tv House Budget Hearing on Single- Payer Health Care CSPAN May 24, 2019 6:49am-9:40am EDT
it will have consequences that ripple through the most personal -- fewer doctors and longer wait times to less access and no choices. that is why this conversation today is so important. before i conclude i would like to ask unanimous consent to enter into the record the three studies i mentioned from george mason university, the urban institute and the american action forum and seek unanimous consent to enter into the record a study of the impact of single-payer proposals on our nation's hospitals. with that, mister chairman, i yield back. >> i think the gentleman for his opening statements. if any other members have opening statements you may submit those statement in writing for the record. i would like to thank our witnesses for being here this morning. mister hadley's statement will be made part of the formal
hearing record. 10 minutes to deliver your oral remarks and we begin when you are ready. members of the committee. >> thank you for inviting me and my colleagues to testify about congressional budget office's recent work on the healthcare system. some members of congress proposed establishing single-payer health care system in the united states. many more people would probably have health insurance as a result but the government would take much more control over the healthcare system. the effects of such a system on its participants until healthcare spending would greatly depending on the details of the system's operation. earlier this month cbo released a report on sickle payer healthcare system. that report describes the primary features of single-payer healthcare systems and some of the considerations for establishing such a system in the united states. it represents the first step in a broader effort to support you
as you consider the issue and fill our capacity for specific proposals. i want to convey two main points this morning. first, moving to a signal payer system would be a major undertaking that would involve significant changes for all participants. individuals, providers, insurers and manufacturers of drugs and medical devices. healthcare spending currently accounts for 1/6 of the nation's economic activity, those changes could significantly affect overall us economy and the transition toward a single payer system could be complicated, challenging, potentially disruptive. second to establish a single-payer system lawmakers would need to make many decisions with complex trade-offs. the first figure on the report i have in front of you is a handout inside to find questions that need to be answered. with the balance of my time i will focus on 3 sets of issues
that illustrate complexities involved in a single-payer system. it relates to coverage. the singapore system but achieved universal coverage, receiving health insurance coverage with special benefits and help status. people who currently have private insurance would enroll in a public plan. under the current system an average of 30 million people per month are projected to be uninsured in 2019. most of those people i us citizens covered by public plan under a payer system. policymakers have a lot of choices about how to extend coverage particularly if each state administered a separate plan. one of those choices would be whether noncitizens were not lawfully present but 1 million people in 2019 about half of them have insurance under the current system. the second set of issues related to cost. under a single payer system, the
national healthcare costs, 2017 private sources like businesses and households contributed just under half of $3.5 trillion of total national healthcare spending. shifting such large amount of expenditures public to private sources would increase government spending and require substantial additional government resources. healthcare spending on a single system might be more or less depending on key features of the new system including services covered, cost-sharing requirements, provider payment rate and administering costs. the benefit package could be designed to cover services that are typically covered by private insurance and medicare. alternatively could be expanded to cover additional services such as dental, vision, hearing or long-term support.
expanding the package to cover additional services would increase healthcare spending. cost sharing affects financial well-being and total healthcare spending. people use more care when their cost is lower. having lower or no cost requirement would tend to increase the use of services and lead to additional healthcare spending. under a single-payer system provider payment rates could be based on rates paid by medicare, medicaid, commercial insurance or some other measure. medicare payment rates substantially lower than commercial payment rates on average. of provider payment rates rather than average commercial rates, total national healthcare system would be lower but the amount of supply and quality of that care might diminish. when fully implemented a payer system would have lower costs than the current system because
it would consolidate administrative tasks. to give a sense of scale the federal government cost of administering the medicare program accounted for 1.4% of total medicare expenditure in 2017 including costs of the administrative costs of part d plans and administering of cost for the medicare program accounted for 6% of expenditures. by comparison, administered of cost averaged 12%. the single-payer system including efforts to coordinate patient care and eliminate fraudulent spending could add administrative costs. a single-payer system can affect the cost to providers in other ways, reducing the amount of care and unlike private insurers which experienced substantial turnover a single-payer system would have no turnover. for that reason a single-payer
system would have greater incentive to invest in preventative measures shown to reduce cost. whether the system would act on that is unknown. final set of issues relates to access to healthcare. expansion of insurance coverage in a single payer system would receive more healthcare. people who are uninsured receive coverage and some people have coverage would use additional services and lower out-of-pocket costs. whether the supplier providers would be adequate to meet the greater demand would depend on various components to the system. of the supplies of services is not sufficient to meet the demand for care patients would increase reduced access to care. the government implementing policies for the provision of services and in the long run provide a deliver more care more efficiently. under a single-payer system people currently covered by
private insurance might have more providers available to choose from. there would not be a choice of ensuring the health benefits however. public plan would provide the same set of healthcare services to everyone eligible and not address the needs of some people. for example, public plan might not be as quick to cover new treatments and new technologies as would a system of competing private insurers. policymakers could try to divine single-payer system to mitigate such risks. as i said at the start of my testimony, working to build capacities for the committee and congress to consider these issues, we look forward to being helpful to you and your staff. my colleagues and i are happy to answer your questions, thank you. >> thank you, appreciate your testimony and we begin the question and answer period. now recognize gentle lady from connecticut for 5 minutes. than.
i think our panel and speaker this morning. it is fair to say my democratic colleagues on healthcare looking at the way in which we achieve universal healthcare in the us. we have several iterations, the one that i introduced is medicare for america which ensures universal, affordable, high-quality health coverage, building both on medicare and medicaid, covering benefits and services. and medicare, we try to do in this legislation. and millions of americans who live with disabilities and those taking care of an aging loved one. and in the healthcare system,
the combination of individuals and employers, choosing medicare for america, and to bring costs down for family, premiums cost 8% of individuals in income. there are no deductibles, and bringing down costs for families and private contracting, the two tier system within america and for the wealthy, and to pay any insurance. the providers, to accept medicare, and student loan depth.
and accept medicare for america payment rates. and there are healthcare providers and the development problem for individuals who work in home and community-based long-term services and support. we are going to increase the number or try to increase the number of caregivers to take care of increasing number of seniors and the disabled. going back to benefit design which is tremendous concern when you consider any universal coverage plan. in connecticut or mississippi, everywhere an american should have comprehensive, affordable healthcare. connecticut our medicaid program covers dental care for adults, alabama, texas did not, missouri, pennsylvania, did not physical therapy, connecticut, arkansas covers eyeglasses, california does not. correct me if i'm wrong, in a
single-payer system that benefit design is at stake, could lead to any quality. since this is true, what safeguards need to be put in place to ensure benefits are standard across the country for all enrollees. >> the section on administration, one of the key questions is whether this would be administered by states or the federal government and there could be lots of variation policymakers choose from how that would be done. even if the program were administered by delegates from decisions, alternatively there is a program administered by the states, the federal government could supervise and regulate the benefit design. >> final question before i lose my time but doesn't that continue the patchwork that we have in this country with regard
to healthcare services and inclusion of long-term services. one of the fundamental problems is your zip code is a determination what kind of care and services you get, doesn't it make more sense to have something uniform directed essentially? >> we don't make policy recommendations. it is a policy choice for you all to decide whether it is a uniform set across the country or at a more local level. >> we do make policy but you have views i would have hoped you might share with us as to how we get to a standardized chair for people in this country. thank you, yields back and thank you. >> thank the gentle lady and i
yield 5 minutes to the gentleman from ohio, mister johnson. >> i want to thank the panel for joining us today. i appreciate the opportunity to move past the, quote, free healthcare tagline and talk about the reality of implementing medicare for all. i'm an it guy, spent 30 years in information technology before coming to congress. in your report you describe a standardized it system that implements portable electronic medical records. question number one. in the us we have a lot of different health systems that would have to be merged together to achieve a standardized system. would this be similar to what the va and dod are trying to do today? >> yes, congressman. they are trying to create a system so that dod and va's medical records can be interoperable, transferred between the two organizations with minimal amount of
transactional work. >> it is a similar process. how many records are being merged in the va and dod systems? if we were to cover every single american under a single-payer it system, how many records would that be? >> i don't have the exact number that are merged but covering the entire united states it would be the population of 229 million people, substantially more than are covered by that. >> i have the number here for you. it is 18 million records, what the va and dod are doing. it is my understanding that since 2011 va and dod have been attempting to merge their electronic health records with a 10 year estimated cost of $16.1 billion. what are the challenges of national standardized it system
would face? >> the interoperability. in the last several years, and more electronic medical records when they did that. >> interoperability is rarely thought about on the backside. and $16.1 billion for 18 million records, any idea what the cost of a standardized system to cover everybody will be? >> it will be similar to the one in taiwan but many countries
don't have a fully developed system similar to that one. >> let's talk about security a little bit. of such a system were implemented with the security of the databases and the networks that house such a system would that be a concern? >> absolutely. they invest in trying to protect the system. >> is there a precedent for large-scale government data breaches in government run databases? >> yes. >> we saw both opm and va experienced databases which exposed an estimated 22 million, and 26.5 million people's personal data. is it necessary for the government to manage all of the electronic health records? around the system of the size? >> it could be run in different ways.
could be a similar design of electronic records or more like a billing system. medicare, fee for service. >> what would happen if there was no central database? you talk about interoperability and we saw early on, the lack of interoperability and how that was such a negative around our healthcare community. if there was no central database with all the problems of cost and security and interoperability we described would quality of care decrease in such a system? >> foregoing the benefits you might get from such a system would include patient care coordination but also eliminating fee for services. >> one of the things, i will wrap up, one of the things that is widely known by it
professionals is the lifecycle cost of a system is one number. 75% of that lifecycle cost is in operations and maintenance. as complicated as this is the easy part is the upfront part of designing and implementing. 75% of the cost is in operations and maintenance and i submit it is a monstrous cost to do what we are talking about here. >> the gentleman's time is expired. i recognize the gentleman from massachusetts for five minutes. >> healthcare is a human right. everyone in america deserves affordable healthcare and we all know that is not the case today. having a health care debate with a republican colleague not too long ago and i asked him if he thought the children of
billionaires, donald trump's children should have better healthcare than the marines i served within iraq? the implications of the question for a minute, and then said yes. if they can pay for better healthcare they should have it. i disagree. i don't think the sons of billionaires should have better healthcare than the sons and daughters of america who risked their lives for our freedom. i think veterans deserve the best healthcare in the world, period. frankly, in the greatest country the world has ever seen all americans deserve the best healthcare in the world. democrats agree on this but we do have differences on how we get there. the closest model for a single payer system in america today is
the va. when i was elected to congress i made a medicament to go to the va myself to continue going there with my fellow veterans because i said until we fix the system i am going to go through what they are going through and see it firsthand. i have seen the good, the bad and the ugly, single-payer health care at the va. there are some things the va does well, they negotiate prescription drug prices which medicare does not do and that means our prescription prices are lower and the system is very efficient. also had surgery not long ago at the va and after the surgery i was sent home with the wrong medications. they were supposed to give me a strong painkiller and they sent me home with a bottle of advil which was not what the prescription was for. imagine if it had been the other way around when i was supposed to get a moderate drug and was instead sent home with something much more powerful or addictive.
we have all heard the stories of veterans literally dying on waiting lists. the day i checked in they couldn't find my record and couldn't prove i was a veteran that would considering taking me in a humanitarian case then sat down next to a vietnam vet sitting there for 5 hours. personally i think president obama had it right. there should be a public option and that is what he had in obamacare before congress took it out. a public option that competes against existing private insurance options. i don't think the american public would be thrilled if the new president, new congress came in and said we are going to put fedex and ups out of business because we don't like that competition in the postal system. no, competition is good. just like we have options for delivering packages we should have options for delivering healthcare. said cooper said if there is no competition your bill will be $9000 higher than average and therefore more competitors.
reasonable regulation among providers improved outcomes for healthcare recipients and i believe the same is true for healthcare coverage. the report suggests substitute of private insurance which seems to be the closest analogy to the program i'm advocating might also improve the quality of care for people in private and public plans. can you share how competition among private and public insurance plans to increase outcomes, improve outcomes and lower costs and share a little bit of your evidence of that? >> it is discussed in the report, one of the ways, might have an increase in quality from substituted insurance. the substituted insurance based on their quality, then you might see other providers competing to be selected through that competition, an increase in
quality overall. >> i believe competition is good, it is american and should be part of the healthcare system. with that, i yield back. >> the gentleman's time is expired. i recognize the gentleman from texas for 5 minutes. >> thank you for holding this hearing to discuss what the government takeover of america's healthcare system would look like for hard-working american families. the conclusions we can draw confirm what we know and that is this type of upheaval abandons free market principles, severely restricts incentive for young americans to join the healthcare field and lazy american people no choice, like away, transfer treatment, ratcheting of care and significantly higher taxes. this flawed thought process would build a single largest bureaucracy in the history of this country to control a sixth of our economy. i thank you and your colleagues for being here.
what is the aggregate spending for a single-payer system. what would that be like? >> we don't have an estimate because there are so many in terms of what is covered. >> in the report you say, it is complicated, challenging and disruptive. can you spend 20 seconds, complicated, challenging and disrupted? >> in the transition, from one insurance plan to another, there will be initial upheaval as you try to reassign people to be enrolled in the plan.
in terms of disruption, the services that are covered and shifts in the economy for who would be employed and shifts in demand for different conservatives and affect the economy as well. >> it was called the good, the bad, the ugly, one of the single largest set of to deal with back in the district. and 378,000 federal employees to do that. the ratio of beneficiaries, is one, to 24. if you use the same ratio to cover 372 million americans, that implies a federal bureaucracy of 16 million people compared to the department of
defense which is the largest federal agency with 2 million people. what is the accurate number of bureaucrats we are looking to hire to take care of americans healthcare? >> i don't have the answer to that. we don't know how the system would change. in 2017, the total healthcare study was $3.5 trillion all in. >> it could be massive. it could be the single largest federal bureaucracy in the government. >> you could end up with more people working for the federal government but also having federal contractors play a significant role might be the action for policymakers. >> do you have a feel for what improper payments are for medicare percentagewise? with the improper payments are? >> i don't have that number in
front of me. >> we have a significant percentage coming out of medicare. is there any reason to assume a government run healthcare system that you would have a lower percentage of improper payments, $3 trillion of healthcare spending? >> it depends on the traces of the system, what to invest in making sure there are not improper payments that are simply because of failure of paperwork and other ones insulted fraud and investment in fraud prevention could be higher or lower than we have today. >> you still have governments running this so you have to assume the government gets a whole lot better at something it struggles with today and you created something massively larger than the va today or
medicare system we have today. the cbo report states in federally administered system the associated cash flows would be federal transactions and the spending and revenue for the system would appear in the federal budget. can you explain this? >> one of the issues we face when thinking about government interacting with the center of the economy, at what point should those be considered part of the federal budget under a single-payer system, it is clear those would be governmental and to the extent it administered the federal level and no question those are federal payments. all the spending that would occur from such a system would show as federal spending and depending on the financing, use to help pay for that. >> i will submit the rest of my
questions and you can answer them supplemental he. if we had a government shutdown theoretically all the healthcare payments would stop. >> the gentleman's time is expired. 5 minutes to the gentleman from texas. >> a great nation should not have millions without access to quality healthcare yet we have 30 million americans that lack health insurance in my home state of texas, one of every four working adults are uninsured. this is unacceptable. and out of control healthcare costs impacting families who have employer coverage. over half of americans, postpone needed care because of costs. more and more americans are finding health insurance deductible is bigger than their bank account and a single illness could put someone into bankruptcy. have a patients with cancer
diagnosis deeply their life savings and two years. americans have so much skin in the game they are getting third-degree burns. the system is unsustainable and unacceptable. amidst it all the bright spot is medicare. contrary to republican attacks, the seniors on medicare aren't languishing on waiting lists and are not being denied the care they need. far from it. medicare provide seniors with guaranteed cost-effective coverage they could always count on. i know many people who would love to be on medicare. they are just too young. medicare has some gaps which is why i focus on prescription price gouging. medicare for all would begin by making medicare more comprehensive for those who rely on it today. the leading advocate for medicare for all, i salute her
and the medicare for america proposal and congressman higgins for his medicare buy-in proposal. each of these has some merit. we cannot transform healthcare overnight. we will need to phase it in and none of these is perfect. each one has value. efforts to improve the affordable care act have been blocked for eight years we need to remove expeditiously for universal coverage. a single-payer medicare for all program would be an effective means of accomplishing this goal. today's naysayers don't have any plan at all. they had eight years to present an alternative to obamacare and what we have? republican nothing care. and donald trump has promised a big beautiful healthcare plan that cuts costs and provides better healthcare for everyone
but wait, that is the same plan in almost the same words he offered in 2016 before he began attacking protections for preexisting conditions. now he says he has a secret plan that must remain under wraps until after he is reelected. a translation of the attacks these republicans are making on medicare for all amounts to this. democrats want to take over your healthcare coverage and make it as bad as medicare is today. i know a lot of americans who say throw us into that briarpatch. we are certainly concerned about a sustainable system. a cost projected for healthcare system is $50 trillion over the next decade. it is the question how to pay for it and how we get quality services for it. mister hadley, is it true the government is paying for most of the healthcare spending in the united states? >> yes. in 2017 -- >> the report you have given us,
explain how medicare for all could be financed more progressively than we have today with more progressive financing. is there a potential for middle-class and low-income working people to pay less for medicare for all than they do today for insurance through their employer? >> to pentagon design of the system. >> chairman of the house ways and means committee, i have been focused on high cost of prescription drugs. i'm pleased about the medicare for america bill and medicare for all bill, both incorporated verbatim the text of medicare negotiation as the best strategy to deal with these pharmaceutical monopolies. this is a bill sponsored by democrats that offers unique american solution to a unique american problem with the highest prices for prescription drugs anywhere in the world, we
propose negotiation and competitive licensing to deal with these monopolies. it is easy until the congress move forward on this year and it be included to deal with one of the most pressing healthcare problems our families face today and i yield back. >> mister stewart. >> to the witnesses, i go quickly because there's a lot i want to cover. we have solutions that will help that again and again and again i hear my democratic colleagues talk about how bad and how the system is failing americans. a dramatic admission, and admission that it failed. the current law of the land is obamacare and it is fair to point that out. what they are saying is
obamacare isn't very good but give us $32 trillion and another chance and this time we will fix it and fix it for real and in my last election i talk a lot about an issue we discussed and i didn't spend much time talking about the $32 trillion price tag or the fact that you have to double taxes for virtually every american in every american business to pay for it. there is a more devastating aspect to medicare for all and that is what i want to focus on today. because the public plan would provide a specified set of healthcare services to everyone eligible participants would not have a choice of insured health benefits. something like 60%, it depends on who you talk to, 60% of americans get their insurance from a private insurer. they are possessive of that, they should be. and a private plan. under the single-payer system
what do you mean when you say, quote, participants would not have a choice of insurer or health benefits? explain that quickly. >> whether it was federal or state, the benefits, it would be one set of benefits for all participants. >> one set, no choice. is that true? >> correct. >> you either opt in or opt in, those are your choices. that is it. >> that is a choice for policymakers. >> i will get to the opt out in a second. this is the key to this and this is what most americans don't realize. it compels them, they have no choice. many think medicare for all sounds wonderful, we should provide that for people and then you say you will not be able to have private insurance. it is taking away your private insurance. you are compelled to go on the government program. is that an overstatement to say that? >> depends on the design of the
system. you would have one set of benefits -- >> thank you. it illuminates private insurance and the cbo report by contract proposals to establish single payer systems prohibiting substantive private insurance, there is a public plan. that is where most americans go sideways on this. all of us want to provide insurance for those who don't. i don't know a single person who doesn't want to achieve that goal but i also know something like 60% of americans don't want to lose private insurance and don't want to be held outside the law. suppose they did this is the second point. quoting again from the cbo report because some allow opt out but here's what happens. they leave the rest of us to
suffer under the government program, private insurance gives people access to private providers faster access to care or coverage for alternative therapies the government doesn't cover but participants pay for it separately in addition to required tax contributions to the nhs. this is the obvious question that i want on the record. if you provide people to opt out after you raise taxes and double them to pay for who will afford to do that? >> they are going to be required to purchase insurance separately, then it would illuminate a lot of people. >> except for the elites and the wealthy. is that true? >> i don't know about the elites but the wealthy. >> that sounds fair.
under the single-payer system, you do have a rich opt out. they opt out, they buy extra insurance in the private sector and ultimately receive better care for that so you have the option of that or where you started and compel people and most americans reject that. my time is up and i yield back my time. >> the gentleman's time is expired, 5 minutes to the gentleman from new york. >> thank you, mister chairman for organizing this important conversation. i had the privilege of serving on the house rules committee, the second hearing i have been involved in that relates to changes in the proposed changes of the medicare system. i will dispense with my opening comments and say i appreciate this report. people on all sides thinking about how to get to the right place whether it is more public investment or a private system
there are many options. my friend mister abca12 did a good job identifying them it is maddening because you don't get any xers. we would like to have answers and help you give us the answers but i think the thing that does point out, there were so many considerations to get here and with many things there could be unintended consequences if we don't think through where you want to go though this is a good map and i appreciate the report a lot of questions each of us have. i have several and i would like to get through a couple of them. you do touch on this, if you were to design a system that was single-payer or public system from the start, one of the choices you could make and there would be some logic to this, the question of not only the insurers being public but also the providers being public.
you touched on this a little bit but i want to ask, the opportunities and challenges of working on the other end especially public hospitals and government employed, in care - there seems to be the logic of this. >> there are a lot of ways to discuss the report and one of those options is to have salaried positions. that is an option you see in some countries, still working in hospitals. one of the questions about their incentives to provide care and the mechanism as a way to encourage them to provide more
services and also focus on patient health outcomes. >> are you suggesting that is a challenge for publicly operated as opposed to privately? >> it is a choice for how to structure that but it is an important consideration for public and private and service situations we have in the current system, incentive is to provide more care and continue to provide more services. studies that show the incentives that go beyond what is optimal. >> it leads into the next thing i want to ask about which is the concept of global budgeting. if we have fee-for-service system how to have a control on cost. it will be a public system whether it is a fully public system or expanded public
system. the cbo report earlier this year on the side of the deficit and a cumulated debt of the united states raises questions about cost-containment if you expand the public system. i am not familiar. you mentioned the report in the maryland system. i'm only vaguely familiar with the red they went to global budgeting but there are risks in that. at the end of the day those risks were called for by the united states. is there another way of doing that? would you penalize hospitals or providers? >> in england where they have a global budgeting system, the growth of healthcare costs, successful in doing that but the consequence was many of the providers running deficits in some of those years and also increases. >> i want to touch briefly in the last few seconds it was establish the medicare administered of costs are 1.4%, medicare with medicare advantage and part d6% administered of costs and private insurers 12%.
are those apples to apples comparison and would you need to go to a public system to reduce administered of costs on the private insurance side? >> one of the reasons it is not exactly apples to apples, 6% number is the full cost of medicare program but medicare compared to the present, 6% to 12 works very well. if you are looking at a different system, it is not as useful number for that purpose. >> i yield back my time. >> mister roy. >> appreciate your time. i certainly agree with my colleagues on both sides of the aisle the american people deserve better healthcare, the best healthcare in the world.
and using our ingenuity to produce that great healthcare. we could have that care but unfortunately my democrat colleagues believe in the magic healthcare ferry and that where there is unlimited funding and their won't be any rationing in such a system. then scare the american people, focusing on coverage when they talk about insurance coverage or government coverage, focusing on the one thing that matters is an individual in this country and their families being able to go to a doctor and get care and that is going to happen more effectively if you drive down the cost of care and increase the 1:1 relationship between doctors and patients instead of focusing all of our time on government bureaucracies and
insurance bureaucracies in which the system we have today's single-payer healthcare being managed by insurance companies ineffectually and inefficiently by regulation. i love my democrat colleagues are racing to push for healthcare reform. especially senate democrat candidates for president who are raising for medicare for all, universal coverage, va for all, whatever branding they want to come up with, 10 years into a system created by democrats that apparently isn't doing very well and therefore needs a new system. let me ask you a question. where in the constitution is the phrase dental plan found? >> it is not. >> how about prescription drugs? standard of care? co-pay? my question here is when we are talking about my colleague talking about states and how we weren't going to allow states to provide and make decisions that are best for the people in their home state this question came up
about how we need a standard of care nationwide. my point is simply this. how many people are in the united states roughly? >> roughly 329 million. >> how many in texas? 28 million. how many in california? >> 40 million. >> people talk about comparing systems. how many are in singapore? >> about 6 million. >> how many and what happened? >> 7 or 8 million. >> comparing apples and oranges around the world, comparing one healthcare system to another khmer system was designed to be a federalist system where we can have differences of opinion, we can have healthcare systems in various states. let's take texas. texas is different from main. my colleague mister doggett knows that very well. how many people of the current uninsured population are people who are present in the united states illegally? what estimate do you have for that? how many people in the uninsured population are people who are
present illegally in the united states? >> roughly 6 million. >> i have seen different numbers ranging up to 30% of those who are uninsured, a sizable piece of the pie particularly in a state like texas or california that have a population that are here illegally. is that true? >> as i said in the opening statement, roughly 11 million people who are here unlawfully and half of them have health insurance. the component of slide 3 on the backside of your hand out, the components of who the uninsured are and my colleague can speak to this. >> without going to that in a limited time i want to highlight that states very. we have different populations. i would add that a significant portion when talking about the uninsured part of the reason we have significant uninsured by commission problem is we have a significant number of illegals illegally present in the united
states in texas because this body refuses to do his job to secure the border. a couple more quick questions in the limited time i have left. it is it true under singapore system the number of providers is not sufficient to meet demand patients might face increased wait time and access to care? would it be -- would you agree with the following others, according to analysis by the freezer institute, wait times in canada is your system, 8.7 weeks for referral from a general practitioner, the analysis wait times, 4.3 weeks for a ct scan, 10.6 weeks for an mri scan, 3.9 weeks for an ultrasound. does that sound right? >> my colleagues are more familiar with those numbers and i am but i characterize generally in the united states we have lower wait times than other countries. >> when i was diagnosed with cancer i got treatment in 10 days, not like i got cancer treatment. >> the gentleman asked time is
expired, i recognize the gentleman from indiana. >> thank you for giving us this opportunity to discuss a critical issue. i want to be clear. i support universal access to health care and i'm committed to working with my colleagues to achieve this goal. i commend my colleague for her work and advocacy, for medicare for all proposal and many other proposals a number of my colleagues have offered. i believe we must work together to protect healthcare coverage for individuals who, like their current healthcare plans, expand coverage for americans who still need it and to bring down healthcare costs for everyone. i want to get to a number of questions that i believe have to be answered in order for us to reach a single-payer system. first, though the affordable
care act has played a significant role in ensuring many more americans particularly medicaid expansion, congressional budget office estimates 29 million americans still uninsured in 2018. 11% of us residents under age 55. my home state of nevada is one of the first to expand medicaid under the affordable care act. governor brian sandoval was the first in the nation to expand medicaid. since that time our uninsured rate declined 40% from 2013-2016. nevada was ranked number 2 for the highest rate of uninsured. 30% of our children were uninsured before the expansion
of the affordable care act and medicaid. today, only 8%. i reject my colleagues who say the formal care act is not meeting its goals. more than 640,000 nevadans rely medicaid which provides coverage for children, pregnant women, parents, seniors, and individuals with disabilities. my question, how many of these 29 million uninsured americans fall into the so-called coverage gap might have coverage if allstate moved toward medicaid expansion? >> slide 3 and a walk-through. this project the number of 30 million people. >> roughly 4 million across the
country came into the category, they moved below 100,000 of poverty and they live in a state that did not expand medicaid. >> why did those states choose to deny their residents coverage is beyond me. employer-sponsored health care benefits were achieved through a long and rich history of collective-bargaining. to date, 49% of nevadans receive healthcare through their employer. many of them were negotiated benefits, they gave up wage increases to have the healthcare they have earned. can you speak to how individuals who receive their healthcare through their employer would be impacted by a single-payer system? >> yes. it depends on the design of the system. if they received public coverage as a replacement for employer-provided coverage, then
we would expect that employers who spend quite a bit on it coverage would return. that is part of their employee compensation. they would return that to employees, or most of it, in the form of wages or other benefits. but we would have to analyze the change because employees may then pay higher taxes to pay for the national health insurance and that would depend on the scheme. >> in your report, you note transition toward a single-payer system would be complicated, challenging and potentially disruptive. healthcare spending in the united states accounts for 1/6 of the nation's gdp. those changes could reflect the overall us economy. what factors should we take into consideration to avoid major disruption from occurring in our
healthcare market? >> some of the questions of how you would get there depends on where you are trying to get to. the design of the plan, how you wanted to be structured in terms of what services would be received, how you are going to compensate, another question, who is that you are most concerned about disrupting, if it is employees who currently employed by private health insurance companies you could look to have a longer time. go before switching to a single-payer system or have job retraining programs for those people. if it is for doctors or other providers, how you structure, bring down payment rates to the
level that was brought down by the administrative savings they are facing because only dealing with one payer as opposed to the current system. >> the gentleman's time is expired. i yield 5 minutes to the gentleman from pennsylvania. >> thank you, mister hadley, and the congressional budget office, for being with us. speak to my constituents in pennsylvania on healthcare quite regularly. we often discuss three priorities important to the family, the ability to choose their own doctor, quality, and affordability. i would like to focus my questions on these areas. first regarding choice. deputy director hadley. page 6 of your smitty reports as, quote, participants would not have a choice of insurers or health benefits. compared to the options available in the current system benefits provided by the public plan would not address the needs
of some people. expand on what you meant by that. >> one of the issues is technology and how quickly a new set of insurers might adopt technology so you might expect competing private insurers, one or two what adopt technology to follow and would accept faster adoption of new technology than you would with one payer. >> more is better and competition is good. regarding quality i often heard the canadian healthcare system described as it is terrific and so you get very sick. people want to be able to go to the doctor of their choice and to know the care they are receiving is excellent. i'm concerned when a
single-payer system removes choice people will not be able to choose the doctor that best suits their particular personal health needs. you analyzed how the single-payer system could and would negatively impact quality of care. >> quality of care, it is possible if you go through a single-payer system there might be more doctors to choose from because narrow networks would be combined and all providers would be in one network depending on design choice. in terms of so many other procedures in terms of the overall quality and so many factors, if there is a mismatch between demand for care and supply of care, and that might
mean for example traveling further distances for that. >> based on models we are aware of quality would be compromised. >> unfortunately i can't answer that directly it depends on the design of the system. .. what would be coming from the congressional budget office some of the ways the revenues would be generated?
>> we discuss three ways it could be financed through cash flows and then there's a half. you could have additional co-pays or other cost-sharing by individuals. there could be premiums paid, or taxes. then the half is you could have financing that would postpone when those services would be paid for and shifted to another generation. >> a system with no cost-sharing such as co-pays and premiums run entirely by the federal government, the only method to generate revenue would be taxes or deficit spending. no co-pays, no premiums, all paid nurses to carry
out services that are truly done by doctors. >> so have less doctors and keep pushing down the requirements. we would sort of the valley expertise we have in the medical field, people have gone a long time to school to give us what some would argue the greatest health care in the world. i know our friends across the aisle argue that the we have a coming from this great countries like canada and europe come here to specialist treatments them because a of my colleague from texas said they can get done in a timely manner as opposed to possibly dying before those procedures could be done. i have spoken to people in england, when they have these immediate needs because i can't afford it, they could use the private insurance and not the national health insurance. >> that's right. in england you can buy insurance that helps have faster access to care. >> much of that is provided through these evil companies that are allowing their
employees to actually buy the private health care, is that correct? >> public plan -- or private plan, excuse me. >> also in their used a quote single-payer system could force compliant to an existing automatic payroll withholdings and taxes, is that right? >> that's correct. >> sounds like an individual mandate we had in obamacare. that one was remote people made the choice not to actually buy insurance. nobody kicked them off. they just decided they didn't want to fight anymore. is that what you could see happen as well? >> in the context of the single-payer system what we were envisioned was there would be taxes that would be withdrawn from the economy, not -- but i see your point about an individual mandate. >> i've got so many here, but you also said that, in their about rural hospitals and about taking over the hospitals, is a true one of the driving forces behind negative profit margins
is due to reduced medicare reimbursement rates? >> yes, that's correct. when the affordable care act put in place a change in the way those providers -- [inaudible] that it now includes an increase for the cost they face and a decrease for the total level of productivity within the economy as a whole. >> i really appreciate your work is and again i read the report a couple times. it's to say socialized medicine is an always been the democrats in the game since all the way back to 2000 -- go back farther than that. one-size-fits-all health care comes with an unbelievable price tag that we've seen through reports, $32 trillion on the low end, even without expanding medicare is corporal that medical hospital insurance trust fund will be installed in 2026. i spoke spoke . programs like medicare and medicaid on the fiscal sustainable path so it
would be available for current and future generations. if we cannot afford medicare as is why our call is making empty promises to the american people we could afford medicare for all. the problem is the exact same problem with social system collapses on itself. i would ask my colleagues to be truthful to the american people and don't be, you know, i guess overtaken by the empty promises that big government, that this is not medicare for all, this is medicare for none. mr. chairman, i just back. >> the time of the gentleman has expired. now yield five minutes to the german from california mr. khanna. >> thank you, mr. chairman. let me commend your leadership for having this hearing and helping educate the committee members and the american public about medicare for all. >> mr. hadley, you believe medicare for all is socialism? >> we haven't drawn the conclusion that socialism. >> do you think anyone would pass economics 10 101 if they ge
that answer in any major university in this country? mit or university of chicago? i studied economics a university of chicago. do you think of someone in first economics wrote a paper sing medicare for all is socialism that the great free-market economists within give them a passing grade? >> well, cbo doesn't have a specific own definition of socialism and -- >> just given the economic definition which is you control the means of production, i mean, do you think this is socialism under common economic definition? >> it would involve more government control over one aspect of the economy. >> so you can't say that it's not socialism? >> no, i -- its come we can't speak on it either way. >> okay. i mean, i think 99% of people with phd, an economist in this
cottage would say it's not socialism. as you know the employer average premium is $12,951 of costs to an employer under the current health care system. most economic studies show the stagnation of our wages for the last 40 years are directly tied to increasing health premium costs. can you speak to how much increasincreased the would be os if the employers were not being burdened by the $12,951? >> well, as my colleague can explain further you would expect a significant portion of that to be passed back to the employees. >> yes, we would expect employers to pass back most of that in the form of other compensation or wages however, employees within face taxes related to the national health insurance. >> do you think one of the
biggest things our country can do to do with wage stagnation of the bottom 50% of income earners is to reduce the burden that employers have in premiums? >> so the bottom 50% of earners do not always receive health insurance through their jobs. >> bottom 50% who have health insurance. do think one of the biggest things we could do in terms of wage stagnation is to reduce the employer cost of health care? >> i don't know what that, what would happen to grow in wages over time. it would certainly cause a change during the transition from private to public health care. >> it would be a massive price for most americans. >> we would expect to see an increase in wages, but if the scheme are financed through payroll tax, they may not take all of that home in their pay.
>> but even if was financed through payroll tax it would be a net increase for most americans, correct? >> i'm sorry, that would depend on the details of the tax system. >> there's no way attacks would be $13,000 on any economic study, you testified earlier to mr. doggett that most americans would actually, who are making under 75,000 would save money by having less costs of premiums than they would have to pay in federal tax, is that correct? >> so i think what i said was you could design a system that would be more progressive than the current system if you're considering what they're currently paying for health care as the tax. so that's really a choice the placenta present in front of them, not a conclusion we can draw about the choices you've already made. >> but you could design a system in your view that the ordinary american who is watching this with pay less money in terms of
the fee for government than they currently are paying to health care, and they would get more money in the pockets in terms of increased wages. it possible to design that system. >> it's possible to design system that we do that for some people can get. >> and most economists would not describe it as socialism, unless you believe reducing peoples cost and increasing their wages is socialism. you get the lessor. >> no, there would not not describe it as socialism. >> the time of the gentleman has expired. now yield five minutes to the gentleman from south carolina mr. norman. >> thank you, mr. chairman. mr. hadley, thank you and your colleagues are coming. the way to predict the future is to look to the past, and i think we all remember during the obama years during obamacare the statement, you can keep your own physician. how did that work out? not to appear think we remember the statement, reductions in our
deductibles. how did that work out? not too well. in my state of south carolina we have single moms who are supporting two or three children. her premiums skyrocketed 62%. not 15-12% not 15-12% as i've heard. how did it work out when they promised lower deductibles? not too good. let's look to the other countries that have, that you can call it not socialism but government run systems in anything is hurting that socialism, if you really look at it and get down to the bottom line. let's look at the great britain. look at the shortages in positions. 11,500 physicians short. 42,000 nurses short. let's. let's look at canada. as mr. royce said, he had history for cancer in ten weeks. how does the canadian system work out?
well, it took patients 8.7 weeks just a special scope for .3 weeks to get a ct scan, 10.6 weeks to get an mri scan, and 3.9 weeks to get an ultrasound. my son-in-law from canada when they had heart trouble, guess where he came. not candidate. he came to the united states of america. so the old system is not sustainable under obamacare so i welcome this discussion to get into how are we going to prove it. it's not government run health care. mr. byrne and i are in the private sector. he has restaurants. i'm into construction worker to think of it can do it cheaper than we can? no. petition is what makes us a better product at cheaper prices. i keep hearing this word free. okay, i'm for free medical care with the caveat get the doctors to work for free. i'm for free education. get the professors who are tenured to work for free. get us as congress to work for free. so this is what we're talking
about and i'm glad to have this discussion. incentives, why come hasn't been any to study on the incentives? would you get more people in the medical profession if you cut their pay? habited any type work on that, mr. hadley. >> was i haven't but my colleagues have looked at that issue and that seen in the context of multi-payer system. i think we need to come back to the and second, that if you cut the competition of providers, they provide less care. the caveat is that was in the context of a relatively small change within the context of a multi-payer system. date of the places to go. hard to know exactly how that would play out in the context of moving to a single-payer system. >> but you would agree to cut incentives will not have the physicians getting in the field to practice their skill, if you cut their pay. does that make sense? >> in general we would expect
fewer people would enter the medical profession and whether that would result in a shortage of services would depend on incentives faced by the people who remain and also the extent to which with foreign trained doctor. >> d agree with me last doctors to see patients that need care, so the patient would ultimately suffer? >> it could reduce, they could result in reduced levels of care, in part because of wait times. >> okay. finally, our nation's that is that 22 trillion. it's been estimated the single-payer system would add 32 trillion. bottom line, you can say it adds to it. it's net but bottom line you are looking at a big number and are looking at a number that is unsustainable as we look forward, as a try to get a system to get this country back on a firm financial footing and not financing with a credit card. would you agree?
>> so two things. one, it would be a very large ships to move all the private payments that are currently financing the health care system to become public payments and that would require substantial additional government resources more generally the current level of debt and deficits are ultimately not sustainable. >> not sustainable, not going to be for the united states as it is been put into the socialist countries which are basic going broke. anybody who believes the government run, a government run health care system provides better health care at lower prices, i've got some land that is underwater i need to sell you for high-rise condos. thank you so much. >> gentleman's time is expired. i now yield five minutes to the gentlelady from illinois ms. schakowsky. >> all this talk about socialism. that's exactly what we heard when medicare was suggested. in fact, ronald reagan was the lobbyist, went around the
country against medicare because it was socialism. i don't know about the v.a. that sounds lik like a social sm to me, too. that is a single-payer system provided for our veterans. social security, oh, my, that is deathly socialism according to my republican colleagues. and a single-payer system would not be any more socialism than any of those current government run programs that people like. an attack the idea of medicare for all is really popular out there. it pulls really well. be careful of your slams against socialism. people want to have health care. the united states of american currently pays more for health care than any other country, is that right