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Hearing of the Health, Employment, Labor and Pensions Subcommittee of the House Education and Labor Committee - Examining the Single Payer Health Care Option

Chaired By: Rep. Robert Andrews (D-NJ)

Witnesses: Rep. John Conyers (D-MI); Dr. Marcia Angell, Senior Lecturer in Social Medicine, Harvard University Medical School; David Gratzer, Senior Fellow, Manhattan Institute; Geri Jenkins, Co-President, California Nurses Association/ National Nurses Organizing Committee; Dr. Walter Tsou, National Board Advisor, Physicians for a National Health Program

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REP. ANDREWS: Good morning, ladies and gentlemen. Welcome to the subcommittee. Having determined that good cause exists to proceed with this morning's hearings, we'd like to welcome our colleagues who are present this morning, ladies and gentlemen that will be witnesses and the members of the public and the press. It's great to have you with us.

The United States is spending more of our national wealth, more of our business firms' income, more of our family and individual income on health care than any of our industrial competitors anywhere in the world. And I do think there's an emerging consensus we're not getting what we're paying for. We're not getting the quality that everyone wants and deserves, and we're certainly not getting the coverage that everyone wants and, we believe, deserves. There are too many people left out of our system. There is too much money spent within our system on other than providing health care to people, spent on what many of us feel is wasted expenditures.

At the president's urging, the country and the Congress have embarked upon a broad national debate about how to fix that problem. And I would like to commend members of both parties in both the House and even the Senate -- even the Senate -- for moving beyond a simple recitation of the country's problems to a robust debate about the proposed solutions to those problems. It is long overdue. We believe that legislating on those solutions is long overdue as well.

This morning, for our subcommittee, will mark an important milestone in debate, and one of the more broadly supported and interesting solutions to the problem will be considered by the subcommittee in the form of a legislation proposed by the very distinguished chairman of Judiciary Committee, Mr. Conyers. He will be our first witness this -- you may applaud if you'd like. (Applause.) He will be our first witness this morning and will summarize and advocate for his legislation. I'm sure he will do forcefully and articulately.

We will then proceed to a panel of what you might call "lay" witnesses. John, I guess that implies that you're a holy person -- (laughter) -- but we'll proceed to a panel of lay witnesses.

And one thing I would ask our colleagues to consider, out of courtesy to the lay witnesses, is that once Mr. Conyers, Chairman Conyers has concluded his statement, those who would like to ask him questions, obviously, under the rules, are permitted to do so. I'm not going to avail myself of that opportunity, and I believe Mr. Kline is not either. And we urge members to consider not questioning Mr. Conyers, not because he's beyond being questioned, but because the lay witnesses have traveled from far and wide to be here today. We'd like them to have maximum opportunity to interact with the panel so we can hear their views as well.

So Mr. Conyers has proposed a solution to this problem. He argues it with great passion. It is a solution that, unlike some in the Senate, I believe belongs on the table for consideration and for vigorous and fair consideration. That's what the purpose of this hearing is this morning.

With that, I'm going to ask my friend the ranking member of the subcommittee, Mr. Kline, for his opening statement.

REP. JOHN KLINE (D-MN): Thank you, Mr. Chairman. Good morning to you all. Good morning, Mr. Chairman.

We're here today, as the title of this hearing implies, to examine single-payer health care. And we're certainly going to hear from Chairman Conyers and from the panel of experts that Chairman Andrews mentioned.

Single-payer is certainly among the most controversial approaches to health care reform. And frankly, Mr. Chairman, I'm a little surprised to see it on this subcommittee's agenda. President Obama and Democratic leaders, as I understand it, have been very clear and very public in rejecting the notion of single-payer. And frankly, I'm glad that they have.

Creating a new, one-size-fits-all health care system modeled on Medicare, I believe, is a recipe for disaster. It would balloon the deficit and add to our mounting debt. It would drive up taxes while driving down medical innovation. It would ration care while empowering bureaucrats.

All of my friends on the other side of the aisle have not included Republicans in their deliberations. I've been following their progress pretty closely in the news. The latest reports indicate that they could formally unveil their legislation as early as next week. While their proposal apparently does not include a single- payer scheme, it seems highly likely that we'll see a government-run option. And I use that word "option" with some trepidation, because it seems clear to me that any government-run option is designed to undercut the private sector and eventually drive private participants out of the market.

So perhaps today's hearing is appropriate after all. If the Democrats are serious about including a so-called government-run option in their plan, and if a government-run option is designed to crowd out the private sector, than the -- (inaudible) -- is that we're only a few steps away from a single-payer system. How else can you explain the urgency with which this hearing was scheduled?

As you know, Mr. Chairman, committee rules require that members be provided at least seven days' notice before any hearing. Often and thankfully we usually receive even more. But today's hearing was announced last Thursday, just barely after the customary seven days that are required to schedule to be administered nonetheless. And it requires this subcommittee to waive our longstanding rules to proceed.

Mr. Chairman, this hastily-convened hearing epitomizes everything that is wrong with the majority's health care reform process. Our health care system is in serious need of reform. Republicans and Democrats alike recognize the shortcomings of the current system and the need for meaningful change. There is a bipartisan commitment to change, and that's why we should have a bipartisan reform process.

Health care reform is far too important to get wrong. It's more important that we do it right than simply do it fast. Unfortunately, the majority seems to have chosen a different path. The speaker, after a partisan strategy session at the White House last month, announced an arbitrary deadline that calls for House passage of a comprehensive health care overhaul before the August district work period. Frankly, it's like deja vu all over again. Just like the so- called economic stimulus package earlier this year, we face the prospect of complex and costly legislation that is crafted behind closed doors.

Members of Congress did not even have the opportunity to review the stimulus before it was brought to a vote. And judging by the announcement made at the White House this week, essentially -- (inaudible) -- the stimulus isn't delivering the jobs that were promised. A partisan package that doesn't receive a thorough review and vetting simply won't work.

Mr. Chairman, I'll say it again. Health care reform is far too important to get wrong. I've come to this debate in good faith, and I stand ready to work with you. But this hearing is at the wrong time. It's too fast. Let's slow down and do this right.

Thank you. I yield back.

REP. ANDREWS: I thank the gentleman.

I also would take the prerogative and introduce a friend and guest this morning. The chairman of the Health Subcommittee on Ways and Means, our good friend Pete Stark from California, is present. My understanding, which we discussed with the minority, is Mr. Stark will be an observer of the hearing; does not intend to ask any questions. And we appreciate your indulgence in having him here.

And I would just say to my friend who I know approaches this in good faith that Chairman Miller and I intend to meet I think as early as today with members of the minority caucus to talk about health care reform before there's any mark-up or any bill filed, which we look forward to your participation in. And I realize that was scheduled, I think, just this morning. But I just want to let you know it's happening and there will be that discussion.

Also, just about timing, I sat in this room 15 years ago on one of the lower daises, much lower. And there was an attempt to get something done about this problem and it failed. And there wasn't a whole lot done after that, which I think was another failure.

So I understand that there are some questions about schedule, but I would simply say that I don't think the problem is that we've gone too quickly. I think we haven't gone quickly enough. And so that's just something we might disagree on.

We're going to turn on to our chairman of the Judiciary Committee, someone I've always regarded as a model of integrity and dignity, conducts himself in such an important way in this House. His jurisdiction touches everything from how we pay our credit cards to whether we have our rights in (accord/a court ?) of law. He has been, I think, a member's member for a very long time; a person we have tremendous respect for. And we're very -- we're very happy to welcome to the subcommittee this morning the distinguished chairman of the Judiciary Committee. The gentleman from Michigan, Mr. Conyers is recognized.

REP. CONYERS: Thank you, Chairman Andrews for that flattering introduction. Ranking Member Kline and all of my colleagues here -- it's so good to see Pete Stark back in the saddle again. And I'm just so privileged to be here. I want to thank you very much.

The one thing we have to do in this discussion of health care and how it is reformed is that we've got to have a discussion about it. And so my brief comments -- because I'm so flattered to have with us Dr. Marcia Angell, the former editor of the New England Journal of Medicine, and Dr. Walter Tsou, Dr. Stephanie Woolhandler from Harvard Medical School and other witnesses that you've been so kind to bring here.

I just want to review with us what I think it is that we're in, and I want to extend an opportunity for our discussions to go far beyond the hearing today. And I want to make myself available to all of the members. First of all, we've got to discuss it.

And the first thing that occurs to me, that there is some -- and I concede this to my ranking member friend -- that there's some notion that universal, single-payer health care is off the table. Well, that raises a very important question. If you take the most popular health care reform measure and take it off the table, heaven knows what it is, I guess, you think you're left with.

The one thing I commended the 44th president about when I met with him first after his election was he said something that no sitting president in my experience had ever said. He said, "I want you to keep in touch with me, to keep me advised. We want to know about what's happening and what you're thinking about." And so I praised him for that. He made a lot of other important statements, but the fact that he wanted to keep in touch was very important to me.

And so we've been keeping in touch. And citizens have been keeping in touch. I know, because I've been invited around the country endlessly, to some people that would like me to travel less and stay in my district more. The fact of the matter is we're dealing with -- and the polls establish it -- I've got something here that tells us through two polls that this is the most popular system in the minds of most Americans, most Americans. And I'm going to put all these things in the record. But here are more than 400 local unions, 20 international unions, 39 state AFL-CIO unions, all resolved around this question.

Now, I wish I could claim some creativity or imagination for this, but universal single-payer is not a new idea. As a matter of fact, every industrial country on the planet except one, us, already have some version of it. What we're doing is developing the American version. What we're doing -- and we've examined all the systems on Earth. We're putting this all together. We're studying this. We are not turning this over to government. We've got another database of myths about this system that I won't try to go into now.

But we want to examine these. We cannot examine them without a hearing. So it's with some sadness that I report that it wasn't easy for me to get to that first summit that the president called. It was an enormous one. He's taken an enormous step here. We've got to help him.

Here's how I'm going to help my president. He is getting some mis-advice about health care. To think that this sad substitute about the Massachusetts plan -- and there are people from this state that can expound on it far more greatly than I can -- is -- it's going to move us forward -- we're at a point now where we're either going to take this opportunity and move forward and have everybody in as a matter of constitutional right to health care, not health insurance, not policies, but health care itself, from the moment they're born to the moment that they leave Earth.

Now, here are what the essentials are. It's a 37-page bill. We're not going back to the 1994 mistake of 1,200 pages. What we're saying is, number one, everybody is afforded health insurance. Number two, they'll be paying -- the rate would be about 3-1/2 percent of your income. It is -- it is not government-run. It is privately administered. No one will be giving up their choice of doctor or hospital or how they want their health service rendered. It would break the employer connection, and it would create out of -- it would create one health insurance system, one -- which would be devised -- we would -- we would come together, whether we want combinations of existing health insurance groups or whether we want to do something differently.

So I want everybody that's thinking about this to start off with number one. This is the most popular form, and it would be very unlike the party in the majority now to determine that the most popular system would not even be examined. I am asking for a hearing in every committee -- every committee, if they will let us into the Senate as well. That's very important.

Now, here's the closing, members. Chairman, this is a great bill, fantastic. I have some saying their father was a single-payer. It's wonderful. Guess what? It's impossible. So we've got to go to the next best thing. What is the next best thing? Well, we're working on that. We'll be back in touch with you. I got a plan of a plan that we would like you to examine.

Okay. Now, let me close with this. This country -- this is where -- this is where we're going to test the mettle. And this is not a test, because bringing health care to 47 million people and 30 million that don't have anything -- this country was founded on the basis that a third of the people wanted to be free, a third of them wanted to stay with England, and a third of them didn't give a darn what happened. It couldn't be done. It shouldn't -- it wouldn't -- wasn't able to happen.

Nelson Mandela was supposed to be in prison for the rest of his life and he ended up the president of the country that sentenced him to a life in a penitentiary. It couldn't be done.

Social Security was supposed to have been the worst thing that had ever happened. And I've got some of the debates. And you would not believe what some people said in opposition to Social Security. It couldn't be done; it wouldn't work.

And what about Medicare? Medicare was fought tooth and nail. I know because I was here.

And now we have Obama himself. You can't elect -- please, folks, you can't elect a person of color to the highest, most powerful government position on earth. It's impossible. Get a grip. Well, it was all possible.

It all could be done. And I'm asking you to consider the political necessity of bringing up a bill that they said was off the table. Then they say, well, it couldn't pass.

Well, I think that the American people are watching very closely, and I am saying that now is the time. And I thank you for allowing me to make this introduction and to include the papers that I would like to be part of the record as well. Thank you for this opportunity, ladies and gentlemen. (Applause.)

REP. ANDREWS: Thank you, Mr. Chairman. As usual, you have contributed a great deal of substance and given us an awful lot to think about, which we're going to think about right now with the witnesses that we have coming up. And I can assure you that the principles you're putting forward will be very much a part of this committee's deliberations and thoughts.

And this media, this is the beginning of the process, not the end. And I do want to acknowledge our colleague. Congressman Watson is with us in the audience, from California. I'm happy to have her with us as well.

Again, Mr. Chairman, so the letter written that says I'm going to forego asking any questions. Is there a member on either side that would like to ask the chairman any question? Well, that's a very good decision. Thank you very much. We appreciate that. Thank you, Mr. Conyers, for coming. We'll get to our lay witness. Thank you, John, very much. Thank you for being here. (Applause.)

All right. If I could ask the witnesses to come forward, and I'm going to read biographies to save us a little bit of time, so get right to the testimony. There's a series of votes coming up. Do we know when this morning? Shortly. So we want to get started so we're not interrupted.

Ms. Geri Jenkins is a registered nurse and a member of Council of Presidents of the California Nurses Association/National Nurses Organizing Committee. She has over 30 years of experience as a surgical ICU and trauma RN with the University of California, San Diego Medical Center's Hillcrest Campus. She received her BSN from San Diego State University. Ms. Jenkins, welcome. We're glad you're with us.

Dr. Walter Tsou. Did I pronounce that correctly? Tsou. Excuse me, Doctor. I should know better. Dr. Walter Tsou is a nationally known consultant on public health and health care reform. Currently he's in the visiting faculty of the University of Pennsylvania. After serving as the president of the American Public Health Association in 2005, and as health commissioner of Philadelphia from 2000 to 2002, under Mayor Rendell I assume, correct? He received his medical degree from the University of Pennsylvania, his MPH from a Johns Hopkins School of Hygiene and Public Health, and he has an honorary doctorate in medical sciences from Drexel University. Welcome, Doctor. It's great to have you with us.

David Gratzer. Dr. David Gratzer, a physician, is a senior fellow at the Manhattan Institute. His research interests include consumer driven health care, Medicare and Medicaid, drug reimportation, and FDA reform. His writings have graced the pages of more than a dozen newspapers and magazines including the Wall Street Journal, the Washington Post, the Los Angeles Times, and the Weekly Standard. Dr. Gratzer has recently been cited in the New England Journal of Medicine, a well-known publication; the New England Journal of Medicine Health Affairs, as well as by major media outlets across the United States and Canada. Dr. Gratzer, did I pronounce your name correctly? The doctor, by the way, holds a BS and an MD from the University of Manitoba.

And finally, Dr. Marcia Angell, correct? is a senior lecturer in the Department of Social Medicine at Harvard Medical School. Dr. Angell writes frequently in professional journals and the popular media on a wide variety of topics including health policy, the interface of medicine and the law, care at the end of life, and the relations between industry and academic medicine. A graduate of the Boston University School of Medicine, she trained in both internal medicine and anatomic pathology and is a board certified pathologist. Welcome.

What a distinguished panel. For those of you who have not been here before, in front of you is a battery of lights. And the battery of lights, we'll have a green light when you begin your testimony. Your written testimony is accepted without objection into the written record of the hearing, so your written testimony is fully on the committee record. We ask you to give us about a five-minute synopsis of the written testimony orally. The reason we limit you to five minutes is so we can maximize time for question and answers with the members of Congress that are here on the dais.

A yellow light will appear when you're about a minute away from the end of your time period. We'd ask you to try to wrap up your remarks, and when the red light goes on you will be finished, and we'll move on to the next witness.

So Ms. Jenkins, welcome. It's good to have you with us. You're on.

MS. JENKINS: Thank you. Chairman Andrews and Ranking Member Kline, and the distinguished members of the subcommittee, I would like to thank you for this opportunity to support single payer health care reform on behalf of the 86,000 members of the California Nurses Association, National Nurses Organizing Committee, the country's largest organization effort representing direct care registered nurses.

I am proud to be a co-president of CAN and NOC, and I especially want to thank Education and Labor Committee Chair George Miller, who is a great champion of health care reform of RNs and of all working people.

In your consideration of changes to our health care system, you should know that registered nurses are the profession most trusted by the American public, as shown consistently in Gallop's annual poll on this question. Nurses are on the front lines of what I can only call a patient care crisis. As a critical care nurse at the University of California San Diego Medical Center I see patients whose conditions are much worse because they avoided earlier treatment due to the high cost, so they arrive sicker; they leave quicker than they should because their insurance companies won't approve medically appropriate care.

I can tell you from my more than 34 years of personal experience, insurance companies ration care. The current system is rationed care based on the ability to pay. Some patients like 17-year-old Nataline Sarkisyan do not get the lifesaving treatment they need. In Nadeline's case she needed a liver transplant, but SIGMA would not approve it until I and hundreds of others protested. During one of the protests I was with Hilda, Nataline's mother, and she got the call that SIGMA had approved the transplant. But it was too late. Nataline died an hour later.

It doesn't have to be this way. We agree with presidential candidate Obama who called health care a "basic human right," and we agree with now President Obama who says, "Health care reform is not a luxury; it is a necessity that cannot wait." The same is true of health care itself. Right now we are the only nation on earth that barters human life for money. We need a guaranteed single standard of high quality health care fit for all.

To make the change we need, let's have a real policy debate on the merits. People talk about evidence-based practice. We need evidence-based policy. If we were to have a debate on containing costs, improving quality and universality, the single payer advantage would be clear.

Let's consider the principles President Obama has established. First, reduce cost. In a survey of eight major industrialized countries, the U.S. fared the worst in out-of-pocket costs and the number of chronically ill adults who were going to care because of cost. Even though the U.S. spends twice as much per capita on health care as the others, 25 percent of Americans are skipping doctor's visits because of cost. And that was before the recession. According to another survey in October 2008, 38 percent of Americans who are insured delay care because of out-of-pocket costs. The reason? Premiums have risen, been rising four times as fast as family income in the past decade; and co pays, deductibles and other transaction fees the insurance industry imposes that can run to thousands of dollars a year on top of premiums. That along with denying claims is how the for-profit insurance companies make money, which ultimately is their job for their shareholders, not authorizing care delivery.

Unless you can stop the insurance industry price gouging, we simply cannot make health care affordable, which means you either have price controls on the insurance industry or you take them out of the equation through a single payer reform.

Cost controls are much better addressed under single payer mechanisms like those contained in HR676. Global budgets to hospitals and clinics based on their patient care operations, negotiated reimbursements to providers, bulk purchasing and negotiated prices for prescription drugs, incentives for preventive care, and reliance on primary care.

Second, guaranteed choice. How many Americans under 65 can go to any doctor of their choice without incurring additional cost, or at all? Very, very few, and certainly not those 94 percent of U.S. metropolitan areas that are served by one or two insurance companies, as shown in the AMA's 2008 study of insurance markets. Insurance coverage and companies now control patient choice of provider and treatment, often with terrible health results.

I often relay the story of a patient seriously ill and in need of immediate intubation who turned up in an emergency room in my community. He needed to be intubated, which means insertion of a breathing tube, to save his life. Because he was so worried about cost, the patient looked up at his nurses and doctors caring for him and said, "Can you wait until next week; I'll be 65 and have Medicare." Respectfully, that is not the way my patients or their providers should be making their health care decisions; nor is it the way our nation should force citizens to evaluate their health care decisions.

One of the great advantages of single payer is that it guarantees patients the ongoing choice of a doctor or other provider who are paid for providing treatment on the same basis.

Third, insuring affordable care for all. Here again single payer has the advantage from a clinical point of view. Taiwan is the most recent country to have adopted single payer in 1995. The percentage of people with health insurance climbed from 57 percent to 97 percent; yet the expanded coverage produced little if any increase in overall health care spending beyond normal growth due to rising population and income. Taiwan had a system much like ours, multi-payer, dysfunctional, broken. They made the switch just a decade ago, though some people said it could not be done, with great success for their people.

The U.S. ranks among 19 leading industrialized nations in preventable death. We rank last among leading 19 industrial nations in preventable deaths. We're last out of 19. U.S. matched the top three, France, Japan and Australia, in timely and effective care, how 101,000 fewer Americans would die every year.

In a study released earlier this year by CNA and which is included as an exhibit in my written testimony, it has been shown that extending Medicare to all would not only provide desperately needed medical care to millions, but would also result in the creation of 2.6 million new jobs in this nation.

The evidence is clear. Single payer works. It best meets the president's principles. And most important, it best meets the needs of my patients for whom I have a professional responsibility to advocate for.

Our history proves that with political leadership any reform that benefits the American people as a whole is politically viable. Dare we waste this moment with a reform that will not adequately control cost, be truly universal and prove quality and guaranteed choices, doctors and providers? Or will we leave the American people feeling the moment has wasted and that once again they cannot trust their government to genuinely act in their interest?

Let's enact single payer, and let's put patients first. Thank you very much.

REP. ANDREWS: Thank you, Ms. Jenkins, very much. And again your entire written statement will be made for the record.

Dr. Tsou, welcome to the committee.

DR. TSOU: Congressman Andrews, Ranking Member Kline, and members of the Health Subcommittee, my name is Dr. Walter Tsou. I'm a public health physician and former health commissioner of the city of Philadelphia.

If you believe that every American has the right to quality, affordable health care, then the only affordable means to achieve that goal is through a properly financed single-payer national health insurance program. Attempting to reconcile the dual imperatives of universal coverage and cost control through alternative methods besides single payer is an exercise in futility. It is clear that cost controls means that someone's ox gets gored. Either the taxpayer's, physicians and hospitals, or the private health insurance industry. When some congressional leaders declare that "single payer is off the table," they are in effect saying that insurers will be protected leaving the pain to patients, taxpayers, and health care providers.

Let's examine each of these categories. For the taxpayers, it is difficult to understand why we must endure an additional $1.5 trillion or more over the next decade in expenses at a time when our national already spends 60 percent more per capita on health care than any other country in the world. For physicians and hospitals, simply cutting reimbursements is counterproductive, especially at a time when we need to increase reimbursements for primary care and mental health services.

And for the private insurance industry, well, they've dominated health care for the past 50 years. But it doesn't work. Despite a supposedly competitive marketplace, health care costs have skyrocketed; nearly 50 million Americans are uninsured, and the quality of care for most Americans is "suboptimal."

Choice is a total misnomer. Americans want to be able to choose their doctor and hospitals, not their health plans. A humane health care system should reinforce the safety net in the face of our nation's worse recession since the Great Depression. But our profit- driven system kicks millions of Americans in the gut and leaves them both jobless and uninsured.

We have saddled our nation with an inefficient and exorbitantly expensive health care system that drives jobs overseas where health benefit costs are low and discourages entrepreneurs from striking out on their own for fear of losing their insurance coverage.

We need a far greater investment in community based public health and preventive medicine including home visitation for newborns and public health nurses doing chronic disease management in the community.

So where will we get the funds? Single payer is the only reform that can control health care cost. It does so by cutting insurance firms' profits, streamlining the massive administrative apparatus that adds to the cost of hospitals and doctors offices, using bulk purchasing, negotiating fee schedules for physicians, and putting hospitals on predictable global budgets.

The $19 billion that has been set aside for health information technology is doomed to fail because it is dependent on a complex, fragmented health care financing system. In contrast, consider Taiwan as Geri noted where everyone has a smart card. The smart card carries your medical history and can be viewed by any doctor in Taiwan. Their national database allows them to identify the few outliers who try to abuse the system rather than hassling millions of doctors and patients.

What the Internet has done to transform telecommunications across the world is what single payer would do to transform how we deliver health care in America. A national public health database would allow us to direct resources to areas of greatest need. We can change the incentives of reimbursement to advance our national health goals embodied in Healthy People 2020 and reward communities that help achieve those goals.

This would encourage health professionals and hospitals to work together with their local health departments to advance national health objectives.

President Obama has stated that if he were to start over again he would favor a single payer system, but argues that moving to single payer is too radical. Well, I come from Philadelphia where revolutionary ideas are celebrated, not dismissed. Our most famous radical document begins with these words "We the people," not We the insurers. "We the people of the United States in order to form a more perfect union, to promote the general welfare and secure the blessings of liberty to ourselves and our posterity, do ordain and establish this Constitution for the United States of America."

This nation captured the world's imagination with bold ideas, that put the people first. It's time for our own generation's revolution.

Thank you.

(Applause)

Thank you, Dr. Tsou. Thank you very much.

We're privileged to welcome Dr. Gratzer. You're on.

DR. GRATZER: Thank you, Mr. Chairman and members of the committee, members of Congress. Mr. Chairman, I am particularly delighted to have received such a warm introduction. Listening to the accomplishments you spoke of I was reminded of a former colleague who had commented to me that on paper I seem quite interesting. (audience laughter)

Mr. Chairman and members, I've been here for a few moments, as have you, and I've had the opportunity to hear from a few of your colleagues, a few of my co panelists. And curiously I've yet to hear the name Claude Castonguay mentioned once. I suppose perhaps it's not so surprising given that Mr. Castonguay has been out of elected office for three decades.

And when he was in elected office, Mr. Castonguay, in fact, wasn't even American -- Quebec, or a Canadian. But Mr. Castonguay's name comes to mind today at these hearings because of his thoughts on government and health care.

And as we move forward and Congress debates something much larger in the coming months, Mr. Castonguay, for those of us born and raised north of the 49th Parallel, like myself, was somewhat of a heroic figure. In the 1960s he was tasked by the Quebec government to consider what would be an appropriate way to organize health care.

Mr. Castonguay's report called for a single-payer system. He is known as the father of Quebec Medicare, as single payer is known there, because of the report. And then, in an unusual twist and turn of a career, he was actually elected to office and appointed minister of health and implemented his own report. Quebequers for decades thereafter referred to the government-issued health card as a castonguette in his honor.

Last year he was tasked again by the Quebec government to review the system and recommend proposals for reform. Mr. Castonguay did not mince his words. He suggested that the system is, quote-unquote, "in crisis," that the days of simply throwing money into the system and rationing care ought to be over, and he argued for a more robust role for private-sector health care.

He went so far as to advocate not just co-pays or user payments but to suggest that public hospitals actually ought to lease out unused office space in off-hours to private physicians and thus stoke the fires of entrepreneurship.

Mr. Castonguay has changed his mind. To put that in perspective, when the father of Quebec Medicare changes his mind, it's as though -- I don't know -- John Maynard Keynes, on his death bed in 1946 in England, suggests that maybe there's a problem with socialism.

Why would this gentleman change his mind on government-run health care? Well, let me just outline a couple of things in Canadian newspapers over the last couple of weeks -- not reports I've written or right-wing think tanks or watchdog groups; just things that have appeared in the newspapers that I've picked. You can Google this later if you doubt what I'm suggesting.

There's a couple in Quebec that are entertaining a lawsuit against the government because, you see, at 5:00 in the morning in a hospital, in active labor, they buzzed the nurse and no one came. They ended up delivering their own child, without any medical assistance. This wasn't in a rural hospital. This is one of the largest hospitals in Quebec. I guess that's consumer-driven health care, Canadian-style.

One is aware that according to the Ontario government's own guidelines, three-quarters of patients requiring urgent cancer surgery don't get it in a timely manner -- not according to my standard; according to the standards outlined by the Ontario government. And, of course, there are the issues around value and quality, where in Quebec there's an intense review going forward suggesting that maybe one in every four breast cancer test results were tainted, and thus unreliable -- one in four.

Mr. Castonguay has changed his mind, and certainly I can appreciate where he comes from. I was born and raised in Canada as well, from a little town smack-dab in the middle of the prairies, Winnipeg. You know, on a cold winter's day it can drop to 40 below on the prairies. That's the same in Celsius as it is in Fahrenheit.

I guess I'm a son of Castonguay, not literally, but as somebody, a generation younger than him, I grew up under socialized medicine, and I understand why people would believe in a single-payer system, why they would believe it would be compassionate and more equitable than the system of the United States. But like Mr. Castonguay, I changed my mind because I saw the reality in Canada and in Britain and across Europe.

We will speak much of anecdote today, but we should also speak of statistics. Cancer outcomes are better in the United States than they are in Canada. Survival rates are better for low-birth-weight children. Even the income inequity health gradient is better in the United States than in Canada and in Britain.

I understand the temptation of single payer, because I used to believe in it. But as Congress moves forward and we discuss this option, but also the government public-plan auction, which might swallow up 120 million people in the private insurance market, I would suggest to you that the answers don't lie north of the 49th Parallel or in Europe. The United States needs a made-in-the-USA solution.

Thank you, sir.

REP. ANDREWS: Doctor, thank you for your participation.

Dr. Angell, you are our wrap-up witness for this morning.

DR. ANGELL: Chairman Andrews, members of the subcommittee, thank you for inviting me and for your leadership on this important issue.

The reason our health system is in such trouble is that it's set up to generate profits, not to provide care. To pay for care, we rely on hundreds of investor-owned insurance companies that profit by refusing coverage to the sickest patients and limiting services to the others. And they cream roughly 20 percent off the top of the premium dollar for profits and overhead.

Our method of delivering care is no better than our method of paying for it. We provide much of the care in investor-owned health facilities that profit by providing too many services for the well- insured and too few for those who cannot pay.

Most doctors are paid fee for service, which gives them a similar incentive to focus on profitable services, particularly specialists, who receive very high fees for expensive tests and procedures. In sum, health care is directed toward maximizing income, not maximizing health.

Most current reform proposals would leave the present profit- driven and inflationary system essentially unchanged and simply pour money into it -- an unsustainable solution. That's what's happening in Massachusetts, where we have nearly universal health insurance, but costs are growing so rapidly that its long-term prospects are bleak unless we drastically cut benefits and greatly increase co-payments.

We're learning that health insurance is not the same thing as health care. It may be too skimpy or too expensive to actually use.

Initiatives such as electronic records, disease management, preventive care and comparative effectiveness studies may improve care, but experts agree that they're unlikely to save much money.

Promises by for-profit insurers and providers to mend their ways voluntarily are simply not credible. Regulation is also unlikely to modify profit-seeking behavior very much without a bureaucracy so large that it would create more problems than it solves.

Nearly every other advanced country has a largely non-profit national health system that provides universal comprehensive care. Expenditures are, on average, less than half as much per person, and health outcomes are generally much better.

Moreover, contrary to popular belief, these countries offer more basic services, not fewer; more doctor visits and longer hospital stays, more doctors and nurses. But they don't do nearly as many tests and procedures because there's little financial incentive to do so.

It's true that there are waits for some elective procedures in some of these countries, such as the UK and Canada. But that's because they spend far less on health care than we do. If they were to put the same amount of money into their systems as we do into ours, there would be no wait. For them, the problem is not the system. It's the money. For us, it's not the money. It's the system. We already spend more than enough.

Now, it's often argued that the first order of business should be to expand coverage and then worry about cost later. But it's essential to deal with both together to stop the drain on the rest of the economy and the further erosion of health care.

The only way to provide universal coverage and to control costs is to adopt a non-profit single-payer system like that called for in H.R. 676. Anything else will either increase costs or decrease coverage inevitably.

Medicare is a single-payer system with low overhead costs, but it uses the same profit-oriented providers as the private system. So its costs are rising almost as rapidly. Setting up a Medicare-like public program to compete with private insurers, as advocated by the president, would have the same problem, and also not realize the administrative savings of a true single-payer system.

I also worry that the insurance industry will use its clout to underfund the public program and make it a dumping ground for the sickest, costliest patients, creaming off the profitable ones for themselves.

I'm aware that phasing out the private insurance industry would mean a loss of jobs.

But I believe the job loss in that sector would be more than offset by jobs gained in the rest of the economy which would not longer battle with the exorbitant costs of an industry that offers almost nothing of value.

Thank you very much, and I look forward to your questions.

REP. ANDREWS: Well, thank you, Dr. Angell, very much.

I think that each of the four of you has validated our optimism that you'd contribute substantially to the debate. Thank you.

We're going to begin with the questions.

Seventy-five percent of health care costs in the United States are attributable to chronic disease. And about 80 percent of that 75 percent is attributable to four chronic conditions and diseases -- heart attacks and heart disease, cancer, diabetes and obesity-related problems and asthma.

What I'd like to ask the panelists to do is for the single-payer advocates, tell me how we would approach solving that problem under single payer.

And then Dr. Gratzer, for whichever system you would support, tell us how you think we could address these four very serious chronic disease problems. And I want to be sure Dr. Gratzer gets some time. So we'll ask one of the single-payer folks to go first and then Dr. Gratzer. I want to be sure we hear from him on this question.

Dr. Angell, Dr. Tsou, who would like to -- Ms. Jenkins -- whichever of you would like to start on that. Maybe a nurse will be the best person since you do primary care.

MS. JENKINS: I think inherent in the single-payer system is prevention, because if it's government-funded, privately administered, government has a vested interest in making sure you stay healthy and out of the system. It's more cost-effective to prevent disease than to wait until people are sick and try to treat it. So I think inherent in any single-payer system is a huge focus on prevention because it's much more cost-effective.

So I think that's a big plus for single payer. The whole focus in the single payer system tends to be way more preventative.

REP. ANDREWS: Okay.

Dr. Gratzer, we'll have you go second, then we'll go to our other two witnesses.

DR. GRATZER: Maybe I should go last.

REP. ANDREWS: No, you can go second.

DR. GRATZER: Mr. Chairman, you know, you hit the nail on the head. We are talking about rises of costs in American health care. As you know, CDA just came out with a report talking about what an extraordinary difference it would make to a middle-American family of four if we could just somewhat hold back on those costs between -- (inaudible).

REP. ANDREWS: So how do we do that?

DR. GRATZER: Pardon me?

REP. ANDREWS: How do we do it?

DR. GRATZER: You know, I think that that's a great question. To be totally --

REP. ANDREWS: That's why I asked it. (Laughs.)

DR. GRATZER: To be totally blunt, I'm not sure it has that much to do with health care system organization. I think that people who advocate single payer paint a magical picture that prevention is at the forefront, everyone gets to see a family doctor, hang out with a family doctor, pontificate on the importance of not smoking with their family doctor.

Look at Canada and Britain and Sweden, and you'll find actually less access to primary care, not more access. There are towns in Canada where if you win the town lottery, you don't get your mortgage --

REP. ANDREWS: Yeah, I understand that. But how do we do this? I mean, there is some evidence that shows that diabetics that get thorough and good nutrition counseling have better outcomes than those that don't. How do we provide that kind of preventive service if we don't do single payer?

DR. GRATZER: I think we need to move money more to the individuals, give them more control.

REP. ANDREWS: But how can we do that if the insurance companies are unwilling to do it?

DR. GRATZER: Well, I think we need to look at more consumer- driven plans. That doesn't necessarily mean just in private insurance. You know, in North Carolina, they have a plan now that if you smoke or you're obese, you pay more financial penalties. I think that's part of it. I think part of this falls to public health care. I think also part of it falls to the individual responsibility.

You know I don't do primary care. But when I do do primary care and I meet with a young smoker and I say, you know, tobacco is linked to cancer, never once -- never once -- did that kid look back at me and say, holy smokes, no one ever told me this before.

I think to simply say that we have problems in America due to obesity and diabetes and so on and that we're going to solve this with some sort of a government solution is a terrible mistake.

REP. ANDREWS: Dr. Tsou, what would your solution be?

DR. TSOU: Well, thank you for the opportunity to address a very important and complex issue. I mean, people have thought about this, the guy, Ed Wagner in Seattle, who has thought a lot about organizing care. A lot of it comes down to, frankly, as Geri had said before -- (inaudible) -- prevention.

There is something that's actually kind of missing in our health care system today, which I believe is a lot more community-based health care services. If I were king of the world, I would actually try to organize within neighborhoods, based on a database that was available to us where we know the prevalence of diabetes or high blood pressure or other major conditions are, we'd organize neighborhood classes where we would teach people about salt restrictions, improving your diet, how to take your medicines properly. And we would try to have individuals, like public health nurses, who would check in on people who have some difficulty with compliance.

REP. ANDREWS: Do you think single payer would facilitate that --

DR. TSOU: I think so because we would actually have enough money to pay for something like that.

REP. ANDREWS: I'm going to give Dr. Angell a chance to answer, and then we'll go to Mr. Kline.

DR. ANGELL: Well, first of all, I'm skeptical about your premise that 70 percent of health costs go to these chronic diseases.

REP. ANDREWS: Well, it would be 56 percent. It's 80 percent of 75 percent.

DR. ANGELL: Well, I know that at least 30 percent go to overhead, administrative costs and profits. So all the rest don't go to these chronic diseases. But still, to go to your point, we have, as I've said, a market-driven system that preferentially rewards specialists for doing highly paid tests and procedures. That's why we have more specialists than other countries, way too many specialists, and why we have too few primary care doctors.

A single payer system could take care of that. It could change the fee schedule or change the way doctors are paid so that we would have more primary care doctors who would do more to help people live with their chronic conditions if they have them or prevent them where that's possible.

So I think, here again, it's a matter of the market rewarding people for doing things, and that's exactly what they do, tests and procedures, curative procedures.

REP. ANDREWS: Thank you very much. We'll turn to the ranking member from Minnesota, Mr. Kline.

REP. KLINE: Thank you, Mr. Chairman.

And I want to thank all of the witnesses. It is indeed a distinguished panel with three medical doctors and a registered nurse. I'm always glad to see a registered nurse. My wife spent her adult life as a registered nurse. She retired, but I feel like we're still doing our part. I have a niece who's now a registered nurse in the field.

Dr. Gratzer, you are from Canada. I'm from Minnesota. I know something about minus-40 degrees as well. And I also know about movement across that border for medical treatment. Why do you think it is? Would you agree with me that there is travel from Canada to the United States for medical treatment?

Minnesota is also sort of a destination state for medical care with Rochester, Mayo Clinic. Why do you suppose it is that there is that travel from Canada to the United States?

DR. GRATZER: Because like under the old Soviet system, everything is free and nothing is readily available. Canadians wait for practically any diagnostic test or specialist consult or procedure. And some of them opt out of the system by crossing the border, so they do that at the Mayo Clinic, but not exclusively so. I mean, if you were in downtown Toronto today, you'd find an office for MDA (international ?), you'd find an office for the Cleveland Clinic. Medical tourism cuts across that border.

REP. KLINE: And so, we're sort of, the United States -- and I'm thinking of it in terms of Minnesota right now -- we're sort of a safety valve. If you can't get it, if the single payer system in Canada doesn't provide the service, you just cross the border and get help in Minnesota.

DR. GRATZER: If you can afford it, sure.

REP. KLINE: Then the question is, what would happen if we're now Canada, we have the Canadian system? Where do they go?

DR. GRATZER: Mr. Kline, your compassion for Canadians is outstanding. (Laughter.)

REP. KLINE: Well, when they come south for health care and medical care, sometimes they stop at the Mall of America, and we're always glad to have them for that as well.

DR. GRATZER: You know, it's not just that Canadians come because of a safety valve. People from all over the world come to the United States because there's medical excellence here. I think that as we move forward and have debates in the United States about how to reform the system, it's important not just to look at the bad but to remember the good and not to lose it. Mayo is an outstanding leader. If you're the king of Jordan and you have a health problem, you go there, too.

But yes, when Canadians need MRIs, Canada having one-third of the MRIs per capita of the United States, they cross the border. When Canadians need to see an internist, they cross the border, which is very often. When Canadians need quadruple bypass, they cross the borders.

REP. KLINE: So you've outlined a system that has some pretty serious shortcomings. And we do see that because of the border crossing. And yet, we've heard here today and other critics say that the American health care system scores low on measures such as life expectancy and others, and single payer systems do a whole lot better. Can you address that issue for me?

DR. GRATZER: I'd be delighted to, sir. When you try to do an international comparison, it's very complicated. I think all too often, we tend to be overly simplistic. We look at crude indicators. One example of that would be life expectancy.

Now, health care, obviously, has import on life expectancy or influence on life expectancy. But it also reflects a mosaic of other factors -- genetics, whether a person smokes, whether a person exercises, a person's diet. In fact, and it pains me to say this as a physician, probably one of the last important things is health care in that overall equation. One finds that Americans smoke too much, they drink too much and they eat too much, especially compared to their northern neighbor.

And America is an unusual place in other ways. Let me just give you one example. There are eight times more murders per capita in the United States than there are in France. If you were to take out accidental and intentional death from life expectancy statistics, you factored out murders, as one example, you factored out (MDAs ?), one would discover that Americans live longer than people in any other Western nation. So be careful about those crude statistics.

REP. KLINE: Okay, thank you very much.

We have several medical doctors on the panel here, who I know are looking forward to their chance to ask questions. So I yield back, Mr. Chairman.

REP. ANDREWS: Thank you, Mr. Kline.

The gentleman from Oregon, Mr. Wu, is recognized for five minutes.

REP. DAVID WU (D-OR): Thank you very much, Mr. Chairman. I just have a couple of questions.

Some of the studies that I've read indicate that technologic drive is a significant contributor to cost increases. And also, the increase in administrative costs, including -- that technologic drive is perhaps 50 percent of cost increases, and the majority of the other 50 percent may be administrative costs, including marketing expenses.

And I'd just like the different witnesses on the panel to address how you all think that a single-payer plan would handle those two different types of expenses technologic drive versus administrative costs, and including marketing costs.

And, Dr. Angell, shall we begin with you.

DR. ANGELL: Yes, if you start with the administrative costs, there is no question that a single-payer system would have much lower administrative costs. As I mentioned, the administrative costs of the biggest insurers average, roughly, 20 percent -- that's administrative costs, marketing (profits ?), compared with 3 percent in Medicare. So, there is no question that we would realize great savings in administrative costs.

If you look at the use of technology, it's not the technology itself. All advanced countries have the same technologies. We have no secrets here. It's how we use the technology. We use them much more widely, because it's profitable to do so.

Many of the technological tests and procedures are done in free- standing imaging centers, laboratories, outpatient centers, and they are paid handsomely for using them. So, it's a matter of generating income, not targeting medical need.

In this country, if you are well insured, if you can afford it, you may get an MRI you don't need. You may get many MRIs you don't need, because it's profitable for someone to do that. But, if you aren't well insured, you may go without an MRI you really do need.

So, it's the mismatch between the technology and the need for that technology that is so bad in this country.

MR. GRATZER: An excellent question. You know, I'm not as technologically phobic as perhaps some of my panel -- co-panelists are. Let me just give you one example.

Death by cardiovascular disease has fallen by two-thirds in the United States in the last 60 years. Part of that is because drugs like beta-blockers have changed cardiac care, but part of it is because of high-tense -- high expense medical interventions, like CABGs.

I mean, to put thing in perspective, the revolution that's occurred in health care: Robert E. Lee on the battlefield, 1864, had a heart attack, and state-of-the-art cardiac care at the time was two weeks of bed rest. Nearly a century later, when -- about 90 years later, when President Eisenhower had a heart attack, state-of-the-art cardiac care at the time was six weeks of bed rest. Today, of course, we do a hell of a lot more for you than bed rest. So, we have (seen more ?) for technology. Let's not forget the incredible advantages that have come with it.

But, I think we would all agree we're not getting value for dollar, that too many tests are ordered, and that there's a quality difference amongst the tests, amongst different providers. The question is ultimately what are we going to do about that?

The administration says we ought to set up a committee, and they ought to help guide doctors in determining who needs tests, and when, and when to pay for it. I'm skeptical of that, but I'm open to that argument.

But, I think, ultimately, we'll address this by moving away from people paying 13 cents on every consumer dollar spent on health care; having people more involved in their decisions.

I also think, though, that we need government to provide us with more transparency and more accountability and more information, and that's the way to move away from the high-expense, not necessarily high-quality care that we have.

REP. : Thank you.

Dr. Tsou.

DR. TSOU: I think it's ridiculous to think that Mrs. Jones down the street can evaluate technology on something as complicated as we have in medicine today.

The truth is is that we have to -- have a responsibility, in government, to actually do comparative effectiveness and figure out which things work and which things don't. And if we don't know which technologies are effective, we should do clinical trials that determine that.

And that's one of the potential advantages, I think, that single- payer has. You create a large database that allows you to look at health outcomes, and you can see which ones actually work and which ones don't. So, I think, actually, single-payer helps advance the decisionmaking around whether technology is advantageous or not.

REP. : Well, my time has expired.

Ms. Jenkins, would you care to comment also.

MS. JENKINS: Well, I'm not an MD. I don't have all the statistics off the top of my head.

But, anecdotally, I know that what Dr. Tsou said is very true. I think we need best practices and evidence-based practice. And I've been a nurse for long enough to see things done routinely just because that's what we've always done; and new innovations that are more cost- effective overlooked because of habit. So, I think he's right.

And I think he's right when he says that when you have a single- payer system you have one uniform system to evaluate, to look at. If you see deficiencies in access in one area, you have one system and you can fix it. When you have 13 hundred different health care providers, with 13 hundred different systems, you run into a problem.

So, I would reiterate what Dr. Tsou said, it's going to be much easier with a single-payer system to track efficiencies in the system, and what works and what doesn't.

REP. ANDREWS: The gentleman's time has expired.

REP. : Thank you --

REP. ANDREWS: The bell that you just heard go off -- there's a series of floor votes. There are three of them. So, the members are going to have to leave to go vote on the floor.

Here's how we're going to proceed: We're going to go to Dr. Price's questions; we're then going to adjourn the hearing temporarily. After the three floor votes are over -- which I would estimate would be in the 12:20 to 12:30 range, we will return and proceed with the members' questions.

So, Dr. Price is recognized for five minutes.

REP. PRICE: Thank you, Mr. Chairman. I appreciate you holding this hearing, and appreciate the testimony of all. I ask unanimous consent that an article entitled, "Medicare, Not the Model for Reform," be included in the record.

REP. ANDREWS: Without objection.

REP. PRICE: I want to thank the Chairman Conyers as well for coming. I was struck by one of his comments, and commend him for his commitment to health care reform.

I'm a strong advocate, as a physician, for appropriate health system reform -- what I call "patient-centered" reform. I would suggest candidly that a single-payer system is not patient-centered, by its very definition. It's government-centered, and that -- and that's the real concern that I have.

The comment that you made -- and I think it was enlightening, the chairman said, we need to determine whether, quote, "we want a combination of our current system or we want something else," unquote. And the question is, who is the "we?" And I would suggest that if the "we" is us, here in Congress, or within the bureaucratic nature of the federal government, then we've got the wrong "we."

The "we" that we need are the patients, the American people. Unless we concentrate on patients, we will not get to the right answer, and I believe that real reform comes when we empower patients.

I've been struck by the testimony about how awful American health care is -- just struck by it. The statistics don't bear that out at all.

In fact, Dr. Tsou, one of your quotes was, "By and large, the quality of care is suboptimal," unquote. Astounding. I think the American people will be astounded to know that the care that they're receiving is "suboptimal." In fact, if you look at disease-specific criteria, what you find is that the care that's provided in America -- all across all demographic quadrants of our society, is second almost to none -- almost to none.

We have principles that we ought to adhere to in the area of health care. Everybody has the top three -- access, affordability and quality. I add three to that: responsiveness, innovation and choice. I would suggest to everyone who's listening that none of the principles of your health care, that you provide, are improved by the intervention of the federal government. None.

Not access -- access is being limited in the programs that are run by the federal government; not affordability -- all of the cost overruns that occur in all of the four systems that are run by the federal government, Medicare, Medicaid, Indian Health Service, the veterans' health care; certainly not quality -- when you see the limitation of care that's, that is, that is imposed by the federal government.

"Responsiveness and innovation," in the same sentence as the "federal government," is rarely used, and rightly so. And then choices -- choices are always limited by governmental intervention.

And to the end of the costs -- which I think is incredibly important to address, Dr. Gratzer, would you comment on what is included in our estimation of health care costs that may not be included in another estimation -- other nations' estimations of their health care costs?

MR. GRATZER: (Off mike.) Well, we -- well, let me -- Dr. Price, I fully agree with your comments.

With regard to, 'what does American medicine do that one wouldn't find so much elsewhere in the world,' well, research and development would be a great example of that. There's more spent in one facility in the United States -- M.D. Anderson, on research and development than there is in the entire country of Canada.

America is a leader in medical technology development and implementation. When people talk about a new drug coming to market, it's almost surely an American drug. When people talk about innovations going on in the United States, as you know, "Health Affairs" rated the top 10 greatest innovations of the 20th century, seven of them were invented within these borders. More Nobel Prizes for medicine go to Americans than nationals of any other country, in fact, combined. This is a country that excels in medicine. We shouldn't forget that as we look at reform.

REP. PRICE: My understanding is that much of the long-term care -- the nursing home care, and the like, is included in our costs for health care in the determination of what we spend on health care, and that's not the case in other nations. Do you know that to be true?

MR. GRATZER: I'm not an expert on such comparisons. I know, for sure, capital costs are not accounted for the same way. You know, Canadians spend less money per capita, okay, but I would suggest it's not quite the huge gap that American experts might put forward.

REP. PRICE: Right.

Mr. Chairman, I would suggest that a right to health care, in other nations that have a single-payer system, is a right to get in line. And that that's the concern that so many of us have, that the last thing we want is just to simply pass something here in Washington that gives -- that is under the guise of giving people the right to health care, we give them a right to get in line for a lesser quality of care that is current being provided.

There is positive reform that's on the table. I would suggest that we ought to look at that as well, as a committee.

And I thank the Chairman.

REP. ANDREWS: The gentleman's time is expired.

At this time, the committee will temporarily adjourn. If you turn around, you can see the floor voting schedule. There will be three votes. We will come back as soon as we've cast our third votes and resume the hearing at that time.

(Gavel sounds.) Thank you.

(Recess.)

REP. ANDREWS: (Sounds gavel.) All right. Ladies and gentlemen, we appreciate your patience and your indulgence. We're going to resume the hearing. The gentleman from Illinois, Mr. Hare, is recognized for five minutes.

REP. PHIL HARE (D-IL): Thank you Mr. Chairman. And thank you for holding this hearing which I consider to be extremely important. I am amazed at some of the things that I've heard, and Dr. Gratzer let me just say a couple things. It's my understanding that when the Canadian people were polled, 97 percent of the people in Canada said that they wouldn't trade their health care plan for the United States' plan on a bet. So if it's in crisis, about only 3 percent of your Canadian friends I think would be in agreement with you.

We've heard a lot about lines, lines for health care, having to wait for health care. Here we don't have lines, we just get rejected. I've had constituents who have had C-sections and go into with their insurance company and go in for procedures later and told that they can't -- they're denied because of pre-existing conditions. Here we don't have lines, we have people if they lose their job because of no fault of their own, that leave and don't have portable health care -- and had a 31-year-old man who worked part time jobs, temporary jobs to try to get health care coverage and they found him dead in the shower of a heart attack.

And his father and mother who were very hard working people said that when the press asked them -- they said are you mad that God took your son, and he said God did not take my son, He made a special place for my son to go. He said this government took my son because it didn't have the courage to pass health care that would cover my son when he lost his job.

And I think when you take a look at where we're at today, if Mr. -- (inaudible) -- or whatever says it's in crisis, I would like him to come and take a look at this system. You have CEOs of Aetna Insurance company making $200,000 a day. You have insurance companies giving people a letter in one hand that approves the surgery, the person goes in, has the surgery and then they get a denial paper after they get home from the hospital from the same wonderful benevolent insurance company.

Now I'm a card-carrying capitalist here but I believe in the single payer system. If this system isn't broken, then I don't know what the definition of broken is. And I will tell you I'm a fundamental believer that health care, I think was mentioned before by the chairman, is not a right -- it is a right, it is not a privilege in this nation, that everybody ought to have it. We don't pay doctors -- I went to hospitals in my district, 243 days late in paying health care providers; pharmacists not getting reimbursed because -- and have gone out of business.

So while we may not have the lines, what we have is, we have -- and all these statistics that are mentioned here today, these are real people with real problems. And I lay this at the foot of greedy insurance companies who care more about the bottom line of making profits than they do about keeping people well.

This whole question about the wellness situation is to blame people -- yeah, we have to take part of this responsibility, but that's like saying if your next door neighbor's house catches on fire because he was smoking, we should do nothing about it because it was his fault he was smoking. So we're not going to go put the fire out, we're just going to watch it burn. And I will tell you to that man who works today repairing gasoline motors for lawnmowers at $8 an hour -- and by the way when his wife came in and saw her son dead on the gurney in the hospital, she had a heart attack and he ended up with $200,000 worth of bills. And he had to borrow $8,000 to bury his own son. And I will tell you that is not what this country is about.

And I -- you know, some people say why are we having this hearing. We have to have this hearing. The vast majority of the American people wonder if we're ever going to get it, they support this system. So here we are once again debating whether or not this is doable or not doable or who's got the best system. I know one thing. In my district when I did town hall meetings -- and by the way, I've got counties that carried not for George McGovern but for George Wallace, so this is not liberal land that I come from. And everyone of the six town hall meetings that I've had, the vast majority of people there supported single payer health care. And I didn't even ask them, they brought it to my attention.

So we've got to fix this system. And, you know, we've heard about the Medicare system the government can't do anything right. Ask a veteran if they would be willing to give up their VA health care. And the government can't do anything right, ask a senior citizen if they want to stop receiving a Social Security check. Ask somebody on Medicare since we can't ever do anything right if they don't like the Medicare system.

I'm not saying that they're perfect but what I'm saying is is that we have an opportunity here to change the way we do business. And quite frankly if you don't have a public option, who is going to go in competition with the insurance companies? They're competing against themselves, they're not even covered under federal anti-trust legislation.

So we need to get real here, from my perspective, and all these statistics that we hear and the lines and people flooding into Minnesota and other states to get health care. I don't know about the floods -- I'm from Illinois, I know about floods on the river -- but I do know this. We have a flood of people every single day that go to bed and worry to death that their children or thierselves (sic) are not going to get sick or if they lose their jobs they don't have portability of health care. And we have to fix that. This bill will do it.

And if I sound a little bit agitated today, it's because -- and I just have one quick question for you Dr. Tsou. If -- from your perspective why --

(Cross talk.)

REP. ANDREWS: -- to the gentleman, the gentleman's time has expired. I mean --

(Cross talk)

REP. ANDREWS: -- ask it and he'll quickly answer it but I do want to get to the other ones.

REP. HARE: That's fine. Sorry.

REP. ANDREWS: I note that the chairman of the full committee, Mr. Miller, is here. I do want to obviously welcome him, thank him for his leadership and see if he'd like to add any remarks at this time.

REP. GEORGE MILLER (D-CA): Thank you Mr. Chairman. Just quickly, I wanted to ask Ms. Jenkins a question because it just, we seem to rerun this argument all the time about how you're rationing medicine and who's available and who's standing in line, who isn't between Canadians and Americans and what have you.

What I'm witnessing in my Congressional district at this time I think in my district if you have insurance about -- I think it's something close to three out of four people probably have Kaiser because of the history of the programs started in the Bay area and that.

But what I now see in the public institutions is they're absolutely being flooded by individuals who have serious medical problems but no longer have insurance because they've lost their jobs. And so if I go to my regional medical center, if I go to the community clinics, we now see this huge inflow of people who bring no resources to this medical necessity that they have, scheduling times have become far more difficult than in the past. I don't know -- I'm not familiar with what's happening in -- you know, in the private sector in the hospitals but certainly what we now see in the public facilities in the Bay area is that obviously your medical condition doesn't know whether you're employed or unemployed, you need help or your children do or your spouse does, whatever your situation is with your family.

And I just -- I mean, so this standing in line and postponement of appointments and delay times and wait times and all the rest of it, it's happening in the current system because of the structure of this system. Is that your understanding -- and correct me if I'm wrong but just as I've traveled around and visited the facilities, it's just stunning what's happened --

MS. JENKINS: Well, I work in a public facility in the University of California and, you know, public facilities are under assault. The public health care system in this country's been under assault for a long time and I think it was kind of pointed out with the swine flu concerns that we haven't funded public facilities anywhere in this country very well and they've been constantly underfunded.

REP. MILLER: I understand that. But I'm just talking about people who now find themselves in situations they need --

(Cross talk.)

REP. MILLER: -- and in some cases immediate and medical attention they have no --

MS. JENKINS: They come through the emergency room which is the most costly way to access the health care system. So we're spending way more money to deal with those crises than we would have to with a single payer system because the most expensive, most costly way to access the system is through the emergency room and people have to be seen in an ER. So as we see this unemployment crisis and people losing their employee based health care, you can see a huge flood of people going to be accessing the most expensive way into the system which is going to be through an emergency room.

REP. MILLER: When people come from Canada to receive some medical care here, are they doing that on their own hook or are they doing that with the government or --

MS. JENKINS: Well it seems that people do come from Canada for care but a lot of those people are sent by the Canadian government to get care here that they can't get or there's an access problem and the Canadian government also sends a checkbook with them because they pay for it. If there's medical necessity that's urgent and the access is not available in Canada, they do send people to this country for care. But they pay for it. So it's not like these people are here because they don't have any other recourse, the Canadian government looks at it and if they have a situation that they deem is -- needs critical care that they can't get there, they'll send them here and they'll also pay for their care. So it's not like they're --

REP. MILLER: Well we send people to UC San Francisco --

MS. JENKINS: Yeah.

REP. MILLER: -- but we usually send them -- you know, in most instances we send them with whatever insurance they have or what have you or we send them to Stanford.

MS. JENKINS: Right.

REP. MILLER: I mean that's the normal business practice.

MS. JENKINS: Right.

REP. MILLER: I assume that's not interrupted because of the national boundaries in this case. We are not adversaries --

MS. JENKINS: No.

REP. MILLER: -- although we blame in on Canada but we're not adversaries.

MS. JENKINS: Right. You know, I think that's a misconception.

REP. MILLER: Thank you. Thank you Mr. Chairman.

REP. ANDREWS: Thank you Mr. Chairman. Obviously, as minority members return, they'll be welcome to have their question time. The gentleman from Ohio, Mr. Kucinich, who I think has been among the most fierce and articulate advocates of single payer is recognized for five minutes.

REP. DENNIS KUCINICH (D-OH): Gentle not fierce. (Laughter.)

There's been a lot of talk here Mr. Chairman about rationing and, you know, during war people have rations. Imagine during war time if one of out six Americans who were getting rations during a critical period in the war, imagine if one out of six weren't able to get rations, imagine if they just starved. Well, you have one out of six Americans starving for health care; 50 million Americans can't get any health care at all.

Now, Dr. Gratzer, you've tried to make the case for rationing in Canada -- it's worse than it is in the U.S.

Do you know what statistics Canada -- the analog to the U.S. census -- says the median wait time is across Canada for elective surgery?

DR. GRATZER: Why don't you inform us, sir?

REP. KUCINICH: It's four weeks. And what do the statistics Canada say the median wait time for diagnostic imaging like MRI's is?

DR. GRATZER: I can tell you the interior government recently looked at that. For cancers --

REP. KUCINICH: It's three weeks.

DR. GRATZER: -- it was six months.

REP. KUCINICH: It's three weeks. How many uninsured are there in Canada?

DR. GRATZER: Probably relatively few.

REP. KUCINICH: That's right -- none or very few. How many medical bankruptcies are they are in Canada?

DR. GRATZER: It depends how you define a medical bankruptcy.

REP. KUCINICH: None or very few.

How many insured Americans go without needed care due to high costs of health care, which is due to health insurance companies?

DR. GRATZER: Am I allowed to answer or are we just going to continue to --

REP. KUCINICH: Well, if you have an answer, you can answer. But if don't, I'll answer. What's your answer?

DR. GRATZER: Go for it, sir.

REP. KUCINICH: What's your answer?

DR. GRATZER: Why don't you answer your question, sir?

REP. KUCINICH: What's your answer?

DR. GRATZER: My answer --

REP. KUCINICH: How many uninsured -- how many insured Americans go without needed care due to the high cost of health care, which is due to health insurance companies?

The witness isn't responding.

DR. GRATZER: The witness is delighted to speak further on those statistic and other statistics, but you keep cutting me off, sir.

REP. KUCINICH: You respond if you have an answer. You didn't give an answer.

DR. GRATZER: I don't want to be led down a garden path. If you'd like to ask me a question, I'd be delighted to answer it.

REP. KUCINICH: You know, you've showed a garden here to members of this committee and to the audience. There's another side of the picture you don't seem to be aware of, even though you want to be an expert on Canada.

Can you provide us with an answer on this one about America?

DR. GRATZER: But my position is respectful and I dislike your comment, sir.

REP. KUCINICH: You haven't answered. How many insured Americans -- insured -- go without needed care due to high costs of health care, which is due to health insurance companies?

He has no answer. Well, what the answer is, is it's one out of every four.

So we're trying to make a case here that somehow Canada is in a mess, but we're not focusing on the fact that in the United States there are people not getting needed care. And this gentleman has expected us to believe that rationing is worse in Canada. I don't know how we can buy that.

Now, if single-payer is so bad, maybe the gentleman -- the doctor -- can explain to us why 60 percent of U.S. doctors want it, according to the peer-reviewed annals of internal medicine, April 2008.

REP. ANDREWS: Are you going to let him answer this one?

REP. KUCINICH: He can answer it -- if he can answer it.

DR. GRATZER: I would suggest that many physicians in the United States aren't satisfied with the system and rightly so. I would suggest that many physicians are looking for reform, and rightly so.

But I would suggest that many physicians are unaware of what really goes on in single-payer systems, perhaps illustrated well by some of the comments you've already made. It's easy for an American audience to look north.

But I would ask you, then, what do you make of studies like the O'Neill paper, published by the National Bureau of Economic Research, that showed that American's have better access in terms of chronic care management, that cancer outcomes are better south of the 49th parallel, that low-income baby mortality rates are lower in the United States?

I would not suggest here for a moment that the United States is a perfect system. Goodness! I have written an entire book on the problems south of the 49th parallel. But I would suggest to you that looking to a government-ration system and a government-managed system -- because inevitably, those two things are the same -- would be a mistake for members of Congress.

Thank you.

REP. KUCINICH: And I'm glad that we have other witnesses here.

Ms. Jenkins, the California nurses found that a single-payer system would act as an economic stimulus, not only by eliminating the under insurance problem, but also by several other means -- including the creation of 2.6 million new jobs.

Could you please describe how you think a single-payer health insurance system would act as a stimulus?

MS. JENKINS: Well, we would be insuring another 47 million people so there would be an economic stimulus there in creation of jobs. We did an econometric study where you look at the ripple effect of what's been in health care and how it translates into other areas of the economy -- the wages that workers make and how they spend them, how they stimulates the economy.

And we not only found that a single-payer system would create a net gain of 2.6 million jobs, it would increase business and public revenues by 317 billion (dollars). And additional employee compensation with those new jobs would be another 100 billion (dollars), which would generate 44 billion (dollars) in more tax revenues. And these people would go out and spend that money in the economy so there's a huge economic stimulus, besides the obvious ethical and moral issue of actually providing care for everyone in this country.

REP. KUCINICH: Thank you very much.

REP. ANDREWS: The gentleman's time has expired. Thank you.

The chair recognizes the gentlelady from New York, Ms. McCarthy for five minutes.

REP. CAROLYN MCCARTHY (D-NY): Thank you, Mr. Chairman. And I appreciate you having this hearing.

Ms. Jenkins, probably I'm going to put my questions mainly towards you.

Before I came to Congress, I was a nurse for over 32 years and so a lot of things that we've been able to do on this committee -- especially on the higher education bill that we got passed -- was basically trying to help nurses, get more nurses into the system. We have plenty of people that want to be nurses. Unfortunately, we don't have faculties that want to hire professors to be able to teach nursing.

The good news is nurses are actually getting good pay now. Going back in the '60s, we certainly got terrible pay.

But the manner in which way we go -- and you know, I do believe that we have a good health care system. Our problem is, we have too many people that are not receiving health care. That's what we're trying to fix and I think that's important for everybody to know that. But we're not going to be able to do that unless we have enough primary care doctors out there and we need a whole ton of nurses out there, because we also have to look to the future.

We're not preparing ourselves at all when the baby boomers when -- they're not going to go to a nursing home. I can tell you that right now. They're going to basically want to have care in their house. They want to stay in their home, as the majority of patients do.

So whatever we do -- whether it's single payer, whether it's going to be a public -- however, we come up with something, nursing and physicians have to be a part of that. And hopefully, the physicians will actually get paid a better price.

You know, I have Blue Cross Blue Shield. I go and I have my tests done. I see what the doctors get. It's nowhere near what it should be getting. I think it's embarrassing the pay that we actually give them.

You've worked many nights. You're the one that calls the doctor at 2:00 or 3:00 in the morning as I did. People kind of forget that. They all think they just kind of like roll in and take care of people.

So what do you think that we need to do even more so to make sure that we have more nurses coming into the system?

MS. JENKINS: Well, we do have to fund nursing education to create more slots for people. There are huge waiting lists. Well, I know in California all the nursing program have huge waiting lists waiting for slots to fill. So I think there has to be an education investment here to train nurses. Senator Boxer's put forth a bill that will invest in nursing education.

And I think we also have to look at the working conditions nurses work under. Nurses have one of the highest incidents of muscular- skeletal injuries of any work group, because of the kind of work they do. So part of her bill would be safe patient handling. We need to create safe work environments for patients as well as nurses. It's very frustrating as a nurse to go home and worry about what you missed, because you just didn't have the time to give the care you need. So we do have to make an investment in creating staffing standards, better working conditions.

Most of us didn't go into nursing to make a million bucks. We went into nursing to take care of people. And I think it's important to understand as nurses we take very seriously our role as being the advocate for the patient. We're kind of the last line of defense for the patient at the bedside. So we need to make those working conditions better for nurses and we need to invest in nursing education, actually, as you say.

REP. MCCARTHY: Well, hopefully we're going to be doing that.

The one more thing that I would say is, unfortunately, across the country we have seen a high incidence of infections in our hospitals, which cause sometimes death to an awful lot of patients.

I happen to believe very strongly if we had more nurses and a better nursing ratio on the floors that we would not see the kind of infections that are out there -- mainly because they would have the time to actually do the work that they need to do.

We used to have -- back in the '60s we might have had one in 10 -- you know, one nurse to every 10 patients. But I have to say, about four of them would be self-care and the others would be a lot more care being given. We didn't have the infections then. We've basically fairly well staffed.

But when nurses were starting to be called in on mandatory overtime, they left the profession. My sister left the profession, unfortunately.

MS. JENKINS: We absolutely do. And I think you're right. There's been a huge speed up in the delivery of care in hospitals. And a lot of it is driven by this profit that let's save some money; let's cut some staff. And so I think that drives some of that. And that does lead to an incidence of increased in infections in hospitals.

There's other factors too, but I think that's a big one. You have to have the time to provide safe care, which means you have to have some kind of realistic staffing ratios for patients to nurses in hospitals.

REP. MCCARTHY: Well, I agree with that. And I hope that, you know, through this committee -- because that's where we're going to be working on -- I'll be working on the issue as we, on this committee, debate what else we're going to do for health care. So I thank you.

REP. ANDREWS: We thank the gentlelady for her contributions. She very -- it's not just because you're here today she talks about nursing. Throughout our deliberations on higher education and health, she's a very valuable member for that reason.

The gentleman from New Jersey, Mr. Holt, is recognized for five minutes.

REP. RUSH HOLT (D-NJ): Thank you, Mr. Chairman.

I thank the witnesses for coming.

Let me begin with Dr. Angell. You've outlined a number of advantages of a single-payer system.

I was impressed by an article that I read earlier this year by Dr. Atul Gawande in The New Yorker where he looked at other countries and how they got to their universal coverage. For example, Britain created the National Health Service based on the wartime health system, and France created a system based on a pre-war independent local insurance program.

Single-payer systems have some advantages. Have you thought about how we could get to that, if you see that as the ideal, from --

DR. ANGELL: Yes, I --

REP. HOLT: -- our fragmented system of today?

DR. ANGELL: Yes, I have. And, in fact, I was on the writing committee that published an article in the Journal of the American Medical Association, August 13th, 2003, that goes through how we would convert, in considerable detail.

There's no time to do that here, obviously, but I would --

REP. HOLT: Could I ask that you provide that to the committee --

DR. ANGELL: Yes, yes.

REP. HOLT: -- and that it be made part of the record?

REP. ANDREWS: Without objection.

DR. ANGELL: While I have the floor here, I wonder whether it would be possible for me to comment on three issues that were raised earlier, and maybe the fourth issue, the nursing situation, if I might.

REP. HOLT: Yes, you may. You may use my time for that.

DR. ANGELL: The nursing problem, the staffing problem in general, is something that can only be handled in a single-payer system, because then you would have the ability to coordinate and distribute resources and make manpower decisions that you can't do in a fragmented system or non-system. We really don't have a system; it's a non-system. So you need some kind of a system to make these kinds of decisions. That's another reason for doing it. And that would include manpower decisions, or womanpower decisions.

The other comment I'd like to make -- earlier it was suggested that somehow a government-administered system would be less responsive to patients' needs and desires. I'd like to explore that by comparing Medicare, our Medicare, which is a government-administered, publicly financed system, with our employment-based private system that relies on investor-owned insurance companies.

Medicare insures almost everyone over the age of 65, whether they have pre-existing conditions or not -- all of them. And it ensures them for the full benefit package. It can't tailor that package according to whether somebody actually needs care or not. And recipients of Medicare have free choice of doctors, completely free choice.

Compare that with the insurance system, the private insurance system, where you may not get insurance if you have a pre-existing condition. If you do get the insurance, you may have certain things covered but other things not covered.

REP. HOLT: If I may jump in here, I have a close -- in fact, the closest possible relationship with the medical profession. (Laughs.)

REP. : He's married to a physician. That's what he means.

DR. ANGELL: (Laughs.) Okay.

REP. HOLT: And --

DR. ANGELL: It's not like your doctor were a physician.

REP. HOLT: And indeed, if most doctors had to choose between Medicare's rules and restrictions and that of any number of private insurance companies --

DR. ANGELL: Absolutely.

REP. HOLT: -- it would be hands-down.

DR. ANGELL: And those patients too. And it's the most popular part of our health care system. Something was said earlier about cancer outcomes being better in this country than in some other countries. Cancer is a disease of older people, and I suspect what we're seeing is the success of the Medicare part of our system and not the private employment-based part.

So I think the notion that somehow a government-administered system is less responsive to patients is quite the opposite of the case in this country.

Second, the flight from Canada -- first of all, I'm not aware of droves of people coming. But we have now about 50 million Americans --

REP. ANDREWS: I should warn you, Doctor, that our time is running out, so please --

DR. ANGELL: We have about -- I'll be fast -- 50 million Americans with no insurance at all. They would love to go to Canada for health care if they could afford it. That would be droves going the other direction. If the king of Jordan can come here and get health care, that's a sad commentary on both of our countries that he can't get health care in his country that's adequate, and that he can jump the queue and 50 million people here don't have health insurance, but he can buy his way in.

REP. ANDREWS: The gentleman's time has expired.

I want to add a word of appreciation and thanks to the witnesses, and also make a request of them. The appreciation is obvious. You've prepared thoroughly for this morning. You've endured the delay in the middle of the hearing, for which I apologize that we had the floor votes. And we very much appreciate this very substantive contribution that you've made.

The committee and the Congress are at the onset of our deliberations on passing a bill that we hope will address the problems that you very articulately have identified today. And I summarize them. I think it includes the fact that we pay too much and get too little, the fact that there's too much interference with the relationship between a patient and a provider, and the fact that the problems seem to be escalating rather than being resolved.

I would ask for each of the four witnesses to continue to have dialogue with the committee as the process goes forward. I invite you to do that. We're accessible; certainly all the different modes of communication. And we'd very much like to hear from each one of you.

I do want to ask if the substitute ranking member has any comments before we conclude.

REP. : Thank you, Mr. Chairman.

And I just want to echo my appreciation, our appreciation, for the witnesses, and especially for Chairman Conyers, who has labored long in an effort to try to reform the system.

I think a couple of points I would like to make. One is that those of us on our side of the aisle do not believe that the status quo is acceptable. Reform is absolutely imperative for all of the reasons that all of us have grave concerns about the situation that we find ourselves in, whether it's on the provider side, as physicians and hospitals and nurses and others who are working as diligently as possible to care for patients, or whether it's on the patients' side, where they are having difficulty gaining access.

I would respectfully suggest that an honest and sober reflection of what has gone on before in other systems would be appropriate, and in our system. If one is a new Medicare patient in this nation, access to care is markedly limited because it's difficult to find a physician who is taking new Medicare patients.

The Mayo Clinic has limited the number of Medicare patients that it's taking in Jacksonville. That's a frightening, frightening statement about an indictment of our current system. The limitation of care under Medicare system I know very well and first-hand, as a physician practicing under that system. And Medicare limits the ability of physicians to care for patients in a remarkable number of ways.

So I would join the chairman in hoping that we would have a thoughtful, sober, reflective, honest debate and discussion. And if we do that, I have great faith that we'll come up with a system that will reflect the ideals of Americans.

REP. ANDREWS: I thank the gentleman.

And I would just conclude with this comment. An American president stood up and said that the country needed a law to be sure that every person had access to quality health care and health insurance. And he said that if we did not take steps to achieve that objective, that the economy of the country would suffer greatly, and more importantly, individuals and families would suffer greatly.

That president was Harry Truman, and his words were repeated by various other presidents since then. In 1971, Richard Nixon proposed a system of universal health care through an employer mandate. I see Chairman Conyers shaking his head. He remembers that. I was in high school then, Chairman, but I do remember the proposal. (Laughs.) Obviously there have been attempts, most recently in 1994, and in other iterations since then.

There is one common thread I hope is running through members of both parties and through both houses. I know it exists in the White House. This time there is going to be a law, not a discussion. And we're going to do our very best to make sure it's a law that works and obviously that can pass.

I think that today's discussions have been very fruitful and constructive in helping us get to that point. As I said, Chairman, to you at the outset, we hope that this is the beginning of our interaction with you, not the end.

And with that, I'd like to thank the members. And without objection, members will have 14 days to submit additional materials or questions for the hearing record.

Without objection, the hearing is adjourned.

END.


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