[House Hearing, 112 Congress]
[From the U.S. Government Publishing Office]

EXAMINING THE IMPACT OF OBAMACARE ON DOCTORS AND PATIENTS

=======================================================================

HEARING

before the

SUBCOMMITTEE ON HEALTH CARE, DISTRICT OF
COLUMBIA, CENSUS AND THE NATIONAL ARCHIVES

of the

COMMITTEE ON OVERSIGHT
AND GOVERNMENT REFORM

HOUSE OF REPRESENTATIVES

ONE HUNDRED TWELFTH CONGRESS

SECOND SESSION

__________

JULY 10, 2012

__________

Serial No. 112-183

__________

Printed for the use of the Committee on Oversight and Government Reform

Available via the World Wide Web: http://www.fdsys.gov
http://www.house.gov/reform

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COMMITTEE ON OVERSIGHT AND GOVERNMENT REFORM

DARRELL E. ISSA, California, Chairman
DAN BURTON, Indiana ELIJAH E. CUMMINGS, Maryland,
JOHN L. MICA, Florida Ranking Minority Member
TODD RUSSELL PLATTS, Pennsylvania EDOLPHUS TOWNS, New York
MICHAEL R. TURNER, Ohio CAROLYN B. MALONEY, New York
PATRICK T. McHENRY, North Carolina ELEANOR HOLMES NORTON, District of
JIM JORDAN, Ohio Columbia
JASON CHAFFETZ, Utah DENNIS J. KUCINICH, Ohio
CONNIE MACK, Florida JOHN F. TIERNEY, Massachusetts
TIM WALBERG, Michigan WM. LACY CLAY, Missouri
JAMES LANKFORD, Oklahoma STEPHEN F. LYNCH, Massachusetts
JUSTIN AMASH, Michigan JIM COOPER, Tennessee
ANN MARIE BUERKLE, New York GERALD E. CONNOLLY, Virginia
PAUL A. GOSAR, Arizona MIKE QUIGLEY, Illinois
RAUL R. LABRADOR, Idaho DANNY K. DAVIS, Illinois
PATRICK MEEHAN, Pennsylvania BRUCE L. BRALEY, Iowa
SCOTT DesJARLAIS, Tennessee PETER WELCH, Vermont
JOE WALSH, Illinois JOHN A. YARMUTH, Kentucky
TREY GOWDY, South Carolina CHRISTOPHER S. MURPHY, Connecticut
DENNIS A. ROSS, Florida JACKIE SPEIER, California
FRANK C. GUINTA, New Hampshire
BLAKE FARENTHOLD, Texas
MIKE KELLY, Pennsylvania

Lawrence J. Brady, Staff Director
John D. Cuaderes, Deputy Staff Director
Robert Borden, General Counsel
Linda A. Good, Chief Clerk
David Rapallo, Minority Staff Director

Subcommittee on Health Care, District of Columbia, Census and the
National Archives

TREY GOWDY, South Carolina, Chairman
PAUL A. GOSAR, Arizona, Vice DANNY K. DAVIS, Illinois, Ranking
Chairman Minority Member
DAN BURTON, Indiana ELEANOR HOLMES NORTON, District of
JOHN L. MICA, Florida Columbia
PATRICK T. McHENRY, North Carolina WM. LACY CLAY, Missouri
SCOTT DesJARLAIS, Tennessee CHRISTOPHER S. MURPHY, Connecticut
JOE WALSH, Illinois

C O N T E N T S

----------
Page
Hearing held on July 10, 2012.................................... 1

WITNESSES

The Honorable Jeff Colyer, M.D., Lt. Governor of Kansas
Oral Statement............................................... 7
Written Statement............................................ 9
Mr. Richard A. Armstrong, M.D., Chief Operating Officer, Helen
Newberry Joy Hospital
Oral Statement............................................... 16
Written Statement............................................ 18
Mr. Ron Pollack, Founding Executive Director, Families USA
Written Statement............................................ 23
Oral Statement............................................... 25
Ms. Sally Pipes, President and CEO, Pacific Research Institute
Oral Statement............................................... 29
Written Statement............................................ 31
Mr. Eric Novack, Phoenix Orthopaedic Consultants
Oral Statement............................................... 36
Written Statement............................................ 38
Mr. Kelvyn Cullimore, Jr., Chairman, President and CEO,
Dynatronics
Oral Statement............................................... 47
Written Statement............................................ 49

APPENDIX

Testimonials from Physicians..................................... 78
Graph on the Average annual cost of family health insurance
premium in the U.S., Rhetoric vs. Reality on Premium cost...... 82
Letter sent to The Honorable Trey Gowdy and The Honorable Danny
Davis from the Doctors For America............................. 83

EXAMINING THE IMPACT OF OBAMACARE ON DOCTORS AND PATIENTS

----------

Tuesday, July 10, 2012

House of Representatives,
Subcommittee on Health Care, District of Columbia,
Census, and the National Archives,
Committee on Oversight and Government Reform,
Washington, D.C.
The subcommittee met, pursuant to call, at 10:00 a.m., in
Room 2154, Rayburn House Office Building, Hon. Trey Gowdy
[chairman of the subcommittee] presiding.
Present: Representatives Gowdy, Gosar, DesJarlais, Walsh,
Issa (ex officio), Davis, Norton, Clay, and Murphy.
Also Present: Representatives Chaffetz, Gingrey, Benishek,
Fleming, Harris, Speier, and Maloney.
Staff Present: Ali Ahmad, Communications Advisor; Brian
Blase, Professional Staff Member; Molly Boyl, Parliamentarian;
John Cuaderes, Deputy Staff Director; Adam P. Fromm, Director
of Member Services and Committee Operations; Mark D. Marin,
Director of Oversight; Laura L. Rush, Deputy Chief Clerk;
Noelle Turbitt, Assistant Clerk; Jason Bourke, Minority
Director of Administration; Yvette Cravins, Minority Counsel;
Adam Koshkin, Minority Staff Assistant; Suzanne Owen, Minority
Health Policy Advisor; and Safiya Simmons, Minority Press
Secretary.
Mr. Gowdy. Good morning. This is a hearing entitled
``Examining the Impact of ObamaCare on Doctors and Patients.''
The committee will come to order. I will recognize myself for
the purpose of making an opening statement, and then the
ranking member, the gentleman from Illinois. Good morning,
again, and thank you for being here.
The recent Supreme Court decision focuses anew our
attention on health care and the role of government therein.
People are rightfully concerned about how the rising cost of
health care is crowding out other financial priorities for
their families; however, in the ongoing debate over increasing
health costs and taxes, we will do well to study the impact on
doctors and patients.
Today we will examine an often neglected, but very relevant
aspect of the Affordable Care Act. We will hear from doctors
whose primary concern is that the Affordable Care Act
significantly increases government's role in healthcare. For
example, the law creates 159 new agencies, boards, and
committees to control how physicians do their jobs.
Additionally, the Affordable Care Act has already generated
over 12,000 pages in regulations and administrative
requirements that only serve to distract and delay a doctor's
primary objective, which is to provide care to patients. These
requirements disproportionately hurt small practice doctors the
most, since larger practices have more leverage with insurance
companies and larger staff to handle the burden of an ever-
increasing paperwork.
According to the American Association of Medical Colleges,
America will experience a doctor shortage of 124,000 to 159,000
physicians by 2025. Compounding this problem will be a surge in
demand. The Affordable Care Act spends nearly $2 trillion
subsidizing health insurance over the next decade. The result
of this new spending will be a massive increase in the demand
for healthcare services, which will inevitably mean longer wait
times for appointments and less time doctors are able to spend
with each patient.
Without fundamental reform our Nation's healthcare
infrastructure will not be able to handle this surge in demand.
The problem of access to care is especially troubling for
participants in government programs; namely, for those on
Medicaid and Medicare. The Affordable Care Act increases
Medicaid enrollment by nearly 20 million Americans. Medicaid is
already in dire need of reform. It is too large and complicated
to effectively serve its patients. In fact, it is so
overburdened right now less than half of all physicians accept
new Medicaid patients because of the low payment rates and high
administrative cost. Under the new healthcare law, enrollees
will continue to overwhelm emergency rooms because of a lack of
access to primary care physicians.
The Affordable Care Act is also bad for seniors on
Medicare. First, the law cuts Medicare Advantage, reducing
choices for seniors; secondly, the law cuts overall Medicare
spending by $500 billion over the next decade and uses these
savings for new government spending.
In fact, these effects are so disparaging that the chief
actuary at the Center for Medicare and Medicaid Services
believes the cuts to Medicare will lead to 15 percent of
providers closing their doors by the end of the decade.
At point, a personal digression, and in the interest of
full disclosure, my father was a physician. I suspect it is
best to characterize him as still being a physician. He just
doesn't practice medicine anymore.
I remember when I was a kid he was paid in vegetables. He
was paid by people who would cut the grass at our home in
exchange for him taking care of their children because they
couldn't pay in cash, some of which is now illegal. He never
refused to see anyone regardless of their ability to pay, and
he didn't need the government telling him that it was the right
thing to do. He did it because medicine was, and is, a noble
profession. It is a helping profession. Regrettably, it now
looks more like a business.
I have scores of friends back home who are doctors, which
is unusual for a lawyer, but nonetheless I do, and I don't know
a single one who would recommend to his or her kids that they
pursue a career in medicine.
So I will look forward to hearing from our witnesses about
the Affordable Care Act's impact on doctors' ability to
effectively practice medicine and the key challenges they face
from the law. Instead of retroactively addressing the
impediments of the Affordable Care Act, it is my hope that this
hearing will aid the committee in its efforts to move forward
in implementing genuine healthcare reform, reform that is
backed by doctors that empowers patients and that lowers
healthcare cost for everyone.
With that, I would recognize the ranking member, the
gentleman from Illinois, Mr. Davis.
Mr. Davis. Thank you very much, Mr. Chairman, and let me
just say that, you know, I think that people like your father
were absolute jewels. They were the salt of the earth, pillars
of the universe. As a matter of fact, I encountered a few of
them where I grew up. There was one doctor in our county, named
Dr. Crandall, and you couldn't get a better physician than he
was.
Mr. Chairman, let me thank you for calling this hearing,
and let me state up front that I believe that healthcare should
be a right and not a privilege afforded to just a few. And I am
absolutely and firmly convinced that because of the Affordable
Health Care Act millions of Americans will live better, longer,
healthier, and higher quality lives.
Now that the United States Supreme Court has held the law
to be constitutional, millions of Americans can know that their
health coverage is on the way and that it is here to stay.
I must confess that I am somewhat mystified by what the
majority thinks it's doing. Today the Republican leadership
scheduled the House to begin debate on a bill to repeal the
Affordable Care Act. This will be the 31st time that House
Republicans voted to repeal the Affordable Care Act, and it
will be the 31st time it will not be repealed.
Today's subcommittee hearing purports to examine the
efforts of doctors and patients. But for a serious discussion
of the impact of mandated care on doctors and patients we need
to look no further than Massachusetts. Since 2006,
Massachusetts under Governor Romney mandated near universal
coverage for its population. Curiously, the majority did not
invite a single doctor or patient from Massachusetts to share
their experiences.
In fact, the majority invited no patients at all. The lone
patient representative invited today was chosen by the
Democrats of the committee. The majority has granted us only
one witness. Why are there no physicians on the panel from the
only State in the union with mandated care? Perhaps it is
because the majority know that you do not hear complaints from
physicians there. In fact, polls show that Massachusetts'
doctors in large numbers support the healthcare law. The New
England Journal of Medicine published a poll recently,
conducted by the Blue Cross/Blue Shield Foundation, of over
2,000 doctors, and 88 percent believe the reforms improved or
did not affect negatively the quality of patient care in
Massachusetts.
So in order to complete the record to date, I am
supplementing the hearing record with actual testimony from
Massachusetts doctors. Many Americans are already benefiting
from the protections provided to patients in the ACA. Eighty-
six million Americans have free preventive care; 6.6 million
college students remain on their parents' insurance policy; 105
million Americans have no lifetime coverage limits; and 16
million are no longer vulnerable to rescission of insurance
coverage after precipitated health events. For doctors the ACA
provides grants to States to increase the healthcare workforce.
There are incentives for primary care physicians, nurses and
healthcare practitioners, and doctors are no longer saddled
with debts from uninsured patients.
I want the American public to know that Massachusetts
doctors firmly believe the bill has gone through thousands of
hours and they believe that the doctors there think it's
necessary, that it's beneficial, and that it is helpful.
So today, we will hear from physicians who have not had the
same experiences as the doctors in Massachusetts. But I
certainly thank you for the hearing, and thank the witnesses
for their participation.
Mr. Gowdy. I thank the gentleman from Illinois. Members may
have 7 days to submit opening statements and extraneous
material for the record. It is now our pleasure to----
Mr. Issa. Mr. Chairman.
Mr. Gowdy. Yes, sir, Mr. Chairman.
Mr. Issa. If I could seek recognition for one minute.
Mr. Gowdy. Without objection.
Mr. Issa. I appreciate that. Listening to the ranking
member, I do have to comment that when ObamaCare was being
rammed down the throat of the minority we were denied any
witnesses. When ObamaCare was being put together in the dark of
night without Republicans in the room, or even the public in
the room, we were denied all activity.
In fact, when the Speaker said, we have to pass it to find
out what is in it, we knew exactly what we were in for.
Something that purported not to be a tax, and then had to be
distorted into being a tax in order to pass constitutional
muster.
So as the ranking member said, yes, the Supreme Court has
spoken, and yes, with 12,000 new pages, and growing, of
additional bureaucracy and requirements, and costs going up
logarithmically, the gentleman in fact is correct that maybe no
one is complaining in Massachusetts, a State with only 4
percent at the time of the enactment uninsured, but the Nation
and my State, with over 16 percent uninsured, finds itself with
no cost controls, Medicaid, a very ineffective program from a
cost-containment standpoint, and other programs driving up the
cost while in fact driving out doctors from practicing. And
people like the chairman's father are choosing to retire rather
than live under ObamaCare.
So I certainly hope that the ranking member when he
complains about the one witness, which is the custom, would try
to remember that under Chairman Towns, the minority was given
no witnesses repeatedly, and ObamaCare was not even offered for
this committee to have an opportunity under the previous
chairman.
And I thank the gentleman and yield back.
Mr. Davis. Will the chairman yield?
Mr. Issa. Of course I yield.
Mr. Davis. Thank you, Mr. Chairman, and let me just say
that I certainly appreciate your comments, and you know, I
remember my mother telling us when I was growing up that right
is right, if nobody is right and wrong is wrong if everybody is
wrong.
Thank you.
Mr. Issa. Well, I'm glad to hear that you realize that you
were all wrong. I yield back.
Mr. Gowdy. I was a little premature in beginning to
introduce our panel of witnesses. We will recognize the vice
chairman, the gentleman, the doctor, from Arizona, and then the
gentleman from Missouri for opening statements as well. Dr.
Gosar.
Mr. Gosar. Thank you, Mr. Chairman, and thank you for
calling this hearing today. We certainly appreciate it. And
thanks for all of the distinguished witnesses. I want to offer
a special welcome to Dr. Eric Novack from the State of Arizona.
It is an absolute privilege, Eric, for all you have done for
Arizona, the patient/doctor relationship and across the
country. So thank you so very, very much. It was great seeing
you traverse Arizona all those times.
You know, we need a patient-centered reform, not reform
dictated to every doctor's office in the country from
bureaucrats. In fact, as a dentist for over 25 years of private
practice before coming here to Congress, most of the symptoms
of our ailing healthcare system come down to one root cause;
the fracturing of the doctor/patient relationship. When
President Obama set out to pass a healthcare reform package he
promised doctors that little would change for them in their
practices and that the folks who didn't have insurance would
now have it. Today's hearing will examine the ways in which
this promise has rung false.
The President's healthcare law is full of reporting
requirements and regulations for practicing physicians. It
stands to reason that the larger practices or hospitals will
have greater leverage to handle these requirements than a sole
practitioner. Physicians in my district are worried that the
private practice model will erode and eventually be
unsustainable. Such a development would be devastating to the
practice of medicine.
The law also contains over 100 new boards, panels, and
groups of bureaucrats to manage and dictate healthcare
decisions, and gives the Secretary of Health and Human Services
unprecedented authority to dictate standards of care across the
country. Imagine a Washington bureaucrat sitting with you in
the doctor's office as you are examined, as you discuss
delicate issues concerning your health. That is the effect that
this law will have on the doctor/patient relationship.
Furthermore, the proposed expansion of an unreformed broken
Medicaid system will be unmitigated disaster. What good is
expanding Medicaid if the program is such a bad deal for
providers that a Medicaid card isn't worth the paper it is
printed on. When I was a dentist practicing in a low income
area of a rural community, I found that I was better able to
deliver care to people of all incomes and ages when I took the
Medicaid system out of the equation entirely.
We need to come together as a nation, and find ways to
lower the cost of health care for the young, the old, the
healthy, and the sick, not pursue party-line legislation, that
enriches bureaucrats and special interests at the expense of
our healthcare system. Let's reenervate the doctor/patient
relationship with a patient-centered patient-friendly
healthcare system, and I yield back the balance of my time.
Mr. Gowdy. Thank the gentleman from Arizona. The chair
would now recognize the gentleman from Missouri, Mr. Clay.
Mr. Clay. Thank you, Mr. Chairman, and thank you for
conducting this hearing. And in response to the last two
speakers on your side, Chairman Issa as well as Dr. Gosar, I
think it would have been relevant if we could have had a doctor
from Massachusetts to be a part of this hearing. You know,
their views would have been relevant since for the past 5 years
they have been living with comprehensive healthcare reform,
signed into law by Governor Mitt Romney, that is substantially
similar to the Affordable Care Act.
But the Democratic staff gathered testimonials of numerous
Massachusetts physicians relating to their experience and the
impact upon their patients and let me share just a few of them.
From a Boston cardiologist, I quote him, ``I have never
felt more confident when my patients and I together are making
the best decision for them without influence of outside
agents.''
Another Boston primary care physician, quote, ``Before
health reform my patient was not able to see a physician and
tried to avoid care except in the case of emergency. Now, I or
a colleague can see her for both preventive and urgent care
since insurance is within her reach.''
A physician from Brookline, Massachusetts states, ``Instead
of worrying about getting paid for each individual visit, we
reach out to patients to prevent repeat office visits,
hospitalizations, and deteriorations. My patients feel cared
for and I know they are receiving better evidence-based care.''
So there are benefits to a law like the Affordable Care Act
when you look at how the insurance industry has come on board,
and voluntarily, seeing some of the benefits in this. It speaks
volumes about how this law will help hundreds of millions of
Americans, and it also speaks volumes about the majority in
this House who has decided that they want to repeal this law.
And it kind of defines where we are going with this debate;
that we are going to divide this country between the haves and
the have-nots, and that this is a class struggle.
If you are fortunate enough to be able to afford health
insurance, then it is okay. You can take care of yourself. But
if you are not, you are on your own, or if you have a job that
doesn't provide you with healthcare coverage, then too bad. And
I think we are a better nation than that, Mr. Chairman, and we
should try to follow that example in this institution.
With that, I yield back, and look forward to the witnesses'
testimony.
Mr. Gowdy. I thank the gentleman from Missouri. It is now
our pleasure to welcome our distinguished panel of witnesses. I
will introduce from your right to left, my left to right, and
then we will recognize you for your opening statement in the
same manner. Dr. Jeff Colyer is a physician and the Lieutenant
Governor for the great State of Kansas. Dr. Richard Armstrong
is a physician in Michigan and Chief Operating Officer of
Docs4PatientCare. Mr. Ron Pollack is Founding Executive
Director of Families USA. Miss Sally Pipes is President and CEO
of the Pacific Research Institute. Mr. Kelvyn Cullimore, Jr.,
is Chairman, President, and CEO of Dynatronics, a medical
device manufacturer. Dr. Eric Novack, is an orthopaedic surgeon
at Phoenix Orthopaedic Consultants.
My apologies if I mispronounced anyone's name. The lights
that you will see mean what they traditionally mean in life.
Green means go, yellow means go as fast as you can and try to
get under the red light, and red means stop. So with that, we
will recognize the distinguished Lieutenant Governor, Dr.
Colyer.
Chairman Issa. Point of order, Mr. Chairman. Are the
witnesses being sworn?
Mr. Gowdy. You are correct, per usual. It is the policy of
our committee to swear all witnesses. I would ask that you
please rise and lift your right hands and repeat after me.
Don't repeat after me, just affirm or not affirm.
Do you solemnly swear or affirm the testimony you are about
to give will be the truth, the whole truth, and nothing but the
truth?
Witnesses. Yes.
Mr. Gowdy. May the record reflect all witnesses answered in
the affirmative. Thank you. You may be seated.
Again, please limit your testimony to the extent that you
are able to do so to 5 minutes, keeping in mind your entire
statement will be made part of the record. And with that, thank
you, Mr. Chairman, and I would recognize the Lieutenant
Governor from Kansas.

WITNESS STATEMENTS

STATEMENT OF THE HON. JEFF COLYER, M.D.

Dr. Colyer. Thank you, Mr. Chairman. Thank you, Ranking
Member Davis, and Chairman Issa, and members of the
subcommittee.
My name is Dr. Jeff Colyer. As a practicing surgeon, as
Lieutenant Governor of Kansas, I care fiercely about my
patients. They need real results.
I had an interesting experience. Twenty-five years ago I
was part of a team writing on Soviet military spending. The
Soviets claim that they spent about one-fifth what the United
States did to produce a fantastic array of tanks, planes, and
millions of men under arms, many times more than the United
States. But under the Soviet-style central planning, prices and
costs had no relationship to production and real expenses. And
to get around that economic reality they created a massive
bureaucracy to ensure results, and it failed.
I have learned that my patients, whether they have
insurance or not, are economically rational. We have
bureaucratized health care so much that it distorts health
outcomes and pricing and, as I described in my written
testimony, health bureaucracy misaligns our basic price signals
and economic forces that would actually help my patients and
consumers. For example, in my own practice, two-thirds of my
employees are dealing with the bureaucracy while only one-third
of them are dealing with direct patient care. And so we can do
a better job and we have some lessons to learn if we use real
economic principles.
One example is Kansas Medicaid. About a decade ago,
previous administrations in Kansas tried a Massachusetts-style
reform. They decided to cut our relatively low uninsured rate
by dramatically expanding the Medicaid program. In those days
our uninsured rate was about 10 percent. Commercial insurance
covered 70 percent, and government programs were about 20
percent. Ten years later, commercial insurance has collapsed;
59 percent of people are in commercial insurance, government
programs have expanded dramatically, and guess what? The number
of uninsured has actually ticked up. Those are exactly the
wrong trend lines.
So without flexibility, and with these mandated maintenance
of effort requirements Kansas Medicaid's budget has now
ballooned from $2.4 billion to $3 billion. To deal with these
cost increases previous administrations decided to increase
taxes. They cut provider rates. They refused dental benefits.
They created long waiting lists and even told Kansans if they
are over the age of 18, they are not eligible for a heart
transplant. Those bureaucratic savings certainly did nothing to
improve patient outcomes.
States have a better way.
When Governor Brownback and I took office in January of
2011, Kansas faced a $500 million deficit, largely due to
Medicaid. Furthermore, the Medicaid program was in disarray. It
was scattered across four cabinet agencies without a common
budget, without common health goals. Governor Brownback and I
made an important decision. Rather than cut people off or make
massive across-the-board cuts, we would try to remake Medicaid
to be more consumer-oriented and provide integrated care.
Two weeks ago, Kansas signed three contracts to provide
integrated care for needy Kansans. And in those contracts, we
specifically insisted on no rate cuts for providers, and that
no one who is eligible for Medicaid would be thrown off. We
estimated that we might save about $800 million. But the signed
contracts actually turned out better than our original
estimates. Every Kansan on Medicaid can keep their
participating doctor. They will have at least three choices of
different health plans and offered benefits like opportunity
accounts and personalized health programs. Our projected
savings are now $1 billion, and we added additional services,
like preventive dental coverage, coverage for heart
transplants, bariatric services for obesity, and we created an
off ramp from Medicaid to get people back into the stable
commercial insurance market. And to make sure that we achieve
these health outcomes that we are after, we are actually going
to hold back $.5 billion from Medicaid providers to get real
results for real Kansans.
In other words, if you let the States make those decisions
on a local level, we can actually set and achieve real health
outcomes and not cut providers and not throw people off of
programs, and we can actually increase benefits.
Of course, all of this depends on CMS approval, which we
are still waiting for. It is clear that a global waiver tied to
health outcomes would more effectively allow States to deal
with these issues. Private insurance has decreased dramatically
in the State of Kansas. Our child-only plans were cut from four
plans to just two counties with one single plan. We have seen
premiums increase dramatically. There is a better way, and that
is to let the States do this. We are working on Kansas
solutions and we appreciate the opportunity to share those with
you and to work with other States.
[Prepared statement of Dr. Colyer follows:]

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Mr. Gowdy. Thank you, Mr. Lieutenant Governor.
Dr. Armstrong.

STATEMENT OF RICHARD A. ARMSTRONG, M.D.

Dr. Armstrong. Mr. Chairman, members of the committee,
ladies and gentlemen, it is an honor to speak with you today on
behalf of doctor/patient care and thousands of practicing
physicians nationwide who share our deep concern about the
effects of the Affordable Care Act upon the practice of
medicine and specifically upon our relationship with patients.
You have my written testimony and the attached information.
In the interest of time, I will depart from the written
documents. In response to the question, how does this law
affect the physician/patient relationship, the answer is, it
destroys it.
This has been developing for many years, but this law truly
makes it crystal clear. In fact, Dr. Donald Berwick, the former
head of CMS, has written that for this law to work the
traditional physician/patient dyad must end.
All of you on this committee see your doctor from time to
time. What do you expect from the visit? You would like a
friendly, compassionate doctor, who will listen to you, examine
you, and talk to you. The doctor will call on extensive
training and experience to devise a plan that you both agree
upon and understand. Your doctor simply wants to do what their
training and experience has prepared them to do: Listen to your
history, do a physical exam, discuss the findings and recommend
a plan.
Unfortunately, that is not how things are going in
medicine. To illustrate how these things are changing, I would
like to share some stories.
The electronic medical record systems have been touted as a
cure for many of the problems in our healthcare system today.
Unproven and untested, these claims are simply not true. During
a recent sales demonstration at my hospital, the presenter, a
physician's assistant, took 30 minutes to demonstrate how to
document the patient encounter in their system. The process was
unfriendly to both patient and doctor. One of our primary care
physicians asked, how do you propose that I do this in the 15
minutes that I have with patients? He answered, the goal is to
reach at least a level 3 visit. I will say that again. The goal
is to reach at least a level 3 visit.
In other words, billing trumps medical care. He added, so
you have your nurse enter the history data. You fill in the
physical exam, make the plan and move on to the next patient.
Really? Where in these 15 minutes do you talk to the
patient or listen to the patient, you, the doctor?
As a patient, how do you feel? Did you develop a
relationship, or are you part of an assembly line? I think that
most of us know the answer and it should make us both sad and
angry.
And then there is this account of a fellow physician's
recent experience taking her father to visit his new primary
care doctor. This is her story.
I took my father, 80 years old and living independently, to
meet his new internal medicine physician yesterday. I sent
ahead a brief summary of the history, list of medications and
request that he do a physical exam since it had been well over
3 years since it was done. After introducing himself he
immediately announced that Federal guidelines no longer allow
regular exams. An exam allows only listening to heart, lungs,
and bowel sounds with the patient sitting. It does nothing else
unless there is a specific complaint to justify it. I ask if
anemia, which my father has, justified a rectal exam. He said
no. He, of course, quoted repeatedly the U.S. preventive task
force recommendations as one of the standards. He recited the
statistics and the societal cost arguments. He had it all down.
A perfectly useful idiot.
He said he only does evidence-based medicine. In fact, he
had just had been to a conference to confirm the validity of
his position. I did not engage him. It was not appropriate with
my poor father sitting there listening to how he is too old
for, well, anything.
Eventually, to pacify me the doctor went through the
motions of the rectal exam after having to leave the exam room
to get gloves and lubricant, which are, of course, of no use to
him. I doubt he even knows how to do a rectal exam since my dad
who has had many of them hardly felt it.
Again, guidelines trump medical care. This is the reality
of ObamaCare. There is no care. This law supported by organized
medicine, has been consistently opposed by Docs4PatientCare and
AAPS.
Things don't need to be this way, ladies and gentlemen.
This doesn't have to occur. American physicians need to be free
to do what they have been trained to do, excel at practicing
medicine. American patients need to be free to choose the
health insurance plans and medical treatments that suit their
needs, not something coerced by a central authority. This is
simply impossible under the suffocating burden of the
Affordable Care Act.
Thank you very much for your invitation to speak today, and
I will be happy to entertain questions.
[Prepared statement of Dr. Armstrong follows:]

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Mr. Gowdy. Thank you, Dr. Armstrong.
Mr. Pollack.

STATEMENT OF RON POLLACK

Mr. Pollack. Thank you, Mr. Chairman, and thank you Ranking
Member Davis, and members of the panel.
I am delighted to join and serve as ballast for the five
other members of this panel. You know, one of the questions
obviously being asked here at this hearing is what does the
medical profession think about the Affordable Care Act? I think
we have a pretty clear answer from the groups that have
expressed their support for the Affordable Care Act, starting
with the American Medical Association, the American Academy of
Pediatrics, the American Association of Family Physicians, the
American College of Physicians, that is the umbrella of all
internal medicine groups, the Association of American Medical
Colleges, the American Congress of Obstetricians and
Gynecologists; groups like Doctors for America, National
Physicians Alliance, and the American Nurses Association.
But with respect to patients, we also have a pretty clear
example of how patients feel that the Affordable Care Act will
serve a positive role. Groups like AARP, the American Cancer
Society, Cancer Action Network, the American Diabetes
Association, the American Heart Association, Consumers Union,
the National MS Society, and many others. And why is it? It is
because the Affordable Care Act provides patients with peace of
mind, and security; security and peace of mind that health care
will be there for them when they need it.
For example, no longer can insurance companies deny
coverage to somebody like a child with asthma or diabetes
simply because that child has a preexisting condition. Why
would we want to repeal that protection?
The Affordable Care Act rescinds the rules that insurers
have followed that they terminate coverage when somebody is
sick or has an accident. Why would we want to repeal that
protection?
The Affordable Care Act prohibits insurers from charging
discriminatory premiums based on health status. Why would we
want to repeal that protection? It prevents insurers from
establishing arbitrary annual and lifetime limits in what is
paid out when somebody has a major illness or an accident. Why
would we want to repeal that protection?
It stops discriminatory premiums based on gender, as women
have to pay more in premiums than men simply because of their
gender. Why would we want to repeal that protection?
And at the same time, in addition to providing these
protections, it makes health coverage more affordable. It
provides tax credit premium subsidies for middle class and
working families that will go to tens of millions of people so
that health coverage would be more affordable. Why would we
want to repeal that and increase the tax burden on middle class
and working families?
It provides tax credit subsidies for small businesses so
they can better afford providing health coverage for their
workers; currently, a 35 percent tax credit; in 2014 that will
go up to 50 percent. Why would we want to hurt small businesses
by repealing that?
For seniors it provides a significant benefit. It closes a
big coverage gap with respect to prescription drugs, the so-
called donut hole. Why would we want to continue that big gap
in coverage and see it grow with each passing year?
It provides seniors with free preventive care services so
they don't have to pay deductibles and copays for annual
physicals, mammograms, and cancer screenings. Why would we want
to stop that?
And it provides for healthier communities because it
provides funding to increase the number of primary care
doctors, nurses, long-term care providers, community health
centers. It establishes school-based health centers. So it will
increase the number of primary care doctors to serve patients.
And I should add that with respect to Massachusetts, as a
couple of you, Mr. Davis and Mr. Clay, have indicated,
experience in Massachusetts has been terrific. Uninsured rate
has dropped in half, while the rest of the country, the
uninsured rate has grown. Employer coverage is stable. People
are receiving more preventive care. They have a usual source of
care. There is less care provided in emergency rooms. And as I
think Mr. Clay indicated, 88 percent of the physicians in
Massachusetts say it has either improved quality or it hasn't
diminished it.
Thank you, Mr. Chairman.
[Prepared statement of Mr. Pollack follows:]

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Mr. Gowdy. Thank you, Mr. Pollack.
Ms. Pipes.

STATEMENT OF SALLY PIPES

Ms. Pipes. Mr. Chairman and Ranking Member, I would like to
thank you for inviting me to testify here today. I am going to
focus on the impact of the Affordable Care Act on patients.
The latest Rasmussen poll, by the way, shows that 54
percent of Americans would still like to see this legislation
repealed. Everyone agrees we all want affordable, accessible,
quality care. The question is, how do we achieve that goal?
There are two competing visions when it comes to answering
that question. One focuses on empowering doctors and patients.
The other focuses on expanding the role of government in our
healthcare system.
This latter vision is the vision of President Obama. It is
my belief that his ultimate goal is to move us all into a
single-payer Medicare for all system.
The President's two main goals are for universal coverage
and bending the cost curve down. On universal coverage, it is
expected that 34 million out of 50.2 million Americans will
become insured beginning in 2014. Approximately 18 million will
be added to Medicaid, with about another 16 million receiving
subsidies from the government. The Congressional Budget Office
has estimated, though, that by 2021, 23 million Americans will
still be uninsured. This is not universal coverage.
It is also important to note that just because a person
does not have health insurance, they do not get health care.
Under the Federal law EMTALA, anyone can turn up at an
emergency room and receive treatment, and they can also pay out
of pocket to the doctor or hospital.
As to cost, the U.S. spent 17.9 percent of gross domestic
product, one-sixth of our economy on health care. An article in
Health Affairs recently said that by 2020, we will be spending
20 percent, one-fifth of our economy on health care. The ACA
will not achieve the goal of lowering the cost of health care.
Spending in the U.S. is often compared to spending in
Canada, the country where I'm from. Canada spends 11.4 percent
of gross domestic product on health care. The question is, how
do they accomplish that? Well, the government took over the
healthcare system in the '70s. The government sets a global
budget of what they are going to spend on health care. As a
result, you have rationed care, long waiting lists for care,
and lack of access to the latest treatments.
Take the case of my own mother. In June 2005, my mother
felt that she had colon cancer. So I suggested she make an
appointment with her primary care doctor, which she did. Her
doctor said she didn't have colon cancer, but he did order an
X-ray, which she got. When she called me, I said you do not
detect colon cancer with an X-ray. You need a colonoscopy. And
so she went back to her doctor and said, my daughter says I
need a colonoscopy. Her doctor said, unfortunately, as a
senior, you will not be able to get a colonoscopy. There are
too many younger people waiting for treatment.
My mother, by November, had lost 30 pounds and she started
to hemorrhage. My mother went to the emergency room in an
ambulance. She spent 2 days there at Vancouver General
Hospital. She spent 2 days in a transit lounge waiting for a
bed in a ward. My mother got her colonoscopy and she passed
away 2 weeks later from metastasized colon cancer.
By denying or rationing care, it is possible to keep costs
down, but it does not bode well for the patient's future
health. Under the Affordable Care Act, it is inevitable that in
order to keep costs down, care will be rationed and patients
will suffer.
The President wanted a health care bill that cost $900
billion over 10 years. The CBO has recently said the decade
2012 to 2022, the cost will be $1.76 trillion. Richard Foster,
Chief Actuary at CMS, said he did not think that the Affordable
Care Act would let everyone keep the health insurance that they
have if they like it.
This goes against the President's oft repeated statement,
if you like your health insurance and you like your doctor,
nothing will change. Kaiser Family Foundation showed that from
2011--from 2010 to 2011, the average premium for family plans
went up 9 percent up to $15,073. In the previous year, they
only went up 3 percent.
Under the employer mandate starting in 2014, any employer
with 50 or more employees who drops coverage will have to pay a
fine of $2,000. I believe that a number of employers, the CBO
said up to 20 million, will lose their employer-based coverage.
So much the President's statement.
America needs a healthcare system that empowers doctors and
patients. Only then will we achieve affordable, accessible,
quality care. The question is, who do you want to be in charge
of your health care: An HMO bureaucrat, a government
bureaucrat, or do you yourself want to be in charge? Universal
choice is the key to universal coverage.
Thank you.
[Prepared statement of Ms. Pipes follows:]

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Mr. Gowdy. Thank you, Ms. Pipes.
Dr. Novack.

STATEMENT OF ERIC NOVACK, M.D.

Dr. Novack. Mr. Chairman, Ranking Member, members the
committee, thank you very much for allowing me to participate
in this hearing today. I would preface my comments by
mentioning in response to Mr. Pollack that the AARP recently
revealed that their actual membership were getting phone calls
and emails 14 to 1 against the Affordable Care Act during the
process.
And so that kind of information does bring a bit into
question whether or not the organizations that he listed
actually have members that actually were in favor of it as
opposed to just the leadership.
A system that combines the spending discipline of the
Defense Department with all of the accountability of the public
education system, that sadly is what the President's healthcare
law's legacy is going to be for the country. Patients and
families are the losers, and none of you or your families will
be immune from the consequences either.
I would like to spend the next few minutes highlighting
some portions of my submitted testimony. According to the
administration's own researchers, the bottom 70 percent of the
healthcare users in this country, accounting for over 220
million Americans, spent only 11 percent of all healthcare
dollars, or about $290 billion. The bottom 50 percent, 150
million people, spent only 3 percent of all healthcare dollars,
which is $80 billion.
The President's healthcare law does nothing to increase
transparency, heighten competition, or make the healthcare
experience one iota better for these people. Instead, the law
imposes mandates of nearly every kind imaginable, and creates
health insurance exchanges that are by design meant to turn
patients and families into bankable commodities for the nearly
$2 trillion in direct Washington subsidies to insurers and
other corporations is at stake over the next 10 years alone.
Our Arizona efforts to work on the issues of transparency
and competition have been met with a level of opposition
reminiscent of shock and awe. Hospital CEOs, insurance company
lobbyists, and even physician representatives essentially
stated that pricing in health care is too complicated and that
patients are simply not smart enough or sophisticated enough to
understand.
In my orthopaedic surgery practice I help care for many
children who have broken bones from a fall at the park, at
school, and even on the trampoline in the backyard. For the
parents of these children, a system where doctors are competing
with one another to provide comprehensive care at a competitive
price, a savings of $20, $30, and even $100 would be
achievable. While members of this committee might not think
much of that, for my patients that money pays for gas, food,
and new school clothes.
The President's healthcare law either directly through
government or through insurance, hospital, company surrogates
is making it harder not easier for these children to get access
to timely health care, and the studies support it.
The administration also shows that they are high utilizers;
1 percent of the country, which is about 3 million people,
spend 20 percent of all healthcare dollars and the top 5
percent spend 50 percent of all the healthcare dollars. And
while we tend to spend more on health care as we get older,
there is little evidence that low healthcare users necessarily
enter the top 5 percent at some time.
Rigid coverage rules and cookbook treatment plans are bad
for patients of all types. I had a patient I treated for
shoulder problems for several years. He is also has heart
issues and is on a blood thinner. In spite of being considered
safer to have a noninvasive colonoscopy, Medicare refuses to
pay for that. Faced with little other options, he came off his
blood thinner, subsequently had a blood clot, a cardiac arrest.
Miraculously, he survived and has done well, though at great
preventable cost to his system.
Under the President's healthcare law as the decision-makers
move further away from the patients and instead resides in
boards of experts, government rulemakers, and insurance and
hospital administrators, to whom will doctors be listening?
American medicine has already begun to shift to a veterinary
ethic described by my friend and colleague Dr. Jeffery Singer.
When you bring your dog or cat to the vet, the doctor listens
to the decision-maker, the owner, and not the patient, the pet.
The pet, of course, cannot decide for itself which treatment
course will be undertaken, whether it is teeth cleaning or
euthanasia. And within reason, the vet will follow the advice
of the decision-maker.
Doctors are mortal, fallible, and respond to incentives
like all others. If the person who pays the bills creates a
framework that patients need to be put into category A or
treatment B, for the doctor to remain compliant there is little
doubt that this is ultimately what is going to happen.
Mr. Chairman, members of the committee, you were generous
to ask me to speak about the impact of the healthcare law on
the doctor/patient relationship. That relationship is complex,
intertwined with many of the finer points of policy, the
economy, and patient autonomy. We need real healthcare reform
that put patients ahead of the special interests who wrote the
healthcare law and who stand to profit substantially from it,
both in financial wealth and power. Healthcare decisions belong
to patients and families, not politicians and their pals. That
is how you protect and defend the doctor/patient relationship.
Thank you.
[Prepared statement of Dr. Novack follows:]

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Mr. Gowdy. Thank you, Dr. Novack.
Mr. Cullimore.

STATEMENT OF KELVYN CULLIMORE, JR.

Mr. Cullimore. Chairman Gowdy, Ranking Member Davis,
members of the committee, thank you for the opportunity to
testify here today. My name is Kelvyn Cullimore. I am the
President and CAO of Dynatronics Corporation, which is
headquartered in Salt Lake City, Utah, with manufacturing also
in Chattanooga, Tennessee. We are a publicly-traded company
engaged in the manufacture and distribution of medical devices
and products primarily for physical therapy and sports medicine
applications, and provide employment for about 180 people.
Dynatronics is a relatively small company with sales about
$32 million, but that is common in this industry. A majority of
medical device companies are small companies, approximately 80
percent having 50 or fewer employees. Many are in the early
stages of product development with no sales, or with sales, but
no profits. Like many companies, we have been required to
implement several rounds of layoffs to cope with difficult
economic circumstances of the last few years. If policies such
as the 2.3 percent medical device tax included in the
Affordable Care Act are implemented, I fear this added burden
will not only harm patient care and stifle innovation but
threaten the very existence of companies like Dynatronics.
Despite widespread economic challenges I do consider myself
extremely fortunate to be part of a generally vibrant industry
that plays a critical role in improving health care and patient
care in this country. There are over 2 million hard working
Americans who help make the United States the global leader in
medical device technology. Data from the Department of Commerce
shows that the medical device industry exported $36 billion of
products in 2010 and had a trade surplus of approximately $3.2
billion. Not many segments of the U.S. economy can claim to be
a net exporter.
It is probably not the first time you have heard this but I
want to be very clear that the United States is in very real
danger of losing our global leadership position. If this
happens, it will be virtually impossible to get this position
back as capital and human resources flow to new centers of
innovation outside of our country.
The challenges of an uncertain regulatory environment,
reimbursement pressures, and of course the medical device tax,
among others, have created what many describe as a perfect
storm. I believe this perfect storm could quickly lead to a
Class 5 hurricane for patients, providers, and innovators.
The Dynatronics story in this current environment is not
really unique, but it is illustrative of how harmful policies
such as the medical device tax are to our ability to improve
patient care and drive job creation. Our fiscal year just ended
on June 30th. We will report sales in excess of $32 million,
but for only the fourth time in 25 years will not show a
profit. After reporting a pretax profit of over $400,000 last
year, we will report a pretax loss of just under $300,000 for
this fiscal year.
In other words, despite not earning a penny in profits this
year, the Affordable Care Act will require that we pay hundreds
of thousands of dollars in a device tax.
Quite simply, a company such as ours and thousands of
others that are similarly struggling or have not yet crested
the hill of profitability as a startup company will have a very
difficult decision to make in addressing this added tax if it
is not repealed.
Where do I get the money to pay the tax? Research and
development are the easier short-term cuts, but they lead to
less innovation and negatively impact patient care. Do I drop
product lines that are marginally profitable that now are no
longer profitable due to the tax but still may have benefit to
patients? Some would say that we make it up by raising our
prices. Pass it along to the end user. Anyone operating in the
current environment knows that there is no appetite on the part
of hospitals or practitioners to accept price increases of any
kind. To the contrary, we are under tremendous pressure to
lower prices.
Because the tax is levied on sales and not profits, it will
take a significant bite out of resources available for
innovation and growth regardless of the company's size, or
stage of development. This hurts patients and providers as the
ability and pace at which innovation occurs slows dramatically,
reducing improved patient care and quality of life.
Many of the most innovative device companies are pre-
profit, and struggling to achieve sufficient profitability to
recover the millions of dollars invested into research,
clinical trials and other development costs or, more
importantly, attract the additional capital needed to complete
product development. This tax is a huge disincentive to
attracting investors.
If a company such as Dynatronics decides to address the
device tax by making severe cuts to R&D, what I have
essentially done is limit the potential for my company to have
new technologies and devices in 3 to 5 years down the road. I
cannot emphasize enough just how delicate the innovation
ecosystem is for medical device makers. Any cuts to R&D today
will manifest themselves down the road in ways that hurt
patients and providers the most.
Medical device innovation plays a central role in patient
care, but we face many head winds and need your help to calm
those head winds and enable the United States to maintain our
global leadership position. I respectfully request that you
recognize the misguided nature of this medical device tax and
the effect it will have not only on companies like Dynatronics,
but the resulting impact on technological innovation and
patient care. Help us avoid this impending hurricane. America's
patients, providers, and workers are counting on it.
Thank you.
[Prepared statement of Mr. Cullimore follows:]

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Mr. Gowdy. Thank you, Mr. Cullimore. I would ask unanimous
consent that our colleagues, Drs. Gingrey, Benishek and Fleming
be allowed to participate in today's hearing. Without
objection, so ordered. I would now recognize the distinguished
chairman of the full committee, the gentleman from California,
for his questioning, Mr. Issa.
Chairman Issa. Thank you, Mr. Chairman. Later today we will
have a panel of business people who will also be before this
committee at the full committee level on the same subject.
No surprise, we won't have a doctor from Massachusetts.
Mr. Pollack, are you a doctor from Massachusetts?
Mr. Pollack. No, I'm not.
Chairman Issa. Okay, so the Democrats didn't pick a doctor
from Massachusetts to bring in either, did they?
Mr. Pollack. I'm not a doctor from Massachusetts.
Chairman Issa. Okay, and when you were mentioning the
various groups that supported the legislation, you didn't
seem--and all the things we wouldn't want to do, you didn't
seem to mention one thing that I'm concerned about I want each
of you to address. Under the ACA, or ObamaCare, if somebody has
50 employees and doesn't provide care, it is going to cost
$2,000. Just sort of a shake of heads, is that true? And if
somebody doesn't buy their own insurance, whether they are
offered it at their company or not, it is going to cost them
$2,000 on their tax return, isn't that true?
Mr. Pollack. Not necessarily. It really depends on the----
Chairman Issa. It is a sliding scale. But if they make
$50,000 in their family, they are going to pay $2,000.
Mr. Pollack. It depends on what portion of one's income
actually is attributed to what one has to pay.
Chairman Issa. Exactly. So it is based on a rather obscure
household income for the entire family, not known at the
beginning, but in fact a family of four with $50,000 will find
themselves with a $2,000 fine if they don't buy it. But in
fact, they won't necessarily know that until the end of the
year.
So let's go through a couple of other similar questions.
If you are an employer and you do provide a healthcare
system under ObamaCare, and then you find that one of your
employees went to an exchange, which they have a right to do,
and did not go through your healthcare system even though you
have a Federally complying healthcare system, isn't it true you
can be billed back $1,000 from the exchange because an employee
with a certain household income chose to do that?
For the Lieutenant Governor, are you familiar with that
provision?
Dr. Colyer. Yes, I am.
Chairman Issa. So included in all of this good work is a
series of taxes that in fact can represent as much as $4- or
$5,000 between the employer and employee, none of which
actually goes to the health care.
Now wait a second, just, Mr. Pollack, you are going to be
asked a lot of questions by the Democrats. That is why they
brought you here as an apologist for ObamaCare, but Dr. Colyer,
I guess my question is, isn't it true, and I think you can all
answer this as yes, even Mr. Pollack, that if an employer
cannot afford to offer health care but was willing to put
$2,000 into the pocket of their employee for health savings, or
something along that line, but a non-federally compliant
system, and the employee has $2,000 that they could put into a
healthcare system, together they have $4,000. But if they don't
buy the $12,000 system they would have to buy, the government
will take $4,000 in many cases from the combination of two of
them, providing no health care for that $4,000.
Lieutenant Governor, isn't that true?
Mr. Colyer. Yeah, that's what happens when you take away
flexibility.
Chairman Issa. Okay. So one of the provisions of the
ObamaCare is, in fact, that you can tax and of course now the
chief justice has made it clear that I guess the Democratic
majority in this House with no Republican support could in fact
tax $2,000 by the family and $2,000 by the employer, and
provide no real solution. Isn't that true?
Mr. Colyer. Yes.
Mr. Pollack. So Mr. Chairman, one of the things you are
missing----
Chairman Issa. No, no, no, Mr. Pollack. Mr. Pollack. Mr.
Pollack. Mr. Pollack, you can answer a question that is asked
as a yes or no as a yes or no. If you do anything else, what
you are really doing is being the Democrat's witness and being
obstreperous. So if you will please wait until they ask you a
question. In my remaining moments, for the witnesses, other
than Mr. Pollack, who will be asked by the Democrats to
apologize for ObamaCare, is there anything so far that has
occurred as ObamaCare is implemented that has reduced cost and
thus made healthcare more affordable for Americans, not more
subsidized, not more taxed? Is there anything that has occurred
so far that has made health care less expensive for any of our
witnesses.
Mr. Colyer. No.
Mr. Pollack. The answer is yes.
Chairman Issa. The record will indicate that our witnesses
all found it to be a no, and you obviously can answer when
called on.
Mr. Cullimore, I just have one question for you. Can you
find a single basis, other than scoring a cheap trick in order
to say ObamaCare didn't cost, is there a single basis under
which you should tax health care, inherently--healthcare
products, inherently making them more expensive? Other than a
cheap trick from Members of Congress, was there any basis to
tax your products?
Mr. Cullimore. I am not aware of any.
Mr. Issa. And any basis under which by taxing them they
don't inherently become more expensive?
Mr. Cullimore. That seems basic economics to me.
Mr. Issa. So we have taxed health care, made it more
expensive, even in your kind of products, even if you are
making no profit at all, and that is what you are finding
undeniably under ObamaCare?
Mr. Cullimore. That is what we are finding. And more
important than just making it more expensive, is it is
threatening the ability to do research and development and
provide the kinds of tools that our practitioners need to
improve patient care.
Mr. Issa. Thank you. Thank you, Mr. Chairman, I yield back.
Mr. Gowdy. I thank the gentleman from California. The chair
will now recognized the gentleman from Illinois, Mr. Davis.
Mr. Davis. Thank you, Mr. Chairman, and, Mr. Chairman, I
ask unanimous consent to insert into the record testimony from
seven physicians who are members of_
Mr. Issa. Reserving a point of order.
If I may state the point of order, if the gentleman would
phrase that as anything other than ``testimony.'' Committee
rules require that testimony be sworn. This would be unsworn.
So if you would call them statements for the record, I would
withdraw my objection.
Mr. Davis. Statements for the record.
Mr. Issa. I withdraw.
Mr. Gowdy. Without objection.
Mr. Davis. Mr. Chairman, let me thank you again.
Dr. Colyer, what kind of physician are you?
Dr. Colyer. I'm a plastic and craniofacial surgeon in
Kansas City.
Mr. Davis. So you are a plastic surgeon?
Dr. Colyer. Yes, sir.
Mr. Davis. Are the services that you provide covered by the
Affordable Health Care Act?
Dr. Colyer. Yes. I spend many days, many nights in the
emergency room taking care of people who have had their hands
blown off by fireworks injuries, women with breast cancer, and
a variety of services.
Mr. Davis. So then you actually do more than plastic
surgery?
Dr. Colyer. That is plastic surgery.
Mr. Davis. Yes, that is your specialty, and all of those
things associated with it you do.
Let me also ask you, you indicate in your written testimony
that we've got to do something quick before irreversible harm
is done to our health care delivery system. Could you tell me
what irreversible harm is done to the more than 30 million
people who for the first time in their lives have access to
health insurance? And could you tell me what irreversible harm
is done to those individuals who for the first time have an
opportunity for a private practicing physician who becomes
their primary care as opposed to the emergency rooms that you
just mentioned?
Dr. Colyer. Yes, sir. For example, in the State of Kansas,
we had four insurers that provided child only policies. And
since the formation of the ACA, those insurers, three of them
have pulled out completely. We have one insurer. That only
covers two out of 105 counties. I doubt that those are going to
be coming back any time soon.
Mr. Davis. Well, could you tell me how those individuals
are going to receive care?
Dr. Colyer. How they will receive care?
Mr. Davis. Yes.
Dr. Colyer. Yes. In Kansas, doctors do take care of
patients. We have a wide array of opportunities through
qualified health clinics, through a number of State programs
and Federal programs, and also the generosity and the
willingness of many physicians to work there. There are
solutions that we can deal with these problems and we can add
additional things. We are very compassionate. We want to work
with them. It is just one solution mandated from someplace else
may not work in Kansas.
Mr. Davis. Mr. Pollack, your organization, Families USA,
estimated that across the Nation 26,100 people between the ages
of 25 and 64 died prematurely due to a lack of health coverage,
and that was from your June 2012 report Dying For Coverage.
Could you describe how lack of health care coverage impacts
premature death.
Mr. Pollack. Sure. Mr. Ranking Member, first, I should say
the methodology for this report was developed by the Institute
of Medicine scientific panel in 2002. But the main way this
occurs is that when somebody does not have health care
coverage, typically they delay getting care. At the onset of a
pain, at the onset of a health problem, people who are
uninsured often feel they can't pay for a doctor or to get an
exam, and so they delay care. And when they delay care,
sometimes the illness gets worse, sometimes it spreads.
Unfortunately, about 26,100 people pay the ultimate price
because they were uninsured.
One other thing I should say, this also affects people with
health insurance, and the reason it does that is when people
who are uninsured get care in an emergency room, they usually
can't pay for that care or at least they can't pay for a
portion of it, and a hospital has to make up for those costs.
And the way they make up for that cost is a hidden surcharge
for all of us who have health insurance, and that ultimately
results in premiums being raised on average more than $1,000
per family per year.
Mr. Davis. Thank you, Mr. Chairman. I yield back.
Mr. Gowdy. I thank the gentleman from Illinois.
The chair will now recognize himself for 5 minutes of
questions.
Eight out of 10 physicians would reconsider their decision
to practice medicine. A significant doctor shortage is on the
horizon. Naively, I suppose, I want the smart kids in class to
be the ones to operate on me. And I want the smart kids in
class to be the ones to put me to sleep, more importantly, to
wake me up. One of the reasons--so I guess unless this
administration plans to cross train the 13,000 IRS agents as
nephrologists and pediatricians and OB/GYNs, things look pretty
bleak in this country. And one of the reasons I hear that
doctors are frustrated is their fear of litigation and their
requirement to practice defensive medicine. And they are in
something of a Hobson's choice because when my colleagues on
the other side of the aisle ask them whether they practice
defensive medicine, it is really a setup to admit that you
engage in Medicaid or Medicare fraud which is why I'm not going
to ask the physicians on this panel whether they practice
defensive medicine. We all know that they do it.
I heard the President in his State of the Union devote
about one-1000th of 1 percent of the time he took in his State
of the Union to mention tort reform.
So, Mr. Pollack, you didn't mention tort reform in your
opening statement. Do you support caps on noneconomic damages?
Mr. Pollack. No, we would not support that. We would
support some changes that deal with malpractice, but not----
Mr. Gowdy. Mr. Pollack, let me tell you the way this works.
I ask the questions, and then you answer them.
Mr. Pollack. I want to give you a full answer.
Mr. Gowdy. Well, I'm going to ask you a series of
questions.
Mr. Pollack. Good.
Mr. Gowdy. And I want crisp answers. Not filibusters; crisp
answers. Do you support limits on noneconomic damages? That is
not a complicated question. That is not a multi-part question.
Do you or do you not?
Mr. Pollack. Do not.
Mr. Gowdy. Do you support limits on joint and several
liability?
Mr. Pollack. Do not.
Mr. Gowdy. Do you support a different standard of care for
emergency medicine as opposed to medicine where a physician has
a robust chart or file in front of them?
Mr. Pollack. I'm not sure I follow the question.
Mr. Gowdy. Emergency medicine where a physician is called
upon in a matter of seconds to make a decision, they don't have
the benefit of patient history or a lot of tests, do you
support a different standard of care for those physicians as
opposed to ones who do have a full history in front of them?
Mr. Pollack. No, not----
Mr. Gowdy. So you would hold physicians who have a matter
of seconds to make a decision to exactly the same standard that
you hold physicians who have treated patients for 20 years?
Mr. Pollack. Most physicians have access to clinical
guidelines as to what works, and I would expect that any
physician, emergency physician or otherwise, would look at
those guidelines, not necessarily feel bound by those
guidelines, but would use those guidelines in order to make a
thoughtful decision for his or her patient.
Mr. Gowdy. So the answer is no?
Mr. Pollack. I gave you a full answer to that question.
Mr. Gowdy. The answer was no. Do you support loser pays?
Mr. Pollack. I'm not sure I follow that.
Mr. Gowdy. Loser pays? You file a lawsuit, the jury finds
it frivolous. With a special verdict form, do you support a----
Mr. Pollack. I think anyone who files a frivolous claim
should pay physician costs.
Mr. Gowdy. So you support loser pays?
Mr. Pollack. Anyone who files a frivolous claim should pay
physician costs.
Mr. Gowdy. Do you know where the majority of the litigation
comes from in this country, whether it is paying patients or
nonpaying patients?
Mr. Pollack. It comes from paying patients.
Mr. Gowdy. No, sir, it comes from nonpaying patients. The
majority of the litigation, the lawsuits filed, come from
nonpaying patients.
Mr. Pollack. I don't believe that.
Mr. Gowdy. I can't help what you believe. I can just tell
you what the facts are.
Dr. Colyer, what should we be doing to incentivize the best
and brightest to go into medicine and reverse the trend that 8
out of 10 would reconsider their decision to practice medicine,
and I don't know a single physician that would encourage his or
her kids or grandkids to practice medicine?
Dr. Colyer. Let them be a doctor. Let them make the
decisions. Let them have a relationship with their patients and
really do their specialty their experience. That's what would
make the difference, and it is the bureaucracy that is driving
us crazy.
Mr. Gowdy. Mr. Pollack, you twice made a reference to
``free'' which I found to be a fascinating word. Free
preventative care. What is free about it? Does that mean the
doctor donates his or her time and the pharmaceutical company
donate the drugs and the medical device company just donates
it? When you say free preventive care, free contraception, what
do you mean by free?
Mr. Pollack. Well, with free preventive care, it means that
one's insurance policy will pay for that without a deductible
and without a copay.
Mr. Gowdy. How will the insurance company make sure that it
doesn't go broke? It will pass the cost on to other people,
right?
Mr. Pollack. By providing preventive care, it avoids much
more costly and cumbersome services later on, so that
somebody----
Mr. Gowdy. So it is free in an economic--from the
futuristic economic sense it's free?
Mr. Pollack. If you're asking ``free'' in terms of
dollars----
Mr. Gowdy. I'm just fascinated by the word ``free.''
Mr. Pollack. It will save money in the long term because it
means a problem will be diagnosed at an earlier stage and it
means somebody will not need complex care later on, which is
far more expensive.
Mr. Gowdy. I'm out of time. I will now recognize the
gentleman from Missouri, Mr. Clay.
Mr. Clay. Thank you, Mr. Chairman.
Since 2001, employer sponsored health coverage for family
premiums has more than doubled, crowding out other investments
in human capital and innovation and placing coverage out of
reach for more families. The ACA was designed to reform our
system of health care delivery to incentivize high quality
care, appropriately priced services, and fight waste, fraud and
abuse. In fact, the ACA contains almost every cost-containment
provision that policy analysts have considered and touted as
effective in reducing the growth of health care spending.
Mr. Pollack, do you believe that the provisions contained
in the ACA to incentivize high quality care, appropriately
priced services, and fight waste, fraud and abuse are important
to a robust, affordable health care system?
Mr. Pollack. I do, sir.
Mr. Clay. Mr. Pollack, won't access to preventative care as
designed by the ACA assist in controlling the cost of overall
care as folks no longer have to use the emergency room for
treatment of preventable health care problems.
Mr. Pollack. Mr. Clay, as you are inferring, care in an
emergency room tends to be the most expensive care possible.
And when it occurs, it normally occurs when somebody has
actually had a disease spread and the illness now needs heroic
treatment. So I do believe that if we can avoid that, it is
both good medicine and it is more cost effective medicine.
Mr. Clay. You know today and tomorrow the Republican
majority will try for the 31st time this Congress to repeal the
Affordable Health Care Act. But what is their alternative? They
have none. They have no solution to continue growth in health
care spending and have offered no comprehensive approach to
deal with the systemic causes of growth in health care
spending.
You know, research has shown that the uninsured are more
likely to delay or forgo needed medical care than insured
individuals. As a result, the uninsured are more likely to be
hospitalized for avoidable medical conditions which increases
overall health care costs for everyone.
The CBO believes that the Affordable Health Care Act will
expand coverage to 32 million Americans with approximately 19
million Americans benefiting from premium assistance credits
for the purchase of private health insurance.
Mr. Pollack, as you know, this vote will not repeal the
Affordable Care Act. But it signals what would happen if
Republicans were to win the White House, the Senate, and hold
on to the House.
Mr. Pollack, have the Republicans offered a viable plan to
insure the uninsured and improve health outcomes while
containing the very problematic increase in health care costs?
Mr. Pollack. Well, Mr. Clay, at the outset of this debate
in the first of 31 different efforts to repeal the statute, we
heard a lot about repeal and replace. Since that time we have
only heard repeal, repeal, repeal and precious little with
respect to replace.
Mr. Clay. Without the protections and expanded eligibility
made possible by the ACA, how else do we guarantee that poor
and working class Americans access cost effective primary care
services?
Mr. Pollack. We do this not just by expanding Medicaid, and
I take issue with my fellow panelists who criticize the
program, but one of the key ways we do it is by improving
private health insurance, and we make it more affordable by
providing tax credit subsidies so that people can afford it.
The chairman of the committee talked about a family with
$50,000 in income. That family will receive huge tax credit
subsidies to make health coverage affordable. If we repeal the
Affordable Care Act, not only will health coverage be
unaffordable, but there will be a tax increase experienced by
those middle-class families.
Mr. Clay. There we go again, beating up on the little guys.
Thank you so much, and I yield back.
Mr. Gowdy. I thank the gentleman from Missouri.
The Chair will now recognize the gentleman from Tennessee,
Dr. DesJarlais.
Mr. DesJarlais. Thank you, Mr. Chairman. I do thank the
panel for coming today and giving us their insight. I also
would like to thank some of the non-committee members, my
physician colleagues, that have joined us today. You have six
members of the Doctors Caucus sitting before you on the panel
today. We have 15 physicians in Congress now and three in the
Senate. We make up a combined 600 years of total experience in
health care. I would say that--I think I can say for all of us
sitting here, not a single one of us went to medical school
thinking that one day we would be sitting in Congress. We went
into medicine because we want to help people, and my colleagues
are joining me here today because they want to talk about this
important issue.
Despite what Mr. Pollack said about the numerous groups
that are in support of the health care law, I think that there
are several doctors here and doctors across the country that
clearly oppose it, and I think there is patients across the
country that oppose it. This was evident by the fact that 63
percent of the people were opposed to this health care law when
it was passed, and that continues to be the case. The majority
of the people don't want it. So to sit here and say that we
should keep it is disingenuous. And now with the Supreme Court
ruling saying that we will all be taxed, clearly the President
has broken his promise about not raising taxes on the middle
class with this enormous tax, and it also cuts and hurts
Medicare. And I'm tired of these attacks as a physician because
we care about patients having good access to care, and I don't
think there is a physician on the panel that thinks that this
will control costs or improve the quality of care, and it
certainly is going to hinder the doctor/patient relationship.
Doctors, would you agree with that?
All of the doctors are nodding.
Mr. Pollack, you said that this is going to make health
care more affordable. How do you justify that when the cost, as
Ms. Pipes has stated, has doubled since President Obama
initially said $800 billion has gone to $1.7 trillion; how do
you justify that?
Mr. Pollack. First of all, I want to just correct one
thing. The Chief Justice did not say this is going to be a
broad tax. In fact, if you read his opinion, his opinion makes
clear that only about 1.3 percent of the American public would
face this tax penalty. He cited in his----
Mr. DesJarlais. I thought it was clearly a tax, sir.
Mr. Pollack. I'm not disputing the language of tax or
penalties. That's not the purpose of what I'm saying.
Mr. DesJarlais. How is it making it more affordable? How is
it more affordable? You say it is more affordable. Ms. Pipes, I
will give you a chance, too, to debate this.
Mr. Pollack. Well, it makes it more affordable because it
provides huge tax credit subsidies so that people can afford
private health coverage.
Mr. DesJarlais. Who is going to pay for the subsidies?
Where does that come from, taxes? We don't have free. As the
chairman said, we don't have free in this country. You said it
reduces cost, that isn't free, and it is not reducing costs.
Mr. Pollack. There are some savings and efficiencies
created in the Affordable Care Act. I will give you an example.
Mr. DesJarlais. Do you think Medicaid is efficient, cost
efficient?
Mr. Pollack. Yes, it is. The Congressional Budget Office
made clear during the debate that that would be the most
efficient way to expand coverage to people who don't have
coverage.
Mr. DesJarlais. Ms. Pipes, do you think Medicaid is
affordable or is this law affordable?
Ms. Pipes. No. As I said, the CBO said $1.76 trillion. Many
economists, myself included, believe that in 2014, the decade
2014 to 2024, this law will cost about $2.6 trillion because of
the cost drivers, the exchanges, the individual mandate, the
employer mandate, the ending of price discrimination based on
preexisting conditions. It is going to be very, very expensive.
On the issue of Medicaid and Medicare, the Congressional
Budget Office and the Medicare trustees have shown, the
Medicare trustees say by 2024 Medicare will cost about $1
trillion, almost double what it is today, Medicaid $800
billion, and these programs will be bankrupt. We need to make
changes so that the people who do need Medicare and Medicaid
have access.
But interestingly, under the Affordable Care Act, Medicare
is being cut by $500 billion over the decade to add those 18
million people to Medicaid.
Mr. DesJarlais. Thank you.
Dr. Colyer, do you have anything to add to that? Actually,
let me be specific. Let's talk about the bureaucracy. What has
happened with ObamaCare? How much of your time is spent on
bureaucracy versus medicine?
Dr. Colyer. Two-thirds of my staff are dealing with the
bureaucracy aspect of it. We are even seeing this in State
government. We've put together health reforms that are really
going to save money and actually reverse a lot of problems and
outcomes, and it is going to take us months to actually get
that through the bureaucracy.
Mr. DesJarlais. Is there anything affordable about that?
Dr. Colyer. No. Our State has had tremendous financial
problems.
Mr. DesJarlais. All right, thank you. My time has expired,
and I yield back.
Mr. Gowdy. Thank you, and the chair recognizes Ms. Holmes
Norton.
Ms. Norton. Thank you, Mr. Chairman. In our discussions
about doctor-patient relationships, and so we all agree that we
would want most patients to have a doctor. And let us stipulate
for the record that the cost of health care will go up. The
question is costs compared under the Affordable Health Care Act
compared to no Affordable Health Care Act. So throwing out
trillions of dollars will get you nowhere unless we have a
comparison to make, and one that is as credible as the CBO's
comparison, I might add.
It may be, Doctor, Lieutenant Governor Colyer, you may be
the appropriate person for this question because you serve in
both roles. I don't know if the Lieutenant Governor of the
State of Kansas has an operational role as well, but let me ask
you this question because you may be the most familiar with it.
Some, a few Governors have said that they will not accept
the 100 percent Medicaid funding, going down gradually to 90
percent, to fund working class and working poor people who are
now included under Medicaid and the Affordable Health Care Act.
Is Kansas, by the way, one of those States that has not yet
made a decision?
Dr. Colyer. No, we are in the midst of a major Medicaid
reform and we are trying to make it so it is much more
responsive to patients.
We have got an election coming up. The Governor has said we
need to change the system, and we are going to make a decision
afterwards.
Ms. Norton. Well, I appreciate you're thinking it through
rather than responding the day after the Supreme Court
decision, but I have a question about where these people, many
of them, most of them, indeed, working people went before and
will now go? Where they went before, of course, was to the
costliest doctors, and those were the doctors in the emergency
room, where in fact they cost the State and the Federal
Government five and six times what they would cost if they had
a medical home.
My concern is with hospitals. Hospitals in big cities like
my own, and particularly hospitals in rural areas, can
hospitals survive if these patients are thrown back with what
looks like to be now no uncompensated care. You do the charity
care and it falls back mostly on the State, it fell back mostly
on the State before, but there was a little something that the
Federal Government gave for uncompensated care.
Again, what are your hospitals saying about the effect on
them if these patients are thrown back into their emergency
rooms at greater cost to the State, and I suppose not to the
Federal Government since they won't be on Medicaid?
Dr. Colyer. Actually, we are creating a system that does
exist, the majority of people without insurance don't end up in
the emergency room. They get their care through a variety of
clinics, through their private physicians in the State of
Kansas. We have a number of federally qualified health clinics,
for example, with very low cost.
Ms. Norton. We all have those.
Dr. Colyer. And we all have those, but they are a really
important safety net. But there are some other solutions.
Ms. Norton. And they are also often largely federally
funded as well.
Dr. Colyer. And also State funded.
We are also able to create incentives for doctors to take
care of people in their own community. It's giving the States,
the individual States the opportunity to make these solutions.
That's what's so important.
Ms. Norton. I can understand that, Dr. Lieutenant Colyer. I
just hope in the process the State will consult with the
hospitals because they may be one of the victims in all of the
play back and forth. We don't know, but I appreciate the
approach you are taking that looks at all of the factors
involved.
May I ask a question of you, Mr. Pollack? I was astounded
by the number, almost 60 million Americans, nonelderly now,
have what are called preexisting conditions. This is a
frightening number. One in five Americans. Prior to the
Affordable Health Care Act, where were these people receiving
treatment? Were they receiving treatment?
Mr. Pollack. They were uninsured by and large because
people with preexisting conditions, a child with asthma or
diabetes could not get health insurance coverage from an
insurer. Now that the Affordable Care Act with respect to that
aspect of the law is in effect for children, those children are
now getting coverage and they are getting care. In 2014, for
adults that protection will be extended.
Ms. Norton. Is there a way other than the way that the
Affordable Health Care Act has found, putting as many people in
the pool as possible, is there a way to provide health
insurance in an affordable fashion for people with preexisting
conditions?
Mr. Pollack. The best answer to that question is some
States have established high risk pools and high risk pools are
a substitute. But the problem is when you have a pool composed
completely of people who have illnesses and health conditions,
the premium costs per person skyrocket and that's why you want
to integrate them into private insurance pools that include
healthy and young people along with sicker and older people.
Ms. Norton. Thank you very much.
Mr. Gowdy. I thank the gentlelady from the District of
Columbia.
The chair would now recognizes the gentleman from Arizona,
Dr. Gosar.
Mr. Gosar. I would like to run a clip first and have you
watch this clip and then I want to get your opinions:
``And that means no matter how we reform health care, we
will keep this promise to the American people: If you like your
doctor, you will be able to keep your doctor; period. If you
like your health care plan, you will be able to keep your
health care plan; period. No one will take it away no matter
what. My view is that health care reform should be guided by a
simple principle--fix what's broken and build on what works,
and that's what we intend to do. If we do that, we can build a
health care system that allows you to be physicians instead of
administrators and accountants.''
Mr. Gosar. Dr. Colyer, let me get your opinion to that
comment. I thought the backdrop was very interesting. It was at
the AMA.
Dr. Colyer. In Kansas, you will not be able to keep your
more affordable plan under the ACA. We've developed a wide
variety of health insurance plans and opportunities, health
insurance accounts, a whole variety of things. And we can
expand those and do that. We have now got a one size fits all
that is much more expensive than what we have in the State of
Kansas. It may work in other States, but it's not for us.
Mr. Gosar. How about you, Dr. Armstrong?
Dr. Armstrong. That is obviously completely false. And for
the President to say that we are going to allow doctors to not
be bureaucrats any more, when you look at what has been done so
far, we have 12,000 pages of regulations that we don't even
know what they say. How can that possibly not allow doctors to
be bureaucrats? That's just ridiculous. Those two statements
that he made, if you like your doctor, you can keep him; if you
like your plan, you can keep it, it is obvious now that that is
just false. That is just completely false. That was a sales
pitch to the American Medical Association.
I might remind everyone that the American Medical
Association receives $80 to $100 million a year from their sale
of CPT coding books and CPT licensing, so they have a small
amount of financial incentive to go along with whatever CMS
thinks is a good idea.
Mr. Gosar. Can I ask a quick question, interject there?
What percentage of the physicians in the country do they
represent?
Dr. Armstrong. The latest numbers are that approximately 10
percent of actively practicing physicians belong to the
American Medical Association.
Mr. Gosar. I find that interesting. I am a dentist and the
American Dental Association represents over 70 percent of the
dentists across the country.
Dr. Armstrong. In 1962 when Dr. Ed Annis gave his famous
talk against Medicare at Madison Square Garden, the American
Medical Association represented 70 percent of American doctors.
Mr. Gosar. Dr. Novack, I want to get your opinion.
Dr. Novack. Well, it is certainly not the case. As was
mentioned earlier, the protection against so-called preexisting
conditions for children means that in at least 34 States is
almost impossible to get a child only policy. If you are a
member of at least two branches of the SCIU in New York State
and you have a child who is insured, you didn't get to keep
what you have because in response to this they dropped all
child policies.
If you had certain health care policies in the Midwest with
a company that had about 900,000 members, they just stopped
offered health insurance entirely.
So people are not keeping what they have. Their costs are
going through the roof. Ultimately, if the goal was to provide
more accessible care for the people who need it at a more
affordable rate, what I have seen in the past 2 years is that
we are going in exactly the opposite direction.
Mr. Gosar. I just had two health care forums on Friday. And
we are from Arizona, and there are large rural parts. If we are
dumping so many more patients into Medicaid, and by the way,
you said we're going to work on things that actually work. The
last time I looked at Medicaid, it doesn't really work.
Dr. Novack. Arizona's Medicaid system, as people know,
Arizona was the last State to join Medicaid in 1982, came in
under a waiver, and has always existed in a managed care
system. And even that, the system is basically at its breaking
point. There was a $1 billion shortfall in the last year or two
at the legislature to try to cover Medicaid. The system just
isn't working. The number of cuts to services, because that's
really the only option that the system has, so now if you're on
Medicaid in Arizona, you can't get durable medical equipment.
So I can't put my patients in certain kinds of boots to help
them get around better. They have to be in a cast or nothing,
which is a big problem for a lot of the working folks I take
care of. You can no longer see a podiatrist if you're on
Medicaid in the State of Arizona. So if you have diabetes and
you need regular footcare and you're on Medicaid, you're out of
luck because the system simply doesn't cover it.
Mr. Gosar. There are groups that are exempt from ObamaCare;
are there not? One that we are very familiar with, the Native
Americans?
Dr. Novack. Well, there are all sorts of different waivers.
There were things put into the law. But the real problem, and I
think, speaking from the provider side and from the policy side
and from the government side, is that the application of the
law is turning out to be completely arbitrary. It would be one
thing if those of us involved in the practice of medicine could
actually count on the letter of the law and try to make
adaptations. But what we've seen with the nearly 2,000 waivers
affecting over 4 million Americans who won't get certain
benefits, if we look to the fact that actually snuck into the
law was that if you were in a self-funded insurance plan, which
is over 100 million Americans, 60 percent of all people with
commercial insurance, you will never get the benefits of the
essential health benefit package that the President and the
Democrats said was urgent or imperative because they were
exempted from that entirely.
So we are finding complete arbitrariness in the
application, and that is making it ultimately harder for people
to get care.
Mr. Gosar. And I find it real interesting that the group of
people who have had government-dictated health care the longest
are rebelling enormously across the board, the self-
determination type plans.
So thank you.
Mr. Gowdy. I thank the gentleman from Arizona.
The chair will now recognize the gentleman from Georgia, a
distinguished physician, Dr. Gingrey.
Mr. Gingrey. Mr. Chairman, thank you very much, and I want
to thank you and members on both sides of the aisle, too, for
extending us this courtesy to be guests today and indeed to ask
some questions.
Let me real quickly turn to Dr. Novack. ObamaCare does not
address the problems of most Americans who have very low
expected health care expenditures. According to the Agency for
Health Care Quality Research, and I think you talked about this
in your testimony, the bottom 70 percent of health care users
in this country, that's about 224 million Americans, spend
only, I think you said 11 percent of health care dollars, or
about $290 billion out of $2.7 trillion. In your testimony, you
stated that ObamaCare harms these 224 million Americans that
are very low utilizers. Why?
Dr. Novack. Number one, costs are going up. That is number
one. Number two is the creation of all of these new
bureaucracies and boards and the effort to shove these people
who are just occasional users of health care into very
complicated medical home models that make it harder to get
access to specialty care when that may be what they need, just
to get in and get out, that makes the system more difficult to
navigate. It makes the process of going to the doctor a less
pleasant experience.
Mr. Gingrey. Dr. Novack, thank you.
Turning to Dr. Colyer, Lieutenant Governor Colyer, you talk
about what you and Governor Brownback have done in the State of
Kansas in regard to the Medicaid program. So I want to focus in
real quickly this question to you. You spoke about the off
ramp, I think you used that phrase, that off ramp of getting
people off of Medicaid into private insurance. You know, part
of PPACA, the Affordable Care Act, has this maintenance of
effort requirement under Medicaid for at least the next 2 or 3
years before the expansion kicks in, the additional 20 million
people. As I understand that maintenance of effort, it would
prevent you and Governor Brownback and Governor Deale of the
State of Georgia and folks that are working on trying to solve
their Medicaid problem in a State based way, the crucibles of
innovation, that you couldn't even look at your roles and
determine if many people in Kansas who 2 years ago were
eligible for Medicaid but maybe today they are not. Indeed,
maybe they are not even legal citizens, legal residents of this
country. But more importantly, from the economic standpoint,
they are not eligible.
Isn't this a tremendous problem for you to get these folks
onto that off ramp, as you describe?
Dr. Colyer. We want to give people the opportunity to get
back into stable, commercial insurance that they can control,
that is very portable, that they can take with them.
Maintenance of effort does decrease that. But part of the
problem with the maintenance of effort is not just that people
are in, it is being really interpreted in very broad ways. The
previous Governor asked for just a small increase in the
premiums that were paid by certain CHIP members, and instead of
a few dollars it was just a few cents.
Mr. Gingrey. Yes. Essentially what you're saying is you
have got handcuffs on you that prevent you from doing some of
these things in an innovative way to make sure that the dollars
get to the people that need them the most on the Medicaid
program.
Let me utilize, Mr. Chairman, the remaining portion of my
time to talk to and ask questions of Dr. Armstrong.
Dr. Armstrong, thank you for wearing that white coat. That
means a lot, believe me, to we physician members that are
sitting up here asking the questions. On page 78 of Public Law
111-148, otherwise known as PPACA, Affordable Care Act,
ObamaCare, there is a section entitled ``Enhancing Patient
Safety.'' Let me read you the section.
Beginning on January 1, 2015, a qualified health plan,
otherwise known as an insurance company, may contract with a
health care provider only if they implement mechanisms to
improve health care quality as defined by the Secretary, indeed
by regulation.
My concern is that nowhere in the many pages of ObamaCare
is the word ``quality'' defined. So I'm interested in the
thoughts of the panelists. If ObamaCare gives the Secretary of
Health and Human Services the power to invalidate the private
business contracts that providers need to stay in business, in
other words they have to be on the panel, what type of
authority does that give the Secretary to direct how providers
deliver care and practice medicine?
Dr. Armstrong, in your testimony you cite the U.S.
Preventative Services Task Force and its findings. It
recommended against mammography screenings for women below the
age of 50. I'm an OB/GYN, 26 years in practice. I do not
believe such a recommendation is the kind of personalized
medicine that my patients deserve. Each patient is different
and therefore I would probably not adhere to this bureaucratic
directive from Secretary Sebelius, or any other Secretary of
Health and Human Services. I would listen to my specialty
society, the American College of OB/GYNs.
So tell me real quickly--I know I'm a little out of time--
so tell me, Dr. Armstrong, could the Secretary of Health and
Human Services literally drive me or any other practitioner out
of business under the authority given to her to enhance patient
safety?
Dr. Armstrong. Yes.
Mr. Gingrey. Thank you. Mr. Chairman, thank you for your
indulgence, and I yield back.
Mr. Gowdy. I thank the gentleman from Georgia.
The chair will now recognize the gentleman from Michigan,
the distinguished Dr. Benishek.
Mr. Benishek. Thank you, Mr. Chairman. I appreciate the
privilege of being here on this committee this morning.
Dr. Armstrong, you've been in practice for a long time.
What is the worst feature of practicing medicine today?
Dr. Armstrong. Probably the risk of a malpractice suit if
you had to say what the worst risk is, but there are many. But
we could start there.
Mr. Benishek. Did the Affordable Care Act do anything to
adjust this problem?
Dr. Armstrong. Essentially no. There was money in it to
fund State demonstration projects for looking at different
alternatives to tort reform, but there were some strings
attached to that money that made it very difficult for States
to do it. For instance, if your State proposed a cap on
noneconomic damages, you couldn't get the demonstration money.
Mr. Benishek. All right. Dr. Novack, what do you think is
the most difficult aspect of practicing medicine today?
Dr. Novack. As was alluded to earlier, the challenge that
in our practice where we have nine providers, we have three
times that many allied health personnel. So as opposed to being
able to devote the resources to try to provide as comprehensive
and as widespread care as possible, we have large expending of
our resources on things that really have very little to do with
patient care.
Mr. Benishek. Is the Affordable Care Act improving that
situation then?
Dr. Novack. Thus far it has made it significantly worse
since regulations. New regulations seem to appear every week,
since we have an environment now where the other parties in
health care are seeking to take huge steps to really take
ownership over these huge chunks of money. In large part we can
look at the potential for the $900 billion in Medicaid spending
that the CBO anticipates over the next 10 years and the $800
billion in direct insurance company subsidies. The problem
there is that patients and families cease to become patients
and families and become entities where if you can get them
under your umbrella you can then get those Federal dollars.
That has very little to do with patient care.
Mr. Benishek. Taking care of patients and seeing what is
happening with medicine now with the Affordable Care Act and
just the third-party payer system, it concerns me that it seems
that physicians are working less and less for the patient and
more and more for some other bureaucracy which is going to
dictate the form of care that they give to those patients. My
feeling is that the doctor-patient relationship should be one
where the patient is in control of the situation.
Dr. Armstrong, do you think that patients can be trusted to
take care of their own health care or do you think that they
need the Affordable Care Act to guide their care for them?
Dr. Armstrong. I think there are many concrete examples
that show that patients can be excellent consumers in health
care markets.
Mr. Benishek. Okay, give us one example.
Dr. Armstrong. For instance, in Indiana with the Healthy
Indiana Plan that has been established by Governor Mitch
Daniels, under Medicaid, patients are given power accounts and
they have to make their own decisions similar to a health
savings account about where the money goes, and they have
actually shown that they have reduced their health care
spending but not affected outcomes. So they have reduced health
care spending by up to 30 percent but have not affected their
health care outcome. That is just one thing. This has also been
done in private industry and private contracts and continues to
be advocated in other areas.
Mr. Benishek. Dr. Colyer, do you have any comments in that
vein?
Dr. Colyer. Yes. I think there are lots of opportunities
where patients can make their own choices. And they can work
with their doctor for good solutions. For example, if you
empower a patient to--we can oftentimes do their procedure in
the office rather than under certain rules it would only be
paid for only if you do it in the hospital setting. Those are
common sorts of problems.
Mr. Benishek. Thank you very much.
Dr. Novack, who do you think should be in charge of health
care decisions, doctors and patients or the bureaucrats?
Dr. Novack. I think and patients and families in
conjunction with the treating physician and other health care
personnel.
Mr. Benishek. Does the Affordable Care Act encourage that?
Dr. Novack. It moves it in the opposite direction. As I
mentioned, when you create 150 plus new bureaucracies, when you
manage to have 13,000 pages of regulations, and that is just
the tip of the iceberg, on top of the 130,000 pages of
regulations that Medicare has created since 1965, and have a
health exchange network that is likely to adopt nearly
wholesale the Medicare regulations, then foisting that on the
patient population and the providers, you create an environment
where the decision makers and ultimately the payers are not
patients and families but people far removed. As I mentioned in
testimony, the ultimate reality will become that the people who
provide care, whether it is physicians, nurses, other people,
are being more responsive to the decision makers rather than
patients. I just don't see, after 24 years of taking care of
patients in almost every setting, how that is good for patient
care.
Mr. Benishek. Thank you, Dr. Novack. I certainly agree with
you.
My time is up. Thank you.
Mr. Gowdy. I thank the gentleman from Michigan.
The chair now recognizes the distinguished gentleman from
Louisiana, Dr. Fleming.
Mr. Fleming. Thank you, Mr. Chairman. Thank you again for
having us as guests for the panel.
I want to bring the panel's attention to this card here.
Now this, you may not be able to see it from there, so I will
explain to you what it is. This is my health care card. This is
Blue Cross/Blue Shield. Despite what you may read on the
Internet, I actually pay 28 percent of my premium and it is a
private insurance plan. This is my on ramp into the health care
system. This is my key in the door.
Now, the ranking member, Mr. Davis, made a comment a moment
ago that sort of tweaked my ear. He said that the ObamaCare
would give access to care to 30 million more Americans, and
therein lies the problem. There is a tremendous myth that just
because you have a card that entitles you to coverage that you
actually have access to care.
Now, let's go to you, Ms. Pipes. You made a really good
point, a really moving story about your mom. And I am sure that
some would like to say that that was an exception, but I have
heard many stories like that as well in Canada where people had
cancer and never got the treatment that they needed. In fact,
if you look at the statistics, death rates from prostate
cancer, death rates from breast cancer in both Great Britain
and Canada where there is supposed to be 100 percent coverage,
everybody carries a card, but yet the death rates as a result
of late diagnosis and also inadequate treatment are much higher
in those countries. So I would love to hear your response on
this differential between carrying a card that says you're
covered and the actual access to care.
Ms. Pipes. Thank you.
Yes, the United States ranks number one in 13 of the 16
most prominent cancers--breast cancer, colon cancer,
mammography. So we do extremely well compared to Canada.
Mr. Fleming. In terms of positive outcomes?
Ms. Pipes. Yes, right. The 5-year survival rate.
In a country like Canada, the Fraser Institute's new study
on hospital waiting list, the average wait today in Canada from
seeing a specialist to getting treatment by a specialist is 9.5
weeks. It is the highest since they started reporting wait
times, and it is up from 9.3. The average wait from seeing a
primary care doctor to getting treatment by a specialist is 19
weeks, almost 5 months.
In a Supreme Court case in Canada, Madam Chief Justice
Beverly McLaughlin, in looking at the Province of Quebec and
denied care, she said: Access to a waiting list is not access
to health care.
So in a country like Britain and Canada, you do have these
long waits. You read stories in the press all the time. As my
friend, the former head of the Canadian Medical Association,
who runs an illegal orthopedic clinic in Vancouver, said a
family can get a hip replacement for their dog in less than 2
weeks and for their family the average wait is 2 years.
I believe unless this act is repealed and replaced with
solutions that empower doctors and patients, we will face the
same kind of rationed care and long waits in America.
Mr. Fleming. There are those who would say well, look, we
don't have the single payer system that they have there,
therefore that is not going to be a problem here. But I would
take everyone back to the health care debate. Many on the other
side of the aisle, many Democrats, actually wished for wanted,
and pushed for single payer, and in fact hope--and this is
their words, not mine--hope that this evolves into that. So
would it be fair to say that there is something different about
the government takeover of health care under ObamaCare and
single payer when it comes to access to care?
Ms. Pipes. Well, as the late Senator Ted Kennedy used to
say, his goal was Medicare for all, which is a single payer
system.
I believe, as you say, there was no public option in the
Senate bill or in the final bill, but we've already seen
Congressman Jim McDermott from Washington State introducing a
single payer bill. We've seen some of the States, Vermont has,
Governor Shumlin has a single payer bill. I think ultimately
private insurers are going to be crowded out because they are
not going to be able to offer insurance at the rates that they
have to with the essential benefit plans. And even Howard Dean
the other day, who said he was against the individual mandate,
has been pushing for single payer. So if we don't get an off
ramp, we are on the road to serfdom with a single payer system,
I truly believe, and I think it is going to happen.
Mr. Fleming. I only have a few moments. Dr. Novack, Dr.
Armstrong, would you like to weigh in?
Dr. Armstrong. I agree with Sally.
Mr. Fleming. Access versus?
Dr. Novack. There are multiple studies showing that people
on Medicaid do not necessarily have any better access to
certain kinds of care than people with no insurance at all.
Mr. Fleming. I would just add to that, since you brought up
Medicaid real quickly, I am a physician and I see Medicaid
patients all the time. The reimbursement levels are very lower
in Medicaid. They are going lower on Medicare, and so we have a
lot of people in this country, a lot of people in my State of
Louisiana who walk around with a Medicaid card and now a
Medicare card, and they ring up the doctor's office and they
are told that they don't have access. Now, some would say,
well, that is an arbitrary physicians. No, physicians all over
this country are saying we're closing our office down. We're
going to have to work in the emergency room. I'm going to have
to do something else as an occupation because I can't survive,
I can't make payroll as a doctor because of the low
reimbursement rates. So where do these people end up going?
They end up going to the emergency room which the other side of
the aisle would be the first to tell you is where the care is
the most expensive.
Thank you, Mr. Chairman, and I yield back.
Mr. Gowdy. I thank the gentleman from Louisiana.
The chair would now recognize the gentleman from Maryland,
the distinguished physician, Dr. Harris.
Mr. Harris. Thank you very much, Mr. Chairman and members
of the committee, for allowing the members of the Physicians
Caucus to participate.
Mr. Pollack, I'm a physician who has always depended on the
conscience clause protection in my practice. Does Families USA
support the HHS mandate that includes abortifacients and
sterilizations and that is now the subject of lawsuits claiming
infringement of religious freedom?
Mr. Pollack. Families USA does support.
Mr. Harris. Thank you very much.
Dr. Novack--a simple yes or no, so you support that?
Mr. Pollack. We support the preventive care services in the
Affordable Care Act.
Mr. Harris. Sure, okay. Thank you. That's what I needed to
know.
Dr. Novack, do you think the average American senior
understands that to make ObamaCare work you're cutting $500
billion out of Medicare over the next 10 years plus $300
billion in SGR scheduled cuts, $800 billion cut out of senior
health care funding, do you think the average senior
understands that?
Dr. Novack. What I'm seeing both in my practice and doing
some of the work I do around the country is seniors recognizing
when they call to try to find a physician they are not finding
doctors who are taking Medicare patients.
Mr. Harris. Do you think ObamaCare will make that worse or
better?
Dr. Novack. It will make it worse. As you mentioned, the
numbers, which were cooked, which of course in our business if
you could cook your anesthesia concoctions----
Mr. Harris. I would live in a courtroom all my life if I
did that.
Dr. Novack. Yes. The supposed savings of course is
predicated on these $300 billion in SGR payments, including a
30 percent in January of next year.
Mr. Harris. Sure.
Dr. Novack. If those go into effect, we will really
significantly adversely impact access to care.
Mr. Harris. Thank you.
Ms. Pipes, we heard a lot about free preventive care, and
so I was giving a town hall a couple of months ago and two
physicians stand up in the back and go, we work in federally
qualified health centers, and they told me that the free flu
vaccine, they get paid over $200 from the Federal Government
for the free flu vaccine that people get when you can walk down
to the Rite-Aid or Walgreen's and get it for $39.95. Ms. Pipes,
correct me if I'm wrong, doesn't this--and a very short
answer--indicate that in fact free preventive care is not free?
And not only that, when the Federal Government delivers it, it
can cost five or six times as much as the private sector?
Ms. Pipes. Yes.
Mr. Harris. Thank you very much.
Dr. Colyer, Lieutenant Governor, why would you possibly
recommend to your Governor to participate in Medicaid, the
expansion from 100 to 133 percent, when you know if you choose
not to every one of those patients will be covered under a
Federal health exchange at not cost to your State? No
administrative cost, no cost at all. And you see, as the
chairman pointed out, and the Congresswoman from Louisiana, in
Texas right now only 31 percent of physicians will take a
Medicaid patient, but a whole lot more will take a private
patient. And, in fact, Mr. Pollack said under this plan, you
get a private health insurance plan. Why would any Governor
possibly do it to those people, those poor people who we heard
about from the gentlelady of the District of Columbia, those
poor working people we heard about from the ranking member, why
would you foist Medicaid on them when their option under
affordable care is a federally subsidized health exchange plan?
Dr. Colyer. An even better solution is win the election in
November.
Mr. Harris. Well, I understand that. But given the
scenario, any Governor who does this to their poor people, to
their people in that 100 to 133 who opt to expand Medicaid,
ought to talk to some of the docs about what, I urge and
everyone listening, call up your doc and ask them if they take
Medicaid and then decide whether you would want to be on
Medicaid or not.
Ms. Pipes, we heard Mr. Pollack say that ``some States have
high risk pools.'' Don't 35 States have high risk pools?
Ms. Pipes. Yes, they do.
Mr. Harris. Thank you very much. I just want to clarify
that in fact the vast majority of Americans are already covered
under preexisting conditions in high risk. Mr. Pollack, it is a
fact, including Maryland. I'm not asking you a question.
Mr. Pollack. These are all very small.
Mr. Harris. Mr. Pollack, I'm not asking you a question.
Listen to what the chairman, how he admonished you. You are to
answer a question when I ask you. I didn't ask you the
question. You already made the statement that some States. We
understand that to you 35 of 50 is just some.
Ms. Pipes, I'm an obstetric anesthesiologist. I have spent
my life delivering health care to women. I've watched the
caesarean section rate go from 18 when I started in 1980 to 35
now. That's the C section rate. Just for all of you young
ladies in the audience, you are twice as likely to have a
caesarean section as you would have been when I started my
practice 30 years ago. You can't find an experienced OB who's
been doing it for 30 years to deliver your baby any more. They
all gave it up. You get the inexperienced, well-intended young
physicians because the experienced OBs have given up. Because
of lack of tort reform, you have a doubling of the caesarean
section rate. If any of you young ladies think that is better
health care, raise your hand. I don't think so. Does this
Affordable Care Act do anything at all to address a rising
caesarean section rate or the fact that experienced
obstetricians are leaving the field?
Ms. Pipes. No. And tort reform is one of the things that we
have seen, the OB/GYNs in West Virginia, Pennsylvania, Nevada,
the States that have the highest med mal insurance rates, the
decline in OB/GYNs has been very significant. And who does that
hurt? It hurts all women who are of child bearing age.
Mr. Harris. It hurts women. I suggest, Mr. Pollack, you
take that information back to your group that opposes tort
reform.
Thank you very much, Mr. Chairman.
Mr. Gowdy. I thank the gentleman from Maryland.
On behalf of all of the panelists, we want to thank our
distinguished panel of witnesses.
Mr. Davis. Mr. Chairman, Could I just clarify something. I
was mentioned in terms of something that I said, and I don't
think that I really said that.
Mr. Gowdy. Sure.
Mr. Davis. Doctor, you implied that I suggested that
because individuals had access to insurance they had access to
care. I've been in this business much too long to have not
understood that insurance does not necessarily mean access to
care. We have many----
Mr. Fleming. Would the gentleman yield?
Mr. Davis. Let me just finish.
We have serious manpower shortage areas. We have areas
where there are no physicians. We have areas where there are no
facilities. And so access to insurance means that you have a
way to pay for care. It does not necessarily mean that the
care, and I'm amazed when I hear individuals suggest that we're
going to put such a burden on the health care delivery system.
It just depends on how you look at it. If you are a young
person who wanted to become a physician or who wanted to become
a nurse, it creates a tremendous opportunity for you to go to
medical school, to go and be trained so that you can provide
care for these millions of people who don't have any.
I just wanted to clear that up.
Ms. Norton. Mr. Chairman, could I correct the record on a
factual matter?
Mr. Gowdy. Yes, the gentlelady from the District of
Columbia can. But I think in fairness, I should give the
gentleman from Louisiana a chance to respond since he attempted
to do so and then I will recognize the gentlelady.
Mr. Fleming. Let me say parenthetically that a study just
came out today that I believer 83 percent of physicians when
asked, when polled, this was a survey, a scientific survey,
said they are reconsidering their occupation. And I can tell
you that I get questions a lot from medical students who ask me
did they do the right thing. So again, I would just say to the
gentleman that right now ObamaCare means for health care
workers a very uncertain future. Yes, they do want to take care
of patients, insured or not, but they see a very dark cloud
ahead of them.
But to respond to your statement, yes, you did say access
to care. That is the actual term. And I'm sure we could pull it
up in the transcript if we need to. Why that is important is
because that is a common myth. Whether or not the gentleman
meant it or not is beside the point.
Mr. Fleming. The point I needed to make with that is that
Americans are getting that message, that once you get that card
that means that you go into the healthcare system and you are
just going to be taken care of, and that is the whole point.
Half of the additionally covered Americans under ObamaCare, and
this is by Democrat numbers, not mine, I think fewer are going
to be covered than the 30 million that are claimed, but half of
them will be covered under Medicaid. And you just heard the
gentleman from Maryland say that very few doctors accept
Medicaid, not because they don't want to accept Medicaid,
because they can't afford to accept Medicaid.
If we don't deal with the cost realities that go with
malpractice insurance and all of that, the access problem is
going to only get worse. So I think that is something we need
to leave with today that just because you have a card, just
because you are in a system does not mean you have access, and
I yield back.
Mr. Gowdy. I thank the gentleman from Louisiana, and now I
recognize the gentlelady from the District of Columbia.
Ms. Norton. Thank you, Mr. Chairman. On the matter of the
health, people on--who would receive Medicaid under the
Affordable Health Care Act, going to the exchange, go to the
exchange, you need to have some cash to pay for the health care
and the exchange. These are people above the limit of Medicaid
but unable to pay for health insurance, and my question is, the
payment for health insurance and the high-risk pool--I'm sorry,
the exchange will not help those people which is why they were
included, in Medicaid. For preexisting, for those with
preexisting conditions going to the high-risk pool, the high-
risk pool is anything but affordable. It should be called the
unaffordable high-risk pool because clustered there are all of
those who have sought refuge there and therefore it becomes
unaffordable for almost everyone who would want access, who
have the diabetes and can't find a podiatrist; I guess what he
couldn't find if he weren't on Medicaid at all.
So the problem, the system has its faults. But it certainly
doesn't have the faults that the present system, which leaves
out of it those with preexisting condition and people who
simply cannot afford health care.
Mr. Gowdy. Thank the gentlelady from the District of
Columbia. Anything else for the Good of the Order? The
gentleman from Maryland.
Mr. Harris. Thank you very much. Well, just to, I don't
know what preexisting pools and high-risk pools cover in other
States, but in Maryland it is very affordable. It is funded by
a small tax on hospital admissions, and in fact, when we
started it, the premiums were $300, $300 and something a month
for someone with a preexisting condition. That's pretty darn
affordable for individual insurance. And just to correct, I was
talking about in my comments about Medicaid, the 100 to 133
percent of Federal poverty level would be 100 percent covered
under the exchanges; higher up you need cash, but at that
level, 100 percent coverage. So that was my point, just in that
narrow range.
Thank you, Mr. Chairman.
Mr. Gowdy. I thank my colleagues on both sides, and again,
on behalf of all of us, we want to thank our distinguished
panel of witnesses for taking time from their busy schedules to
appear before us today.
With that, the committee stands adjourned.
[Whereupon, at 12:09 p.m., the subcommittee was adjourned.]

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