Panel II Of A Hearing Of The Health Subcommittee Of The House Energy And Commerce Committee - Comprehensive Health Reform

Statement

Chaired By: Rep. Frank Pallone (D-NJ)

Witnesses: Marian Wright Edelman, President, Children's Defense Fund; Jennie Chin Hansen, President, Aarp; David Shern, President And Chief Executive Officer, Mental Health America; Erik Novak, M.D., Orthopedic Surgeon, Patients United Now; Shona Robertson-Holmes, Patient At Mayo Clinic; Jeffrey Levi, Executive Director, Trust For America's Health; Brian Smedley, Vice President And Director, Health Policy Institute, Joint Center For Political And Economic Studies; Mark Kestner, M.D., Chief Medical Officer, Alegent Health

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REP. PALONE: I ask that if -- we're going to get right to it, so if the second panel would be seated, I'd appreciate it. If you could take your seats. Are we missing, are we missing Dr. Shern? Outside. I think we'll start at least with the introductions.

Is that Dr. Shern? (Laughs.) Great, thank you.

Let me introduce the panel. Again, this is the panel on consumers' views. And from my left is Dr. -- well, I shouldn't say doctor, you may, in fact, be a doctor, but you're, she's certainly well-known -- (laughs) -- in any case -- Marian Wright Edelman, who is president of the Children's Defense Fund. Thank you for being here.

Next is Jennie Chin Hansen, who is president of AARP. And then we have Dr. David L. Shern, who is president and chief executive officer of Mental Health America. Dr. Erik Novak, who is an orthopedic surgeon with Patients United Now. And finally, Shona Robertson-Holmes, who is a patient at the Mayo Clinic -- I assume in Rochester, right?

MS. HOLMES: (Off mike.) -- (inaudible) -- Arizona.

REP. PALONE: Arizona, okay.

Again, you know, we have five-minute statements. Your full statement would be submitted for the record, and whatever else you would like to put forward, and then we'll have questions after. And we will get written questions after -- you know, in the next few days, to be submitted to you in writing.

And I'll start with Ms. Wright Edelman. Thank you for being here. You've been here so many times.

MS. EDELMAN: (Off mike.) Thank you so much for the opportunity to testify -- (inaudible) --

REP. PALONE: Is the green light on?

MS. EDELMAN: No, now it's on.

REP. PALONE: There you go.

MS. EDELMAN: Thank you for the opportunity to testimony on behalf of the nine million uninsured children, and the millions more underinsured children which we have a chance to correct this year. And we've said many good things about your proposal. They're in the written testimony.

I want to just limit myself to my hope for true health reform for all children and pregnant mothers within any health insurance plan. So, whatever you adopt, within the -- as a health insurance plan for all Americans, I want to just make sure that all children, all pregnant women are treated equitably and get affordable, comprehensive coverage.

And what a great opportunity that this is. I'm so pleased, and thank you for the CHIP bill that you enacted and the president signed, and that was a significant step. We now have a chance to finish the job. That was not true health care reform for all children and it's not the child health plan the president promised. But, here we can do it now.

The need for health care reform that expands coverage for all children; cure benefit inequities between CHIP and Medicaid children; and establish a national floor of eligibility of 300 percent; to end the lottery of geography across 50 states; and simplify enrollment and retention, particularly in Medicaid and CHIP -- are the key things that I would hope that you will address in your final health proposal.

In these particularly devastating economic times when the number of poor children could rise by a million-and-a-half to two million more, the need for a guaranteed, strong health care safety net to ensure their continuous access to coverage, and every opportunity for a healthy start in life, is absolutely urgent.

I want to just address these four points for a brief moment each: One is, I hope you will ensure that health coverage is affordable for all children and pregnant women, and with a floor of 300 percent of the federal poverty level -- which is about $6,000 for a family of four. Just as all children in the United States are entitled to a free public education, all children should be entitled to affordable health care.

The high number of uninsured children exacts a high health, economic and social toll on these children, their families and our nation. Uninsured children are at high risk of living sicker and dying earlier than their insured peers, and they're almost 10 times as likely as insured children to have an untreated medical need. These consequences of untreated medical needs can carry on into adulthood, and we must prevent them.

The consequences of being uninsured fall disproportionately on children of color, who represent almost two-thirds of all uninsured children. Children of color are at higher risk than White children of having unmet health, and mental health and dental health needs, and they are at greater risk of being sucked -- because of the absence of this preventive health and mental health coverage, of being sucked into something the Children's Defense Fund is very concerned about, that we call the "cradle-to-prison pipeline."

Many children without mental health services are being -- having to be locked up in order to get mental health care in their community, at an enormous cost of $100,000 and $200,000 a year. Children should not have to go to jail in order to get mental health coverage. You can cure that this year.

The need for health care begins with maternity coverage. We have 800,000 pregnant women who are uninsured and having babies every year. They receive less prenatal care than their insured counterparts. They face greater risks for expensive and tragic outcomes, including complications, low birth weight, preventable illness, and even infant and maternal death.

We have about 350,000 low birth-weight babies. In the most recent data, their cost is 25 times greater than normal weight babies. We're the only industrialized country that does not provide prenatal care to all of its mothers. You can cure that. I hope your health reform act will do that.

All of our children need to be able to get what they need regardless of the state they live in. Today, each state sets its own income eligibility levels for CHIP and Medicaid which results in a profoundly inequitable patchwork of eligibility across the United States.

Imagine being a low-income parent or grandparent raising several children -- one is eligible for Medicaid, the other is (ineligible ?) for CHIP, with different income eligibility standards and benefit packages for each program. Why should a child in North Dakota be eligible for CHIPS if their parents earn more than 150 percent of the federal poverty level, while in 12 states and the District of Columbia families can earn twice that amount and children are still covered?

Children's ability to survive and thrive and learn must not depend on the lottery of geography or birth. A child is a child wherever they live. They should have the comprehensive benefits. We must end this inequitable system.

Ten states have no children eligible for Medicaid above 133 percent, but offer Medicaid to children of all ages in families with incomes -- but, half of our states, excuse me, offer Medicaid to children of all ages in families with incomes above 133 percent of the federal poverty line. Almost half cover children at 200 percent. Thirty-nine states offer CHIP to children in families between 185 percent and 400 percent of the federal poverty line.

We urge a national eligibility floor of 300 percent for all children and pregnant women, wherever they live, and we should not force parents to have to choose between paying for child care, paying for health care, paying their rent. And so this is our chance to, sort of, give then the kind of national health safety net that I, as a grandma, have. I think I'm important, but I think my grandchildren are even more important, and we should treat them fairly.

Secondly, we hope that all children -- (inaudible) -have the same comprehensive benefit package, which include health and mental health coverage. We like the EPSDT program. It was designed, and was appropriate for, children. Children are not little adults. It has health and mental health coverage.

We believe, and if you believe that every child's life is of equal value, and that children don't come in pieces, and they should get what they have to have their conditions diagnosed and treated early, and prevent later costs, I hope you will make sure that every CHIP child and every child in this exchange will get the same benefits that the Medicaid children get.

REP. PALONE: I hate to -- I hate to slow you down, but you're a minute over.

MS. EDELMAN: I'm a minute over already. Good gracious.

And, thirdly -- two last quick things, and I'll end, Mr. Chair. All of our eligible children should have simplified ways of getting and keeping enrolled. The bureaucratic barriers that keep six of the nine million uninsured children now unenrolled need to be addressed.

The packages I see, it does not do that. And we think that we lay out in our testimony -- our written testimony, and we lay out in specific legislative language in the "All Healthy Children Act," the steps that you can take to make Medicaid work.

I'm glad you've moved 133 percent of the federal poverty level for adults, but the children are already eligible for 133 percent. But, they're not getting it because of bureaucratic barriers, which you must address -- the simplification measures we lay out.

And last, I just want to say I know people are saying costs -- "we can't afford it." Well, you know, we can afford whatever we want to afford. We do not have a money problem in a nation with a $14 trillion GDP. We found the money to bailout the banks. We found the money to bailout the insurance companies. We found the money to do the Alternative Minimum Tax.

We can find the money if we (believe in it ?) -- to make sure that we give our children the chance to survive and thrive. And they are (cost-effectiveness ?) And while CBO may not score prevention, we know the dollars invested in immunization saves states $16 (trillion ?) on the other end.

We know that if you give a child -- (inaudible) -- visit in a primary health care setting, it's about $100 in Harrison County -- in Harris County, Texas. It's going to cost you $7,300 if they go to the emergency room and have to be hospitalized.

If we want to contain costs, children is the way to do it. All of them should be covered. All should get the same benefits. It should be simple and easy. And you have a great opportunity to do it right this year. Thank you.

REP. PALONE: Thank you.

Ms. Jennie Chin Hansen.

MS. HANSEN: Thank you. Chairman Palone, Ranking Member Deal, and distinguished other subcommittee members, I'm Jennie Chin Hansen, president of AARP. Thank you very much for inviting me to be here today and for your leadership on leading comprehensive health care reform.

Enacting legislation to give all Americans quality, affordable health coverage options is AARP's top priority this year. The draft Tri-committee legislation marked substantial progress towards this goal. Today I'm really proud to represent nearly 40 million members of AARP, half over the age of 65 and half below 65. Both age groups face serious problems in today's health care system, especially the seven million people aged 50 to 64 who are uninsured.

The draft includes critical reform priorities for AARP members for all ages. For our younger members, it would curtail discriminatory insurance market practices that use age and health status to block access to affordable coverage. Reforms must include strict limits of no more than 2:1 on how much more insurance -- insurers can charge the people who are in this age bracket of 50 to 64. Reforms must also provide sliding scale subsidies for those who need help to make coverage affordable, as well as provide some strict limits on cost-sharing.

The draft legislation achieves our goals on these vital points in health care reform.

For our older members, the draft closes Medicare's prescription drug donut hole so that they will be able to afford the medications that they need. This gap in coverage has been a major reason why one in five people who get drug coverage through Medicare delayed or didn't even fill the prescription, because of that cost. Under current law, the hole keeps getting larger every year. The draft begins to close the donut hole and includes other steps to lower drug costs.

And for people with limited income, the draft closes the gap right away by strengthening the Part D low-income subsidy and eliminating its asset test that penalizes people who really did the right thing in saving for a small nest egg in retirement. The draft also fixes Medicare's broken system for paying doctors and puts Medicare on a path to fiscal stability by revising payment systems to reward quality instead of quantity of care. It includes incentives to reduce costly and preventable re-hospitalizations. It strengthens our health care workforce that we know is actually, at this point, short already, let alone what will happen in the future. And it takes important steps to address racial and ethnic disparities in care.

Many challenges remain on the road to really full comprehensive health reform, but AARP and many other stakeholders share a broad and growing consensus that any differences that we may have cannot stop us from finding common ground and enacting comprehensive health care reform this year. We know and it's been said time and time again, the status quo is just unsustainable, and we cannot afford to fail.

Thank you all for your leadership. And we continue to look forward to working with all of you in Congress to enact this comprehensive reform this year.

Thank you.

REP. PALLONE: Thank you. Dr. Shern?

MR. SHERN: Mr. Chairman, members of the committee, Mental Health America is honored to participate in today's hearings on ways to reform our health care system.

I want to start by expressing our appreciation for the many important proposals included in the tri-committee bill released last week that recognize how integral mental health is to overall health.

Now, this is our centennial year. Our organization is 100 years old this year. And for the last hundred years, we've advocated for people with mental health. And from the beginnings of our organization, we had kind of a dual vision. On the one hand, we were concerned with people who had severe and disabling illnesses who would have traditionally been treated in state hospitals. But on the other hand, from our very beginning, we have had a commitment to a public health perspective and to prevention as the only real way to drive down the prevalence of illness.

So we're very heartened by this bill, because we see it as including many of the issues that need to be addressed in order to become the healthiest nation. We think that it addresses historical patterns of discrimination by including mental health subsidies -- I'm sorry -- including parity for mental health and substance abuse services. And importantly, it addresses the prevention and management of chronic diseases as the real strategy to control costs and improve overall health care status. I think these are very important.

You know, mental health and substance abuse conditions are really paradigm cases for what goes wrong when we discriminate against a class of illnesses and fail to prevent and appropriately treat them. This resonates very much to what Ms. Wright Edelman was talking about in terms of not addressing issues of mental health services with children. Increasingly, our science is telling us that mental health and substance abuse conditions -- we used to think they were -- they were diseases of early adulthood. We now know that they're diseases of adolescence. They're developmental disorders that occur early in life.

For all people who are going to develop a mental health diagnosis during the course of their life, 50 percent of those people will have that diagnosis by the time they're 14 years old. However, they will not receive services until, on average, they're 24 years old. So during that 10-year period, substantial disability begins to develop. Academic achievement starts to drop off. These are very strong predictors of academic achievement. Ultimately, occupational achievement is compromised.

We need to do a much better job at early identification and addressing issues of mental health and substance abuse disorders if we're going to develop the healthiest nation. The reasons that WHO estimates that mental health and substance abuse conditions are, in fact, the most burdensome of all health conditions, cause twice as much burden of disease as cardiac illnesses is, in part, because they are diseases of early adolescence that we do not effectively address.

So clearly this bill, from our perspective, includes all the key components that are necessary to start to address this problem, at least structurally.

First of all, it clearly addresses the importance of preventative services. You know, we're -- I think in some contradiction to some of the things that were said earlier, we have a brand-new report from the Institute of Medicine -- it was released in March -- that's a comprehensive summary of what we know about the effectiveness of preventative services for emotional and behavioral disorders in children and young adults. And we know a lot. Our science base is strong. We know that community-based interventions work, and we applaud the committee for emphasizing the importance of community- based intervention. We know that early identification when coupled with treatment works, as the -- (inaudible) -- task force had indicated, and we applaud the committee for including those services as well.

It's also clear, if you look at what it requires -- what's required to manage chronic disease, it's very clear that in order to do that, you need to address the entire person, not the person in segments or sub-specialties. The notion of the medical home that's included in the bill I think is extraordinarily important. And the inclusion of behavioral health services in that medical home is absolutely critical. Not only are mental health and substance abuse conditions the most chronic illnesses, they're the most common co- occurring illnesses with other chronic disorders. And when they co- occur, they drive costs way up; they drive outcomes way down. So the medical home and comprehensive integrated care is clearly an important part of what we need to accomplish here.

You know, we have a tragedy in this country, in that people with chronic mental illnesses who are served in our public system die 25 years early -- 25 years early. They're dying, on average, in their 50s, and they're dying from a broad range of the same disorders that will kill all of us in our 70s or 80s or 90s. So it's a critical imperative that we address comprehensively the needs of that population, as well as persons with other chronic conditions who are likely to have mental health and substance abuse conditions.

Finally, I'd just like to say that closing the donut hole is very important. For people who rely on psychiatric medications, it can be very expensive. The committee's attention to workforce provision is critically important, as several people have noted. We have a very predictable workforce crisis coming up on us quickly.

And then finally, a word about comparative effectiveness research. You know, I left academia three years ago at the University of South Florida, where I used to work for Ms. Castor's mother, to join an advocacy organization because of my frustration with our inability to get our incredible science base to people who need those services. Comparative effectiveness research provides a framework for us to better codify and understand what works and to translate it into information that can be supportive of individuals and their clinicians, their caregivers in making better decisions.

So I applaud the committee for the -- all the components of the bill, which seems to nicely round out both improving the quality of care, emphasizing preventative services and bringing better science to bear in terms of our decision-making process.

Thank you, Mr. Chairman.

REP. PALLONE: Thank you, Dr. Shern.

Dr. Novak?

DR. NOVAK: Good afternoon. I want to thank Chairman Pallone and the rest of the committee for having me here today.

My name is Erik Novak and I'm a medical doctor who's actually spent the last 23 years training and working in health care. Make no mistake, the very ability for everyone in this room and your families to seek out the kind of health care that you believe is best is under direct assault, and the risk you will lose control over your health and health care has never been greater. Unbelievably, nowhere in the U.S. Constitution or in the constitution of any of the 50 states do any of us have any right to be in control of our own health.

In November 2008, Arizona's Proposition 101 sought to place two basic rights in the state constitution: first, to preserve the right of Arizonans to always be able to spend their own money for lawful health care services and, second, to prevent the government from forcing us to join a government-sanctioned health care system, because once we are forced into a plan, our health care option will be restricted by the rules of the plan, whether it be public or private. It was a true grass-roots campaign and an idea that went from concept to well over a million votes in less than 18 months and failed by less than one-half of 1 percent.

Fortunately, the Arizona legislature has courageously recognized the critical issues raised by the initiatives and just yesterday referred the Arizona Health Care Freedom Act to the ballot in 2010. Unfortunately, the reforms that have recently passed Congress and the bulk of those that are being considered do not appear to have much respect for the basic freedoms that the Arizona initiatives seek to protect.

The stimulus bill was used as a tool to vastly expand the federal health care bureaucracy. By the end of 2014, every American will be forced to have an accessible electronic health record that can be viewed by government officials without consent, permission or notification. The stimulus bill created the Federal Coordinating Council for Comparative Effectiveness Research, whose ultimate function will be to become a federal health care rationing board for all Americans, starting with seniors. As Health and Human Services Secretary Kathleen Sebelius said during her confirmation testimony, quote, "Congress did not impose any limits on it," referring to the council.

And now MEDPAC may be empowered to make the full slate of recommendations for every condition and treatment. Congress will only be able to make an up-or-down vote on the entire package.

The president recently spoke to the American Medical Association, touting the importance of using evidence-based medicine to figure out what works and what does not. When it comes to the best treatments for our ailing health care system, we have some compelling evidence. Leaders in Congress regularly cite Massachusetts as a model for reform, but what really is going in Massachusetts and do we want to repeat in on a grand scale? Costs are even more out of control than in the country as a whole. Use of the emergency room for care has not diminished, despite the higher percentage of people with insurance.

And there is exactly zero evidence; there is exactly zero evidence that forcing people to have insurance has made any difference on slowing health care spending.

Medicare has tried several disease management and prevention projects. The idea that spending upfront to prevent Medicare patients from needing expensive hospitalizations and disease complications will save money in the long run -- unfortunately, the results do not bear that out.

Among the conclusion in the June, 2007 report to Congress on the trials, quote, "Fees paid to date far exceed any savings produced." In other words, the costs of administering the plan made the prevention plan more expensive.

Real research also suggest that obesity and smoking prevention, while admirable, do nothing to reduce health care spending. Supporters of the president have also reviewed the literature on the impact of electronic health records on spending and concluded, quote, "We need the president to apply real scientific rigor to fix our health care system rather than rely on elegant exercises and wishful thinking."

And research has been done demonstrating geographical variations in health care spending, but there is no evidence that having Washington forcibly take money being spent in Massachusetts, New York or California and sending to lower-spending states will improve anyone's health.

We cannot afford to make mistakes that will mean our grandchildren will, in the words of the president, suffer from, quote, "spiraling costs that we did not stem or sickness that we did not cure."

Congress should fix Medicare first before radically fixing the health care of every American. Congress should demonstrate that the government can prevent the disturbing failures -- even more exposed this week -- of the VA system before radically changing the health care for all Americans. And Congress should work very hard to increase the options and availability for the 3 percent of Americans who are truly, quote, "chronically uninsurable" before radically changing the health care for the other 97 percent.

Health care reforms are critically needed. Our path is unsustainable, but jamming through a piece of legislation that you will have read the American public will not have had time to fully review makes no sense.

Cynics who shout that we cannot have health care reform without sacrificing our personal freedoms are false prophets offering up false choice. I urge the members of this committee to consider health care legislation that protect individual liberty, preserves privacy, limits government power and has reforms that have actually been shown to work. In other words, reforms that protect patients first.

Thank you very much for the opportunity to present (some ideas ?) today.

REP. PALLONE: Thank you, Dr. Novak.

Ms. Robertson-Holmes. Thank you for being here.

MS. HOLMES: Thank you.

Thank you chairman and members of the committee.

Four years ago sitting in my doctor's office never did I believe that I would be here in Washington talking about this situation. But I'm here because I was fortunate enough to be able to -- in amongst my nightmare -- come to this country and get treatment.

I actually am the face of public insurance. We have -- I'm from Canada and we do have public insurance -- a mandatory monopoly on insurance. And I'm here to say it doesn't work; it doesn't work.

In Canada we have 33 million people, which is approximately the size of the state of California, and we currently have 5 million people without family doctors.

What started many years ago as a seemingly compassionate move in our government to treat all equally and fairly by providing the same medical coverage, has in fact turned into a nightmare of everyone suffering equally. Now we have limited resources and funds that offer timely treatment to our citizens.

A system like this starts to crack under pressure and special treatment is ultimately given to those who have contacts and resources to jump the line for treatment. And for someone like myself, the average Canadian citizen, is forced to go to another country for care.

I will never get the time, money or life back that I've dedicated to the fight for the basic treatment that I was promised by my government -- not only promised; it was ordered. I will never forget the experience of the treatment in a facility suffering so bad from government funding and shortages of staff and resources.

I know that the American health care system is not perfect, but I do credit the system for saving my life. It is because of the choices available here in this country that I was able to receive immediate care.

We as Canadians have one insurance company -- the government. We have no options. We can't choose another country; we can't supplement with after-tax dollars to purchase extra care. We can purchase health insurance for our pets, but not our children.

I have very few rights as a patient. Patients there have to fight for every basic service and care -- much less any kind of specialized care.

Another thing that I'd really like to point out is that our health care is not free. In fact, I would argue that the cost is much greater than the taxes we pay -- each and every citizen -- towards this care. The costs are loss of quality of life while living with pain, discomfort or just the fear of unknown; and also waiting long term for diagnostic testing; the costs of employers and self-employed people waiting for employees to be treated and be well enough to return to work.

Medications are also something that Canadians are struggling, like Americans, to pay for. We are not covered for our medications under our health care plan. We pay the costs of local ER's closing, losing a wealth of talented doctors leaving the country because they just don't have the resources to do their job properly at home. We have rationed services and treatments and a fear of living without a safety net.

The one thing that I wanted to sort of point out when making my testimony today was if I have gotten any criticism from anybody that I've done -- for what I've done, is that I must have had the resources in order to be here today. I'm here to say that I didn't. I am so average. And in order to get what I had to do my husband took a second job, he put a second mortgage on our house. We owe every single person we know money.

And I will never forget all that that's happened, but I also want to wake up grateful for what happened to me in America. And I want to have the same options in Canada. And I just felt from the very beginning of my experience that it was my job to point out to both Canadians what we can do together and what we need to learn from each other's situations.

Thank you.

REP. PALLONE: Thank you.

And now we have questions -- five minutes from the panel. And I'll just start with myself.

And let me just say, I'm not looking for a response, but I just really appreciate, Ms. Robertson-Holmes, that you came today. And I'm not being critical in any way, because I know you took your time, but I really have to stress that, you know, this draft is not meant in any way to put together a single-payer system or emulate Canada.

I mean, Canada's a nice place, but I'm not really looking to create a Canadian system or even praise the Canadian system, because you know, I really believe that the draft implements a uniquely American system that in no way replicates Canada.

But you know, I appreciate you being here. I'm not trying to denigrate it in any way.

MS. HOLMES: Well, once you start on that sort road --

REP. PALLONE: Right.

MS. HOLMES: And unfortunately, a lot of Americans that I've talked to have said to me, well, we're going to get free health care. We're going to get Canadian-type of health care.

REP. PALLONE: Yeah. Well, I think you're right that there's some people who think that somehow, you know, this is single-payer. But I just want to stress that I don't think it is and I don't see how it becomes a single-payer.

But whatever. Look, I appreciate your being here and I don't want to take away in any way the fact that you came here and how difficult, I'm sure, it was to be here.

Let me ask a question of Ms. Wright Edelman.

I'm very proud of the fact that in this discussion draft we've really addressed Medicaid in a major way in the sense that, you know, we're trying to cover and fill in the gaps, again, with 100 percent federal dollars for those who are not covered by the states now up to the 130 percent; that we're increasing the reimbursement rates so that it's more like Medicare. I mean, a big part of this is Medicaid and I think in many ways it hasn't really gotten attention -- unfortunately.

But what I want to ask you is there have been those who say that once we -- if we set up what's in the discussion draft that Medicaid would no longer be needed and that those people who are in Medicaid should be put into the exchange -- be able to get their insurance through the exchange. The draft doesn't do that. And because we're concerned that you know, that that might be harmful at least initially to Medicaid.

So I just wanted you to discuss the types of benefit and cost- sharing protections available in Medicaid that are generally not found in private health insurance products. And if you could talk about the need to keep and improve Medicaid's safety net undisturbed for years to come in response to those critics. You know, you know we're not putting Medicaid in the health exchange.

MS. EDELMAN: (Off mike) -- will not.

REP. PALLONE: I'd like you to comment on that.

MS. EDELMAN: Well, do not put Medicaid into the exchange. Nobody should end up worse off than they are currently.

Medicaid is a crucial safety net. I applaud in my written testimony your extension of 133 percent for all -- and the adults that need that help. I applaud you for it.

I'm glad that you're reaffirming it for children, but all children are currently covered at that level, so it will not result in an increase. But what we do hope you will do in protecting Medicaid -- in fact, I'd like, if you want, to take it up to 200 percent that would be wonderful too. I don't care how you can do it, as long as you can kind of try to get all of those folks who are uncovered. But I think that Medicaid is essential. It's comprehensive benefits. As I go for children it's essentially. The fact that it's an entitlement is absolutely crucial and I think it's one of the strongest pieces of what you have done.

On the children's front, I hope that you will make sure that Medicaid's benefit protections are extended to CHIP children and children in the exchange, because we think it is the most appropriate benefit package. And so we hope you will do that. But it also raises another important point, because many of the children now at 133 percent of poverty under Medicaid are eligible, but are not getting it, because the bureaucratic systems are impeding that.

And so one of the things that's essential if the children under 133 percent of federal poverty level are going to get their Medicaid coverage we're going to have to simplify, and we've laid out a number of simplification steps.

One of the good things you have in your provision is automatic enrollment of any child that is uninsured at birth . I think that's fantastic. We'd like to see automatic enrollment for any child that's in any means pass the program. We would like to have 12 months continuous eligibility. We've laid out a number of steps that can be taken to ensure that those children currently eligible for Medicaid will in fact get it. You're going to have to do the systems reform to make it effective.

REP. PALLONE: I appreciate and I'm sorry to stop you, but I want to ask another question of Ms. Hansen. You know, yesterday the PhRMA and the president announced some kind of a deal to cut costs for seniors with incomes up to 85,000 in the donut hole by 50 percent. In other words, to fill in the donut hole in part, people whose incomes are up to 85,000, that they would only pay 50 percent for brand-name drugs once they fall in the donut hole.

Now, I'm not taking away from that. I appreciate the fact that pharmaceuticals are doing that, but in the discussion draft we feel about $500 of this cost for the donut hole immediately and then phase out the donut hole for all Medicare beneficiaries over time. And we also reinstate the ability of the federal government to get the best price for prescription drugs for the most vulnerable low-income Medicare beneficiaries. Those are the rebates again to fill the donut hole.

How do you see this provision in the draft, the discussion draft, as working together with the commitment by the pharmaceutical manufacturers yesterday? I mean, I don't see them as mutually exclusive; I think they're both positive. But I just want you to comment on that.

MS. EDELMAN: Well, I have actually --

REP. PALLONE: Well, I was going to ask Ms. Hanson.

MS. EDELMAN: Oh, good.

REP. PALLONE: I'm sorry.

MS. EDELMAN: That's all right.

REP. PALLONE: We're just out of time always here. Go ahead.

MS. HANSEN: Thank you. Well, Mr. Chairman, we agree with you. This does not preclude a continuance of it, because it is actually only 50 percent of the donut hole. And for people who are at that income level, it doesn't cover every Medicare beneficiary. But part of what it does do for the people who are on drug coverage, as I stated briefly, that people who are falling in that hole are not oftentimes continuing with their medications.

So part of our job as an organization is to really get the most relief in the quickest time on behalf of people who are already in that conundrum. I mean, that even relates for becoming bankrupt as well. So that cost element is really important. I think what the draft does is importantly to continue to build on that so that we have a more whole, seamless coverage on behalf of people, so I do think that they can work and we'll continue to work with you on making sure that that coverage continues.

REP. PALLONE: And I appreciate that. I know you were part of the deal -- I don't know if that's the right word -- or agreement yesterday, but I also appreciate your working, you know, with us to try to completely fill the donut hole.

MS. HANSEN: Well, I just wanted to be really clear that I think it was Senator Baucus who really took a leadership role with PhRMA and I know that the president supported and we, again, appreciated it because it makes such a big, real difference in people's pocketbook.

REP. PALLONE: We try not to talk about the Senate here, but there are occasions -- (laughter) -- when we have to acknowledge their existence.

The gentleman from Georgia, Mr. Gingrey.

REP. PHIL GINGREY (R-GA): Mr. Chairman, thank you. I want to ask Ms. Shona Holmes, first of all, thank you all for your testimony, I really appreciate that. And as a medical doctor, I mean, I understand, I think, what you were describing to us. I guess a benign pituitary tumor -- the pituitary gland is about the size of your little thumbnail in the normal circumstance, but when it's growing so rapidly as in your case, it's right in front of the optic nerve where it crosses over and as it compresses on that optic nerve, as it gets larger, that's what would lead to the blindness.

And I'm assuming that the doctors at the Mayo clinic in Arizona informed you of that and said that, hey, you really need to get this surgery done within about six weeks. Now you went back to Canada and I understand from your testimony that they said there was no way they could do it in the six weeks. Did they say way? Did they have a reason for that?

MS. HOLMES: I think problem in Canada is the wait time even just to get in to specialists in order to get diagnostic testing done. So when I returned -- in fact, I had this false sense of security when I was in Arizona, because two of my doctors were, in fact, Canadian. I'd never questioned the talent that comes out of the medical system in Canada. They just don't have the resources. And so when I saw this doctors who said go home, you can get this done at home and you have insurance. This is what you should do. Here's your --

REP. GINGREY: And you said it would probably have cost you $100,000 to have it done in the United States.

MS. HOLMES: In total with all my expenses and everything, being away. And I had to return -- I took three solid runs at this particular situation, so this is not just that I fell through a crack. And I had to go originally for diagnostic testing, I had to go back for surgery and I had to return for follow up because I couldn't get any of those things done in Canada.

REP. GINGREY: So there was a real problem with rationing, basically, a long queue and getting --

MS. HOLMES: And at the time I was also diagnosed with a potential tumor in my adrenal, and it was recommended at the Mayo Clinic at that time that I have that surgery, you know --

REP. GINGREY: That additional surgery and also that was going to be delayed in Canada as well.

MS. HOLMES: (Inaudible) -- to the date. I had --

REP. GINGREY: Let me -- I've got -- my time's running out but I want to ask you one other thing. In your testimony you credit the United States health care system for saving your life. You said that. You also mentioned your lack of (right?) to the patient in Canada. Tell me, as someone who has seen health care from both sides of the Canadian border, what advice can you give to American patients who may be following this debate in Congress?

Now, keeping in mind what our chairman -- and I know in all sincerity he mentioned that this is, in his opinion, not, nor is it designed to lead to a single-payer U.K. or Canadian-type system. That's what Chairman Malone said. You have some concerns about that; I have some concerns about that with this public option. What would you say to the American in regards to this?

MS. HOLMES: Well, it's my understanding from actually all my family is in Great Britain and it actually is a two-tiered system. They actually have public and private, and they're almost in a worse condition than we are. What I'm saying is I am insured; I have insurance. But the money isn't there. It's expensive; health care is expensive anyway. And I was promised that I had insurance, but when it came to using the services that I was supposed to be covered for, they weren't there.

REP. GINGREY: Yes. So having an insurance, a plastic card, doesn't guarantee you access, affordability, availability, if there are no positions there to provide that care. Great point, thank you very much for your testimony and for your response.

I want to go now to Dr. Novak. Dr. Novak, thank you. I know you practice orthopedic surgery in Arizona, I think you mentioned to us. And you referenced in your testimony the study published I think May of 2009 -- the Journal of Health Affairs -- one in five Massachusetts adults were told in this last year that a desired physician was not taking new patients. You know, and here again, they had insurance, they had coverage, they just couldn't find a doctor.

Do you know if the type of insurance a person carries influence their ability to see their desired physician, whether it was a public plan, option or a private plan option? Was there a deltor (ph) in regard to who could get --

DR. NOVAK: I don't have an answer for you on that, but what's it's illustrative of is kind of regular attempts to -- (inaudible) -- health insurance with health care. So here's the 47 million number ,which is a bit inaccurate in and of itself, that don't have health care. Those are people who don't have health insurance. Twenty million of these people change every year because of job changes, et cetera.

About 10 million are in the country illegally; about 10 million are between 18 and 30 and don't think they'll ever get sick. You're left with about, you know, as I mentioned, about 3 percent of the country that's chronically uninsured. So just giving people health insurance -- we see in the Massachusetts example -- is no guarantee that you have access to health care.

REP. GINGREY: Well, Mr. Chairman, if I might ask Dr. Novak to submit a written answer to my question in regard to the different discrepancies between among the plans, where there were no doctors available, I would appreciate that. My time has expired and I yield back.

REP. : Yes, it is a pleasure now to yield five minutes to our chairman of the full committee, our former chairman, John Dingell.

REP. JOHN DINGELL (D-MI): Thank you, Madame Chairman. I'd like to begin by welcoming our old friend, my very dear personal friend, Marian Wright Edelman, to the committee. Glad to see you.

MS. WRIGHT EDELMAN: Thank you.

REP. DINGELL: I want to get right down to the business at hand here, and say to you, Ms. Holmes, your comments I found to be most interesting. Tell me, you are referring to a single care system you have in Canada, is that right?

MS. HOLMES: I certainly am.

REP. DINGELL: You're aware that the bill that's before -- the draft that's before us not a single care bill?

MS. HOLMES: All I'm aware of is that -- (inaudible) --

REP. DINGELL: So then help me. How would your concerns with a single care system apply to the draft to the legislation we're working on today?

MS. HOLMES: My concerns are basically in order to open up to new patients so that people know the questions -- (inaudible) -- when a bill is passed so that they know what it is they're getting into --

REP. DINGELL: In other words, your comment is a warning rather than a criticism.

MS. HANSEN: Yes, this is my (theory ?)

REP. DINGELL: Well, I think -- I think it's a very good criticism and I thank you for it. That was a very good warning as opposed to a criticism.

Now, Mr. -- Dr. Novak, I found your -- you made a very frightening comment here that I'd like to address with you because if your figures are correct this is a very bad situation, and in this -- and I can tell you that I'm going to stay up night and day to get it out if there's anything like that in here.

You made this statement. You said, no matter what name the bureaucrats and politicians want to use the plan being put forth by the committee will mean Washington bureaucrats will have the power to deny you care. That's a very frightening statement. And I'd appreciate it if you can tell me where in this draft that there's language that would authorize that so that I can get this out, and I'll work with you to get it out. Now, tell me what it is.

DR. NOVAK: Well, I think the issue here is when you look about -- what's been very vague, of course, is exactly how the cost control is going to happen.

REP. DINGELL: No, no, no, no. Where is the language? Your -- you've made a -- you've made a bold flat statement and, frankly, I'm scared to death. Now, I want you to tell me where it is in there so that I can get it out.

DR. NOVAK: I don't have the exact line for you, sir. But I can give a --

REP. DINGELL: But where -- but where is it, Doctor? Now, I'd be -- I'm probably being unfair to you because you're a doctor and I'm a lawyer, and I would never -- I would never presume to tell somebody how to take out an appendix or to fix -- or to replace a knee. But I do know a little bit about drafting laws; I've been doing it for about 50 years. And you've made a statement that scares the bejeebers out of me. And I want you to tell me where it is.

DR. NOVAK: Again, I don't have the exact line numbers for you but I will get it for you.

REP. DINGELL: So you -- you've made the bold statement though which you're not able at this time to tell us where the language is in the bill that has caused you to make this statement -- and I'll repeat it again because, quite frankly, it's a very serious charge. Bo matter what name the bureaucrats and politicians want to use, the plan being put forth by the committee will mean Washington bureaucrats will have the power to deny you care, and you capitalized deny you care.

DR. NOVAK: Again, I -- the answer --

(Cross talk.)

REP. DINGELL: That's a very frightening statement.

DR. NOVAK: -- care could be denied because you have to come up with a package. If the plan is to come up with a standard benefits package and then to give some authority the ability to determine which benefits are going to be acceptable to -- it'll start with seniors, I imagine, if we start to apply this to patients in Medicare first, and if those benefits are different than the benefits that people currently enjoy today that'll potentially be care that will be either delayed or denied than what they're getting right now.

REP. DINGELL: That's the basis for your statement, is it?

DR. NOVAK: Yes.

REP. DINGELL: I find that to be interesting. It's kind of like building a house of cards or maybe setting up a straw man, and that's a good thing to do because then you can knock them down fairly easy. But I still want to hear you tell me what is the precise thing. We're going -- you -- let's -- (inaudible) -- something. You got Blue Cross, Blue Shield. You got Aetna. You got all kinds of insurance companies in this country. Remember when we had the big fight over patient's bill of rights? Remember that?

DR. NOVAK: Not --

REP. DINGELL: And they was very, very interested in it and they were very helpful to me in my efforts to try and get that legislation through. That was to stop a bunch of health insurance bureaucrats (in ?) green eyeshade actuaries from telling you, a doctor, what you could do and telling me, the patient, what treatment I could get. I find that your same apprehensions were joined in by my friends at AMA when we tried to correct this iniquitous situation which we have now, and I'm trying to find out where the abuses that we complained about are to be found in the legislation --

DR. NOVAK: Sir, I --

REP. DINGELL: -- and how this -- how this situation, even if it is as you say is true, would be worse than that which we have now where we have 47 million Americans who haven't got any health care and who haven't got anybody to tell them what they can have or not have. The only thing they can say is you can't have treatment because you can't pay your bill.

DR. NOVAK: Well, I think the questions are we -- what kind of tradeoff are we looking to make. It is true and I can tell you both as a provider and as a patient and as a patient advocate that I -- there's oftentimes no love lost between me and the bulk of the private health insurance industry.

What the tradeoff that the legislation appears to be making is to be moving away from green eyeshade private health insurers towards green eyeshade Washington bureaucrats. And I think at the end of the day when we look at examples where there have been abuses in the private health insurance industry there was recourse when Blue Cross did rescissions in California and the other companies did rescissions in California. There has been --

REP. DINGELL: Well --

DR. NOVAK: -- significant -- (inaudible) -- of that.

REP. DINGELL: Doctor, I'd love to listen --

DR. NOVAK: But my concern is, for example, in the VA system --

REP. DINGELL: Doctor, I'd love to listen to you --

DR. NOVAK: -- is government-run there is no recourse for the 10,000 people were exposed to HIV --

(Cross talk.)

REP. DINGELL: -- I'd love to listen to you further but my time has expired. Thank you.

REP. CAPPS: Thank you, Mr. Dingell. And I yield now five minutes for questions to Mr. Whitfield.

REP. WHITFIELD: Thank you, Madame Chairman. Let me ask you, have any of you read this bill? Ms. Edelman, have you read the legislation?

MS. EDELMAN: I have read or my staff has read it multiple times and we have struggled to make sure that I read the key portions of this bill that relate to children.

REP. WHITFIELD: When did you all receive it?

MS. EDELMAN: We got it on Friday and it's over 800 pages long and --but we've done pretty good.

REP. WHITFIELD: Well -- you know, I don't think any of you have read it. Certainly, I have not read it. Not many members up here have read it, and one of the things we're concerned about when you have this sort of dramatic change in health care, and evidently this bill -- they're going to try to bring it to the full committee the first week of July or the second week of July -- we don't really have a lot of time here. And -- but let me just talk philosophically about a couple of things and then I'll get into some specific questions. I would ask all of you does the American taxpayer have the responsibility to pay for non-emergency health care for illegal immigrants? Ms. Edelman, what do you think?

MS. EDELMAN: I think all children should be covered because as a public health issue if there are any children in our country or in our schools.

REP. WHITFIELD: What about adults?

MS. EDELMAN: All children go to school.

REP. WHITFIELD: What about adults?

MS. EDELMAN: Well, I'm here to talk about children.

REP. WHITFIELD: Okay. You're talking about -- okay.

MS. EDELMAN: Our bill is for all children being covered.

REP. WHITFIELD: What about you, Ms. Hansen? What about you, Ms. Hansen?

MS. EDELMAN: I think it's cost effective and preventative because they're going to show up --

(Cross talk.)

REP. WHITFIELD: What about you, Ms. Hansen?

MS. HANSEN: We don't have a policy on immigration because that's not part of our public policy covering our --

REP. WHITFIELD: So you don't have a position? Okay. Dr. Sheen, or is that Shern?

MR. SHERN: Similarly, we don't have a position on it.

REP. WHITFIELD: Okay. Dr. Novak?

DR. NOVAK: I would just say currently as a provider, and I take about 14 days of emergency room call every month, I take care of, in the Phoenix area a whole lot of people who are not in the country legally and they get the same care --

REP. WHITFIELD: But I said non-emergency room care. Okay.

DR. NOVAK: I think that given the tens of trillions of dollars --

REP. WHITFIELD: Okay.

DR. NOVAK: -- of unfunded liabilities that we ought to be directing the resources for people in the country legally first.

REP. WHITFIELD: Well, you know, there's been a lot of discussion here about there's not going to be any government payer plan or government plan, and yet in Section 203 of the bill, which very few of us have read it, says the commissioner that will be established under this legislation shall specify the benefits to be made available under exchange participating health benefit plans during each plan year, and I've been told that that applies not only under the government option but also private plans. So do you think it's right that some government officer will be dictating what benefits will be available under private as well as the public option plan? Dr. Shern?

MR. SHERN: Well, I think that the intention, as I understand it, of that provision is to provide a floor of services that will be available for everyone upon which you could build. I also think that when you --

REP. WHITFIELD: That's your understanding. Do you know that to be a fact?

MR. SHERN: No, I don't know that to be a fact.

REP. WHITFIELD: How about you, Ms. Hansen?

MS. HANSEN: I can't answer it with --

REP. WHITFIELD: Have you read the bill?

MS. HANSEN: Not since Friday, but the staff --

REP. WHITFIELD: But you all have helped work on this legislation. You've been a part of drafting this legislation. Is that correct, Ms. Hansen?

MS. HANSEN: We don't draft the legislation. I think we --

REP. WHITFIELD: Did you have input into it?

MS. HANSEN: There have been conversations between our staff.

REP. WHITFIELD: Okay. Now, the CBO says that they estimate 15 million people will lose their present insurance -- health insurance coverage as a result of this legislation. So Ms. Hansen, what would you say to your members who will lose their employer health coverage because of this bill?

MS. HANSEN: Well, we take the position that people -- the principle of choice, and we also support that people who have insurance now can and want to keep that, and that's something that we actually believe in ourself. The maintenance for public and --

REP. WHITFIELD: Does this legislation give each individual the right to keep their current insurance?

MS. HANSEN: Those are the principles that we are (supporting ?).

REP. WHITFIELD: But do you know for a fact that it does it? Do you know for a fact that it does this?

MS. HANSEN: I don't know for a fact personally.

REP. WHITFIELD: Okay. Okay.

MS. HANSEN: But the principles I can ascribe to and --

REP. WHITFIELD: Now, my understanding that this legislation also includes an employer mandate which will force businesses to either provide health insurance to their employees, which is fine, or pay a tax of 8 percent wages paid.

Now, that's going to particularly hit hard small businesses. And there have been estimates that there may be 4.6 million Americans that lose their jobs because of the additional tax that small businessmen and -women will have to pay.

Does that concern you all? Does that concern you at all, Dr. Shern?

MR. SHERN: If those estimates are correct, that would be a concern, yes.

REP. WHITFIELD: Ms. Hansen?

MS. HANSEN: Right. We feel that the ability to cover should also be supplemented by understanding affordability and cost for both employer as well as the employee.

REP. WHITFIELD: Okay.

MS. EDELMAN: It is also my understanding that small businesses can buy into a public plan, but everybody should be contributing something.

REP. WHITFIELD: Everyone? Everyone?

MS. EDELMAN: This should be a shared sacrifice --

(Cross talk)

MS. EDELMAN: -- Americans.

REP. WHITFIELD: Let me ask you a question. What would you think if we just took the money that this plan is going to cost and just put everyone under Medicaid?

I know you're a supporter of Medicaid. It is a good system. What do you think about that?

MS. EDELMAN: Well, I think the Committee can deliberate. I don't care how we do it. We should thoughtfully determine that we're going to get health coverage for everyone.

REP. WHITFIELD: But would you be opposed --

MS. EDELMAN: What we're trying to do here is to give people --

(Cross talk.)

REP. WHITFIELD: Would you be opposed to that? Would you be opposed to everyone being under Medicaid?

MS. EDELMAN: I would not be opposed to all children being in -- Medicaid. That's what I'm --

(Cross talk.)

REP. WHITFIELD: But what about adults?

MS. EDELMAN: -- Medicaid benefits.

But I think the issue here is how we're going to give everybody coverage and choice about a public or a private plan. And I support --

(Cross talk.)

REP. WHITFIELD: And my question is would you object to everyone being under Medicaid?

MS. EDELMAN: I'm here to talk about children today, and to say whatever plan we do that we should absolutely make sure that all children and pregnant women are covered. And I would love it if Medicaid took them all up to 300 percent; all of the children got the Medicaid benefits and the Medicaid entitlement.

REP. WHITFIELD: Thank you. My time's --

REP. CAPPS: Thank you, Mr. Whitfield. And may I just make a correction to a statement that was made?

It's my impression, or my understanding, that CBO has not taken a position on this bill and that actually a private-public benefit advisory committee determines what the benefit is. It should be on the floor of what is offered in coverage in the new marketplace, or sold in the new marketplace. And that's just for the record.

And I now call upon, or recognize, our colleague from Colorado, Ms. DeGette, for five minutes.

REP. DEGETTE: Thank you, Madame Chair.

And I want to add my thanks to Ms. Robertson-Holmes for coming today. It's always important to hear the patient perspective.

And when you were testifying about the great care you got at the Mayo Clinic, I was thinking about my next-door neighbor when I was a little girl, Randy West. I knew him since I was six years old.

And about two years old -- or, two years ago, Randy was diagnosed with prostate cancer. And he was treated and the doctors said they thought he was cured.

And then the next spring when his private insurance plan came up for renewal, his insurance company said they would renew his insurance but that they would not insure him for any future complications he might have gotten from the prostate cancer.

So he said, well, why should I get insurance, then? Because that's the thing that's the most likely to affect me. So he didn't get the insurance renewal, and you know the rest of the story.

Last summer his symptoms returned. He went back to his old doctors. His old doctors would not now treat him, because he didn't have health insurance anymore. And he spent about two or three months trying to get off of -- trying to get onto Medicaid so that he could afford to go see the doctor and get treatment for his now-advanced prostate cancer.

And last week, on Wednesday, was Randy's 57th birthday, and he died suddenly of a heart attack because of the advanced prostate cancer that had riddled his body.

So there's problems with the single-payer system in Canada, but there's real problems for 47 million Americans like my friend Randy West, who died because he didn't get the insurance.

And I just -- I don't even need a response to that. I just want to say what we're trying to do is make it so insurance companies don't deny people for those pre-existing conditions and that -- so that people who have diseases in this country can go to the doctor.

I want to -- and I just want to point out to you, Ms. Hansen, I want to thank you for mentioning the Empowered At Home Act in your written testimony, because Chairman Pallone and I worked on this bill a lot together.

And what that does is it incentivizes states to provide home- and community-based services which allow disabled individuals to stay in their homes. It's not only a better health outcome; it's also more cost-effective.

And so I want to thank you for that and I think, Madam Chair, that's an important component to keep in the bill as the week goes along.

And finally, I have to thank my dear friend, Ms. Edelman -- all of our dear friends and a real icon for children in this country -- for coming over today. And I want to ask you a couple of questions about kids. As you know, I've worked for many years on kids' health.

The first one is do you think that, as we design a program to try to enroll all kids in this country in health insurance or some kind of health coverage, that we should look at their unique needs and not just assume that the adult programs will cover them?

MS. EDELMAN: Yes. This is why we feel so strongly about the Medicaid benefits package, which has been thought through as being the most child-appropriate.

REP. DEGETTE: Because it's targeted at kids.

MS. EDELMAN: It's targeted at children, and it's targeted at early diagnosis and early treatment. And so I don't think we need to re-invent anything. And I hope you will not come up with a benefits package, whether -- whatever it is -- that takes away what children now have that works. And we want you to extend that package to all children, because that's at least what they need.

REP. DEGETTE: And that includes mental health --

(Cross talk.)

MS. EDELMAN: Mental health, physical health. It's for comprehensive, all medically necessary services, and we think that that should be Medicaid children, CHIP children, and any children, regardless of whether they're in the exchange or not.

REP. DEGETTE: And we talked earlier -- I think you mentioned in your testimony -- the early and periodic screening diagnosis and treatment benefits. That's very expensive, though.

And I'm wondering if you can opine as to whether you think that additional cost is worthwhile and might even save money in the long run for kids. And if so, why.

MS. EDELMAN: It would save money, and when we had Lewin & Associates do cost estimates for extending coverage to all children and giving them the Medicaid benefits package, they said that you could do -- extend the EPSDT benefit package to all uninsured -- 9 million uninsured children, and this was a two-year-ago study -- and for about 12 percent added cost.

And so I think that the cost-effectiveness of this in the long run is going to pay itself back, and so we think it's not a big, huge add-on.

REP. DEGETTE: You know, part of the draft legislation, and the part which I'm sure you have read, because it applies to children, is the part that if children come in at birth and their parents don't have insurance, would automatically enroll them in Medicaid for the first year.

Do you think that's a good step in the legislation.

MS. EDELMAN: I think that's terrific, and we'd like to have automatic enrollment when they go to preschool or if they are in any WIC program or Early Head Start Program.

You want to get children in, because they are -- prevention. You want to prevent them --

(Cross talk.)

REP. DEGETTE: And preventative care for children actually saves --

MS. EDELMAN: Many, many dollars on the other end. And we can give you added testimony that shows you the cost of --

REP. DEGETTE: I'd appreciate it if you'd supplement your testimony in that direction.

Thank you very much.

MS. EDELMAN: Thank you.

DEL CHRISTENSEN: Thank you, Ms. DeGette.

And now I'm pleased to recognize for five minutes Dr. Burgess from Texas.

REP. BURGESS: Thank you, Madam Chair.

Ms. Wright Edelman, let me just ask you a question on --

Last fall, in the interest of full disclosure, I was a surrogate for the opposite side. I got to know President Obama's proposals last fall pretty well because I always had to prepare to argue against them.

And one of the over-arching themes that was always put out there first was that there was going to be a mandate to cover children, under President Obama.

Have you talked to him lately about what happaned to that?

MS. EDELMAN: No, but he certainly -- I'm -- he certainly knows that I'm expecting him to keep his promise. And I know that he has expressed his great interest in seeing that we take care of all of our children. And I think that this is the time to do it, and in the individual mandate --

REP. BURGESS: Let me -- I don't mean to interrupt, but -- I always had difficulty getting his surrogates to identify the definition of a child. Sometimes it was age 19, sometimes it was age 25, sometimes it was age 27. Do you have an opinion as to where that limit should be set?

MS. EDELMAN: Well, I certainly -- you know, if we would take the definition of a child that's under Medicaid or CHIP now. But I think that we are talking about everybody getting coverage.

And we know that there are a lot of younger people in college and --

(Cross talk.)

REP. BURGESS: Ma'am, I'm going to -- in the interest of time, I've got to interrupt you.

What is the difficulty -- with a child on Medicaid today, what is the difficulty with getting them in to see a dentist, if they have dental coverage under Medicaid?

MS. EDELMAN: Well, the first part, if it's Texas, since you have the highest number of unenrolled children, and we --

REP. BURGESS: Yeah, but let's just focus on those that are enrolled. Those that are already in Medicaid.

(Cross talk.)

MS. EDELMAN: Well, let's talk about those that -- (inaudible) -- provider reimbursement rates. We all heard -- and because children do still face bureaucracies. But let's just take the child out in Prince George's County, Diamonte Driver, who -- Diamonte Driver, who died last year.

REP. BURGESS: Right. We hold a hearing on that.

(Cross talk.)

MS. EDELMAN: Tried to get-- 25, 26 dentists his mother went to, couldn't get them to take him because of low Medicaid reimbursement rates. And I know you're trying to do something about that in your proposal.

And the upshot was his tooth abscessed and infected his brain. Then he died, 250,000 -- (inaudible). So huge bureaucratic barriers, first, even to enroll children, and not enough providers. And in rural areas, it's worse.

REP. BURGESS: But fundamentally, the problem has been reimbursement rates.

Now, Dr. Novak, you've talked about 14 days out of every month you cover the emergency room. And we have put a mandate on providers -- we may not have a mandate for kids; we may not have a mandate on employers or a mandate on individuals.

But you have a mandate called EMTALA, which requires that within 30 minutes of somebody showing up at the door, you have to see them. So -- is that not correct?

DR. NOVAK: That's correct. And the consequence, of course, is that the very large majority of my colleagues no longer have any privileges at the hospital.

So for -- sometimes in complex things where it might be nice to have a particular person available and when someone comes into the emergency room, you're no longer even able to get that person's assistance on a difficult case because -- because of the regulations, people have abandoned their privileges -- (off mike).

REP. BURGESS: And this is an extremely -- both of these issues are really getting to the same problem.

And I recall back in -- I practiced obstetrics back in Texas for 25 years, and we made an agreement amongst ourselves that our individual practices would each take a certain number of Medicaid patients every month into our obstetrics practices so no one would be unduly burdened by a larger number of patients who reimbursed at a lower rate.

And that worked great until you had somebody who had a complicated medical condition and they had to be referred to a specialist, and it was virtually impossible to find anyone because of just exactly what you described, and there's those very low reimbursement rates.

So as we sit up here and plan a national program that may very well be based on Medicaid, I just think we're obligated to make the program that's already there work first and demonstrate that it can work before we go extending it to increasingly larger segments of the population.

Dr. Novak, do you have an opinion about that?

DR. NOVAK: Yeah, my sense is it's no different than when I do something in orthopedics, which is you're not going to introduce a new procedure until there's some data -- (inaudible) -- that it works. And what's being proposed here is to push through massive legislation in an incredibly short order, where there's not been full time for people across the country to look at it and examine the problems, and try to get it passed before people realize what happened. And then all of us as patients will live with the unintended consequences of those actions.

REP. BURGESS: So we should have evidence-based policy as well as evidence-based medicine.

DR. NOVAK: I suspect that the -- as Shona has demonstrated, look, there are good people in health care, whether they're physicians, nurses, all through the system, top to bottom, in lots of places, not just the United States. But the system within which you're allowed to provide care is as important for the delivery as the people providing it. And so if we're not willing to put the same level of attention and same level of attention to detail on the level of intellectual rigor in designing the system, it is doomed to fail.

REP. BURGESS: Doomed to fail.

Shona, let me just -- I know I have no time left, but I just wanted to let you know that my grandfather was an academic OB at Royal Victoria Hospital at MacGill, and my dad also did his training at MacGill Medical School. He did a fellowship at the Mayo Clinic back in the '50s -- there was only the one in Rochester -- and never went back to Canada. So just -- and I'm so grateful you're here today, and thank you for sharing your story with us.

MS. HOLMES: I don't want to pull down any doctors or anything from either side of the border. It's just what they're able to do.

REP. BURGESS: The doctors and nurses are all good people. The systems that they're having to work under are where we're encountering the stress. But again, thank you for sharing your story with us today.

DEL. CHRISTENSEN: Thank you, Dr. Burgess.

And now I will yield -- recognize myself for five minutes.

And I want to just point out that this legislation is not coming out of nothing, that there -- I'll just mention three examples of best practices or good care; medical home, if you want to call them that. Cleveland Clinic is one, Mayo Clinic is another, and Johns Hopkins all have been very participatory. And many of our hearings have been focused on areas where practices have worked and where we see examples in small communities.

I want to start with you, Dr. Shern. Mental health and substance abuse are some of the most chronic and disabling of conditions. Treatment often does not begin until as long as 10 years after diagnosis. And diagnosis, we all know, oftentimes happens much after the symptoms begin. This increases the risk of developing a very costly disability. Mental health and substance abuse conditions also go hand in hand with other costly chronic conditions like diabetes and heart disease.

Can you comment -- and I want to turn to children, as well as a former school nurse; we must address that. But I want you to comment briefly on how we might be able to improve the provisions of the draft bill to better guarantee earlier access to mental health treatment. We tried to take as many steps as we could, but this is a single -- with all the stigmas and stuff to (fill ?) around. Please address it for us.

MR. SHERN: Well, first of all, I'd say that we're lucky to have the Institute of Medicine report on prevention in general. And there are many things we can do universally to drive down the rate of mental illness over a long period of time. So one thing we should think about -- and I think that the community task force that's anticipated in the bill is, in fact, moving in the direction of the evidence about what's effective in terms of prevention.

I also think that the inclusion of mental health screenings in adolescents, as recommended by the Preventative Services Task Force, and as is included in the bill, is a very important step forward.

You know, it's ironic that we test eyes, we test hearing, we look to see whether or not there's scoliosis in the spine, but we don't test kids for the things that they are most at risk for routinely, and those are social and emotional problems. We have data that indicates that when we do that with an appropriate model, as the Preventative Services Task Force has recommended, we can effectively identify and treat those conditions and that will be beneficial in the long run. Anything we can do to strengthen those provisions, I think, would be very helpful.

REP. CAPPS: And let me just -- and I'm going to have to ask you to submit this to the written record. If you have ideas about how we could better integrate -- support better integration of behavioral health and medical care as well, in a way of maybe branching out, hopefully this will be a beginning start, and then we can expand upon it.

You mentioned children, naturally, because when you talk about health care and mental health, really, as you know, Dr. Marian Wright Edelman, that's when we should start looking at screening.

I want you to focus on a different topic. When you mentioned children, I always think of the mother. And I want to elaborate on the importance -- I would like to hear you elaborate on the importance of insuring that women receive adequate maternal care coverage and the effect of the mother's health on the health of her children. It's so clear to those who have studied it: If you have adequate prenatal care, your chances of having a healthy baby are that much more important.

MS. EDELMAN: Well, and a depressed mother is not going to be the best mother for her child. And so what is good for the mother is always good for the children. And so it is in all of our self- interest to make sure that mothers do get prenatal care, that any problems that they have -- substance abuse problems, domestic violence problems, other things that may lead to them being less able to do all they need to do for their children, and those can be detected early and treated early, because the impact on their both in the short and long term will be enormous.

And we also just know the cost effects on prenatal care if they are having babies that are low birth weight, they're not adequately nourished and don't know how to take care of themselves and their children.

So I just can't -- you can't separate the two. And so I think, going forward, we should make sure the mother's in good shape and children are in good shape. And I'm happy to submit additional evidence of the effectiveness of prenatal care and the effectiveness of maternal care, and hope that there will be a full-fledged -- (inaudible) -- to make sure that all children have mothers who get full maternity care in this bill.

REP. CAPPS: Thank you very much. We've done a bit of work in Congress recently to recognize the situation around maternal mortality, but also the fact that I don't think many Americans realize that this country, the United States, has one of the highest rates of infant mortality, 27th out of 30th industrialized countries. That's a red flag for starters.

And I want to thank each of you again for your testimony.

And now I will recognize Ms. Christensen for five minutes for her questions.

DEL. DONNA CHRISTENSEN (D-VI): Thank you, Madame Chair.

And thank all of you for your testimony.

Ms. Chin Hansen, AARP has taken a position back a few years ago in support of lifting the Medicaid cap for the territories. AARP has taken a position in support of lifting the cap on Medicaid for the territories. This bill does not go that far. Is it still the position of AARP that all of the federal programs should be equally accessible to all Americans, regardless of where they live?

MS. CHIN HANSEN: As you have in my written testimony, that it does speak to really supporting that elevation. So it is something that we continue to support.

DEL. CHRISTENSEN: Thank you.

Dr. Shern, you talk about providing mental health care and the savings that we would realize from that and the reduction in productivity losses that we experienced, and you give some pretty good figures to back that up. But I wonder, just for the record, if you would speak to the impact of treating mental health, mental illness, on chronic disease and how that would also produce savings in terms of chronic disease treatment.

MS. SHERN: As I said in my verbal testimony today, mental health conditions are the most likely co-occurring conditions with other chronic illnesses. And when they occur, there's lots and lots of data that indicates that the course of treatment is much rockier, costs are much higher, and outcomes are much poorer.

We have a study of older adults with diabetes called the Fosbeck (sp) study who also had depression, half of whom were randomly assigned to effective depression treatment. The other half were assigned to watchful waiting counseling, but to balance off the amount of time that was spent.

What we found was, over a two-year period, those people who didn't have their depression effectively treated died at twice the rate the individuals who had their depression effectively treated. And in this study, we found that in the first year there was an overall cost increase for care, but in year two the overall cost of care for those people declined and their clinical status improved.

So we have lots of examples of what's called collaborative care models in which the entire person's needs are addressed. In this case we're talking about diabetes and depression.

Additionally, and quickly, if you look at workplace presenteeism and productivity, there is also ample data -- and this gets to your earlier point, I think, about thinking about costs more broadly than simply the costs within health care sectors -- there's ample data that shows that these are very cost-effective programs that have effective return on investment.

DEL. CHRISTENSEN: Thank you.

And Ms. Edelman, I think most of the questions that I wanted to ask you have already been asked, but you know that I've always shared your passion and your commitment to making sure that every child and pregnant female has been covered.

We're expecting a pay go bill to come through the Congress shortly -- I think it's still coming. And cost being the major barrier to achieving what we all know we need to achieve on behalf of children and really all Americans. Do you agree that it's important to enough to take this issue out of pay go if that's where it -- ?

MS. EDELMAN: Well I don't think we have a money problem in the richest nation on Earth, I think we have a values and priorities problemS. And if we can find the money for all the more powerful special interests, if we can continue without having had a pay go for the tax cuts, many of which came through the Bush Administration, if we can find the money so quickly to bail out the banks and then others, if we can continue to have, you know, these different things, I don't for a moment believe we can't afford to take care of our children.

It's really about values and if we're serious about cost containment and we're serious about prevention and if we're serious about creating a level playing field for everybody and if we believe as we profess to believe and which is American's promise that every child's life is of equal value then we will find the money to do what is right and cost effective. And so I hope we will do it.

DEL. CHRISTENSEN: Dr. Novak, do you agree? I don't agree with a lot, some parts of your testimony, but I agree with your position on MedPac -- as I understand it correctly -- where you say that using cost control as a driving force behind health reform will turn every American -- (inaudible) -- patient into an expense. So do you also agree that it ought to be done regardless of cost because we cannot as the president says afford not to do it?

DR. NOVAK: I disagree, I think that if you look at overall government spending, governments should work the same as families, and that you have some point we have -- look, we actually have a health care bubble like we had a housing bubble. Our overall unfunded liabilities are massive in health care, and that bill will come due someday no matter where people want to stick it on the ledger.

And so given all the bailouts and I share the concerns with the other members of the panel about some of the bailouts that have gone on, they seem to go with whoever has, you know, the biggest megaphone.

But that is not an excuse to not use basic fiscal responsibility when we're trying to reform it.

DEL. CHRISTENSEN: But families do in emergencies borrow to meet those emergencies and make sure that they're taken care of.

REP. CAPPS: Now recognize Mr. Green for five minutes.

REP. GREEN: Thank you Madame Chairman.

Dr. Stern, I'm a co-sponsor of the H.R. 1708 the Ending Medicare Disability Waiting Period Act, and it would actually phase out the 24- month disability waiting period for disabled individuals. And I want to thank you for being a member of the coalition to end the two year waiting period which has more than 120 members. Can you speak on the importance of that elimination that 24-month waiting period for individuals with mental disabilities and illnesses even with the creation of this exchange that's in the bill?

MR. STERN: I think it's very important that we eliminate that waiting period. It's such a counterintuitive thing and you know how difficult it is for someone to qualify for SSDI to make it through the disability process and people with mental health and substance use conditions have a particularly difficult time making it through. And then once one finally gets through to say well in two years, you know, we've now agreed that you have a chronic illness that needs to be treated, to say well the good news is you made it through this, the bad news is we're not going to be able to provide you health care coverage for two years. It makes no sense.

So I think that that repeal is really important. Anything we could also do to expedite the elimination of the discriminatory 50 percent co-pay in Medicare. We took care of eliminating it over a five year period, you know, we have good data to show that that in fact drives costs on the inpatient side by denying people or making it more expensive for them to get ambulatory care. So we're very enthusiastic about reducing that two year waiting period, and anything we can do to drive down that co-pay would also I think be very cost effective and beneficial.

REP. GREEN: Dr. Edelman, you know in Texas we have the largest uninsured in the United States and approximately 900,000 children uninsured. Approximately 600,000 of those children are Medicaid eligible but unenrolled and the remainder are S-CHIP eligible but unenrolled. Now, this can be attributed to the times in the past when Texas was facing budget issues and required parents to re-enroll their children in S-CHIP every six months. And the same six month reenrollment for Medicaid. There are two pieces of legislation -- in fact, my colleague Ms. Castor from Florida and I both are co-sponsors of it.

In your testimony you mentioned 12 month continuous eligibility for Medicaid as part of the solution to the problem with the number of uninsured children in the U.S. Can you explain why that is important? Also the 12 month for the S-CHIP program?

MS. EDELMAN: Well, I think if, you know, you want to keep children enrolled, you make the enrollment and re-enrollment procedures as easy as you can possibly make it rather than as difficult as many states, including Texas, has made it. And you know we lost a child last year to Bonnie Johnson, whose mother tried to do everything right but couldn't get her paperwork sorted out in Texas and this 14-year old child died from kidney cancer which could have been allayed had he not been dropped from coverage for four months.

And I've been so pleased that the business community in Texas has come now and really understood the importance of investing preventively and that Texas is losing millions of dollars -- in fact, it wants $1 billion by turning on federal matches, and local taxpayers are paying for it and emergency care.

And so I just hope that we can and we've submitted as part of our longer testimony all the simplification things, including the 12 month eligibility, presumptive eligibility, express lane and a number of things that can make it easy to get children into preventive care. And I would love Mr. Green and thank you for your comments this morning -- (inaudible) -- the new study done by the Baker Institute that talks about the cost effectiveness and investing in coverage for all children in Texas and nationally and lastly similar studies that the business community has done in Texas in support of their reforms for 300 percent eligibility in Texas as well as the 12 month continuous eligibility.

REP. GREEN: Well -- and we know that the numbers -- you can actually decide if you want to keep children from -- off of CHIP or even Medicaid, you know if you make those parents go down and stand in line every six months as compared to the year.

Now during that year, they could still be investigated if somebody finds out that family may not be qualified for Medicaid or even S-CHIP they could go get that.

I appreciate also Congressman Doggett's working with the Ways and Means Committee on the same issue for both S-CHIP and Medicaid. Hopefully we can at least get S-CHIP. It's much smaller, but, you know, we would need to do that, look at the total goal for Medicaid also.

Dr. Novak, let me just ask questions about your statement that health care reform must be built on foundation consisting of the protection of the right of individuals to control their own health and health care, not special interest or government bureaucrats. I would submit right now, I don't know if it's controlled by government, but it is controlled by somebody in special interests. If you're lucky enough to have insurance, if you get preapproval, I can tell you that it's already going to be controlled by someone that's -- you know, whether it's insurance companies or Medicaid officials or someone else.

So I agree with you. I want health care to be controlled by individuals but we all have to answer to someone. And I just can't go to the doctor and get everything I want. They tell me that's not part of the policy or not treated for that.

Let me go next to your statement on the first preserving their right to be able to spend their own money and then let me understand that in Arizona there's a constitutional amendment that the goal is to preserve the right to always be able to spend your own money for lawful health care services.

MS. HANSEN: That will be on the ballot in 2010.

REP. GREEN: Is there something in Arizona law that prohibits people from spending their own money for their health care?

MS. HANSEN: No but it is in federal law. Then there's the 1997 Balance Budget Act that effectively prevents Medicare beneficiaries from spending their own money. So if you're the patient on Medicare and you come to me as a Medicare provider and let me give you 00 if you bear with me because it only takes a moment to explain -- to do an example.

If you've had your hip replaced for example two or three times and you need it done for the fourth time, which happens, you want to go to somebody who really knows what they are doing. Well the physician you want to go to who does a lot of hip replacements, what we're seeing more and more frequently is that those people are no longer doing what we call redo or revision operations. And the reason is why for a primary or first time uncomplicated hip replacement, Medicare pays $1,400.

REP. GREEN: I understand where you're coming from. Let me give you another example, though, because I'm out --

(Cross talk.)

REP. PALLONE: The gentleman -- excuse me. You're over almost a minute-and-a-half, so I'd like to end this if I --

REP. GREEN: Well, let me ask you just to compare to that, if someone comes in to you to buy insurance right now --

REP. PALLONE: Well, Mr. Green, you can't -- you can't ask an additional question.

REP. GREEN: You don't have time?

REP. PALLONE: If he wants to respond fine, but we will have --

REP. GREEN: I just wanted to make the comparison Mr. Chairman --

(Cross talk.)

MS. HANSEN: -- $250 difference for what could be three times the work. So if you say I want Dr. Jones to do the operation, I'll pay you the difference out of pocket because, with that extra time the only recourse the physician has is to resign from Medicare and not see any Medicare patients for two full years.

REP. PALLONE: If you want to respond to that, you can but I've got to move on.

MS. HANSEN: -- basically an effective prohibition -- (inaudible).

REP. PALLONE: All right. If you want to respond to that --

REP. GREEN: And a number of members here who had voted for that Balanced Budget Act in '97, there's a lot of things that happened since then I disagree with. But I also know one of the concerns is is that in an area that I have that's not a wealthy area, if we didn't have that, if we didn't have the current provision in there in the '97 Act, we would not have people being able to find a doctor to be treated under Medicare because they couldn't afford that extra money plus what they're already spending on Medicare.

Thank you Mr. Chairman.

REP. PALLONE: Okay. Thank you.

Gentlewoman from Tennessee, Ms. Blackburn.

REP. BLACKBURN: Thank you Mr. Chairman and thank you all for taking your time to be here. Ms. Holmes, I wanted to talk with you for a few minutes. It sounds like you had an incredible journey and you were happy to be able and grateful and fortunate to be able to find health care.

You were here during the first panel, and you've heard what I've had to say about TennCare in the state of Tennessee and our concerns there, because what you outline in your testimony is what I see happening many times in our state. You had to fly 2,000 miles to access health care. In rural west Tennessee, the cause of all the cost-shifting that has taken place because people are not able to access health care, and many providers are no longer taking TennCare, then they find that that health care is available a long way away from them. And sometimes, you know, 30 miles might as well be 3,000 miles, if no one has the ability to take you there.

And I am just assuming from what I read in your testimony and listening to you that your outcome, had you had to depend on a single payer system that allows you no recourse, that allows you no alternative, which said, "Take a number, get in the queue and wait your turn" -- that your outcome would have been very, very different.

MS. HOLMES: Very, very different. And this is the whole reason why I'm here, because I feel very -- you know, to stick my nose in American business, but I was fortunate to be able to come here. But not only did I have to travel away from home, I had to travel outside my country. And when it gets like that -- because I -- it's actually illegal for me trying to do what I did in Canada. And that's what we have to be able to do, open the doors of communication about it and realize that you get rationed care. You get -- it's one thing to not have insurance, and it's another thing to have insurance and not have doctors.

REP. BLACKBURN: So basically, your government-provided insurance -- when you needed it, your government-provided insurance was worthless to you.

MS. HOLMES: Exactly.

REP. BLACKBURN: So you mortgaged your home, put a second mortgage on your home. Your husband picked up a second job.

MS. HOLMES: That's right.

REP. BLACKBURN: And you got the money that was necessary, the hundred thousand dollars to pay for that.

Now, when you had flown to Mayo and then you went back to Canada with your test results and you said, "All right, here it is. I'm going to be blind in six weeks," did a bureaucrat make the decision or a physician make a decision --

MS. HOLMES: They wouldn't even look at my medical reports. It was, get back in line and wait till we get to you --

REP. BLACKBURN: So the bureaucrat turned to a citizen and said, "You're out of luck, get in line."

MS. HOLMES: Get in line.

REP. BLACKBURN: That's real compassion, isn't it?

MS. HOLMES: No, absolutely zero compassion from a country that's known to be compassionate, the same country that will cover illegal immigrants the second they arrive in our country.

REP. BLACKBURN: Okay. Thank you, ma'am.

Ms. Hansen, a quick question for you. And thank you for being here. And I know you all work hard for our nation's seniors.

I have lots of seniors in my district. And I had the opportunity this weekend to visit with some of them. You know, there are really very concerned about what they've been hearing from the Obama plan, because they feel like they've had money taken out of their paycheck every week and now they get to near retirement or they get to retirement, and they're being told basically that that is worthless to them, that if there is a nationalized plan, that they're going to be treated more like they're -- they're feeling they're going to be treated more like Medicaid than Medicare. And they are very, very concerned about losing Medicare Advantage. They're very concerned about losing options. They're concerned about losing their Part D coverage.

What is -- what would you suggest that I tell these seniors that say, "I have been putting money in. It has -- it is my money. It has come out of my paycheck. I have been letting the government have first right of refusal on that money all of these years, and now it is basically people -- everybody's going to have the same thing"? So what do -- how do you respond to that? What should I tell the seniors?

MS. HANSEN: Well, I think that -- what I think I've heard that -- the president says that if you have current insurance and it works for you, you can keep it. So I don't know if in this discussion, whether it is that everything comes back into the pot. And I don't think that the Medicare program is meant to be structurally dismantled. So I think that -- that my sense is that their assurance, whether it's the Medicaid program that Dr. Edelman's spoken about and Medicare -- I mean, we have these right now codified in law with each of these different parts, so there is that.

I think one of the things that we want to do is to make sure they get best value for their hard-earned money for what they've spent. So in other words, we want to make sure they get safe care. We want to get timely care. We want to make sure that when they need medications -- and most older people have medications -- obviously the fact that it's affordable for them. So these are things that I know AARP really strongly supports. And so I think the ability to really square as to what is discussed about President Obama's plan and the principles of maintaining choice, coverage and private options.

REP. BLACKBURN: Thank you, I yield back.

REP. PALLONE: Thank you.

The gentlewoman from Ohio, Ms. Sutton.

REP. SUTTON: Thank you very much, Mr. Chairman.

Five minutes isn't going to do it, but I'm just going to request that Ms. Wright Edelman and Jen Hansen and Dr. Shern, if I can follow up with you outside the committee to talk about some ideas of how we might strengthen some things and make this work for our children and our seniors and those who have needs, Dr. Shern, that you have so eloquently identified.

And I just -- I just -- I want to thank you very much, Ms. Robertson-Holmes, for coming and testifying, and Dr. Novak. And I want to just address the issue that I think that you raised. And I think it is very important, as we have this discussion, to talk about the reality that this isn't just about getting people health care insurance. This is about improving the delivery of health care to people when they need it the most, in a way that makes sense both for health outcomes and economically.

And so your point is well taken when you talk about -- you paid for your insurance, right, and then when you needed it it wasn't there. Okay. Now, I guess -- I listened to you and I'm so struck because I was in the state legislature in Ohio and I did a lot of work on this issue related to the private insurance industry. And that very same problem -- people who paid for care and then when they needed it and their doctor said they needed it they weren't -- the insurer wouldn't pay for the coverage that they had been paying for all of this time.

And there was a person by the name of Linda Kerns. Linda was a -- it's K-E-R-N-S, doctor -- and Linda was a witness who came into testify. And Linda was a very special person, as most people are. But she was special because she was actually an H.R. person for an insurance company, okay. And Linda had a history in her family of breast cancer, and it was a very aggressive form of breast cancer. And so her doctor, when she went in for a treatment -- that she was vulnerable to this potential for breast cancer -- the doctor wanted to treat her aggressively. And the insurance company bureaucrats overruled the doctor and said, "No, I'm sorry. You've been paying for coverage, but that coverage -- that care is not going to be provided. We don't think you need it." Okay. So she didn't get it. She didn't get that coverage.

Now, what she did was what you did. She eventually, over time, with great delay, raised the money and went into debt to get that surgery. But there was a delay, right. And so there's -- we really never know the value of that delay to the health outcome.

MS. HOLMES: (Off mike.)

REP. SUTTON: And in this country, unfortunately, there was no recourse for her, even if there was a proven health consequence to the unreasonable delay or denial of that coverage, even though if a doctor had done it -- if a doctor had said, you're -- we're not giving that to you, and then he was found to have unreasonably delayed or denied, then there would have been a malpractice case against them. There was no accountability for that private insurer to be held accountable for the health outcome other than the cost of the procedure, not the loss of life or health.

MS. HOLMES: (Off mike.)

REP. SUTTON: Okay. And, see, that's my -- and this is my point, though, isn't it? Because you experienced that under your system. We see people experience that here under our system as well and people going into bankruptcy, people going -- because the costs are spiraling or they don't have access to the care they need when they need it.

And the problem is that I guess maybe what I would just ask is that if you had -- and you talked about the need to have some competition for your government-run plan. And that's exactly what we're offering here. We're assuring that people will have access to coverage in this country. And, you know -- and right now, the private insurers are the only game in town. And so if they unreasonably delay or deny, no accountability. But if we have a public option that also allows people to have the chance to purchase it, that that can not only drive down costs, but I would argue can drive up the quality of the delivery of care.

And so I just -- I just point that out, because I can't help but think of Linda, who --

MS. HOLMES: (Off mike.)

REP. PALLONE: Ms. Robertson, I -- you've got to turn that mike on, because otherwise you won't be transcribed.

MS. HOLMES: Okay. The major difference between her and I is that what I did, by coming to this country, mortgaging my house, et cetera, et cetera, was illegal for me to do at home. That's not an avenue for me to do at home. I cannot step out of that. I am mandated to use that, and that is --

REP. SUTTON: And you would have preferred to have the option of buying private health insurance.

And then you would be --

MS. HOLMES: (Inaudible) -- if worse came to worse, the same situation had happened to me here, I could have at least stayed in my house, had my children with me, had my father -- you know, months before he passed away -- still with me at my hospital bed. Instead, I was in Arizona 2,000 miles away alone.

REP. SUTTON: I understand. And I thank you very much for your testimony.

And I know that I'm out of time, so bureaucrats there, bureaucrats here -- of course, this bill, I know you had the question, Dr. Novak, from our chairman emeritus about the exact language that you used in your testimony to describe the bureaucrats that will, in your opinion, be performing the functions under this bill. But it really does provide, the bill, if you find the language, it provides for health care professionals to do the analysis.

And of course, what we must tell the American people is that right now insurance companies are doing it. So with all do respect -- thank you.

REP. PALLONE: Well, now, listen. I'm sorry.

The gentlewoman from Florida, Ms. Castor. And I apologize that I passed over you by mistake.

REP. CASTOR: Thank you, Mr. chairman, very much. And thanks again to all the witnesses that are here.

So Dr. Shern, you were an outstanding director of the Florida Mental Health Institute in Tampa at the University of South Florida. They miss you there. We miss you -- USS is doing great things, as you know, in medical -- in health care policy and research.

And you know, back in Tampa before I was elected to Congress I served as the county commissioner. And the county government there has the responsibility for all health and social services -- including fairly robust children's services, compared to many other places across the country.

But I was always floored by the total lack of mental health care services. There is nothing! There is nothing for these families that struggle day-to-day with what's going on in their homes.

Now, of course, the county government also has responsibility for law enforcement and the county jail. And the greatest advocate for mental health care services was always the sheriff and the folks that were running the county jail, because the understood the population in jail. And that's the most expensive way to address mental health care in America.

So I'm pleased that the discussion draft here in the House takes the first few steps in providing that comprehensive early-integrated care. And there's no better place to start, of course, than children's health.

You know, I think as a mother -- what would I do if I didn't have the same pediatrician that I've had for my daughter's 12 years of life? To be able to just make that phone call to call a nurse in the office? It's very cost effective rather than trying to chase down -- go to a clinic or go into the emergency room. We're all paying for that very expensive model out there.

If you have health insurance and you think you're not paying for other people's care right now, you're wrong. You are paying -- that's one of the reasons your health insurance bills and co-pays have been increasing over time to such a great extent, because of the uninsured showing up in the ER.

But to promote this early-integrated comprehensive care reform that we've taken the stab at here early in our discussions draft, I'd like you to focus on a couple of things. Work force: Do we -- we know we don't have those primary care medical professionals and I'm not sure we have the mental health professionals that we need. Are we doing enough in our discussion draft to tackle that problem?

We've also -- and I'd also like you to address two terrible bureaucratic (threats ?) this (element ?) has emphasized that time and time again. You have some good recommendations in here, but I don't think the discussion draft goes far enough.

We need -- you know, in the state of Florida we have 800,000 children that do not have that easy access to the doctor's office. The state of Florida, one time, even quit printing the application for for SCHIP.

So what else can we be doing to knock these crazy bureaucratic barriers that make it difficult for a parent just to walk into the doctor's office to make sure that their son or daughter gets a check up?

So the work force issue and this terrible bureaucracy.

DR. NOVAK: Well, work force is a critically important component. And I'm heartened that it's addressed in the bill. And of course, we'd always like to be able to do more, because we have a real pipeline problem in terms of people who are being trained to deliver the services that we need across the spectrum.

And you've talked about primary care physicians and I think we continue to rely more and more and more on primary care positions in the medical home. And as we know, our current incentives system isn't producing enough primary care physicians and we're not reinforcing them or rewarding them to the degree which we can or should.

Additionally, I think we need to think about what we can do to continue to improve practice of people who are in practice now. We don't have very good models for doing that. We have kind of what's been characterized as the Nike model. So of train them and say, "Okay, go out and just do it." We give them CME, but we know that the CME doesn't do what it needs to in terms of improving skills.

And there are other models. Some of the hope of HIT is better support and comparative effectiveness research. So better support for people to make better decisions. And I think I will defer to my colleague, Ms. Wright Edelman, to talk about the bureaucracy.

MS. EDELMAN: (Off mike) -- eligibility everybody -- (off mike). A single set of benefits that are child appropriate. And secondly -- and third, we've talked about all the simplifications that we have in the legislative language. They're all included and the All Healthy Children Act would be another terrific start.

But getting rid of all the state lottery and all the district things and the two child health bureaucracies that put the children in the exchange or in -- (off mike) -- or in Medicaid or in CHIP should all get -- (off mike) -- sort of measures that we all know how to do.

And I just hope that you'll look at the specific legislative language. I'd be happy to submit part of -- (inaudible) -- and these are the two child health reforms that we need in order to make sure -- (off mike).

REP. PALLONE: Mr. Sarbanes.

REP. JOHN SARBANES (D-MD): Thank you, Mr. Chairman.

I want to thank the panel.

Mr. Chairman, I want to thank you and Chairman Waxman and everyone who's been working on this issue for so long, because this is it. This is not a dress rehearsal. These panels that we're having probably are kicking themselves that they are here to speak on an actual discussion draft that includes these critical proposed changes to our health care system.

And I just hope that Americans watching this realize that this is exactly what they were pushing for in the last couple of elections when they were expressing their frustration with the current health care system.

This is our chance to get this right. It doesn't have to be perfect, but we have to get a new framework in pace -- one that we can build on and one that answers the frustrations and feeling of helplessness that millions of Americans feel out there.

I think the source of that manifold, but I'll point to a couple of things -- that sense of helplessness that I'm describing. One is that your dealing with an insurance industry that appears to be primarily engaged in the exercise of denying payment for the kinds of services that people need. And there's a paper chase. You get the things in the mail that say "We will not pay. This is not a bill. This is your third notice; this is your fourth notice." Many Americans just give up after a certain point, because they can't fight it.

So that's one source of the frustration. That's why I think we need a public plan option to compete and I'm not going to revisit that discussion. But as the train leaves the station on health care, public plan isn't on the train, it's a train to nowhere. It's got to be there.

The second source of frustration on the part of many people is that they know that there are certain kinds of things that if that was reimbursed in the system it would be better for their health, it would save the system money over the long term. They can see it. It's right there, but the system doesn't cover it.

Elderly patients know that if they can spend another 20 minutes with their physician or a half an hour, God forbid, that in that time, the physician could better understand their situation and probably prescribe a regime that would make a lot more sense to that patient and save the system over the long term. But physicians who do that are penalized by a system that doesn't recognize that kind of primary, preventive care.

So that's another thing that needs to be on the train as it leaves the station -- primary and preventive care. And the other one is investing in the work force, because if we have the coverage, that's all very well. You show up with your insurance card, but there's no providers to deliver the care.

So these are all things that are part of this draft. This is why people need to be incredibly excited. We are talking about this right now. This is it! This is it. This is the moment.

Now, with that preface, let me go to health care delivery. I wanted to ask you, Ms. Wright Edelman, because you talked a lot about SCHIP and getting these services to children, but we continue to be frustrated on kind of the delivery system.

Congresswoman Capps and I have pushed to try to create more school-based health centers and also allow for reimbursement of services provided there if they would otherwise be reimbursed if delivered in a physician setting -- a physician office setting -- and so forth.

Could you just speak briefly to this idea of capturing people where they are? This concept of place-based health care. Go to where the children are and make it easier to access services at that point on the front end. Ninety-eight percent of our kids ages five to 16 are in one place five days a week --

MS. EDELMAN: That's true.

REP. SARBANES: -- for six to seven hours. We ought to take advantage of that. So if you could speak to that as part of this overall perspective.

MS. HOLMES: I just think that -- I just want to say "amen"! You go to where they are. You make it as easy as you can. We need to expand the community health centers; we need to expand school-based health centers. We to again get mothers in WIC and that's where kids are coming in. You get them enrolled and you make sure that you're making it available.

And one of these days I look, as we talk about health and school reform, is that we can really the new schools that we construct real community centers and co-locate services so it's easy rather than hard for people to get their care.

So whatever we can do to go where children and families are and make sure that it's accessible would be terrific. None of this is rocket science. I think we know how to do it.

And I just want to reemphasize what you have just said. This is it. You've got all the skeletons for what you need to get done in your plan. We just need to kind of finish it, make sure you've got the structural reforms there.

And I would just like in one little thing -- (off mike) -- this is not a dress rehearsal. This is a window of opportunity. If we miss this opportunity, we're going to lose more generations of children and see escalating costs. And I just was looking for a thing that's in the written testimony about the president's statement. And I guess I think it states what you have stated in strong terms.

But he says, "I refuse to accept" -- when he was signing the CHIP bill -- "that millions of our kids fail to reach their potential because we fail to meet their basic needs. In a decent society there are certain obligations that are not subject to tradeoffs or negotiations." Health care for our children is one of those obligations. This is the moment to fulfill that obligation, for you to fulfill it. You know how to do it. You've got lots (of the bill ?) done. We've been working -- and many of the leaders here -- on Medicaid for 42 years.

You know, we know from the incremental problems how to make it simple. But we can address the health infrastructure. You made such a good start. I just hope you can just finish it and make it complete and make sure that it's transformation and true health reform for all of us.

REP. SARBARNES: Thank you very much.

I yield back.

REP. PALLONE: Thank you.

And I think we're done with the questions, but I want to thank all of you again. Obviously, what we're doing is crucial and we really do plan to move ahead and meet the president's deadline.

So thank you very much.

DR. NOVAK: Thank you.

REP. PALLONE: Again, you'll get written questions, you know, within the next 10 days and we'd ask you to respond to those.

And could I ask the next panel to come forward, please?

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