about, because that's the kind of case work we do each and every day. what we have shown today, i believe, is that medicare for all is possible. that we can build on the principles of the affordable care act to make even bolder reforms. reforms that we give doctors like dr. brown and dr. navi the ability to treat patients and give them the best care every time, without letting costs dictate medical decisions. that we can treat patients like addie barkann without forcing them to battle with insurance companies. if you walk away with nothing
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else today, know that we have the ability to do that. medicare for all is possible. it is reasonable. it can move forward, and i think it should. and i'm proud to support this bill. and to work with congresswoman jai apoll and dingell and many others championing it. and by the way, that includes not just supporters here in congress, but many advocates. the doctors, nurses, patient advocates, skmconsumers and all across the country who have worked tirelessly to make this histo historic day a reality. it's been the result of calls and e-mails going on for a long time. i believe in people power. i've got to be honest with you. i don't think we would be talking about any of this if our constituents weren't raising their voices. i'm proud to stand with you and fight alongside you for medicare for all. this is just the first phase of the conversation. and i look forward to continuing this dialogue with all of you. and, again, i just want to say
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to addie, i love this picture. and i look at your wife, rachel, and your son, and i don't help but believe how proud they are of you. and i've been watching your dad sitting behind you. and i can see how proud he is of your courage and your commitment to being here. this is a big deal. and your presence here is making a huge difference. i just want you to know that. you know, we can do great things. we really can. and, you know -- but it means we have to stand up to the naysayers who tell us, no, you've got to think small. we need to think something -- we need to think bigger than tweets, right? we need to think in terms of, you know, how we impact the lives of millions of people in this country who are -- you know, who are struggling every day, wondering whether or not they're going to go bankrupt because their sick or kids are sick. it just shouldn't be. as everybody has said on all sides, we can do better. we have to do better.
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and so i -- again, want to thank everybody for being here today. this is the first step. it's a big step. but we're on our way. so thank you and the rules committee is adjourned. [ banging gavel ] .
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be with us later today for more of from the road to the white house with joe biden. he continues his campaign rollout with an event in iowa. you can see that live at 7:15 p.m. eastern on c-span. also online at c-span.org or you can listen live with the free c-span radio app. wednesday at 10:00 a.m. eastern, attorney general william barr will testify before the senate judiciary committee on the mueller report. and on thursday, at 9:00 a.m. eastern, he'll testify before the house judiciary committee, live, on c-span3. c-span.org. and listen on the free c-span radio app.
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once tv was simply three giant networks and a government-supported service called pbs. then in 1979, a small network with an unusual name rolled out a big idea. let viewers decide all on their own what was important to them. c-span opened the doors to washington policy making for all to see. bringing you unfiltered content from congress and beyond. in the age of power to the people, this was true people power. in the 40 years since the landscape has clearly changed. there's no monolithic media. broadcasting has given way to narrow casting. youtube stars are a thing. but c-span's big idea is more relevant today than ever. no government money supports c-span. its nonpartisan coverage of washington is supported as a service by your cable or satellite provider. on television and online, c-span is your unfiltered view of government so you can make up your own mind.
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the national commission on military, national and public service held a hearing recently on potential policies to encourage or acquire military, national and public service from all americans. during the morning session, panelists discuss whether women should be required to register for the selective service, and whether they should serve in combat roles. this this this is two hours, forty-five minutes. [ banging gavel ] . >> good morning. and welcome to the third public hearing on selective service by the national commission on military, national and public service. the purpose of this hearing is to address an important question. should selective service registration be expanded to include all americans. in 2016, t

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