tv Medicare for All House Hearing - Part 1 CSPAN April 30, 2019 9:27pm-2:30am EDT
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>> the house and rules committee held a hearing today on the medicare for all proposal .ntroduced by representatives the witnesses included physicians, health care advocates and economists approach thatthe might impact cost and access. squeeze't think we can anybody else in here. good morning, everybody. i want to welcome our witnesses to the rules committee. before i give my opening you will kind of get
a hearing. >> we will have rules today. rules of the committee provide members to ask questions. that will has not been followed for as long as i can remember. with ample members time to ask questions, so the chair ranking member will we ask a statement and that you submit those statements. each witness will then have five minutes to provide an opening statement. if you go over a little bit, tried to wind it up. as the committee receives testimony, each member will have a few minutes to ask questions and if a member has a question, please ask your question at the
beginning and then proceed with your other questions. be sure to leave some i want to thank ranking member: his assistance in reaching this agreement. i think all our members for participation in this hearing. begin, i just want to acknowledge some people here in the audience. speaker pelosi, we appreciate are coming by and we have congresswoman katie porter here from california.
we are grateful she is here in the audience. in addition we have jean ross from national nurses united. the coal the consortium of citizens with disabilities, robin gray with people's action, savanna outlines with people's action. rebecca and her daughter charlie are here, that they are over there. charlie was born prematurely and over the age of three she suffered more injections and therapies that most people face in a lifetime. addison, from the center for popular democracy. the president of be a hero, her
his father is -- here and i'm sure you're very proud of your son as we all are. when i get to my opening statement, i want to thank her again because it is her legislation that is why we are all here today. i believe this is a historic day . today the rules committee is holding a hearing on the medicare for all act here at this marks the first time congress has ever held a hearing on medicare or all. thent to thank congresswoman and senator sanders and his staff as well all their help with this hearing.
i want to thank congresswoman jaya paul for her commitment and dedication to this issue and we are all grateful to her. we have a talented witness panel with us today. i have a sneaking suspicion that we will have a lively debate. and that is a good thing. after nearly a decade of republican -- 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, how to lower cost and improve outcomes in the process. i have long believed that helped there is a right for all, not a privilege for the lucky few. this congress is putting that belief into action. the affordable care act gave 20 million more people access to health care. insurance companies from discriminating against cancer patients and women and make sure cap transaction covered the essential benefits. the aca changed lives and saved lives. we knew it was never going to be the last up in health care
reform. that we were always going to have to come back and build upon those core values. that is what today is all about. because the work of reform isn't done. 29 million americans are still without health coverage. 44 million people have covers that is not there for them when they needed. all of us deserve help you are in without health insurance middlemen jacking up the costs are deciding who gets care. it is still true today that there are too many in america who 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 is health care that remains out of reach for too many. the medicaid for as medicare for all act would change that. the 44 million underinsured people would have the peace of mind of finally knowing that health care will be there for them when they needed. and all of us, workers, seniors,
students, all of us, will be free from crushing out-of-pocket cost. the good will also guarantee for the first time that people living with disabilities have access to services they need to live with dignity. the medicare for all act is a serious proposal. that's why more than 100 vendors of congress are cosponsors. that includes me and some others on this panel. not only doesn't deserve to be part of the discussion as we consider ways to expand and strengthen coverage, it deserves to move forward. i hope today is just the start. congress should be a place where we tackled big things, where we are not afraid to have hearings and real debate. i know we won't pass this bill overnight, but we won't pass it unless we start the dialogue. this democratic majority was built by americans tired of political leaders who try to sabotage their health care and who looked after the wealthy and well-connected over everyone else. the american people spoke loudly
and clearly. they wanted a congress that works to expand coverage. they are sick and tired of the problems that are fundamental in our system today. my republican friends want to use a lot of scary words like government takeover or socialism today. have added. the tri-debt during the passage of medicare. they tried it during the passage of social security. they try that during the passage of the affordable care act. every time, the american people saw through it and supported those programs. this would be no different. i now we all know that the republican plan for health care can be summed up in one word, repeal, no replacement. had a said that they health care plan, i think it could probably be summarized as take two tax breaks and call me in the morning. this majority is taking a different road. we have to -- fantastic
witnesses who will talk about this bill today. some are for, some are somewhere in the middle, some are against. but i want to focus on one witness. is mr. barken. we have a picture of his beautiful family here today, and i'm sure your son is incredibly here at the, being first-ever medicare for all hearing. we are so honored that you are here. he has been fighting like hell for his life and all of ours. als in thenosed with follow 2016. since then he has battled insurance companies, drug company's, medical device companies, you name it, he has battled it, just to get the care he needs. i say battle, because that is exactly what he is had to do. battle to get care, services,
life-sustaining medical equipment. but no one should have to fight a health care company while they are fighting for their lives. . cannot do his story justice but i believe my colleagues with this. if you think health care in this country is just fine today, if you think we only need to nibble at the edges of reform, look at what he has gone through, try to tell him that. you are welcome to stay here as long as you want and take any breaks that you want. we are just honored that you are 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. we talk a lot about national security. that is everyone's favorite topic. i believe we need to expand the definition of national security to include more than just the number of bonds 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 abroad. i don't think it's too much to expect the federal government to protect us against illnesses here at home. >> i had the opportunity to read all of your testimony and i found it quite informing. it's interesting to me to know that as you pointed out, there's a variety of perspectives, as there should be, amongst our witnesses today, each and every one of them is interested in the best possible health care for the american people. they may disagree over how they get there but it's a noble and worthy goal that we all share that you've all dedicated a lifetime in pursuit of, so i'm
very grateful for that as i know every member of this panel is. today's hearing is quite extraordinary. hr 1384,re to consider the medicare for all active 2019. unlike her usual weekly hearings, today's hearing is an original jurisdiction legislative hearing covering the bill of which the rules committee has some original jurisdiction. i say some, because out of the the rules committee has jurisdiction over precisely one of those pages. that is it, just one page. yet we are about to hold our first original jurisdiction legislative hearing in nearly three years on this bill. that's what makes his hearing extraordinary. it's worth noting that speaker pelosi's personal committee is the one to take the first swing at this ball. three other committees in the house can claim wider jurisdiction of the rules, energy, ways and means, should all conduct multiple hearings on
this legislation as well. frankly, i'm sure ranking republican members of those committees will be requesting their chairs to take up this legislation in the relevant committees, and i hope that happens. there is a reason is coming to rules first and that's because this is an extraordinary bill. what democrats are proposing today will completely change america's health care system, and not, in my view, for the better. medicare for all will are all americans to pay more taxes, wait longer for care, and receive potentially worse care, even worse than would -- he would put our current medicare recipients at risk. current medicare recipients and medicare dated plan holders are by large satisfied with the health care they receive. in particular, medicare dennis plans are extremely popular. this radical bill puts medicare itself at risk by enrolling millions of new recipients who
have not paid into the program and way current recipients have. it would reduce the quality of services and enforce longer wait times and ban medicare advantage entirely. for current medicare recipients, medicare for all really means medicare for nine. bill is a socialist proposal that threatens freedom of choice and will allow washing to to impose one-size-fits-all plans on the american people. private health insurance would be completely banned. everyone, every man, woman, and child in america with private employer-based reunion-based health insurance would lose their plan. even if you like to plan, you really cannot keep it. more than 150 million people will lose health plans they like, plans they have bargained for and in many cases, plans they have earned through years of hard work. medicare for all throws it all out the window in favor of one-size-fits-all government run health plan. we will hear from one of our impact this the
will have on employer-sponsored insurance and the method by of americans half receive their health care. in the midst of all this, i think the majority needs to be honest about the phenomenal cost of this new program. we're going to hear from dr. charles playhouse, a former trustee for social security and medicare. andeviewed medicare for all authored a very telling study on the topic. he showed the previous, more basic version of medicare for all would cost at least $32 trillion over the next two years . has told -- has not told thomas's massive new whosem will cost and taxes will have to go up to pay for it. on the last concern, i can assure you that the answer is everyone. everyone's taxes will have two
than double to pay for this program. the majority needs to be honest with us and with the american people about the cost. the office, i would like to point out one of the most egregious parts of the federal health care bill is that it relates to the federal funding of abortion. it has been limited for over three decades by several legislative provisions. the amendment prohibits states from discriminating against providers do not support abortion. the church amendment text the rise of health care -- practitioners. this bill contains none of them. it requires coverage of comprehensive reductive care which includes elective abortions paid forward taxpayer dollars. of the bill explicitly states this bill us ignore these federal laws dating back 33 years. mr. chairman, i would hope that
you are encouraging your leaders to pursue markets within the committees that have primary jurisdiction over the majority of health care issues. energy and commerce and ways and means. so that we can ensure long-standing protections are included as you move medicare for all to the floor for a vote. mr. chairman, i'm looking forward to today's hearing and hope our witnesses can shed some light on these and other questions as we review this proposal that if passed into law will dramatically change the american health care system for absolutely everyone. in my opinion, not for the better. thank you, mr. chairman. >> thank you, mr. cole, for your statement. let me assure you i hope all the --mittees with jurisdiction as i mentioned in my opening statement, a contrast in the way our friends on the other side of protected themselves
when they try to repeal the affordable care act, there were no hearings. ofike to think it is because an enlightened chairman. we are ready to begin. barkan.st witness is ady who helpedizer design and drop policy proposals to enhance the quality of low-wage jobs in york city including regulation of major retailers, and unionization of the car wash industry. he graduated from yale law school and columbia college cum laude. as i said in my opening statement, we are deeply honored to have you here. and the floor is yours. mr. barkan: chairman mcgovern and members of the committee,
thank you for inviting me to testify today. my name is ady barkan. i am 35 years old, and i live in santa barbara, california with my brilliant wife rachel and our beautiful toddler. she's an english professor at the university of california, santa barbara, and i am an organizer at the certainty for -- center for popular democracy and the be a hero project. i earned my bachelor's degree from columbia university with a major in economics and my yaw -- my law degree from yale law school. over 20 years 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 the mountaintop.
we had fulfilling careers. a 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. a.l.s., 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 50's and 60's. 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 simply not up to the task. although my story is tragic, it is not unique.
indeed, in many ways it is not so rare. jennifer, the president of my organization, is sitting next to me. like me, her husband was struck at a young age by a neurological disease. 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 on 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 problems, high cost, bad outcomes, mind-boggling bureaucracy, racial disparities, bankruptcies, geographic inequities, and obscene profiteering. the ugly truth is there. health care is not treated as a human right in the united states of america.
this fact is outrageous. and it is far past time that we change it. say it loud for the people in the back, health care is a human right. for my family, although we have comparatively good private health insurance, a.l.s. now 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 into medicare and move into a nursing home away from my wife and my son. so we are cobbling together the money from friends and family and supporters all over the country. but this is an absurd way to run a health care system. go fund me is a terrible substitute for smart congressional action. like so many others, rachel and i have had to fight with our insurer, which has issued outrageous denials instead of covering the benefits we paid for. we have so little time left together, and yet our system forces us to waste it dealing
with bills and bureaucracy. that is why i am here today. urging you to build a more rational, fair, efficient, and effective system. i am here today 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 american health care system. i will summarize them here, but i urge you to read the fantastic testimonies submitted by the national nurses united for more details. first, medicare for all will deliver to everyone living in america the high quality care that we deserve. the law will provide comprehensive care including primary and hospital care, dental, vision, reproductive, and mental health care. we will all be allowed 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 life for the tens of millions of people whose families include older or disable 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 that we will no longer need to choose between paying the rent and filling a prescription. 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 destroy so many lives, that rob our communities of so much dignity, that strip us all of our common humanity. any proposal that maintains financial barriers to care, any proposal that continues to charge patients co-pays,
deductibles, and premiums will leave people out. any proposal that maintains the 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 absurdly wasteful cost shifting, delays, billing disputes, rationing, and worry. 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 immoral price gouging by pharmaceutical and device companies. the fundamental truth is that too many corporations make too much money off of our illnesses, and they are spending gazillions
of dollars lobbying and fighting to stop us from building something better. it is very important to emphasize the following point. these cost savings are only possible through genuine medicare for all system. other proposal 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.
and for patients and our families, it will mean less time dealing with the 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. the moneyed interests will do everything in their power to stop us. yet despite these obstacles and despite the personal challenges that i face, i sit before you today a hopeful man, a hopeful husband, and 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 that there is a better way to structure our society.
a better way to care for one another. a better way to use our precious time together. and so my closing message is not for the members of this committee, it is for the american people. join us in this struggle. be a hero for your family, your communities, your country. come give your passion and your energy and 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. mr. mcgovern: 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. mr. mcgovern: thank you very much. i appreciate it. we are grateful for your testimony and honored to have you here. yield to mr. cole. mr. cole: it's a great privilege to have you here at considerable sacrifice and risk to yourself. testament to your courage. very happy and honored to have you in this debate and hearing today. thank you. we'll go next to dr. charles blahous. jake fish and lillian f. smith chair and senior research strategist at the mercatus center at george mason university, and a visiting fellow at stanford university institution, previously served as a public trustee for the social security and medicare programs. deputy director of the national economic council under president
george w. bush. dr. blahous: thank you very much. chairman mcgovern. ranking member cole, all the members of the committee, 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 of
second is my testimony is based on an analysis of the medicare for all act of 2017, introduced by senator sanders in the last congress. obviously there are more recent bills introduced by representatives jayapal and senator sanders himself, these are expected to cost more. but i have not had an opportunity to analyze these bills. medicare for all would add somewhere between $32.6 trillion and $38.8 trillion in new federal budget costs over the first 10 years. the $32.6 trillion estimate lower. it essentially assumes every cost containment provision in the bill saves as much as possible. if things play out with historical trends, the new costs would be $38.8 trillion.
i'll say more about this later. such enormous numbers are difficult to grasp. we are talking about 11% to 13% of our g.d.p. in 2022, rising to 13%, 15% in g.d.p. in 2031 being added to the federal ledger. we do the not have historical experience with permanent government expansions of this size. to provide a sense of the magnitude, the study notes doubling all current individual and corporate income taxes would be insufficient to finance the lower bound estimate. now, to be clear, these would not be the total costs of medicare for all. this would be the federal government's new cost above and beyond currently projected health obligations. it would be somewhere between $54.8 trillion and $64.7 trillion. the vast majority of the costs would arise from the government of health spending by others by state and local government, private insurance, and individuals in the payments out of pocket.
other aspects of medicare for all would add to that existing health fend spending. still others are intended to bring costs down. the biggest factor increasing health spending under medicare for all would be its 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. perhaps most importantly, as has been noted here, medicare for all would provide first dollar coverage of all americans' health expense, meaning no deductibles, co-pace, or cost sharing this. would considerably increase the demand for health service force the well documented fact the more people's health care financed by their insurance, the more they consume. under medicare for all, the federal government would not only take on responsibility for funding currently projected health services, but a significantly increased demand. 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 the brackets a range of
possible outcomes of efforts to negotiate lower drug prices. the big variable here is payment rates for health providers. the bill indicates providers will be paid at medicare payment rates. these are lower than those paid by private insurance. hospitals, payment reductions will be more than 40% for treatments now covered by private insurance. for doctors the reduction from private insurance rates would start out around 30% on average. they grow steeper over time reaching 42% in 10 years. importantly these reduced payment rates would be substantially below providers reported cost of providing services. we do not know what would happen to the supply, time limits, or quality if we were to impose sudden provider payment cuts of this magnitude while simultaneously increasing the demand. because of this, several other studies performed prior to the bill's introduction assumed higher payment rates than medicare would be needed. my study did not take side on whether these provider payment cuts would be desirable. surely from an analytical standpoint you have to recognize the much larger a and more sudden the lawmakers have been willing to implement. if historical patterns continued, medicare for all would further increase national health spending even above current projections. my written testimony provides comparisons shown. these items are similar to other experts when you adjust for the years being estimated and alternative assumptions regarding administrative costs, prescription drug cost, and provider payment rates. i hope this information is useful. i thank the committee again for the opportunity to discuss these important aspects of medicare for all. mr. mcgovern: thank you very much. dean baker is a co-founder of the center for economic and policy research in washington, d.c.
his areas of research include houses, microeconomics, intelligent support, social security, medicare, and european labor markets. he's the author of several books and his piece "medicare for all is not a fantasy" was published on cnn's website. he received his b.a. from swarthmore, and ph.d. in economics from the university of michigan. great to have you here. mr. baker: thank you chairman mcgovern and ranking member cole. i appreciate opportunity to speak here. i have to say it's a great honor to be next to ady again. i knew him from prior days when we were in the coalition to pressure the fed to allow more full employment. that was amazing effort that he deserves credit for in addition to his subsequent work. i want to make three main points and say a little about the transition. first i want to say that medicare for all is affordable. that the bulk of the payments should be coming from shifting employer premiums to government basically to taxes. it's not additional money out of workers' pockets. secondly, that the amount of additional revenue, here what we have to keep front and center we pay twice as much for everything as everyone else in the world that. doesn't make sense. the third point is that lower costs can be associated with better care, not just for the obvious reason that will increase access, but for other reasons we should expect better outcomes. the first point, in terms of the overall affordability, taking a look at the numbers, basic story comparable that you are looking at incorporating somewhere, looking at 2021 to 2030.
incorporating the private payments into -- under the government budget, about $33.4 trillion by my calculations using c.m.s. numbers. first off we know that 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. most obviously you have the huge difference in what we actually pay up front for insurance, but in addition to that, we have huge administrative costs on providers, hospitals, doctors office, nursing homes. they have to have large numbers of staff to deal with different billing from different insurers. using their figures i calculate that we would get that tab down to $25 trillion. still considerable. that's shown in table one of my written testimony. second point, second adjustment we will see more utilization. i think -- we are shooting in the dark here because we don't
know what happens when we make more health care for cheap for people. the important point to keep in mind, 70% of our health care costs come from roughly 10% of the population. the point is those 10% are either on medicaid or they have hit their out-of-pocket limits. in other words, they are not already constraint. we are looking at 30% of costs. how much more will that with go up? we tonight know. i assumed 10% in the calculations. we also, there will be some out of pocket. that will be debated how much you have 1% of g.d.p. that leaves us after we account for the $11.6 trillion in employer payments we are left with $13.6 trillion. still a substantial bill over a decade. ok what, about input costs? i won't go into these in great detail, it's in my testimony, if we look at our cost, if we took
through medical equipment, prescription drugs, physicians payments, dentists, we pay twice as much as everyone else in the world. will we get down to other levels? that's an open question. but there is no obvious reason we should be paying twice as much for our drugs, for our medical equipment as people in france and germany. we don't pay auto workers twice as much. or twice as much for cars. it's not clear why we do that for health care. low me focus on prescription drugs, c.m.s. expects we'll spend $6. trillion in prescription drugs. this assumption in the bill most , people analyzed we can get that down. one of the points i like to make we are not talking about making prescription drugs cheap, we are making them expensive. him drugs would be cheap if we didn't give government granted patent monopolies. i understand there is a rationale for that. the point is we could fund the research in alternative ways a and they would be cheap. to come quickly to last points, we could expect better care, people shouldn't have to deal with the stress. ady and his family should have
to deal with the stress of paying for their bills that. has to be a negative in terms of care for someone. cancer victim. someone else suffering from a serious disease they have to deal with with bills. also in the case of prescription drugs, our opioid problem, at least it's alleged, is the result of our patent monopolies. purdue phrma would not have done, push their drugs insisting it wasn't addictive when the evidence was it is. we have helped create that problem. last points on the transition i , would be cautious on how you do it. first off fix medicare it's absurd that 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 drug plans in the private sector. why do we have that in medicare? that raises costs. we overpay the medicare advantage plans. recent analysis found we overpay
them by roughly 13%. allow a buy in. have a competitive medicare plan. third put, reduce input prices. i can introduce lots of ways to do that. public funding for research for prescription drugs. lastly, very, very simple first step, how about lowering the medicare age of eligibility 64. that's very affordable. a lot of 64-year-olds are already on medicare through disability or on medicaid. a great down payment in my view. long and short, i think it's affordable, but we have to be careful how we get there. thank you. mr. mcgovern: thank you very much. mr. cole: thank you very much. ms. grace-marie turner is president of the institution of a public policy organization founded in 1995 to provide and informed debate over free market ideas for health reform. she's been instrumental in developing and promoting ideas for reform to transfer power over health care decisions to
doctors and patients. she speaks and writes extensively about incentives to promote more competitive patient centered marketplace in the health sector. ms. turner: thank you, ranking member cole, thank you, chairman mcgovern, members of the committee for the opportunity to testify today. let me begin by saying i believe there are important shared goals for health reform. everyone should be able to get health coverage to access the care they need. it should be affordable. people should be a able to see the doctors they choose. we must guard quality of care. and we must protect the most vulnerable with the strong safety net. millions of americans are frustrated with the current system. care costs too much. and many are simply priced out of the market. others with insurance they claim deductibles are so high they might as well be uninsured. those on public programs struggle to find physicians, especially specialists who can afford to take the low payment rates. people are hurting and they feel
powerless. as cogs in the $3.6 trillion health sector with little power to impact choices or costs. but it is hard to see how consumers would be more empowered when dealing with a single government payer in a country that values diversity, where one massive program, with one list of benefits, and one set of rules work for everyone. i was in the gallery the night the house passed the affordable care act in march of 2010. and heard member after member talk about the importance of passing the bill in order to finally achieve universal coverage and to lower costs. nine years later with millions still uninsured and costs doubling in the individual market, our nation is still struggling to achieve those goals. here today you acknowledge the growing interest in this
proposal, but when people learn that medicare for all would mean much higher taxes and losing the coverage they have now, support plummets. what happened recently in colorado and vermont when they tried and failed to create their own single payer system i think is important to study. i believe the growing presence of government in the house sector is a consistent, is a significant contributor to its dysfunction. government officials not consumers increasingly determine what services can or must be covered, how much will be paid, who is eligible to both deliver and receive these services. third party payment systems lead to significant disruptions. insurers others must respond to government rules, shoving consumers to the bottom of the health care totem pole. rather than expand the role of government, i believe we need to look more carefully at these problems and target appropriate solutions that empower consumers and build on what works. medicare for all's promise of
unrestricted access to benefits is virtually unprecedented, and it is difficult to anticipate the impact of this new system. representative jayapal's bill implies a recognition of cost bias imposing global budgets to contain spending. paying doctors and hospitals at medicare rates would force many to close or significantly cut back on services and would worsen the existing physician shortage. we do know from the experience of other countries that centrally determined benefit structures leads to rationing, waiting lines, and lower quality of care as i describe in my testimony. tragically it is often the most vulnerable who are left behind when demand for services outpaces resources. many americans would he see this severely disrupted to lose their current coverage on public programs as well as job-based health insurance would be shut down under medicare for all.
173 million americans get health coverage through the workplace. a highly valued benefit. my colleague explains that this system is really a central pillar in our health sector. it produces nearly three to one ratio in value to tax expenditures. employer plans also pay doctors and hospitals more than medicare. and providing the margins most need to maintain quality and even keep their doors opened. employers also have more flexibility to tailor insurance to the needs of those in the work force to advocate for them and provide education can and incentives about good health. i describe in my testimony targeted solutions already under way to give individuals and workers more not fewer choices, and to provide states with more resources and flexibility to help their health insurance markets recover.
i also describe work by the health policy consensus group in developing a plan to reduce the cost of health insurance while protecting the poor and sick, including those with pre-existing conditions. finally, americans want more not fewer choices in health coverage. yet medicare for all would put them on a single government program. when government officials are making decisions about what services will be covered a. the legislation explicitly says, how much providers will be paid, how much they must pay in mandatory federal tax, consumers will have even fewer choices than they do today. it will reduce access to new technologies, stifle innovation, and result in a near doubling of the tax burden. i would welcome the opportunity to work to achieve the goals of better access to more affordable coverage and better protection for the vulnerable. thank you for opportunity to testify. mr. mcgovern: thank you very much. dr. sarah collins is vice president for health care coverage in excess of the
commonwealth fund. she directs the fund's program on insurance coverage and access. dr. collins has led several multiyear surveys on health insurance and offered reports, issued briefs on health insurance coverage, health reform, and the affordable care act. early she was associate editor at the "u.s. news and world report." senior health policy analyst in the new york city office of the public advocate. dr. collins holds an a.b. in economics from washington university, and ph.d. in economic from george washington university. thank you for being here. doctor collins: thank you, mr. chairman, and members of the committee for being able to testify on proposals to reform the u.s. health system. my comments are going to focus on gains. the problems people continue to report. and potential of recent congressional bills to address these problems. the a.c.a. brought sweeping
change to the health system. expanding comprehensive health insurance to millions of americans and making it possible for anyone with health problems to get coverage by banning insurers from denying coverage for charging more because of pre-existing conditions. the number of uninsured people has fallen by nearly half since the a a.c.a. became law. there's been a decline in the share of people reporting problems paying medical bills or not getting care because of cost. the large combroid of research on the a.c.a. shows that the law's overall impact on people's ability to afford insurance and get health care has been positive. however, three distinct yet interrelated problems remain. 29.7 million people remain uninsured. 44 million people with insurance have plans that are leaving them under insured. and health care costs are growing faster than median income in most states. the stalled gains in coverage stem from five primary factors, 17 states have not yet expanded medicaid. people of incomes just over the eligible threshold for marketplace subsidy, and many in employer fans have higher
premium costs. congressional and executive actions on the individual market and medicaid have reduced potential enrollment in both. undocumented immigrants are ineligible for subsidized coverage. and cost sharing is climbing in individual market and employer plans. a major factor underlying trends in both uninsured and underinsured rates is close and health care cost, health care costs are the primary driver of premium and deductible growth in private insurance. there is growing evidence that a major cost of health care cost growth are prices paid to providers, especially hospitals. there is evidence these prices explain the wide health care spending gap between u.s. and other wealthy countries. and there is also evidence that the greatest provider of price growth is occurring in private insurance. congressional democrats have introduced several bills to address these problems. the bills all propose to expand the public dimensions of private
and public health system and grouped into three categories. built to add more public plan features to private insurance such as enhancing marketplace subsidies. bills that give people a choice of public plans alongside private plans such as plans based on medicare or medicaid offered through the marketplaces. bills that make public plans the primary source of coverage such as medicare for all bills. these bills are an amalgam of provision that is individually or collectively have the potential to make the following changes in the health system, improve the affordability, benefits, and cost protection of insurance, slow cost growth in hospital and physician service, prescription drugs, and administration. reduce the number of uninsured and under insured people. some notable estimates are the effects of these bill's provisions include lifting the top income eligible threshold for marketplace tax credits could ensure nearly two more million people and lower
premiums by nearly 3% at a net federal cost of $10 billion. allowing h.h.s. to negotiate prescription drug prices under a medicare for all approach could lower drug prices by 4% to 40% in medicare for all approach could lower administrative cost from a current 14% of spending in commercial plans to anywhere from 6% to 3.5% of all spending. the estimated effects of a medicare for all approach on u.s. health expenditures range from a decline of 10% to an increase of 17%. what has captured the most attention in the debate about medicare for all is a significant shift in how health care being would be paid for. most medicare for all bill shifts most of the responsibility to the federal budget. this shift raises important questions about financing. in particular the incidents of taxation. what is notable about the range of national health expenditures estimates under medicare for all
approach is that the increase in 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, prescription drug cost, and administrative costs. the mechanisms for slowing cost growth in these proposals could be considered refined and applied not only in single payer approaches but other health reform approaches as well. in the absence of congressional action on improving coverage, many states have stepped up and implemented policies such as reinsurance programs. improving coverage for everyone will ultimately require federal legislation. expanding coverage, limiting family cost, and slowing cost growth are achievable goals and these bills provide mechanisms to move forward on each. i look forward to your questions. thank you. mr. mcgovern: thank you very much. dr. browne is a retired colonel in the u.s. army medical corps
and 118th president of the national medical association. dr. brown retired from the national medical institute where she managed the breast cancer chemo prevention portfolio. she was a woodrow wilson public policy scholar in 2007 where her research focused on breast cancer health disparities. her focus is on achieving health equity. she now serves as the president and c.e.o. of brown and associates, a small business specializing in improving health outcomes. dr. browne graduated from a college in mississippi. university of california in los angeles and georgetown university, m.d. she's a medical oncologist by training. we are thrilled to have you here. dr. browne: thank you.
thank you chairman mcgovern, ranking member cole, and members of the committee. i thank you for the opportunity to appear before the committee to discuss universal health coverage for all americans, particularly the vulnerably underserved population. i am here as the retired military medical officer and immediate past president of the national medical association, the largest and oldest national organization representing the interests of more than 30,000 african-american physicians and the patients we serve. as the nation's only health care organization still devoted to the needs of african-american physicians and their patients, we are disturbed by the vast inequities of vulnerable populations. with numerous and often insurmountable obstacles to receiving quality health care, people of color experience differences in access to care, the affordability of these service, and bias by some providers, and limited participation in clinical research which has consequences around valuable medical treatment.
in my written testimony, i address some of those concerns. but given the disproportionate impact on chronic diseases in -- research reveals that african-americans are more likely than other ethnic groups to experience health in equities. but given the disproportionate impact on chronic diseases in communities of color, congress must find ways to make health care coverage affordable, accessible, and of high quality for all. but the national medical association health care is more than a provision of medical services. health care is a multifocal, complex product which takes into account the critical determinants of health, including the socioeconomic
conditions, housing, education, food and nutrition, environmental, exposures, genetics and biological factors. while the a.c.a. was a step in the right direction and made substantial improvements in our health care system, it did not go far enough. in order to stem the high prevalence, morbidity and mortality of chronic diseases, we must first develop a comprehensive agenda around health equity, and health equity is the state in which everyone has the opportunity to attain their full health potential and no one is disadvantaged. it's imperative health care be provision to surpass one's socially defined circumstances. health equity and opportunity are inextricably linked. when health equity is achieved, there is no health disparities. and universal health coverage is a pathway to achieving that health equity. it has the potential to address
poverty, inequality, and discrimination. it can also provide a more efficient and effective cost saving health care system for everyone. because health equity and opportunities are linked, the health equity, as i indicated, there will be no health disparities. the government has maintained a track record for providing comprehensive health care throughout the military's tricare program, the department of veterans affairs, and other sponsored programs, as you know, medicare, medicaid, and others. and these programs have diligently worked to confirm affordable access to high-quality health care benefits for millions of citizens covered by these programs. under d.o.d.'s tricare, which is the second largest single payer health system in the country and second only to the v.a. program, both of these high-caliber systems adhere to high-quality, evidence-based, accessible care for their beneficiaries.
a patient should not have to decide between getting their full prescription filled and whether they should buy food and, of course, that certainly is something that we've seen in the private sector, taking care of cancer patients, where they would decide, maybe i should fill only part of the prescription. part care does not get you to remission in cancer. every patient should have the opportunity to receive first-class medical care rather than being considered second best because of a lack of insurance, provider bias, limitation of the medicaid system. we've seen this over and over where an individual may not get the approved drug for care in cancer but get the second best because their system did not have the drugs on the formulary. the best framework for universal health coverage is through collaboration and engagement of diverse partners, including the
communities in which they serve. some of the existing health care programs already have the infrastructure and provider network to serve our communities. but improvement is needed to target the excessive costs, service flexibility while minimizing the duplicate services we see in many cases. i want to leave you with two points. first, we must adopt a system of universal coverage that minimizes the administrative medical costs. it does not matter what label you use, whether it is medicare for all, universal health coverage, single payer, whatever. the coverage must be one that would allow the patient's ability to choose the provider for their care and care should be the same no matter whether you receive it in mississippi or california, whether you're in rural america or urban america, and it should not be restricted based upon language, age, gender, racial and ethnic areas.
secondly, we must continue to address the physician shortage and funding of our safety net hospitals. universal health coverage would allow for increased investment in educating more providers and allowing for additional residency slots. with consistent and predictable provider costs, we can end the two-tiered system of health care that has placed hospitals that serve low-income and minority communities at risk for closure. universal coverage would ensure that our safety net hospitals are sufficiently funded and resourced. they will continue the long history of advocacy and education. we believe that all individuals in every community in the united states have a right to equal, quality, high-quality health care that is accessible, affordable, comprehensive, and
coordinated. we begin by providing the comprehensive coverage benefits that we have under medicare for all. thank you. mr. mcgovern: thank you very much. i want to acknowledge congresswoman debbie den go from michigan, who has arrived here. she's co-author of the medicare for all bill along with congresswoman jayapal. we appreciate her leadership and her being here. last but certainly not least, dr. nahvi is an emergency medicine physician and assistant professor of medicine in new york city. dr. nahvi completed his m.d. at nyu school of medicine and is on "now this" discussing his patient struggles with the current health care system. and he's on the board of directors of the new york metro chapter of physicians for a natural health program. i would urge my colleagues to
google dr. nahvi, and he has interesting and compelling videos that kind of highlight some of the inadequacies of the current system. google dr. nahvi, and he has interesting and compelling we are happy to have you here. make sure that your mike is on. dr. nahvi: is that too close? mr. mcgovern: it's good. dr. nahvi: thank you, chairman mcgovern, ranking member cole. i'm an emergency medicine doctor in new york city and i support medicare for all. as a new york doctor i have the , opportunity to help all sorts of people in all sorts of ways. i get to save investment bankers from heart attacks and strokes get to help homeless veterans with hypothermia in the winter. that's what i love about my job. ed idea i can help any person -- the idea i can help any person with any problem at anytime is what attracted me to emergency medicine. it's hard to care for someone when they fear of bankruptcy and foreclosure when it comes to seeking medical care. ask any er doctor, nurse or
janitor in this country and you will hear countless, countless stories of those who came to care, only to walk out in the middle of the treatment ama. ama stands for against medical advice. they are concerned about the cost of their treatment. the reality for many people in this country is that seeking medical care means weighing one's health against one's wallet. now, everyone in this room is very smart. everyone knows all the statistics. you already know that 41% of americans have skipped a visit to the er in the past 12 months because of cost concerns. that is easy to gloss over, but we should let that sink in. that's 41% of americans. over two in five americans have skipped a visit they felt they needed to go to the er, but then decided not to go seek medical care because they were concern ed about the cost of that visit. you also already know 45% of americans live in fear that a health event could lead to bankruptcy. i have to look these patients in
the eye and i want to put some face on the numbers you already know so well. a few weeks ago, i took care of a patient who i was sure had an appendicitis. we recommended a cat scan i , discussed antibiotics and possibly surgery. she flagged me down, asked me to pull out her i.v. because she wanted to go home. now, she wasn't stupid, crazy, didn't distrust doctors or anything. the patient was concerned about the cost of her treatment. she did research on her phone. she learned that in some rare treated withld be antibiotics alone for appendicitis, and asked to get a prescription. this is far, far from care of appendicitis. all appendicitis needs hospital care, admission and possibly surgery. i strongly advised against her plan. now, she asked me about the risks and i told her the truth. i told her about the possibility of an abscess, perforation of her bowels, sepsis from her infection and even death. , this is not an exaggeration. this is the truth if you don't treat an appendicitis. she thought about it for a long
while but eventually she flagged , me back down and decided to leave. in her own words she said thanks, doc, i appreciate all you have done, i really do, but i just don't know if i will be able to afford this. i am going to go take my chances. now, in my line of work, i have to give people bad news. i often tell loved ones that their family members have died. i have to tell parents their child has died, told spouses their husband or wife has died. but i can tell you with complete sincerity that watching someone sick walked out of the door with something that is treatable, especially in the richest country in the world, is the awfulest feeling as any of those conversations. about one year ago i took care of a young lady who came in for an overdose on fish antibiotics. she decided to go to a local pet store to get fish antibiotics to treat her symptoms. she wanted to make sure she was better for her interview.
fish antibiotics come in a packet of powder, you put them in the fish tank so the fish can eat it there is no instruction , for human consumption. she ended up overdoses. she had side effects that affected her brain and central nervous system. she fell down a staircase while on the job interview and had to be admitted to the i.c.u. all of that, because she felt that she couldn't afford a simple visit to the e.r. for a simple fever. 21 years ago, when she was 10 years old my fiance, who is here , with me right now, lost her mother because her mother decided to delay medical care for abdominal pain until after her stomach cancer spread beyond any hope of treatment. my fiance's mother was worried about the cost of her care and she paid for it for her life. i am here today because my deserve and my fiance better than this. these stories and countless others are absolutely ridiculous to be taking place in the richest country in the word. i am not asking for much. all i want to do is practice medicine so i don't have to
watch a patient walkout of the er without medical care because they fear of going bankrupt or thinks thetient who best option for medical care is to go to the local pet store. to simply treat someone for something as simple as an append 2019, or taking pet medication, these are not radical ideas. this is something as easy as maintaining our roads, educating our students. this means creating a universal health care system like medicare for all so when they are at , my patients don't have to make their most vulnerable any , consideration except do what they need to do in order to get better. thank you, chairman mcgovern, ranking member cole, and the rules committee for inviting me to be here. i look forward to any questions. mr. mcgovern: thank you. thank you all very much for testifying. before i ask some questions, i have a few unanimous consent requests i want to enter in the
record. you know, our health care system is built with checkpoints that prohibit a person from being able to access health care, including pre-authorization requirements, lifetime limits, network restrictions, costs and the inherent discrimination built in the system. without objection i would like to submit a letter from the national nurses united, an organization with 150,000 members. their letter explains how gatekeeper obstacles would be eliminated with this bill, and i would like to thank jean ross, president of the national nurses united who is with us here, for , her leadership and her work and ensuring every american has access to affordable health care in this country. jean is here in washington, d.c., with nurses from 28 different states advocating for medicare for all. i want to thank you. i will enter it into the record without objection. without objection, i'd like to submit in the record a letter from diane archer, the founder and past president of the medicare rights center, which is a national nonprofit consumer service organization. in her letter she brings to light serious concerns about medicare advantage, and how
medicare for all, and improved and expanded medicare system can , fix these problems. a child's access to health care is crucial. they're going through a time of rapid brain and body development and it's important their health coverage reflicts their needs. yet a recent survey by georgetown center for children and families found an increase in uninsured children for the first time in a decade. so without i'd like to submit a letter from a california-based nonprofit child advocacy organization working to ensure that every child has access to health care. this letter outlines the critical components of health coverage and care for children that should be addressed in any policy congress considers, including medicare for all. and i'd like to thank mayra alvarez, president of the children's partnership. those will be in the record. so let me begin my questions. mr. barkann, let me ask you a question and i'll come back to you in a minute for the answer. but you know a little bit about how health insurance companies deny claims.
and you testified that your medical bills cost thousands and thousands and thousands of dollars a month. you also talked about the time commitment it takes to fight back against these denials. i guess my question is, what are some of the services or medical devices that were denied by your insurance company, and how is your life impacted by not having those services? and i'll go to the next question and come back to you, ady, in a minute. let me say to doctors baker, blahous and collins, you are all economists. tell me, are economists always right? [laughter] i mean, you should try being a member of congress. we're always right, right? [laughter] seriously, though, let's look at
studies. even looking at dr. blahous' study from the conservative merkatus center. it seems like the studies suggest that medicare for all could cost a little more or a little less than we're currently paying now, right? getting that right? dr. blahous: i think that's fair. mr. mcgovern: ok. so worst-case scenario, we could spend about what we are spending now nationally on health care and guarantee that another 29 million people get health care coverage. we could end crushing costs for everyone, and we could include new services for seniors and the disabled. that sounds like a pretty good deal to me. so i mean, when we have all these, you know, warnings about the high cost, we're spending an awful lot on health care right now. and we're not getting the services and the effectiveness
that we're all demanding. so i just want to put that out there because i think it's important for people to put this all in perspective. i am not talking about new costs. we are talking about costs that are already built in the system. dr. baker. dr. baker: i would just throw a quick point in about economists not being right. i think the affordable care act hasn't gotten credit. how much it deserves credit for the slowdown in cost growth. but if you go to 2008, the projections from the center for medicare and medicaid services for 2017, compare with what we actually spent, we spent 1.5 percentage points of g.d.p. less on health care than what they had projected. so that comes to $300 billion that year. same thing if you look at the c.b.o. projections. we're spending half a percentage point of gdp less on medicare than what they projected in 2010 before the bill passed. now, whether you want to say the affordable care act was responsible for all that slowdown, that's a totally arguable point.
but the point was, we are actually doing pretty good in terms of slowing the cost of health care cost growth if you like increased government involvement. mr. mcgovern: dr. collins. dr. collins: yeah. i just wanted to -- my testimony covers the range of estimates that are currently out here, including dr. blahous'. and what you do see is exactly what you said. some estimates show a decline in national health expenditures. some show an increase in national health expenditures. it depends on savings we can potentially get from provider prices, from prescription drug costs, from administrative costs. but i think one of the major contributions of the medicare for all bill is putting the issue out there on how much we're paying providers right now. i think that is a really critical issue. it's why we do see some savings in some of the estimates that we've seen of the medicare for all bills. it's a conversation that the country needs to have right now. and i think the differences and
changes in expenditures under these approaches put a fine point on that issue. mr. mcgovern: look, all of us here as members of congress, we do casework too. and we get an inordinate amount of casework that is health care related, and it is always about fighting with insurance companies, it is always about these crippling costs. i guess the point i am trying to make, i like to think we all believe we can do better and i'm just simply saying, when people push the panic buttons on cost, i mean, we're spending an awful lot right now and we're not getting the result we want. and i think, you know, to me medicare for all offers a better way to go forward and gives us more care. and by the way, for senior citizens, it gives them medicare plus. they get a lot more than they're getting right now. i don't know, ady, are you ready? all right.
[captions copyright national cable satellite corp. 2019] [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. visit ncicap.org] >> i was reminded by my neurologist it was not necessary, and i would have to play -- i would have to pay full price. the company also denied me a brand new f.d.a. approved medicine to treat a.l.s. first of all, my plan doesn't cover long-term care and so we have to pay for 24-hour care, which is incredibly expensive. but in addition, my insurance , health net, company denied me a breathing assistant machine. health net ruled the ventilator and medicine provided by my neurologist was not necessary and that i would have to pay full price. the company also denied me a brand new f.d.a. approved medicine to treat a.l.s. the first time i had to complain publicly and generate an outcry for them to reverse their decision.
the second time i had to organize a protest at their headquarters. but most people don't have the ability to do that, and nobody should have the obligation to do that, but this is a big part of how insurance companies make their money. they deny, delay, and wait for patients to give up. i believe that approximately one quarter of claims are denied. as a result, people get sick, get sicker and die. fundamentally, the priority for health insurance companies is to make a profit, but that is not in the public interest. by getting the profit mode out of the health care industry, we can focus on the real priority, delivering high-quality health care. mr. mcgovern: thank you. dr. nahvi. dr. nahvi: i just want to piggyback on that. i do think when health insurance companies deny claims, it's not only unethical.
i just want to show a couple examples when it's kind of just financially stupid as well. i have a couple cases i'll share real quick. in my hospital recently there is a 28-year-old female that came in with a regular run-of-the-mill urinary tract , infection. course of to treat, antibiotics, no problem. she was denied that claim for antibiotics. no good reason was given why. she was charged $300 over the counter in cash. she could not afford it. she went to the other side of the pharmacy and bought cranberry juice because she thought that might be the best option for treating her uti. she ended up coming into the hospital two days later septic, high heart rate, had to get admitted to the hospital and i.v.'d antibiotics. we denied $300 and now had to pay thousands of dollars for that. there is another example. i had a patient come in, he was having a heart attack. his cardiologist came down and recognized him and started yelling at him and said, why did you stop taking the antiplatelet medication i told you cannot stop taking?
he said six months ago i was , admitted to the hospital with complications from my diabetes medication. my and her chronologies told me i can't stop taking those. in with up coming back a heart attack. because we insufficiently covered these patient's prescription medications we , ended up paying more in the long run. another example, there is a patient i had, she was 38 years old. she had a long history of depression. her depression was controlled with some psych medications. she had been on these medications for many years. out of nowhere her medical , insurance company started denying that medication. she stopped taking them. couldn't get in to see her she psychiatrist for a month or two. she ended up coming in because she was feeling suicidal and had to be admitted. the patient had bad medical outcomes and that's horrible in and of itself but it just financially doesn't make any sense. we ended up paying more for these bad outcomes. that needs to be part of the discussion as well.
and when we talk about all these estimates of cost, i imagine that the kind of cost savings we would see by making sure patients are covered and fully covered, we don't see that in these numbers because there's no way to account what we're seeing on the ground level. these would save a lot of money. mr. mcgovern: dr. browne. dr. browne: well, certainly in the oncology area we see this , most particularly with people of color. have a number one, they fear of going to the doctor to begin with, and they will deny that lump is there and think it will go away and many cases they will pray at away, but after coming in after being denied it is an advanced disease. it is much more costly and the outcome is negative because they tend not to survive. mr. mcgovern: you indicated, again, you're paying all these thousands of dollars worth of it is much more costly and themu turned to a gofundme page online
, using a fundraising website to help you cover the cost. gofundme whathave , other household costs or family bills might not get covered to cover your care? you're a pretty popular guy. and even i have seen your twitter feed and know all about your work. might ben gofundme something that someone of your stature can do, but not everybody can do that. what if you don't have the twitter following you have? how would you afford the care? and do you think there's anything sane about our gofundme health care system? while you think of that answer, let me about to dr. nahvi. you know, based on your testimonies, i'm guessing the stories of insurance companies denying care isn't surprising, right? dr. browne, you're a cancer specialist. can you tell the committee how a prepaid system like the military
compares to a postpaid system like the one for the civilian population, and how it differs when it comes to patients getting the care they need and actually following the doctor's best medical advice? and dr. nahvi, you testified about your patients who put cost before their health care out of necessity or fear, and you have told some horrible stories here. do you believe you are free to practice the best medicine you can, that your patients are free to take your advice without fear, or do you think there's something standing between you and your patients getting the care they deserve? dr. browne: yes. in the prepaid system in the military, as a military provider, whether it is cancer or general internal medicine, it is unequal access system, and we do not have to be concerned with, can that patient afford an m.r.i. or should i just order an x-ray?
again, i know that the best possible care is what i can provide for those patients and so i order the m.r.i. and get the best care for those individuals. they don't look at, do i have a co-pay, is there some out of pocket? they go to that facility in the integrated system and they get the best care. if you're outside, you weigh that. maybe i should see if a cat scan will suffice, and i can still see the dimensions of this mass and its distinguishing feature to whether i should order , surgery. if the patient cannot afford for even a c.t. scan, then i look at whether the other kinds of things that i can order to get that patient to the care they need. and that is not the way i was trained to practice medicine. you go in to provide the best possible care for those patients and it's not based upon cost. it's based upon need. so you can improve the health outcomes. mr. mcgovern: dr. nahvi. dr. nahvi: i couldn't agree more. the answer to your question is,
no, i don't think i'm practicing the best medicine i can practice. i feel like i'm practicing with one hand tied behind my back. oftentimes when i recommend something to my patients, they sit down and they think, can i afford this, should i do it before they decide to do it or not? and these are lose-lose conversations. i feel if i try to tell somebody to do something and say, no, i don't think i can afford that cat scan, they walk out, their health suffers. but even if i convince them, i don't feel terribly good about myself. if i convince someone to get a cat scan they are not sure they can afford, i walk away thinking, did i just kind of sentence this person to years of debt they are not going to be able to pay off? so there's no winning in a lot of these conversations and i am , not giving the best care. mr. mcgovern: mr. barkan. mr. barkan: if i couldn't use go fundme, i would probably start asking my parents to start spending down their retirement
savings. then we would go hat in hand to friends. no one dealing with a serious illness should have to do either of these things. we should instead have a rational, fair, comprehensive social safety net that actually catches us when we fall. mr. mcgovern: thank you. mr. cole. mr. cole: thank you very much, mr. chairman. if i may, i will follow your lead here. i want to submit a letter, without objection, from the american hospital association in opposition to the legislation. mr. mcgovern: without objection. mr. cole: thank you very much, mr. chairman. if i could, as turner, i will start with you. h.r. 1384 explicitly makes it illegal for private health insurers to provide for a service that the government would provide under this legislation. how many people would lose the current health insurance if they have if we did something like that? ms. turner: everybody would lose the current health coverage they , 173 million americans with
job-based health insurance. but those on the a.c.a. coverage, people on medicare, people on medicaid, the children's health insurance program, all would be folded in to the new medicare for all legislation. mr. cole: under this legislation, if you liked your plan, liked what you have, you wouldn't have any option at all to keep it? ms. turner: only if you are in v.a. or the indian health service, as i understand it. mr. cole: believe me, people in the indian health service might want to make the change. ms. turner: oklahoma used to. mr. cole: depends what congress does and doesn't do in that service. anyway, let me ask this in follow-up to that. how would this impact both employers who provide the coverage and employees who are satisfied with what they are actually receiving? ms. turner: i think this is really a significant issue and it's one when colorado tried to enact a ballot initiative in 2016 to try to create a single
-payer system for the state of colorado, they did wind up with serious pushback from people who didn't understand what it meant that they would lose their private coverage. they would particularly lose their employer coverage. the employer-based system is really a central pillar in our health sector for a number of reasons. because employers have easier access to health care for employees with different health plan options. they listen to their employees, what benefits they need, what matters to them, they are always trying to balance the cost against benefits and trying to get the best deal for them. they also have a lot of wellness programs. they know that a healthy workforce is beneficial to them so they invest a lot in their , employees. but i think there are two other points that are really crucially important. one is that because employers pay more for private coverage,
they in turn pay more to hospitals doctors and other providers in order to make sure their employees have access to the care and the treatment they need. by paying them more, it allows medicare and medicaid to pay less so that people on those , public programs will also be able to access care. so there's a real balancing and i think the value of the employer-based health insurance, 473 million people, half of the people in the country, retirees, workers, dependents, etc., are really helping support the current medicare system that we're talking about ameliorating. also, because employers get a tax break, as providing health insurance is part of the compensation package for their employees there's a tax break
, there. also, employees have -- the value of their health insurance is excluded from their income. my colleague assumes that the value of employer-sponsored $991h insurance is about billion, almost $1 trillion in 2016. and there is a tax break worth about $350 billion to support employer-based health insurance. so that tax break supports 3-1 , and some estimates are even higher health insurance for half , of the country in order to get private payers to contribute to that health insurance. i think that equation, that is something that's developed over 70 years in this country, america.que to but perhaps that's because we, through some permutations of history, started on that path. it's something people enormously value and it really has become a central pillar in our health sector. mr. cole: your answer
anticipated a lot of my next question, but let me put it to you this way and get your response on this as well. if we, as this bill calls for, held the reimbursement rates for providers and medicare and medicaid levels, how would that impact the providers? what do you think the response would be? ms. turner: i'm not an economist. i am a policy person, but the former actuary for c.m.s. anticipated when congress was considering and actually enacted cuts to medicare providers, when we were still having the doc fix battles, if hospitals and physicians were to see 40% payment cuts, many of them simply could not keep their doors open. they do not have that kind of margin. they would either dramatically curtail services or they would wind up closing their doors.
mr. cole: fortunately you're , sitting right next to an economist. \[laughter] mr. cole: i would ask dr. blahous for his response to the same question. dr. blahous: i think the honest answer is the effects are unpredictable. we do know the data. we know the data indicates payments for hospitals over the time window, first 10 years of medicare for all, medicare payment rates are little bit below 40% of private insurance rates. for physicians they are about 30% below at the beginning of that 10-year period. but those relative reductions under the macro law become even steeper, so they would be 42% by the end of 10 years. the honest answer is, we have no idea how providers would respond to this. we do know that roughly under , the legislation, the demand for health services would increase by probably about 11%. other studies made similar estimates. and if we make simultaneous, very dramatic reductions in payment rates to providers at the same time as this increase in demand, none of us can say for certain how they would respond.
office thatctuary's medicare payment rates, that the margins on treating medicare patients are negative for about how providers would react to that, what sort of disruptions there might be in the timeliness or quality or supply of health services, we simply don't know. mr. cole: let me ask you this because we all know that not all hospitals are equally profitable or serve populations that are equally affluent. certainly in my district, we lost rural hospitals in recent years. they're treating a population that's older, quite often sicker and enjoys less private coverage so they rely very heavily on medicare and medicaid and they're having a tough go. again, if we remove that, suggest know the impact wouldn't be equal all across the country. in other words, i think rural areas, in particular, would take
a pretty hard hit unless something was done to change the rates, is that fair? dr. blahous: i think that's fair. i just -- to add additional perspective on this from the vantagepoint of my study, my main reason for flagging this issue is primarily just to help with understanding of the numbers. we have a set of cost estimates that would arise if you assume these very dramatic payment reductions were implemented, right from the get-go, right from the very first year but if you look at the historical patterns of congressional behavior, you don't see a willingness to impose sudden cuts for providers or anything close to that magnitude. we have a set of cost estimates if you think historical patterns of congressional behavior would continue, the cost estimate of the legislation would be much, much higher. it would be in the area of $38 trillion. a rather than 32.6 trillion. mr. cole: let me ask you this.
i will address to all of you, if i may. we'll start actually down here and go across. this is enormously complex undertaking we are talking about, to change the entire health care system. i lived through one of these things with fisa, as many of my colleagues did, the discussion, debate, and then implementation of obamacare, the a.c.a. is two years a sufficient period of time? that's what the legislation calls for, as i understand it. within two years we would make this entire transition. is that a realistic, even for those of you that want to go in this direction, worry about the time frame? >> i would have to say you have to be cautious. two years is ambitious. you're referring to your hospitals as largely rural and they already have a large number of medicare patients, if that's the case, they are less likely to be in danger because they are already getting reimbursed at medicare rates. mr. cole: they also get private payments as well.
>> i understand. smaller share. mr. cole: every patient they treated, medicare and medicaid levels, i promise you most of them would close. dr. baker: i can't comment. may well be true. dr. collins: i think the transition issue, you can certainly decide to extend it, make it a longer period of time. the a.c.a. was a four-year transition period, so that's certainly something you could consider. i did want to say -- address the cost shift argument in the medicare payment area. it is the evidence really does not show that the reason that private provider prices are higher is because medicare prices are so slow. if that were the case we would see consistently higher margins all the way across the country. instead, we see a lot of variability across the country. so the way this works is that private providers are negotiating with their commercial care -- with commercial carriers, prices that work the best for them. in concentrated markets they get
higher prices. insurers want them in their network, want them in their network so they concede to those higher prices. they then take those -- that negotiated rate to employers. employers have to pay higher premiums. they reduce the workers' wages, increase deductibles so those costs get shifted ultimately to people. there's not a lot of evidence that the cost shift argument is a reason for higher prices. it's really these nontransparent price negotiations that occur in the private market. mr. cole: yes, absolutely. mr. barkan: you asked earlier, 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. mr. cole: thank you.
dr. browne. dr. browne: yes, just wanted to add, in terms of people of color, medicare and medicaid reimbursement costs are not the same across the board. our providers are already getting a lower rate. it's not likely they are going to go out of business. in terms of employers and the amount that's being paid, many of the smaller businesses go to part-time individuals so they do not have to carry that cost. so, again, i think for providers we are concerned about, they are not going to walk out on taking care of their patients even though they are getting a lower rate. mr. cole: dr. nahvi. dr. nahvi: sure. i assume you ask a question from an implementation perspective but from a physician perspective, we are ready for this, not in two years, but two years ago.
i am ready to stop seeing my patients not get good care because they can't afford things. >> i'll answer the question from the federal cost perspective, when did i my study i was dealing with a bill that had a four-year transition. dr. blahous: 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 assumed in that fourth year everything just instantly sprang forth fully formed, that we instantly have cost savings, we had a level shift downward in prescription drug costs, we instantly had the full implementation of these provider cuts. you can look at that and say those may be reasons why the lower bound estimates, even
assuming a four-year transition, would be an understatement. if you had a two-year transition, obviously that increases the likelihood that the lower-bound estimate is a gross understatement because there's probably very little chance that we would attain those instant administrative cost savings, those instant drug cost savings i am assuming in the lower-bound estimate. mr. barkan: representative, may i weigh in on that? mr. cole: i have very little time left. if i have time left i will come back to you. ms. turner: mr. cole, there was a good piece in today's "washington post" about vermont's experience and i think it's instructive. they took an in-depth look at the experience -- their experience in trying to achieve 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, how the taxes would be collected.
and the -- what they found was that the initial projections took what she calls a 36,000-foot view what the costs were going to be. when they really got down to the hard wiring of the implementation, they found it would be so disruptive to the state's economy and so disruptive of the current structure of the health care system they had to pull the plug on it. she said it's very difficult to dismantle one health care system and replace it with another. mr. cole: may i -- ok. mr. barkan, please. mr. barkan: 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 trying to accept the status quo.
that leaves people like me behind. mr. cole: thank you very much. thank you, mr. chairman. mr. mcgovern: thank you very much. i want to yield myself a minute here just to make a couple points to amplify ady's point, employer-sponsored health care means the effects of job loss are amplified. it puts a huge burden on employers. imagine if we expected employers to provide for fire insurance, as mentioned, police insurance, school funding for k-12, paperwork that's all part of it. it's insane. just one other point here. because i think what some of us are looking at this whole initiative from a different perspective, people won't lose their health care with medicare for all. you can keep your doctors, go to your hospitals you currently have. the only difference is you won'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. anyway, i now yield to my good friend, mr. perlmutter. mr. perlmutter: i just want to thank this panel, everybody. the professionalism in your testimony is very much appreciated by this congressman and i know the rules committee generally -- mr. barkan, couple questions for you. you know, you talk a lot about time. another guy in a chair like you, stephen hawking, you wrote a number of essays on time. but time is really a key piece to all of this and you talked about a number of things. the effect of taking time and the waste of time on you personally. i'd like you to expand on that a little bit and then you also said we could save enormous sums of money. i'd like you to expand on that. and then you said, we could avoid immoral price gouging. i think those were your words. i'm just putting those three
things that you talked about, i'd ask you to expand. now, to the economists, i'd like to talk a little bit more about the money in the health care system, 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 compare to the rest of the world, other countries, industrialized countries? and i guess to all of you -- and dr. blahous, to you as well -- the overall savings that we might expect from something like
this. there was an economist, bob pollin, and his approach to these things, because it's 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? and i'll get to you doctors, medical doctors in a second, to talk about the outcomes. and then ms. turner, just so you know, i am going to talk about colorado. i'll tee that up to you. dr. baker: 18% of our g.d.p. is on health care and that's twice the average. if you take a lower cost system like the u.k., we could finance that whole system from what we spend now in the public sector. that's how much we are out of line with everyone else. and you know, the point i think that's striking, on the one hand we have huge administrative costs but the other point i was trying to emphasize in both my comments and written testimony,
we pay twice as much for the inputs. twice as much for the drugs, for the medical equipment, doctors, on down the list. and, again, that's not true of our cars. it's not true of our auto workers. so you're 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 here and cars here? but we do. that i think speaks to the enormous potential savings. again, i understand none of that -- you are the ones that have to fight with these people because these income for people. what does it look like for the u.s. compared to everyone else, we're paying twice as much. dr. collins: i'd just echo dr. baker's comments. we have a -- there's a chart in our testimony that shows the details on the countries that pay so much less than we do. but i would also make the point, our point, too, we also don't get commensurate outcomes for the spending that we're making. we actually have worse outcomes in a number of areas that other countries that are spending far
less. so the quality issue is a huge issue internationally as well. mr. perlmutter: dr. blahous, i appreciate your testimony when mr. mcgovern was talking maybe it's a push, maybe it's a little bit of a loss, maybe a little bit of a gain. this dr. pollin, i guess, economist from the university of massachusetts, thinks there's a big savings. do you have any comments on that? dr. blahous: well, sure. if i could try to unpack it a little bit. mr. perlmutter: sure. dr. blahous: i want to build off some of the things that dr. baker and dr. collins have said. i think 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 borne by the private sector to the federal government. i would add to that, the federal government would be assuming costs that are currently borne by state and local governments.
it's not just the private sector. it's all of that. it's a shift. that's a big piece of the cost. now, there are other things that would increase costs beyond that. and i thought dr. collins said something earlier where it was useful where she said basically the total national cost increase would be less than the utilization increase. so 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 those in favor say aye crease by savings on administrative costs, savings on drug prices, things like that. now, we won't be able to offset those costs 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? mr. perlmutter: and i think dr. nahvi mentioned this and in somebody else's papers, you know, two out of five people don't take advantage of health care, their need for health care because of fear of expense, that they walk back out and he gave some dramatic examples.
in effect, there is a lot of demand that's not being met because people are afraid of the cost. so i was a bankruptcy lawyer for many, many years before i was elected to congress. obviously one of the biggest areas of bankruptcy is because of health care costs. so i do appreciate your comments, dr. nahvi, 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? there are all sorts of issues here, but i think, to dr. browne and to dr. nahvi and then to dr. pollin's estimates, if we were to go to this medicare for all or universal health care system, do you agree that there would be more demand on the system? can we -- could we, from a
provider standpoint, manage that? dr. browne: thank you. yes. i don't think there would necessarily be a demand on the system. i think would you practice medicine in a more appropriate, better way. and the idea is that you are 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 hospitalizations that will end up in the intensive care units. and so there are cost savings there. we have not practiced prevention, and we have 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, find the
diseases at an earlier stage. again, you can then provide that care at a more cost-effective. so the demand is not going to increase. we're practicing care in a more efficient way. dr. nahvi: yeah. i'd like to echo that. so 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. we can utilize the health care system. 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 then we end up paying more than that. the reason is we have a law, emergency medical treatment which makes it such anyone uninsured, undocumented, whoever they are, they could come to the e.r. and we treat them. 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 the primary care doctors get their diabetes, high cholesterol under control so they don't have strokes. mr. perlmutter: do you think a system like that would help you avoid paperwork? [laughter] dr. browne: yes. mr. perlmutter: ms. turner and then i'd like to go to mr. barkan, and i appreciated your testimony because you really laid it out as to 70 years ago it was you paid out of your pocket or you got charity care and a lot of that charity care was underwritten by the churches, by charitable organizations, and then kaiser came along and said people are getting hurt, we got to do a war effort and so kaiser steel and kaiser aluminum and those guys -- they started the employer system.
so we are in this massive system and to change it is obviously a big undertaking. so i agree with all of that. with respect to colorado -- so i am from colorado. and i support ms. jayapal's legislation. i support the -- briefing -- beefing up the affordable care act. there san effort out there that says 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, 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. and that's why i went this way. but i'm happy to have you comment on it a little bit more. ms. turner: just briefly, you know more about the debate in
colorado than i do. in vermont, they were assuming that much of the money that currently is flowing to the state through health care, whether it was employer contributions, whether it was a.c.a. funds, existing taxes, etc., all would be part of that. so they were assuming a much larger pot of money because there would be additional federal funds coming in, and they still couldn't make it work. i know in colorado that there were -- from my reading on it, and did i a couple debates about the ballot initiative, the feedback we continually got was people so nervous about the taxes that would be required to support it and, yes, they -- there were arguments that the current money going to employer-based health insurance would be go but that just wasn't enough. mr. perlmutter: i think you're right. from a policy and kind of a
political standpoint, it wasn't enough to overcome a number of the concerns and fears. but i think listening to the testimony of the economists and the doctors, and just, you know, our own experience. my wife had a difficult surgery. initially denied. i mean, i can't tell you the panic that hits a family when something like that happens. you know, there are all sorts of issues. i'm just pleased there mr. pollin and mr. mcgovern were able to work out the details -- mr. cole and mr. mcgovern were able to work out the details to have this hearing. mr. barkan, are you ready for my questions. mr. barkan: 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 i should have to pay $9,000 per month for a lifesaving medical care at the time when the insurance industry is bringing in record profits. that's wrong and it needs to stop. here's the thing. it's a huge trust to -- >> live coverage of this hearing have come to realize that our time on earth is the most precious resource any of us have. i think you are wonderful congressman but i would 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 everyday realities of their health care do not have time on their side. toone should have to fight
be treated with dignity again and that is why i am here today. >> i yield back. >> thank you. woodall: we have a tough time. it might not be obvious with your reference to awakening the conscience of congress. it may be obvious we do not always get a healthy conversation on issues like this. i credit the woman to your right. , i cannot support her legislation but i support her and there is a way to have a conversation -- i know you are. there is a way to have that. the washington post, i know -- don't know if you saw the article, they did an article on this hearing and on you all as witnesses and they quoted ms. shall elect as he we are not
going to make ourselves look crazy this morning is the quote they grabbed. the washington post observed there are lots of ways to start this conversation and 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 last. i read it more than when you are in the government world. ournderstanding is that payroll taxes, medical or and social security taxes are the american families paying and every time i read a report or read those reports, they had not gotten any better,
there is not enough money coming in to do the things we promised to do. i can believe that i read your testimony correctly by want to check it out with you. years asion over 10 the best case scenario, not for the total cost of medicare for all, but just the -- to add on to the current medicare program that is there. am i reading that correctly? >> that is a lower bound estimate of the additional federal obligations above and yawned current federal obligations. >> i sit on the budget committee and we are not able to pass a budget because we could not agree as a committee on how to sort out our current challenges, much less future challenges, but it was going to be a $4.5 trillion budget. , $3.2st case scenario trillion annualized over 10 years, or appropriate scenario your nearly $40 trillion
number the worst-case scenario an expected scenario? >> i would not say it is a worst-case scenario. basically, the cost estimate over 10 years would be in the region of $40 trillion if you did not assume any particular targeted savings from medicare for all. of the different categories of savings for medicare for all, the most likely is administrative cost savings which would bring the total down to 38.8 alien dollars over 10 years but depending on your assumptions for provider payment things likecosts, that, the additional federal 38.8would be $32.16 and trillion dollars. >> help me with the math. looking your best case, your lower bound, everything goes right, what are we talking about her american cost, per-person cost? very crude. it is $10,000 per capita per person.
in addition to federal costs. trillion, it is $10,000 per person. >> i was listening to your testimony. as you are going through some of those numbers and talking about after the affordable care act, things had gotten better and i agree with anything that you said about increased outcomes, but was it reflected their, though, is whether we got the best bang for our dollar. we spend a trillion new dollars on health care, subsidizing american families with costs but i read a poll that says are the health care costs easier to manage than yesterday? i think the question is we agreed to spend $1 trillion. are we spending that in the way that helps the most families do themselves, reduce
those stresses that we have talked about. have you seen any data along those lines? not did we do better but there we do the best we could do given the and or miss resources we invested? >> we can do better. 17 states have expanded medicaid so that is one area where we have not fully implemented the law. there have been some changes to the cost stream reduction subsidies in the marketplaces to have premiums on silver plans which has heard some people. people's tax credits a just and the government is paying a lot more because we are not paying these subsidies. in terms of implementation, there are areas where we could do better. we could extend the subsidies of people over that threshold for mac -- market take -- marketplace tax credits could afford that. i understand that if we wanted to improve the affordable care act in its current structure, there are lots of
things that would do it and i expect there are people who would rather do that than the medicare broadband. my question is a goes to what dr. navi said. not go to the did er even though they needed to go? every physician says we are in a conscious effort to keep people out. people keep wanting to come. we do not want them to come. we want them to go to our urgent care center next or because we -- when they come to see us, if they do not need to see us, we are wasting valuable resources on them in our environment because it is hyper expensive. we could have served more people in more ways if we could have redirected them and that is what i am thinking about, maximizing the dollar where spending. let's agree we will spend more the very let's manned best of that money. i think about that in your case. how does that medicare for all plan as ms. jayapal has crafted, what incentive is there to do
what all er physicians are telling me needs to be done, we have to keep folks out and get them into urgent care. what is the skin in the game that keeps me out of your office ? dr. navi: they do not want to see me and i do not want to see them. i agree with the doctor you talk to. when they want me to adjust ,heir diabetes dedication because i am the only doctor they can access, i feel comfortable into beating someone, treating a heart attack or stroke or a stab or a gunshot. i don't feel comfortable blood pressure medication. >> that does not come from misunderstanding as a consumer, -- they from the require me to see you. >> patients come in and come to the er, i took my blood pressure at the pharmacy and had the machine there and it was through
the roof so i come into the are. i want them to go to the primary care. it would be cheaper and better for all of us in better for me. --on't need to incentive incentivized them. they already want to go, they cannot get in. >> that is a win-win. your desire to do better and trying to move us in a better policy direction. medicaid inxpand georgia and he said you hand out all the new medicaid card you want to it will make you feel better but i am the only doctor still sees medicaid patients and i cannot get anyone else in my waiting room. you're not going to achieve the goal of providing more care. we will achieve a policy goal of feeling better about what we are doing in rural georgia as it sits today. what policy reason is there? if i want to achieve dr. nabi's goal of not seeing folks walk out the door because they cannot pay for their care, i don't
understand the policy reason to healthay all of the dod care system that my men and women in uniform tell me they love. i don't understand way -- why we have to abolish every system. my members say i have the best health care on the planet. why achieve the goal of serving the underserved is the policy solution to take everything away from people who feel well served? >> that is a crucial issue. what do we need to do to fix the current system rather than blowing it off? aere are lots of systems in community to provide this coordinated care, to provide better access for people, more humane, better coordinated care. if medicare fee-for-service is uses the model, that is blown up and can we create a new system for better core needed care in
two years? asked ordinary -- extraordinarily difficult. we can hold on that and solve the problems we have but not destroyed what has worked and what we built over decades. >> in the medicare system, i live in a suburban area so we have lots of providers. more than 40% of my seniors have opted for medicare it vantage. they said i do not want the traditional medicare system. i am going to choose that. that goes away. we poison the well of productivity around her on a regular basis and i want to thank each one of you for your testimony. no one went out of their well to poison -- out of their way to poison the well i think we can achieve the goal of not having the underserved walkout on what an affordable procedure. i think we can do it.
dr. by house is doubling the federal budget that i am not paying home -- paying for today. not hide fromes the numbers you have laid out. she recognizes it will be a tremendous increase in tax burdens for the country. you cannot get to $40 trillion without that. and it has worked. that is the conversation that we have to have . ask, i will ask the good doctor who has more experience in the military system than most of us do. i don't hear frustration from my servicemen and women about their quality of care. what i hear them say is when i am deployed all over the planet, i have to have something different than what would work in metro atlanta in general. is it necessary to achieve the goal that you want for our
health care system to abolish that system that we promised our men and women in uniform or could we keep that system well-trained trying to achieve some other goal? >> a think you can keep that system and build on it. medicare for all, or whatever label you put on it can be that system and that is what i am saying. the government is paying for your health services, my health services, medicare, medicaid, a v.a., dod already. you can duplicate that and label it whatever you want. because you see the efficiencies there. and particularly when we talk avi hashe goal that dr. no said. you have to address the social determinants of health. if you are in an area where there is a food desert and you cannot get nutritious food, you cannot exercise, you have to a 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 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 am glad you raised that. thes troubling to me given trillions upon trillions that we are talking about investing here that we are only talking about treating people after something bad has happened. there is nothing that says what we ought to do is make sure that you are better before this happens. diabetes contributes to a quarter of our health care costs. nothing that says we need to get to exercise ahead of time. it is in response to crisis instead of intervening before. that is what health care officials say. i don't want to bad day. and goes to what
mr. barkin said, 10% of american families are grappling with someone who is disabled in their household. the here -- health care costs are related to that. i do think it is outrageous that gofundme is what folks would call a successful health care system. i do not call that a successful health care system but what i do not want to do is refocus america's resources away from your family and towards my in the 10% that is facing crisis. resources onus the the families that need the most. is it clear from your advocacy and your work that we have to change it for everybody instead of doubling down on those arelies that we know, they not touched by your testimony and or is not want to do better for you. not just on this committee but
this congress. i worry that we are losing an opportunity to agree on that by trying to take the conversation even broader. representative, may i please weigh in on the cost issue? >> please. >> one thing i can't help but congressman,oday, 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 will 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 reticle care for every american by doing what every industrialized nation on earth already has. if you would indulge me for just a moment. >> i have to disagree with you.
i do worry that that kind of pithy one-liner makes it hard to get to where we need to go. it is not just health care. i live in a district that is a district.inority we have the best education system in the country in our district. we take for that and it is hard to pay for it. our taxes are high, but we make a decision every day, are we going to have the best educational system or the second-best or the bottom best question mark public housing, referenced that earlier. we have people who live in desperately dangerous and unhealthy communities and we are not coming up with the money for those things either because money is in every conversation and i want to agree with you 100%, i support a war tax, it is immoral that we have taken the
war of the front page of the paper. unless you have a family member by putting skin in the game. you mosthare with respectfully, i need you to on every sideolks of the aisle care is much as serving men and women in need as folks from any other side of the aisle. it is not a budget dollars and cents issue. it is paying for those things that we value. we value you and we want to pay that cap. you have been overly indulgent and i am thankful. i wanted to pick up on one thing you did say. you talk to to the men and women in uniform and they are usually satisfied with their care. i work in a private hospital and the public hospital and at the v.a. and that has been my experience. made a greatntly
case for medicare for all. our v.a. system is wonderful, they provide excellent care, and i have never had a patient leave against medical advice because they were worried about the cost of their treatment. i think that our men and women in uniform have great care and it is a federally funded program where the doctors there are employees of the government, and we have a single formulary, and we take pair -- care of patients in a great medical way and financially responsible way. i think it is it enough for men and women in uniform, it is good for all americans. >> just so we don't confuse the issue. the v.a. system stays under the dod. have dod families who are serving abroad but i take your point. thank you. we have some extra time.
you do have that extra time. you have not used it. you can yield it back if you want. point to, to mr. barkin's when it comes to certain things, we do not question money and the cost, when it comes to health care, we do. that is just a fact. i know it is an uncomfortable fact, but it is. we passed a tax cut bill which i know you guys supported. i did not support it. we did not have a hearing on it. they came to the rules committee and went to the floor. we could argue whether that was a good idea or a bad idea. the issue of how we are going to pay for it never really came up. you and i agreed on the issue of engaged and when we are in wars around the world, we ought to pay for it, not just put it on a credit card. we do not do that.
we make believe we do not have to. when it comes to health care, we do. important points. medicare rates are lower than private insurers. that is when they pay. that we know private insurers do not always pay and i would appreciate if you could explain this for us and with medicare when you pay the lowest rates? upmedicaid rates would go under medicare for all bozo. >> and the issue, insurance does not pay oftentimes. we do casework where we have people who have issues and when it comes to paying for the bill, the insurance companies say no. that is a reality in this country. >> that is exactly right. surprise medical bills are huge issue. people are getting bills for
services that they thought were covered and that continues outside of the surprise billing issue, people have high deductibles. people talked about how great employer-based coverage is. 12% of people across the country, about 12%, the premiums and the deductibles comprise 12% of median income. employer-based coverage is the -- one of the largest sources of increase and underinsured rates. >> i have a lot of hospitals in my district. they have complained to me all the time the fact that they invest in so many man and woman intoawyers -- woman hours filing claims with insurance companies to get them to get paid for what they provided and sometimes to get to the point where it is not worth the time and they eat the cost.
that is another issue as well. there towing that out make sure people appreciate that fact. yield to mr. raskin from maryland. esther raskin: before i wanted -- i begin, i wanted to submit estimate for the record. making the important point that even americans who have insurance, they are facing spiraling costs and a medicare for all system would enable us to lower drug prices and restrain extraordinary growth and drug prices we have been saying. i want to recognize the presence today of the president of national nurses united jim rogers who is the leader of an organization that has been for healthfighting care for all americans for many decades and i wanted to recognize her. thank you for calling this historic hearing which is a breakthrough in the national
dialogue about health care and what we are going to do to deliver health care to all of our people. not since senator kennedy had a hearing several decades ago about health care have we had one that is this comprehensive, this detailed, and is serious. i want to thank colleagues are both sides -- from both sides were participating. i want to thank you, mr. barkin, for your lucid and poignant and compelling testimony today. i wanted to start by saying that nine years ago, i sat where you said metaphorically speaking. refluxuffering from symptoms and went to the doctor for anommended i go in endoscopy and they said while we are at it, why don't we have a colonoscopy, we would not normally do at this early, i was 47 at the time. let's go ahead and do it and when i woke up, they said, we
have good news and bad news. we endoscopy went fine, but found something in the colonoscopy. -- state street colon cancer and was off to the races. all, radiation, chemotherapy, i had surgery .wice i can 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 are going to get insurance. i was covered by maryland's health insurance plan. most state legislators do not make much money. we are paid 40,000, $45,000.
i was able to do with it. it opened my eyes to the fact that this is a crisis in our country, that there are tens of millions who do not know what they would do in the event they came down with a diagnosis like that. like mr. barkin, i decided i was going to try to go through this staying atisis by work and by engaging with the things that i loved, and one of the things i was working on was i was leading the four fight in maryland for marriage equality. we adopted marriage equality, we became the first state in the union to do so without a traditional order compelling us to do so. all glory to massachusetts in all cases but massachusetts did not have that judicial order from the supreme judicial court telling them they had to do that. we passed it anyway. as the four leader, you have the opportunity to make a speech and i got up to thank my colleagues because i had been wearing a
tomo belt to the debates and session for several weeks. the guy who sat next to me who is a great conservative democratic state senator from baltimore county said that i wore the bell to get sympathy and votes for marriage equality which is probably right. we ended up pulling him over and exchanging us changing his mind about it. i got up and i said i had learned something in this process about the difference between misfortune and injustice. because if your life is going great, you have not one but two thatthat you love, a wife you love, and my wife is here today and kids that you love and constituents you love and you go to the doctor and the doctor tells you you have state street cancer and you have a 50-50 chance of coming through it alive. that is a misfortune. it is a terrible misfortune, but it is just a misfortune because
it is built into the nature of our species. suchf us could be assigned a verdict on any particular day. anybody could get such a diagnosis. but, if you experience such a misfortune and you get such a diagnosis, and you cannot get health care, because you love the wrong person or you lost are not, or you working, or you are too poor, that is not a misfortune. that is an injustice because we can do something about that. and life is hard enough, mr. chairman, with all of the illness and accident and heart break, for government to be compounding the misfortunes of life would be injustice -- with the injustice of denying people access to health care when they get sick and in the richest country in the history of our species, at its richest moments, not to advance forward to adopt a medicare for all system is to
deny i think the common humanity of our fellow citizens. and i read an essay during that sontag who said everyone is born with two passports. what is the land of the healthy and the living and the other is the passport of the sick in the dying and we all hope we are going to use one of our passports in life but in truth, all of us are going to use both of those passports. to me, it is an elementary question of democratic solidarity and equality whether we are willing to acknowledge that all of us are going to use those passports and we should make everybody's trip as easy as possible. i am a cosponsor of this legislation. i am not going to hide that fact. i am not just a neutral, objective question are here. but i am fascinated about how we are going to get through this process and bring everybody aboard and, with a system that
makes sense to all americans. now, i want to ask a question that came up before, i think mr. barkin raced it. about how we ended up tying in our society health care to people's employment. i read something, and i don't know if it is true, this goes back to world war ii where they were wage and price controls and employers, in order to attract new talent, had to give them something better than higher wages and they offered them health insurance. accidentally,te quite arbitrarily, the connection of employment and health care. i wondered if anybody could eliminate that for me. perhaps mr. baker, you could. mr. baker: that is in fact the history and it spread to a wider range of employers so that the vast majority of people below medicare age are getting their insurance through their employer. this has, previously. i could speak nor -- now as a
former employer. we hated having to deal with health care insurance. we are busy, we are trying to do lots of other things. >> most small businesses hate it because they are not in the health care business. >> we are trying to keep our workers happy, our employers happy and they have different needs. we are trying to find -- i do not know what the best insurance plan for my individual workers is but we have to talk about one-size-fits-all, we have two pick one plan that was better for some and worse for others. we did not want to be in the business. >> the medicare for all system will live rates will bezos america to figure out what is the best health care plan for their workers and hang for it. >> that is right. we had an insurance broker at additional cost, someone will who -- who would go through the plans and this was a waste. >> you described how financing medicare for all started by
looking at how we are spending money today and making it more efficient. that is that description, it sounds similar done here by blumhouse.ness, mr. observers arecare correct to observe that americans already pay and for most of the medicare for all costs are not new to the national economy. do you agree on that point? >> absolutely. there will be some increase in utilization, that is partially the point. that is limited for two reasons. one, that the people who most heavily use care, basically 10% account for 70% of costs. they are not limited by costs because they are either on hit theirr they have out-of-pocket maximum. this is where we might expect a big increase in cost. have a lotoint, you
of people who incur high costs because they are not getting the care they should in the earlier stage so they go to the emergency room with expensive care when they could have had simple scare -- simple care if they had access to a physician. the plan that has proven elusive -- i want to ask a couple of questions. what is the principal value they are seeking, 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 i'm a to advance public health? what are the values they are seeking to vindicate? >> i would say certainly all three. having universal coverage and everybody to get health care testneed, that different fdle 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 that reduces their overall productivity as well. i would say it is all three of those things. >> do you agree that all of those values are achieved? >> certainly. i think you also have to look at , you have a healthier workforce am a you're going to have cost savings in your employment business. the time that you lose to sick days and getting off and taking care of family and all that would not be achieved because you are working and staying healthy. so, yes. >> i have a question for you. i have received an increasing number of visits from doctors and nurses and people in the health care system who say that the current system we have 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 hate for people's health care. the question i want to ask you is this, it was ms. turner who said we should have just blown the system up. of course, some of my colleagues across the aisle voted 70 times two blowup the affordable care act. they wanted to take that system down. 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 and we all paid for co-pays deductibles and constantly escalating premiums. it, presidentd obama said we want to reach across the aisle and we will go to the plan that was cooked up at the heritage foundation.
this was the plan, the affordable care act and it was the model for what governor romney did in massachusetts. right? the idea is let's take the individual mandate which they came to revile and announce and put that at the heart of the system. they considered it an expression of individual responsibility. what happened was he became politicized and rather than the compromise working, they turned on it, they reknit -- renamed it obamacare and they 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 what the limitations are. is it going to be possible for is it going to be possible for us to move from the affordable care act to a medicare for all system? >> i don't think it is too
complicated and i would say that we need to do it. just expanding would not cut it. i gave three examples earlier of the 28 world female that tried to join cranbury juice to stop her uti and the gentleman who stopped taking medication, the lady with the depression medication. i don't know if i made this clear what they all had private insurance, and it just was not cutting it. they ended up having the strong despite private insurance. they ended up having the strong despite private insurance. >> some people think medicare for all is for the 30 million people without health insurance. but it is actually for the 45 or 50 million americans have a week insurance plan, where the deductibles are going up, the co-pays go up. what we are looking for is a system that will serve all american. it has been suggested by our
distinguished colleagues that while we do not want to interfere with the plans that are working, the plans that are cited are single player lands -- plans. they say don't mess with people who have single-payer now, and that the point of the political opposition is to scare everybody into thinking single-payer for all americans, then it will interrupt the single-payer provision that we've got now. we cannotcase that afford a system that works for all americans without taking away health care for people who are getting it from the v.a. in the military. i am not an economist, that one of the first thing i learned is that when people are getting crazy, you have to stay call. usually, the problem is not that hard to deal with.
from a big step back perspective, i applied something i call the look test, to just look at what is out there and what makes sense. someone is arguing that heavier than air flight is not possible, i point to a template from saic. the corollary to that is that when everyone starts screaming doctors will get paid less the systems cannot function, hospitals close, i just point to other countries that are doing similar things and say that i hear you but it seems to be working just fine. >> any economists that want to weigh in on this point? >> i want to let you two minutes of my time. for you. e me.rgiv >> congressman, may i make a comment? >> congressman, may i make a comment? >> sure.
>> congressman raskin, 10 years ago, just before you got sick, when i was in law school, you came to speak to a student group. i was so inspired and amazed by the vision you laid out and decided you were the kind of lawyer and public servant i wanted to become. your comments today, once again, inspire me and give me hope for the future. >> i want to refer to an article titled post juppe plan would cut the budget. i bring that up to simply point out that when you complain about the lack of adequate
.eimbursements of, ia little bit, kind also want to knowledge that adam schiff came in during the hearing and now we have congresswoman ilhan omar, we're happy to have you. . now yield to dr. burgess >> i used to be a student of medical irony, i am a physician. i worked in er is what i was putting myself to presidency at parkland hospital. we do not have cat scans in those days, see that operated on for appendicitis. -- so you got operated on for appendicitis. student of medical
irony, now policy irony is part of my realm as well. it is ironic we are here ,riticizing sponsored insurance and yet the affordable care act that we debated in this room had an employer mandate built into the formal care act. employer insurance is so good, we want to require them to happen. is not my goal to relitigate the affordable care act and how we got here, there are good books written on it. one of our witnesses has written a book, one of your committee members has written a book. i encourage you all to check out amazon, i'm sure they are still available. obama was to say that elected, elected on health care, health care mandate. i reached out to the transition not and said look i did
come up to her to sit on the sidelines while you do this talk there may be some places we can work together thank you for my participation, that's what i heard. same for the chairman of my committee. had the same discussion with chairman westman, i did not quit my day job to watch somebody else to health care reform. talk to me, there are places we .ould work together it is not my place relitigate the affordable care act. that, and for people who are watching it home, i don't want to say the committee is not normal, but normally, health care policy would come through one of the committees and what are called authorizing committees.
mr. cold paper everything we authorize very graciously. they probably would have done .ver several iterations i have been on the rules committee for more than eight years, but it is unusual in my experience. hearings whenmary republicans were in the majority, they were on things that were outside of the normal realm. i want you to know it is unusual. but also indicates -- >> there's a new sheriff in town, that's what we're doing the hearing. >> exactly the point. of issue is so important to the speaker of the house. this is a speakers committee, this committee is 9-4.
mr. mcgovern is never going to lose a vote in this committee. committee, speakers the ratio was set up by a texan, -- samer -- raeber -- rayburn. he set up the rules committee in 1961 to facilitate connecting the agenda of a young activist president jfk. the ratio has stood ever since. but it is unusual, and i make that point because this is the speakers committee. speaker has elevated this. this is what the speaker wants us to be talking about today, this month, and so we shall. i have a number of specific questions and apologize for itting -- it is just hard devoted my time and experience
the operating committee that deals with health where -- health care. our committee produce cures for the 21st century. if we haven't got the things to pay for, it is a crazy argument. . and dr. brown, thank you so much for being here, thank you for your service with the national medical association. and tell you it has gone through all the machinations we could go .here in the committee , we passed a version quickly got a committee together and work out the differences. and bobby rush, on the energy comes committee, came up and said we forgot sickle cell. forget, did not really
we're trying not to be disease specific. because, what you say several months before, we had a 2016 and had a witness from the sickle cell disease association. she made a statement that it has since a sickle cell treatment has been approved 40 years. it was an astounding statement. obviously, we were at a point with the cures bill that nothing could be changed. the senate had agreed, the house had agreed, we were going to the floor. it was the last bill signed by president obama, it is a great bill. and 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. 2004, not happened since tax onto one of the books -- tacked on to one of the bush tax cuts. bill, it a sickle cell took forever, but they passed the version, we approved it on the house floor and the president signed into law. the first major sickle cell authorization that had been passed in over a decade. here is why this is important. because i normally don't watch 60 minutes, i don't think i watched it the night it was reset go tout some youtube and watch this broadcast on sickle cell. 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. that is unheard of. is a two base error, just a spelling error, spell check should have caught it but it didn't. and this doctor has worked out a system where they are actually dna to put that corrected into the patient's cells. patient on 60t minutes, the young woman who they were treating and these were all normal red blood cells, i broke down and cried. that was incredible that the child could have that condition fixed. and you know from your time, it is tough. not a lot you can do.
we should be judicious, but at the same time, these are people who need pain relief. this is the great step forward, and i bring that because the authorizing committee did that. did talkill that we been cuticare for all the medical reimbursement for doctors. 20 some percent every year. that, written in a way even if congress came back in and add some money if we did that, it still added on to the eventual cost of the .ongressional budget office i'm not an economist and do not understand exactly, but it was
bad. we had 393 votes on the floor of the house, 92 votes on the floor of the senate. that was a great example of bipartisan cooperation to correct a major problem we had. there, thist stop is one of the things i learned. bill andfinish a big handed off to the agency, with all due respect. when you hand it off, things can happen to it. and you have got to keep your eye out. we have had multiple oversight on the implementation of what is called the medicare access reauthorization act.
major improvement that was agreed to in a bipartisan fashion. week that goes a by the summons not call my office with some concern about something that they will either not be able to do or be required .o .t is a real bill talk about secretary of health and human services, with all due respect to anybody who might that isn the secretary, a difficult way for health policy to evolve. it goes out of the realm of the people to the agencies. what was the statements mr. raskin made? a ridiculous amount of time
spent on bureaucracy. if you think that is going away if the fine folks at the humphrey building are in charge of everything, if you think that time is going away, it ain't. it will still be there in some form and quite possibly could be worse. indulgent, iyour have a lot i wanted to get off my chest. mr., let me ask you, because this comes up all the time in the issue of administrative cost. costs, that is a little misleading. if i did do it i would have to borrow a lot of money that i would incur. cms does not have to account for the cost of capital. >> know, dr. burgess.
actually, matthews was the institute of policy innovation to the study of an economic consulting firm. looking at the comparison of medicare administrative costs with private insurance. he said most of these comparisons are apples to oranges. when you conclude everything, capital, but only the federal government's ability to collect premiums and in the population of medicare versus those who are younger. it comes up pretty even, but the key point is that somebody is going to have to determine what benefits are allowed or not. who will be an authorized provider, how they will get paid, how the patent is collected -- payment is collected. , andody will have to do it so the processes of providing services that the taxpayers are part of thisd are
program are going to have to be documented. . >> let me take what i have remaining, we are limited, only two witnesses on the republican side i wanted to bring this article that was created this morning, a mother in nova scotia . meeting with her after a years long battle with the health care system. she says she went undiagnosed for two years because she could not access a family doctor, by the time she was diagnosed, her cancer had progressed to stage three. this is the face of health care in nova scotia. for, ireceive care experience until sometime in july from the health. scotia haveova replied, president of doctors for nova scotia, this is the
first time he has heard the story to this experience, it has the elements of all the problems nova scotia is our -- are facing. knowing full well that these departments are not equipped to be diagnosing cancer and are .tretched thin >> if you cannot act as a primary care physician, you cannot get these. the average wait time is about five months. we see it in the u.k., ambulances that are driving around london for hours, waiting for the emergency room to let a patient in. when they get in, they are often warehouse and hallways. testimony, people die in a
hospital emergency room hallway, waiting to get care. that is how they ration care. they ration through waiting lines and the lack of access to medicines. in the united states, we have access to more than 95% of all new medicine. .n france, half of them first, i just want to say i am always impressed with how management was practiced back then and thankful for the .uxuries our generation has
if we do sunning on the scale, we have to do it right. the reason i hear is because my patients are suffering and dying, we have to have a sense of urgency. , butve to take our time with a sense of urgency that people are dying as we are waiting and doing this. we need to have that fire to .eep moving solutions andd need to invest more to try and start with the starting position that we can get this done and need to, because people are dying and suffering. and then going to the right .hannels
>> will always be left without health care under medicare for all? how will that be better than today? >> the way to build a structured, everybody would move from the coverage they have into a new system, for the most part. with more comprehensive benefits in many cases. it is not true that people would lose their insurance coverage. i do want to address the wait times in other countries and the ration of care. clearly, we are rationing care, insurers are rationing care meeting so many people uninsured. it is all a matter of how you use that term. but in other countries, we have to wait times that are very consistent. are surveys of international forems show which times specialists are about the same as they are in the united states.
and countries that have had wait time issues like the u.k., they have addressed those. it does not mean a single-payer system there is going to be a single-payer system here. there are ways to address wait times. >> i just want to say something about the rules committee. it was brought up that it is unusual we are having a hearing, is not so unusual. this is the oldest committee and congress and we do big things. i'm proud of the fact we move the affordable care act forward and insured 20 million people. and it should not be unusual we do hearings. the aca and the holding 79 bipartisan hearings and over 239 amendments, 121 accepted. this is an enormous undertaking. with the way my republican friends handle the repeal bill. they buy cost the hearing process entirely. the game -- bypassed
hearing process entirely, just came right to the floor. i do not think they should be undesirable, this is a opportunity for but it say what is on their mind, that's not a bad thing. to mention rationing, we are rationing even with the uninsured. when 40% of americans felt they needed to go to the garbage did not, considering 12% are employed, that is still a third that feel the need to go the yard but don't. that is -- to the er but don't, that a self-imposed rationing. commentn, may i make a -- chairman, may i make a comment? , we knowtes aside single-payer systems in other countries have better outcomes than we did. -- than we do. >> i want to thank the doctor
for support of the sickle cell bill and how it has come about yes, we have one that was recently approved for the disease. speaking to mr. raskin's comment, i want to say that even though i have a niece who, unfortunately, died from colon 48, shet the age of could not get the screening test because her insurance did not cover it. she waited too late and have advanced disease and died. all., having medicare for allowing individuals to get the kind of tests that does not follow those guidelines because at any age, if you're having symptoms, you need to be treated. >> thank you, chairman mcgovern for the opportunity to participate.
they try to make a commitment to affordable, universal health care. i'm grateful for the expertise and effort that my colleagues, especially the congressman and havellow freshman shalala put into producing this legislation. i have no question that health care is a human right and no family should have to go bankrupt or worry about food due to medical costs or create a gofundme page. i understand we have to find a way to address my colleague calls the injustice of being unable to afford medical care. i have already supported measures that would charge to lower prescription drug costs. i'm trying to parse the best way forward from here. to protect the affordable care act and moved to whatever our next step is.
who believeents this is the best path forward and others who are concerned about how it will work. ,hose concerns are multifaceted rooted in a fear of rising costs. changes of fear to existing employer or you faith insurance, and for many, the impact on their jobs is my hope i will get some information from this 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 transition to medicare for all look like and how we achieve that elusive universal coverage. baker, whenand dr. we are talking about the best ways to get universal coverage, one of the things we talk about is the financial burden of the current health system on individuals. so whatever we do, how do we address those costs?
can you talk about the impact a medicare for all system would have on those premiums, co-pays, and knuckles? -- deductibles? >> if you don't the full rent, basically does all go away. what we are doing is taking money we pay out of our pocket where employers pay for us. it goes into taxes, if you think that's bad, whatever. it is money we are now and instead is paid by the government for services it relieves the problem, no doubt about it. the question is how to do that in a way that is least disruptive. but no doubt, you take away those costs that are now borne by individuals. is there any analysis of how an individual's tax burden compared to their savings? >> a lot depends on how you atually structure the tax
friend at the university of massachusetts did an analysis and they had a plan. it would really depend on how you panic. i emphasize this earlier, getting costs down. we could argue how much, but no doubt, we are getting rid of an insurance industry. we are getting rid of the administrative expenses that hospitals and other providers have. those clear savings. and how much will we save on drugs? i argue we will save a lot. drugs are cheap, we make them expensive. same with medical equipment. i think our doctors patiently more in line with doctors elsewhere, but those are all things up for debate. but for other reference, other countries pay half as much per person on average. there is no reason we should be paying so much more. can we get as low as the average, will it take us five years?
those are all dense, up for grabs, but should mean atypical person will pay much less in taxes than what they are paying now. that, there are 10 other bills that provide smaller steps towards universal coverage . or had lots of reform approaches mobbed by the urban institute. these are approaches the --monwealth fund has models modeled. to reduce of ways premiums, even employer-based plans obviously, there are trade-offs. beenfore will care act has that we have not seen any congressional change in legislation to improve the aca since it was passed. there's deftly a trade-off.
but for people with thereer-based coverage, are lots of hidden costs in employer-based coverage. people make wage concessions so that they can have employer coverage. people pay and contribute a lot in premiums, even with the concessions. are seeing an increasingly deductible. so a movement towards medicare for all but obviously replace those costs, because it does away with the employer base system. taxes would rise in order to finance that. for many people, depending on how you would structure the taxes, many people would probably see a net cost of insurance go down. the incidence of taxation would matter quite a bit. the controversy in vermont really would come down legislatures not be able to explain.
change the financing from premium to taxes to their constituents. can just say quickly, i think everyone up with agrees on at least the goal. it is to put downward pressure on prices like drugs and medical , which the u.s. can clearly do. lamont, with 600,000 people, probably does not have the same sort of bargaining power. speaking with experts in pennsylvania, they talk about long-term care being one of the big drivers and cost and an ,ssue we need to struggle with particularly with all of the aging boomers. have is medicare for all deal with that? >> the plan does cover long-term care. problem in the current system, both because it is not covered in general, but also you do have coverage under medicaid. many people who could
get by fine with health care that is not covered or nursing home care that is covered. it is obviously less desirable if they could get by with having some minimal amount of home health care, rather than going facility on topacility of that, it is much more expensive. while he want to do is provide people with the care they need, not having them get care they may not need but is affordable gaza power structure to the system. >> there has been talk of people losing their medicare, but under the bills, benefits would improve substantially. that could be an area with substantial savings. we have had references to this earlier, we had all sorts of perversions of the current system to some things are covered people cannot see a primary care physician.
it is an incredible waste of resources, the people should be dealing with an emergency situation. >> 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 how and what you right into the law. where youomething have special employment benefits for the people in the insurance industry. that is the most recent thing with climate change -- has come up with climate change as well. it is reasonable for members of congress to look at. 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 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 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 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 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. >> 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. >> the committee member has
wanted to be here, but was unable to. i know she is a strong advocate for health care. at this point, i will you get to miss. -- to you, miss. >> we have had a long discussion and i can speak for myself and friends on the republican side, we want to solve the health care problem. we do believe there are problems in the health care right now and that improvements can be made. but i think we should do this in a bipartisan fashion. de, 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 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 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 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 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%. 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 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 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 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 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 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. 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, 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 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 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. 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. 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 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. 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 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 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. 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 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 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. 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 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 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 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. >> 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. 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. >> 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 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 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 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? 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 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. 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 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 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 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 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. 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. 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. 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 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? >> 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 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 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 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 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 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. 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 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. 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 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 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 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? >> 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 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 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 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. >> 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. >> 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? >> 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 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 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 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 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. >> 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. 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. 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 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 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 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 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. 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 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 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 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 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 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 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 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 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 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 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. 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 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 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 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 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 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 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 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. >> 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 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. 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 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 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 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 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. 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 ] .
>> barr heads to kapoho twice this week to testify on the mueller report. his first appearances before the senate judiciary committee. we spoke with iowa senator and former judiciary chair chuck grassley from capitol hill. >> senator grassley, as former chairman of the judiciary committee, you lead a lot of these high profile hearings. who gets to determine the format? >> the chairman. unless there is any disagreement between the chairman and the ranking member, the top democrat, you consult with them about it. most of the time, particularly hearings on legislation, it is very easy to work out. the only thing that was not easy for me to work out was the democrat leader