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tv   Representative Michael Burgess Discusses Health Care Policy  CSPAN  January 15, 2017 3:01am-3:41am EST

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trump has-elect price.d tom >> c-span, where history unfolds daily. in 1970 nine, c-span was created as a public service by the macros companies and is brought to you today by your cable or satellite fighter. talks abouturgess efforts to repeal the health care law and the future of medicaid expansion.
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this was part of a health policy forum hosted by the american and -- american enterprise institute. it is 35 minutes. everyonewant to thank for attending this event today. i am joe and toasts -- i'm joseph antos, wilson scholar for healthcare retirement policy at the american enterprise institute. on behalf of aei, the brookings institution and the pacific business group on health, i want to welcome everyone here and everyone watching remotely, including those are watching c-span. we are going to discuss the challenges of providing high-quality healthcare that is affordable for patients,
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employers and taxpayers. this is clearly a critical topic for government policymakers. the recent election obviously highlighted the disagreements among many people in this country about what's the best way for government to proceed in this area. and, obviously, changes are coming. the expansion of health insurance coverage under the aca has come at a steep price and incoming administration is looking for ways to get costs under control while ensuring that people continue to access to health insurance. employers have long been at the forefront of this struggle for affordable health care. about 159 people and 165 of these are cut by health plans sponsored by employers. the employers. the average premium for family coverage offered by employers
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was over $18,000 last year, 2016. that's a nearly 50% increase in total premiums since 2006. health benefits are a major component of employee compensation and the rising cost of health benefits has slowed wage growth for millions of americans. and healthcare costs have increased, have increased. large employers have invested in innovative strategies to promote value and to control costs through patient engagement, provider payment reform and delivery system improvement. we are going to discuss some of the initiatives undertaken by four large employers, initiatives to promote more efficient healthcare delivery and lower cost. what can we learn from their successes? what can we do to help resolve the problems they effaced indeed with cost and quality problems? -- problems they faced in dealing with cost and quality
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problems? what is the role of government in promoting effective private sector initiatives? and what are the barriers that need to be lowered to make those efforts more effective? these are the seems to be addressed by art expert panels coming up shortly. but to start the discussion we are honored to have dr. michael burgess, chair of the health subcommittee for the house energy and commerce committee. dr. burgess represents the 26th congressional district of texas but equally important he is a practicing physician who cares deeply about meeting the needs of patients. dr. burgess has been a strong advocate for legislation to reduce healthcare costs, improve the choices and ensure that we all have the capacity or that we will have the capacity to provide appropriate medical care to all who need it. he also played a key role in forming medicare's system for paying physicians that intend to promote better value and greater affordability. and with that, dr. burgess, please join us. thank you. >> thanks for the kind introduction and thank you for the invitation. thanks for allowing me to be
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here. if i understood my task to -- my task correctly this , it's to talk about innovation and policy, does innovation form policy or does policy form innovation courts the answer of course is it's both, but we might look to just a couple of examples as to why it is perhaps more satisfactory when innovation drives the policy rather than the other way around. as we say do there's really not much happening right now in washington, right? and there's not much happening in healthcare. it's kind of a sleepy little backwater of policy subcommittee that i'm going to chair this term. it's phenomenal opportunity, and it is a phenomenal opportunity to get things right and to provide for people in a way that has never been provided in the past. it's also an opportunity where
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things could get much more dangerous in the days and weeks and months ahead. so that is, that's kind of the challenge. certainly before me as a member of the subcommittee on as an individual member of congress, as someone who represents 790,000 people back in north texas. my life has been in medicine if -- in medicine before i came to congress, and so what i think of things like game changers in healthcare, i typically think of things, discoveries and devices, drugs that a been developed and how they've changed medicine. as you know as a take a step back this might think about over the last 20 years, for two things my opinion profoundly changed providing healthcare for people that actually do have a lot to do with things in the -- actually did not have a lot to do with things in the laboratory bench.
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20 years ago last august, that kennedy kassebaum bill passed and although there were a lot of things in the bill. one of the little demonstration projects tucked into bill was a billet to provide health savings accounts. and, in fact, they were capped at seven and 50,000 of those it would be allowed in the term of the bill. i wanted one. i was afraid i wouldn't get my stuff in in time to get one of those $750,000 health savings accounts. it turned out i needn't worry. there are plenty to go around for anyone who wanted to. they were not all that flexible back in those days. there were only one or two insurers in my area that would even talk to you about the phenomenon of the health savings account. but when you stop and think about all of it, medicine is, there can be an unlimited demand. i know this because i used to practice medicine. the barriers that should be
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placed need replaced by the government should be a waiting list should he be rationing? or do you want some insensitivity, some market feedback on the part of yes a physician but the patient primarily because the patient is a one who i believe should be in control of the situation. the health savings account is a perfect model to allow that to happen. last night in the rules committee, we were marking up the budget will allow the reconciliation, repeal and repeal plus whenever they come down the pike from the committees. and in that, a question was posed by democratic member from florida. i challenge anyone of you on this rules committee to point to me a year when her health insurance premium went down. and i said i would be happy to. it's the day i got health savings account. my health premium was dramatic reduced. if i had discipline to put some of that money on that spending -- that money i'm not spending on a premium into a tax-deferred savings account, i can, that was 20 years ago over that time span there is the ability for me to garner a significant mistake against medical expenditures.
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egga significant nest against medical expenditures. i would argue that whatever we do next i would like to expansion of health savings accounts as not for everyone but as a fundamental part of policy. i would like to see that happen. one of the things were hearing a lot right now and another issue that came up yesterday, last night late in the rules committee markup was another democratic member from massachusetts said 20 million, 30 million, whatever the figure of the day is, are losing their health insurance. i don't recall the individual being terribly concerned when i was one of the six among people -- 6 million people that lost my health insurance at the end of 2013. i had a health savings account. i had a high deductible policy. the president president told it was a junk policy and had to get rid of it. but he knew that her. -- but he knew better. they were health benefits that had to be covered and may not of been covered in the high deductible policy that i had. but where was the concern for
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people who were losing those policies when the affordable care act implementation happened january 1, 2014? i will tell you, as the affordable care act was implemented, there was a special deal for members of congress. i thought i was wrong. the special deal for members of congress was that we could take a subsidy and walk into an exchange as long as we willing to purchase in the d.c. shop exchange. number one, my doctors are not in d.c. they are back in texas so that was of no real value to me. the other thing was i knew my constituents in town halls back in taxes would not understand why i as a member of congress got a special subsidy that was not taxed that i could walk into an exchange. i said i can't do it, no, thank you. i went to and signed up just like so many other people tried to do that october, november, december. it was one of the most miserable exchanges i've had in my life. i was worried i wasn't going to be able to get signed up by the time the deadline expired at midnight on december 31.
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remember they they extended it for a few days but it was a tense time for people buying in the individual market. it was the appropriate thing to do because my constituents that i represent four in the individual market were going to the same thing and, of course, i've heard from a lot of them over the course of time with the affordable care act. now, two or three days ago the president did a beautiful address in chicago, and talked about how great things work with healthcare. you almost feel like you're in a dickens novel. it's the best of times, it was the worst of times. people are struggling right now under the constraints of the affordable care act, and i view myself as on a rescue mission here to try to help people who have, in fact, been hurt by the federal policies that have been imposed. but again the other thing that happened over the last, in fact, 10 years ago, 10 years ago last week the introduction of the iphone. you don't think that as a
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startling medical discovery but my iphone can take my ekg. in fact, this morning just to make sure because i read a lot of twitter reports on the rules committee last night, this guy has no heart, so thought i'd better assess -- [laughter] -- whether, in fact, it was electrical activity in the myocardium. i'd happily to report that there was. in fact, on my watch that talks to my phone, there's a digital icon that i can actually click on the icon to get the ekg function of the phone except when i do that it says this function is not available in your country. so maybe that something we ought to work on from a regulatory standpoint. thank you life is changed for people in the last 10 years because of a handheld devices, the smart phones that we all carry with us. mine will take my blood pressure, will take my, ss my blood sugar, check my weight. i'm worried the nsa has hacked
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into that and altered it on me, but i practice obstetrics. back in the days of practice d obstetrics, it never failed. 4:30 pm on a friday afternoon a patient would come in in the last two or three weeks of pregnancy with a blood pressure that was just enough elevator or what it had been before to cost some concern. here's the problem. most people who have that, it will turn up to not be a problem. and it just didn't because i didn't have enough parking places close to the office and she was mad at me the time her blood pressure was measured. but bad things can happen in that situation also. so if you go to the ultra- careful route and say look, you have a blood pressure measurement that is higher than it's ever been before. i need to put you in hospital for a couple days and monitored this and make sure something that isn't going to happen. we did that a lot.
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late in pregnancy, in order to assess or make sure that preeclampsia was not going to lead to a clamp syria -- lead to lamsia and all kinds of bad things down the road. if you guessed wrong, you're both blood pressure is up, let me say first thing monday and let's get this checked again and make sure it's not going to be a problem, and that at 3:00 on sunday morning in the emergency room with a platelet count that is what low, a baby that is in distress, all kinds of bad things happening. you guessed wrong. how great is it in this day and age that someone can a blood pressure cuff can actually measure the blood pressure, record on the iphone e-mail it to the doctor, and that monitoring can occur in and out of hospital event as an out of hospital event and people can go about their business. you significantly reduced unnecessary hospitalization but more important to me an obstetrician who practice d defensive medicine, you also can significantly reduce the unfortunate sequela if you fact assess incorrectly at the time of that event. so those two things, health
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savings account, put the patient back in charge, the iphone or the smartphone that gives the patient actually the ability to participate in the monitoring of their care, these are two things i think will profoundly change and affect the future of care, certainly it would if i were still in practice i will be incorporating those activities on an ongoing basis. now, as i mentioned, my smart watch will knock you make it -- my smart watch want to make it with my smart phone about the ekg because it's not available in my country. one of the other tasks we have, by the way, is reforming or replacing the affordable care act was not enough for the subcommittee that i am chairing now this term in congress, we also have the use of the -- the user fee agreements of the fda that are expiring. and i know many people, american enterprise institute are interested in what happens at the fda because i've heard from some of you.
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i am interested as well. we just went through a big, big legislative effort, cures for the 21st century. it will be ongoing work that is done on the regular side with the food and drug administration in the use of the wii authorizations. -- in the user fee reauthorization's. this happened in 2012. that was an election year, tough year to get any kind of our present agreement but we did and the bill got assigned. got signed into law three months early. you don't know that because the president signed it in a broom closet. it was 2012. he did want to be seen with others. we didn't want to be seen with him. so just happen. it just got done. the work got done for the american people and i would point out it was three months ahead of schedule. same thing will happen this year. all the time the affordable care act, whatever happens next in that is being marked up and debated in the subcommittee of health and energy and commerce and ways and means. there will also be activity happening on the food and drug administration reauthorization. and that's critical work. the aca reform is something that's going to happen right now. the fda reform are things that
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happen for years into the future. i know that because of when we did our last one. it was very rare that a week went by that there was not some in my office with a tale of woe of how that difficulty dealing with getting things done the fda and we need to make that, we need to make that a more, a more straightforward. i'm not saying anything needs to be shortened or curtailed but we need to make a more straightforward. and the agency cannot change the rules late in the game, since everyone back to the starting gate and say we've decided on a different set of parameters that have to be shown for this, and you just simply have to start all over again. let me just, in the next couple of minutes, talk to you more from my role as a member of congress, my role as being on the subcommittee that will be doing a lot of this work on the affordable care act. three big pieces of health policy have happened in my brief tenure in congress, which started in january 2003.
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2003, you may recall, was of the year the medicare modernization act. bill thomas on the chairman of the ways in means actually worked very close with counterparts over the senate for when ted kennedy was involved in it. and ultimately came up with part what's now known as part b, -- part d prescription drug benefit and medicare. president bush when he was running said i am going to get this done. said there was no question of whether or not it would be done and the fact that got done. arguably bipartisan, although certainly there are people on the democratic side of the subcommittee will say it really wasn't bipartisan. you held the vote open for four and half or five hours. it may be true but we are just waiting for david wu to vote and when he did it was all over pretty quickly. but as that implementation occurred with part d, there were some tough spots. january 2006, the date that all
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began, phones ringing because people were having problems. i would argue because it was bipartisan, because both president bush and senator kennedy were interested in this thing working right, of course should set up a mike leavitt at -- of course, you had secretary mike leavitt at the department of health and human services was interested in it working correctly. there was a lot of effort into fixing those problems and i was impressed that the problems that started at the first of january were quickly ameliorated such by the end of that month or certainly by found on stage were pretty much old news or ancient history. the affordable care act past in 2009 and 2010. the affordable care act was a singular party that was in charge of that. so when trouble occurs, do i want to step up and help? no. my fingerprints are not on that. why would i get involved at this point? so the lack of bipartisanship,
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if you will, i think was a damaging on, when the affordable care act get into trouble with the implementation. it was not just distracting. it was damaging for the future of the law. then in april 2015, we passed the bill a bill called the medicare access and chip reauthorization act. i like to call it the ncr repeal because assault a problem, a problem created by congress. if you solve problem that had bedeviled doctors, patients and policymakers for 17 years. it took us 13 years to solve it but indeed we did. that vote was strongly bipartisan, strongly bicameral. 392 positive votes on the house, 92 yes votes in the senate. well, when the proposed rule came out in june of this year, it scared everyone to death. what are you doing to small practices? are people going to be able to continue in a one or two person practice because of some of the
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things that have come out in the cms rule interpretation? and a valid question. because of the fibers and make -- because of the bipartisan nature of that bill when it passed, the administrator for the center for medicare and medicaid services heard from members and it changed. between june and october, that rule when it was republished in october was vastly different. and a lot of flexibility was built into that process. i will go one step further. andrew slavik said he will leave the comment. -- comment period open on comments coming in on the macro rule that was published in october. that is exactly the type of interaction that you want. we've had three oversight hearings in energy and commerce on the implantation, even with all the other stuff that is going to happen this year and next. we will continue to have oversight hearings on the accommodation because it is so important that it be done right. there's going to be some changes at the agency which may affect for better or for worse how
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things happen on the implementation side. but regardless of who is the head of the agency, i want them to know that the subcommittee still feels very strongly that the legislative language that was passed is what we want to see enacted, and we don't want someone going off in a different direction from what congressional intent was when that vote received a strong bipartisan majority. so the lesson going forward and the point i tried to make two -- to make to younger members of congress were at the rules committee last night coming both as witnesses and on the committee, the lesson going forward for us is we have a job to do for the american people. it's not a republican or a democrat. it needs to be done by both sides in both houses working together. yes, we need to listen to what the white house has to say because ultimately the president will either sign or not signed sign the product that we deliver to them. but it does require all hands to be on deck.
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it's difficult because right now the landscape is difficult. the well has been poisoned by so many people in someway different -- in so many different flavors it's hard to know who went first and who drank first but we've got to get over there. we just literally do. people are counting on us to get this done and to get this right. my focus goes to the patient but sure, i hear from hospital executives. i promise you i hear from doctors. i hear from people in industry or making investments right now in either medicines, devices, technologies that they think will be important for the future. i want them to do that. that's what the cures the 21st century was all about. we want to facilitate that activity. so dr. antos will join me on stage which i know is my key. -- is my cube. -- is my cue. i would just stress for people, there is the speakers better with age and unveiled here at aei earlier, or last year, and the better way is the roadmap, those are the building blocks for the policies that the subcommittee is going to take up.
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i do want to point out and i will leave this point for dr. antos. this is the book i wrote right after the affordable care act passed, select from doctors perspective what does it look like acid policy came through. i would just point out before there was a better way, there was a doctor in the house -- [laughter] those policies that using as part of the better way. dr. antos, i give this to you for your historical record. [laughter] >> thank you very much. [applause] okay. dr. burgess has graciously agreed to answer a few questions. so while you're getting yourself organized, let me just suggest that you identify yourself and make a statement in the form of a question. that means raise your voice at the end of whatever statement
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you're going to make. does anybody have a question? right here. >> dr. burgess, you mentioned the importance of the latest health reform effort being bipartisan. what's the process for engaging your friends on the democratic side, both in the house and the senate, to achieve some sort of bipartisan reform, and what do you think a five person -- think a bipartisan replacement of the aca looks like? >> it starts with listening to people who have good ideas. i would use the food and drug administration safety improvement act of 2012 as an example. certainly when we got really deep into repealing the sustainable growth point was -- sustainable growth rate formula, it was that same template, allow people to be in the room. there was quite honestly when we said we're going to repeal the scr, really wants to repeal the scr but it hasn't been done, folks on the democratic side were suspicious of us. what are you going to try to pull on us here at the last
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minute? they suggested replicate -- suggested perhaps we get together and just do a white paper. we suggested that no, enough energy had only gone into this, that we need to write legislative language and counsel would be in the room with us as we're having these discussions. we also opened up an email source so that people from outside, doctors and patient groups, could provide their input. of course, they hearings that went on, tried to be not slanted toward one particular philosophy or the other. we sometimes can't help ourselves on that as you know, but it did try to be an inclusive process. now, is that still possible in the environment today at the level of national healthcare policy? i don't know. in fact, one of the things i would point out is i feel very strongly on the issue of medicaid, block grants, really something it's an idea whose time has come. i spent the better part of december talking to my
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counterparts in the state house and state senate saying you guys have griped about washington being too onerous and too much in your business and you want to block grants. be sure that you are ready. because you may, in fact, get that. you may get that back. and i would like to see that happen. i do think, i generally don't favor things that require a larger government to administer because as you know where the government that is so big that it sometimes seems absolutely insensitive to the needs of average americans pics i do look -- average americans. so i do look at it through the lens of what will pare down the size of government without being terribly disruptive unless we need to be terribly disruptive . but i also recognize people of differing philosophies around that. part of it, my task as a chairman of that subcommittee, is to be open and receptive to those ideas. we will have our fights. we will have our on that
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markups. but that's appropriate. that's what we need to do. >> again, wait for the microphone. great. one of the things that is in your jurisdictions, obviously, medicaid. you talk about block granting. i think you see letters from some governors were there is concern about medicaid expansion and keep an eye going. mr. cassidy, senator cassidy and nominee for hhs, mr. price, dr. price, have talked about having an option where states can opt to keep expansion, medicaid expansion under the aca if they want to do that. is that something you would consider? >> yes. [laughter] >> [inaudible]. is it something you are inclined to do? >> look, my state did not expand medicaid.
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i receive adler from my governor just yesterday. the majority leader, kevin mccarthy sent letters to the governor, give us your ideas, which i think is a good thing. governor abbott copied me on his letter saying the block grant approach is something they would like to see. now, you know, i guess, part of your question, that at least in my mind, what is the, what is the pool of money that will form the block grant and does it need to be more equal between states and that means a state has expanded obviously is drawing down more federal medicaid dollars than a state that didn't expand, using its legacy or historic amount. i don't know the answer to that question. i expect we'll have a lot of input from a lot of folks on this. i didn't mention it, but before the end of this fiscal year we have the, not the -- not the reauthorization, but the funding for the state childrens health insurance plan
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in our laps. is this something we can incorporate into whatever happens next or is this something that will have to be done individually, then we'll talk about whether we go the per capita block grant or some other more flexible model. i don't know the answer to that . i would, the reason my answer to your question is yes, obviously a willingness to listen to those ideas. 7:00 on wednesday mornings for the past several years, i have positioned myself in a corner table in the capitol hill club over on the republican side to listen to any republican doctor that wanted to come in and gripe at me about anything and the reason i did that because senator cassidy when he was a house member was always coming up to me, here is 14 great ideas i have about things we ought to do. bill, i will give you one hour of every week, and that, dr. price eventually joined us as well at that group.
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so, i know dr. cassidy has a lot of ideas. i know he has a lot of very good ideas, and sure, there's a willingness to listen. >> great. someone back there. >> dr. burgess, paul heldman, from simpson partners. the follow-up to the previous question, correct me if i'm wrong, you but i think a better way keeps the medicaid expansion but phases down the federal match. my question to you, my first question to you, is, do you at least anticipate the federal match to those states that expanded being reduced, based on the house proposal, and then, you talked about really wanting to pare the government's role in health care and other areas. the president-elect the other day said, he opened his press conference saying that he wanted the government to be involved in some bidding process on drug prices.
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i'm wondering what that means to you, and you would address the issue that he raised? >> well, that is a two-part question. tell me the first part defend? -- the first part again. >> the first part is on, first part on the medicaid expansion and better way talked about reducing the federal match. >> i don't know the answer to your question. i expect the answer to your question is yes followed by an if. but i think the larger place where that discussion will be up -- be front and center, we're bumping up to statutory debt limit at some point in the near future, when the new head of office of management and budget, former representative mick mulvaney says we're out of borrowing authority at that -- a thursday. at that point in this administration with that omb director, we'll look at places for savings, and that 100% fmap or 90% of fmap part of the
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medicaid expansion may be well one of those things on the table. i don't know that for a fact but i long suspected that is where that, that anxiety is going to play out. the, on the issue of drug pricing, look, i understand there is a significant difference between deraprim and sovaldi. daraprim antibiotic been around since the earth cooled the first time. should be dirt cheap. was dirt cheap, somehow, i believe the federal regulatory agencies participated in this, somehow we created a supply chain problem that someone decided to manipulate. on the other side you have sovaldi. that is not just a treatment for the management of hepatitis-c, it's a cure for hepatitis-c. for a little perspective, when i
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was a resident at parkland hospital in the 1970s, we knew we had hepatitis-a and hepatitis-b and there was this other hepatitis. someone figured out we need to call this non-a, and non-b hepatitis. someone figured out why not call it hepatitis-c? [laughter] a new disease that went through the bureau of nomenclature, wherever that is, that is baby boomer disease. see advertisements on tv you but sovaldi is a cure with that. -- a cure for that. in my professional lifetime, we went from something didn't know existed and came to our consciousness was in existence, it was named. there was no treatment for 30 years. now there is a cure and it's expensive but a liver transplant is expensive and death is permanent. so yeah, i will pay the money for the cure whatever it takes but the want the cure to be there. i don't want to do anything that is going to stop the next cure from occurring.
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i know when we make policy, daraprim, that is a real problem. it may be partly our problem on the supply chain side. we need to look at things we've done, we as federal regulators and legislators have done that allow for something like that to exist. and i, i will tell you, i don't think there is any secret that the cost of generic medications over the last three or four years has significantly increased. i'm not exactly sure why but i know all of the reasons why, but i also say the president-elect provided a, sort of a different perspective on that. i'm sure you all read "the art of the deal." i know i dusted mine off and reread it during the summer. the chapter in there where he talks about the skating rink in new york and how this was a six or eight-year problem, millions of dollars into it, but never is fixed.
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he could see it from his apartment building, and it bothers him this public skating rink is not functional. he and the government, he and the mayor get into a hair-pulling contest about the papers about it. eventually, you're so smart, you fix it. and he did in a very short period of time. and one of the statements that was made by the mayor after it was all over, well he has the ability that the rest of us doesn't have. he gets the best people to work on it, they know if they screw up they will never work for donald trump again. well, maybe that is a philosophic approach may be overdue in our large and overburdened federal government. the fact he brings in fresh perspective i appreciate that. i don't want us to harm innovation. price controls don't work in areas they have been tried but i understand there is problem and he wants to fix it. i appreciate that. >> dr. burgess, we have one minute. let me ask you a one-minute question.
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it is an easy one. >> great. >> when do you expect to see a replace bill? [laughter] >> well, you know the moving parts of the replace bill were in fact, it was the press conference that the speaker had here at aei. i don't really remember what month it was, but four-month side but better way agenda and it, there's not, i don't think there will be any surprise. now all of the parts that are in the replace bill that come through the subcommittee, i think are available to you in that better way agenda. probably too many ideas there. they probably all can't be incorporated in whatever happens in the next weeks and months. i will tell you this, just from my perspective, not as a chairman of the subcommittee, member of the energy and commerce committee or member of the republican conference. i favor smaller bills over bigger bills. the fact we have a list of
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things that can be used to fix the problems in the marketplace and in delivery of health care, i think that is good. let us evaluate those. let us perhaps rank in order and start with the most important and work our way down, get as much done in the time frame allotted to us. i think, when i did my town halls after the affordable care act was unveiled and people were frightened of this 2700 page bill that they saw in front of them, i don't any i saw anybody on the right or left we want to see a 2700 page republican bill. that was not part of the equation. they didn't want interference or wanted things fixed that need to be nexted. -- fixed that weren't being fixed. >> great. thank you very much. everyone join me in thanking dr. burgess. [applause] thank you. that was terrific. more about the
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affordable care act this weekend on newsmakers with steny hoyer. he talks about republican efforts to repeal the law and how democrats plan to respond. we are against repeal. that does not mean that we are against making the affordable care act better, more effective, higher savings, more accessibility. that is to say simply that there ought not to be an appeal until you -- a repeal until you have an agreement on how you improve or, from the republican standpoint, you replace. we are in the position where you ought not to repeal. that is what the republicans have been attempting to do. this is the 65th or 66th opportunity for them to do so and they have taken it. but they have no replacement. they have no fixeso


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