[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]







MAKING HEALTH CARE WORK FOR AMERICAN FAMILIES: IMPROVING ACCESS TO CARE

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

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED ELEVENTH CONGRESS

                             FIRST SESSION

                               __________

                             MARCH 24, 2009

                               __________

                           Serial No. 111-20









      Printed for the use of the Committee on Energy and Commerce

                        energycommerce.house.gov

                                _____

                  U.S. GOVERNMENT PRINTING OFFICE

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                    COMMITTEE ON ENERGY AND COMMERCE

                 HENRY A. WAXMAN, California, Chairman

JOHN D. DINGELL, Michigan            JOE BARTON, Texas
  Chairman Emeritus                    Ranking Member
EDWARD J. MARKEY, Massachusetts      RALPH M. HALL, Texas
RICK BOUCHER, Virginia               FRED UPTON, Michigan
FRANK PALLONE, Jr., New Jersey       CLIFF STEARNS, Florida
BART GORDON, Tennessee               NATHAN DEAL, Georgia
BOBBY L. RUSH, Illinois              ED WHITFIELD, Kentucky
ANNA G. ESHOO, California            JOHN SHIMKUS, Illinois
BART STUPAK, Michigan                JOHN B. SHADEGG, Arizona
ELIOT L. ENGEL, New York             ROY BLUNT, Missouri
GENE GREEN, Texas                    STEVE BUYER, Indiana
DIANA DeGETTE, Colorado              GEORGE RADANOVICH, California
  Vice Chairman                      JOSEPH R. PITTS, Pennsylvania
LOIS CAPPS, California               MARY BONO MACK, California
MICHAEL F. DOYLE, Pennsylvania       GREG WALDEN, Oregon
JANE HARMAN, California              LEE TERRY, Nebraska
TOM ALLEN, Maine                     MIKE ROGERS, Michigan
JAN SCHAKOWSKY, Illinois             SUE WILKINS MYRICK, North Carolina
HILDA L. SOLIS, California           JOHN SULLIVAN, Oklahoma
CHARLES A. GONZALEZ, Texas           TIM MURPHY, Pennsylvania
JAY INSLEE, Washington               MICHAEL C. BURGESS, Texas
TAMMY BALDWIN, Wisconsin             MARSHA BLACKBURN, Tennessee
MIKE ROSS, Arkansas                  PHIL GINGREY, Georgia
ANTHONY D. WEINER, New York          STEVE SCALISE, Louisiana
JIM MATHESON, Utah                   PARKER GRIFFITH, Alabama
G.K. BUTTERFIELD, North Carolina     ROBERT E. LATTA, Ohio
CHARLIE MELANCON, Louisiana
JOHN BARROW, Georgia
BARON P. HILL, Indiana
DORIS O. MATSUI, California
DONNA M. CHRISTENSEN, Virgin 
Islands
KATHY CASTOR, Florida
JOHN P. SARBANES, Maryland
CHRISTOPHER MURPHY, Connecticut
ZACHARY T. SPACE, Ohio
JERRY McNERNEY, California
BETTY SUTTON, Ohio
BRUCE L. BRALEY, Iowa
PETER WELCH, Vermont

                                  (ii)





                         Subcommittee on Health

                FRANK PALLONE, Jr., New Jersey, Chairman
JOHN D. DINGELL, Michigan            NATHAN DEAL, Georgia,
BART GORDON, Tennessee                   Ranking Member
ANNA G. ESHOO, California            RALPH M. HALL, Texas
ELIOT L. ENGEL, New York             BARBARA CUBIN, Wyoming
GENE GREEN, Texas                    HEATHER WILSON, New Mexico
DIANA DeGETTE, Colorado              JOHN B. SHADEGG, Arizona
LOIS CAPPS, California               STEVE BUYER, Indiana
JAN SCHAKOWSKY, Illinois             JOSEPH R. PITTS, Pennsylvania
TAMMY BALDWIN, Wisconsin             MARY BONO MACK, California
MIKE ROSS, Arkansas                  MIKE FERGUSON, New Jersey
ANTHONY D. WEINER, New York          MIKE ROGERS, Michigan
JIM MATHESON, Utah                   SUE WILKINS MYRICK, North Carolina
JANE HARMAN, California              JOHN SULLIVAN, Oklahoma
CHARLES A. GONZALEZ, Texas           TIM MURPHY, Pennsylvania
JOHN BARROW, Georgia                 MICHAEL C. BURGESS, Texas
DONNA M. CHRISTENSEN, Virgin 
    Islands
KATHY CASTOR, Florida
JOHN P. SARBANES, Maryland
CHRISTOPHER S. MURPHY, Connecticut
ZACHARY T. SPACE, Ohio
BETTY SUTTON, Ohio
BRUCE L. BRALEY, Iowa
  
                             C O N T E N T S

                              ----------                              
                                                                   Page
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................     1
Hon. Nathan Deal, a Representative in Congress from the State of 
  Georgia, opening statement.....................................     2
Hon. Anna G. Eshoo, a Representative in Congress from the State 
  of California, opening statement...............................     4
Hon. John Shimkus, a Representative in Congress from the State of 
  Illinois, opening statement....................................     5
Hon. Gene Green, a Representative in Congress from the State of 
  Texas, opening statement.......................................     5
Hon. Michael C. Burgess, a Representative in Congress from the 
  State of Texas, opening statement..............................     6
Hon. Henry A. Waxman, a Representative in Congress from the State 
  of California, opening statement...............................     7
    Prepared statement...........................................     9
Hon. Marsha Blackburn, a Representative in Congress from the 
  State of Tennessee, opening statement..........................    13
Hon. John D. Dingell, a Representative in Congress from the State 
  of Michigan, opening statement.................................    13
Hon. Joe Barton, a Representative in Congress from the State of 
  Texas, prepared statement......................................    14
Hon. Diana DeGette, a Representative in Congress from the State 
  of Colorado, opening statement.................................    16
Hon. Tim Murphy, a Representative in Congress from the 
  Commonwealth of Pennsylvania, opening statement................    16
Hon. Lois Capps, a Representative in Congress from the State of 
  California, opening statement..................................    17
Hon. Mike Rogers, a Representative in Congress from the State of 
  Michigan, opening statement....................................    17
Hon. Tammy Baldwin, a Representative in Congress from the State 
  of Wisconsin, opening statement................................    18
Hon. Ed Whitfield, a Representative in Congress from the 
  Commonwealth of Kentucky, opening statement....................    19
Hon. Donna M. Christensen, a Representative in Congress from the 
  Virgin Islands, opening statement..............................    19
Hon. Kathy Castor, a Representative in Congress from the State of 
  Florida, opening statement.....................................    20
Hon. Christopher S. Murphy, a Representative in Congress from the 
  State of Connecticut, opening statement........................    20
Hon. Zachary T. Space, a Representative in Congress from the 
  State of Ohio, opening statement...............................    21
Hon. Bruce L. Braley, a Representative in Congress from the State 
  of Iowa, opening statement.....................................    22
Hon. Jane Harman, a Representative in Congress from the State of 
  California, opening statement..................................    22
Hon. John Barrow, a Representative in Congress from the State of 
  Georgia, opening statement.....................................    23
Hon. Roy Blunt, a Representative in Congress from the State of 
  Missouri, prepared statement...................................   178

                               Witnesses

Brian D. Smedley, Ph.D., Vice President and Director, Health 
  Policy Institute, Joint Center for Political and Economic 
  Studies........................................................    24
    Prepared statement...........................................    27
Michael John Kitchell, M.D., President-Elect of Iowa Medical 
  Society, McFarland Clinic PC...................................    47
    Prepared statement...........................................    49
Michael A. Sitorius, M.D., Professor and Chairman, Department of 
  Family Medicine, University of Nebraska Medical Center.........    54
    Prepared statement...........................................    56
Risa Lavizzo-Mourey, M.D., M.B.A., President and CEO, Robert Wood 
  Johnson Foundation.............................................    61
    Prepared statement...........................................    63
Fitzhugh Mullan, M.D., Murdock Head Professor of Medicine and 
  Health Policy, Professor of Pediatrics, The George Washington 
  University.....................................................    81
    Prepared statement...........................................    84
Jeffrey P. Harris, M.D., F.A.C.P., President, American College of 
  Physicians.....................................................    99
    Prepared statement...........................................   102
James R. Bean, M.D., President, American Association of 
  Neurological Surgeons..........................................   119
    Prepared statement...........................................   121
Diane Rowland, Sc.D., Executive Director, The Kaiser Commission 
  on Medicaid and the Uninsured..................................   133
    Prepared statement...........................................   135

                           Submitted Material

Letters from physicians to Mr. Shimkus...........................   180
Letter from the Georgia Mutual Insurance Company to the Medical 
  Association of Georgia, submitted by Mr. Gingrey...............   189

 
MAKING HEALTH CARE WORK FOR AMERICAN FAMILIES: IMPROVING ACCESS TO CARE

                              ----------                              


                        TUESDAY, MARCH 24, 2009

                  House of Representatives,
                            Subcommittee on Health,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 10:10 a.m., in 
Room 2322 of the Rayburn House Office Building, Hon. Frank 
Pallone, Jr. (chairman) presiding.
    Members present: Representatives Pallone, Dingell, Gordon, 
Eshoo, Green, DeGette, Capps, Schakowsky, Baldwin, Weiner, 
Harman, Gonzalez, Barrow, Christensen, Castor, Sarbanes, Murphy 
of Connecticut, Space, Sutton, Braley, Waxman (ex officio), 
Deal, Whitfield, Shimkus, Blunt, Rogers, Myrick, Murphy of 
Pennsylvania, Burgess, Blackburn, Gingrey, and Barton (ex 
officio).
    Staff present: Karen Nelson, Deputy Staff Director for 
Health; Karen Lightfoot, Communications Director; Jack Ebeler, 
Senior Advisor on Health Policy; Stephen Cha, Professional 
Staff Member; Tim Gronniger, Professional Staff Member; Purvee 
Kempf, Counsel; Anne Morris, Legislative Analyst; Virgil 
Miller, Legislative Assistant; Camille Sealy, Detailee; Miriam 
Edelman, Special Assistant; Lindsay Vidal, Special Assistant; 
Alvin Banks, Special Assistant; Allison Corr, Special 
Assistant; Brandon Clark, Minority Professional Staff; Marie 
Fishpaw, Minority Professional Staff; Clay Alspach, Minority 
Counsel; Melissa Bartlett, Minority Counsel; and Chad Grant, 
Minority Legislative Analyst.

OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE 
            IN CONGRESS FROM THE STATE OF NEW JERSEY

    Mr. Pallone. The hearing is called to order.
    Today the subcommittee is meeting for the third hearing in 
the ``Making Health Care Work for American Families'' series. 
In the previous hearings, we heard from the leading experts in 
health care that our delivery system is dangerously 
disconnected and that providing universal coverage means and 
affordable and quality health plans for all. Today we will 
explore the next step. Simply providing universal coverage will 
not guarantee that everyone will have access to the necessary 
care. We must also eliminate the inequities and disparities in 
health care, properly support and train our health care 
workforce and make prevention a national priority.
    As a Nation, we have made tremendous strides in improving 
the health of all Americans. However, as numerous reports have 
highlighted, there remain significant inequalities with respect 
to both access to health care and the quality of care provided 
among different ethnic groups in this country. For example, the 
mortality rate due to heart disease and cancer is higher among 
populations including African-Americans, Asian-Americans and 
Pacific Islanders. The rate of new AIDS cases is three times 
higher among Hispanics than among Caucasians. I personally am 
also very concerned about the health disparities for American 
Indians and Alaska Natives. The mortality rate among Indian 
infants is 150 percent higher than for Caucasian infants, and 
Indians are nearly three times as likely to be diagnosed with 
diabetes. These disparities are not limited, however, to ethnic 
and racial divides but are consistently also found between 
genders, geographic area and among different income groups. For 
example, there are significantly more access-to-care obstacles 
for rural populations than there are for urban populations, and 
the 2002 Institute of Medicine report found that these 
disparities persisted even when factors such as insurance 
coverage and income level remained constant.
    One of the contributing problems in my mind is the current 
state of the health care workforce. Study after study has 
proven the importance or primary care yet two-third of the U.S. 
physician workforce that practice as specialists and the number 
of young physicians entering primary care fields is declining. 
In addition to this, there are disparities in where these 
physicians are practicing. Metropolitan areas have two to five 
times as many physicians as rural areas and there is a shortage 
of physicians willing to practice in economically disadvantaged 
areas, both rural and urban.
    Part of the solution, in my mind, is to strengthen our 
existing programs while at the same time exploring new avenues 
to reduce disparities and expand the workforce. As highlighted 
in a recent Commonwealth Fund report, Medicaid is vital in 
improving access to health care for low-income Americans. Title 
7 and 8 of the Public Health Service Act are crucial programs 
to increase the primary care workforce and the National Health 
Service Corps is a very successful program to entice young 
medical professionals to practice in underserved neighborhoods. 
But we face many obstacles in ensuring access for all 
Americans. I am optimistic that in this Congress we will take 
action to ensure that all Americans have both coverage and 
access to care.
    I want to welcome all of the witnesses today. I do want to 
say that certain members, not to take away from the others, but 
Ms. Christensen was very crucial in asking that we have this 
hearing today and address some of the disparity issues and 
certainly Ms. Capps, who is our vice chair, constantly making 
reference to the workforce and the need to address those 
workforce issues.
    Mr. Pallone. With that I will ask Mr. Deal to begin with an 
opening statement. Thank you.

  OPENING STATEMENT OF HON. NATHAN DEAL, A REPRESENTATIVE IN 
               CONGRESS FROM THE STATE OF GEORGIA

    Mr. Deal. Thank you, Mr. Chairman. I want to also express 
appreciation to all the witnesses for being here today.
    As we move forward in this series of hearings looking at 
what health care reform should encompass, I think there are 
some fundamentals that we all ought to keep in mind. I believe 
that some of the true issues in health care reform include 
transparency, efficiency and accountability in the health 
delivery system, and allowing a system to exist that involves a 
patient's right to choose.
    This hearing, of course, is going to focus on access to 
health care services and various proposals aimed to overcome 
the obstacles to care. Unfortunately, too many Americans across 
the country do lack access to quality, affordable medical care. 
As we all know, there are a variety of reasons why this exists. 
Physical, geographical, cultural and financial influences all 
play a role in patient access to health care. While there are 
scores of obstacles to stand in the way of receiving it, 
effective reform such as cross-state purchasing of health 
insurance, association health plans, consumer-driven options 
that enhance quality and value, and similar options which build 
upon the doctor-patient relationship would make great strides 
forward in bridging the gap that exists under today's system.
    There is a lot of talk in Washington that suggests that the 
most appropriate way to put our health care delivery system 
back on its course is to increase the role of government-run 
health care programs, particularly Medicare and Medicaid and 
SCHIP. I of course don't agree with that proposition. Patients 
receiving care through Medicaid oftentimes find it very 
difficult to find a physician who will accept their coverage 
due at least in part to abysmal reimbursement levels rendered 
for their services. Medicaid participants are frequently forced 
to travel great distances to receive access to needed care. In 
fact, just before the hearing today I had an opportunity to 
meet with a group of podiatric physicians from my district and 
they reiterated the challenges that their Medicaid patients 
face in finding a providing who will actually accept their 
coverage. In my rural district in north Georgia, this presents 
a significant challenge to many of my constituents and 
funneling even more individuals into government-run health care 
programs without addressing the heart of these programs does 
not reflect the reform that the American people are asking for.
    Additionally, Congress should also consider other forms in 
the health care delivery system. I believe that any package we 
sent to the Floor should include a significant medical 
liability reform provision. Time and again we have repeated 
instances of frivolous lawsuits for medical liability cases 
being brought against health care providers as trial lawyers 
seek to exploit every opportunity to game the legal system and 
yield an oversized award. Unfortunately, we have seen as a 
result physicians continue to change the way they practice 
medicine, usually resulting in an onslaught of medically 
unwarranted diagnostic testing and referrals to other 
physicians solely for the protection of the provider, not the 
patient, under the practice of defensive medicine.
    We are all aware of the significant and growing cost of 
health care. Unfortunately, with the understandably defensive 
nature of the health care delivery system in the United States, 
we can only expect these strains to multiply as the number of 
Americans receiving care grows. By empowering physicians with 
the ability to provide needed health care services without the 
burden of defensive medicine tactics, an estimated $70 to $126 
billion per year could be saved, outcomes could be improved and 
utilization of our limited medical resources would be more 
effectively maximized. Rest assured, I value protection of 
patients' rights and efforts to reform the medical liability 
system should not be misconstrued as an effort to infringe upon 
those rights. If tragedy occurs, then certainly there should be 
redress for the individual who has been harmed.
    I lost sight of the clock up there. There it is. I finally 
spotted it. I have run out of my time, so I am going to stop, 
but thank you all for being here today.
    Mr. Pallone. Thank you, Mr. Deal.
    For an opening statement, the gentlewoman from California, 
Ms. Eshoo.

 OPENING STATEMENT OF HON. ANNA G. ESHOO, A REPRESENTATIVE IN 
             CONGRESS FROM THE STATE OF CALIFORNIA

    Ms. Eshoo. Good morning, Mr. Chairman, and thank you for 
the series of hearings that you are holding as we prepare 
legislation for health care for everyone in our country. I 
guess today can be called Doctors Day, so welcome to all the 
witnesses.
    As a Nation we have innovative equipment, I think we have 
the most knowledgeable doctors, we have the widest array of 
medicines, but if millions of Americans don't have access to 
this, obviously something is very, very wrong, and it is worst 
for minorities and lower-income groups. In addition to the 47 
million Americans who have no insurance whatsoever, there are 
millions more who are underinsured. Racial, ethnic, cultural, 
socioeconomic and geographical barriers exist in getting people 
the care they need and that is why it is critical for us to 
keep these factors in mind when addressing health care reform 
and I think that you are going to teach us a lot today.
    I look forward to discussing how we can improve Medicaid 
and Medicare as well. There are parts of the country where two 
out of three doctors will not see Medicaid patients, in parts 
of my own district, and it is the heart of Silicone Valley so 
one might think that even though the Gallop Poll said that it 
is the most contented district in the country, we still have 
many gaps where no doctor will take new Medicare patients 
because they are reimbursed at rates far below their costs. The 
Geographic Price Cost Index, or the GPCI, has severely skewed 
doctor reimbursement rates so low in Santa Cruz County that 
many of my senior constituents have to travel an hour or more 
over a winding mountain road to see a doctor in another county. 
So this is just one example of how our health care system is 
broken and fails too many Americans.
    I thank each one of you for being here today. I look 
forward to your testimony and most important of all, look 
forward to all of you working with us where in the year 2009, 
God willing, we will really reform the system once and for all.
    Thank you, Mr. Chairman.
    Mr. Pallone. Thank you, Ms. Eshoo.
    The gentleman from Illinois, Mr. Shimkus.

  OPENING STATEMENT OF HON. JOHN SHIMKUS, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF ILLINOIS

    Mr. Shimkus. Thank you, Mr. Chairman.
    When I started practicing medicine in the same location 30 
years ago, my malpractice premium with the same insurer was 
$10,000 a year. Today my premium is just shy of $100,000 
annually. Major malpractice reform with bipartisan support 
should be a starting point for our country's health care 
overhaul. Threat of litigation causes an inestimable amount of 
practice of defensive medicine. It will not take too many rate 
hikes for those of us providing obstetrical care in rural 
counties to say enough is enough and that we will not continue 
to provide high-risk services.
    These days, malpractice insurance premiums are prohibitive. 
We have not been able to recruit new doctors in the area, 
particularly in surgical specialties, due to excessive 
premiums. Addressing medical liability reform and health care 
reform will free millions of doctors that can be directed 
toward improving care and access to care. It would also provide 
for a better distribution of physicians as recruitment and 
retention of physicians is greatly influenced by the medical 
liability environment of each State.
    I have two additional letters, Mr. Chairman, and I ask 
unanimous consent that these be submitted for the record. They 
are from doctors in my district and health care providers, 
especially hospitals.
    [The information appears at the conclusion of the hearing.]
    Mr. Pallone. Without objection, so ordered. We thank the 
gentleman.
    The gentleman from Texas, Mr. Green.

   OPENING STATEMENT OF HON. GENE GREEN, A REPRESENTATIVE IN 
                CONGRESS FROM THE STATE OF TEXAS

    Mr. Green. Thank you, Mr. Chairman, for calling this 
hearing. In following my friend from Illinois, if we could 
handle medical malpractice, in Texas we wouldn't have 900,000 
children and not covered by SCHIP because the State won't cover 
the match because we have one of the strong medical malpractice 
laws in the country and we still have a huge number of 
uninsured. I think we have to look at other issues.
    I want to thank you for holding the hearing today on health 
insurance and access to care. Houston has the third largest 
Hispanic population in the country and I represent an area that 
is 65 percent Hispanic and medically underserved. In 2007, 
nearly half of the 47 million uninsured in the United States 
were minorities. Unfortunately, most minority populations have 
higher rates of diseases like diabetes, cervical cancer, HIV/
AIDS and heart disease in our community. In fact, Mexican-
Americans are twice as likely as Anglos to be diagnosed with 
diabetes. These diseases are mostly preventable but lack of 
access to care is still a barrier to the minority communities 
in part because of the many health problems in the Hispanic 
community.
    As we know on this committee, access to quality primary and 
preventive care leads to a better quality of life and fewer 
health problems down the road. We will hear today that aside 
from barriers to primary care, we are facing a shortage of 
primary care physicians. This is troublesome because even if we 
reform our system, we may not have enough primary care 
physicians to serve all the patients who will be entering our 
health care system.
    We are addressing the issue of health reform but as we move 
forward we have to reiterate that State and federal 
partnerships do not work if the State cannot come up with the 
federal match. Texas unfortunately has a long history in the 
SCHIP and Medicare program of not providing the matching funds 
much to the detriment of our residents. Health reform must be 
at a national level, and if we truly want to cover all 
Americans, although many States have their own wraparound 
programs, some of us do not and we can't leave those uninsured 
behind.
    Again, I want to thank our witnesses today, and Mr. 
Chairman, I yield back my time.
    Mr. Pallone. Thank you, Mr. Green.
    The gentleman from Texas, Mr. Burgess.

OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE 
              IN CONGRESS FROM THE STATE OF TEXAS

    Mr. Burgess. Thank you, Mr. Chairman. Thank you for holding 
this hearing. I feel like I am in a Chevy Chase movie, doctor, 
doctor, doctor, doctor and doctor, but, you know, reading 
through the testimony today, we are going to have an 
opportunity to touch on several important issues and they are 
issues that have been near and dear to my heart for a long 
time.
    I do look forward to discussing the role of Medicare and 
Medicaid in providing care and the very serious issues we face 
in ensuring that our primary care workforce is able to meet the 
demands of the future and the role of health disparities among 
the various populations. Some very basic questions that we need 
to consider. How can we think of going forward until we have 
some solutions to the problems that we know exist within our 
public systems today and this hearing might very well serve as 
a checklist of what we know to be broken within those public 
systems. The federal programs, Medicare and Medicaid, that 
cover well over a third of our population, are headed for a 
budgetary collapse. We expect these programs to service the 
populations that they do now and in the very near future to 
serve even more, and the providers in the workforce face the 
threat of annual Medicare cuts, this year to be at 20 percent 
unless Congress acts before the end of December, and Medicaid 
reimbursements that are even worse, and to top it all off, the 
Association of American Medical Colleges reports that the 
physician shortage is expected to exceed 124,000 doctors by 
2025.
    I am encouraged to see attention being given to the 
physician workforce issues. I have been concerned about that 
for some time. In my home State of Texas, the number of doctors 
between 1995 and 2005 increased by 46 percent, nearly 5,000 
doctors, but the State is still well below the national 
average. I believe that a good start for Congress is to enact 
legislation that this committee, this subcommittee approved, we 
approved in full committee that I introduced along with 
Congressman Gene Green, H.R. 914, the Physician Workforce 
Enhancement Act of 2009, to create additional residency 
training programs where historically none have operated in the 
past. We all know doctors are not very imaginative. We tend to 
go into practice within 50 miles of where we do our training 
and this is a bill aimed at capitalizing upon that fact, but it 
is only one small step.
    I also represent an area that has a significant minority 
population who suffers from a lack of direct access to medical 
services and obviously the health problems that result 
therefrom. But that is just it, Mr. Chairman. We need a lot of 
discussion before we proceed on the path of a comprehensive fix 
but we all know we need to proceed. Coverage does not always 
equal access. Coverage doesn't help the Medicare or Medicaid 
patient who cannot find a doctor willing to accept the program, 
or worse yet, a doctor who can no longer afford to keep their 
doors open because they have accepted what the government will 
pay. So simply burdening future generations is not the answer. 
It is up to us, it is up to this Congress.
    I look forward to the testimony today and I will yield back 
the balance of my time.
    Mr. Pallone. Thank you.
    The chairman of our full committee, Mr. Waxman.

OPENING STATEMENT OF HON. HENRY A. WAXMAN, A REPRESENTATIVE IN 
             CONGRESS FROM THE STATE OF CALIFORNIA

    Mr. Waxman. Thank you very much, Chairman Pallone, for 
holding this hearing.
    We have already had two productive hearings in this series 
on health reform. At the first hearing the Institute of 
Medicine testified that health insurance coverage makes a big 
difference in personal health. For example, the health of 
uninsured middle-aged adults who have chronic conditions such 
as diabetes declines more rapidly than the health of insured 
adults with these conditions. Overall, uninsured adults are 25 
percent more likely to die prematurely than adults with health 
insurance. The data are overwhelming. Health insurance improves 
access to care, which in turn improves personal health, while 
we also know that health insurance coverage does not 
necessarily guarantee access to needed care. Racial and ethnic 
minorities often don't get the care they need, even if they are 
insured. People living in rural areas of our Nation have some 
of the highest rates of chronic health problems like obesity 
but some of the lowest numbers of physicians and nurses to 
address these problems. Communities all over the country in 
urban and rural areas alike face growing shortages of primary 
care physicians and nurses. Coverage for all is essential but 
health insurance by itself won't solve these shortages. We will 
need additional measures to ensure that we have enough primary 
care physicians and nurses to meet the Nation's needs.
    As the Institute of Medicine told us, many more low-income 
Americans would be uninsured today and at greater risk for poor 
health and premature death were it not for expansions in public 
programs like Medicaid and CHIP. Medicaid and CHIP are the 
Nation's insurers for low-income families and children and 
individuals with disabilities. However, just as Americans with 
private health insurance do not always have access to needed 
care, so those enrolled in Medicaid and CHIP may not always 
have access to the care they need. When our committee takes up 
health reform, we will provide coverage for the uninsured. 
However, I also want to make sure that our legislation 
addresses the barriers to access that insurance coverage by 
itself can't fix. Today's hearing will help us craft solutions 
that will improve access to care for all regardless of race, 
ethnicity or geography.
    I look forward to our witnesses' testimony. I yield back 
the balance of my time.
    [The prepared statement of Mr. Waxman follows:]



    Mr. Pallone. Thank you, Chairman Waxman.
    The gentlewoman from Tennessee, Ms. Blackburn.

OPENING STATEMENT OF HON. MARSHA BLACKBURN, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF TENNESSEE

    Ms. Blackburn. Thank you, Mr. Chairman. Welcome to our 
guests.
    In order to truly reform the Nation's health care system, I 
am one of those that believes we have to focus on cost 
reduction, improved quality, increased access to all Americans. 
True medical liability reform is a critical component of the 
health reform debate. It is concerning to me that there has 
been little attention on how tort reform will affect access to 
care in the broader health care reform debate. The lack of 
liability reform hurts patients, hurts our constituents, 
impacts their ability to receive care due to enormous added 
costs incurred in the practice of defensive medicine which has 
driven trial lawyers looking to cash in on what they deem to be 
bad outcomes. Any attempt to make health care available to the 
underserved and uninsured will be doomed to failure if the 
legal costs of practicing medicine are not addressed.
    With reimbursement issues added to the high cost of 
liability insurance, physicians who are often small business 
owners must weigh the risk of taking new patients, particularly 
the uninsured, if costs exceed reimbursement. A physician in my 
district recently told me without significant and real tort 
reform, no plan to control increasing health care costs will 
succeed. While it is healthy to consider the best practices for 
both patients and physicians, the debate must be resolved so 
the medical system can operate in a more effective fashion and 
be improved to consistently deliver high quality of care.
    Mr. Chairman, I would like to ask unanimous consent that I 
enter some letters into the record from physicians in my 
district who have highlighted their concerns with the need for 
medical malpractice reform in the overall debate.
    [The information was unavailable at the time of printing.]
    Mr. Pallone. Without objection, so ordered. I thank the 
gentlewoman.
    Ms. Blackburn. I yield back.
    Mr. Pallone. The chairman emeritus, Mr. Dingell.

OPENING STATEMENT OF HON. JOHN D. DINGELL, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF MICHIGAN

    Mr. Dingell. Thank you, Mr. Chairman, and I commend you for 
holding today's hearing on improving access to health care. 
This is a particularly timely topic since this is Cover the 
Uninsured Week. There are 46 million people in the United 
States who lack health insurance and some have estimated that 
without action, the number could reach 61 million by 2020.
    It comes as no surprise that the uninsured have trouble 
accessing quality health care but access is a problem even for 
those with insurance coverage. The high cost of health care and 
lean insurance benefits have led more than 25 million people to 
be classified as underinsured. These people are more likely to 
forego needed care because of costs. Furthermore, the 
Commonwealth Fund reports that in addition to gaps in insurance 
coverage, Americans lack timely access to care, meaning they 
are not able to see their doctors within 2 days of becoming 
sick.
    As we move forward with comprehensive health care reform 
legislation, there are a few key issues that we must tackle 
with regarding to expanding access to care. First and most 
important, we must set a goal that our health care reform bill 
moves us toward universal coverage. That is why I support a 
provision that would require everyone to have health insurance. 
However, we must insure that care is affordable to everyone and 
I believe that is the only way we can have universal coverage 
and have it in a fair and proper way. Even if we require 
everyone to have health insurance, many Americans will still 
lack access to health care due to a shortage of primary care 
providers. Strong primary care systems have been shown to 
reduce costs and improve quality. However, of the 800,000 
physicians in the United States, only 40 percent are primary 
care providers. By the year 2025, we will have a shortage of 
over 40,000 primary care doctors. Our health care payment 
systems have essentially subsidized specialty care.
    As we construct new health care networks, one that I hope 
includes a public plan, nay, that must include a public plan, 
we must move from a fee-for-service payment structure to one 
that rewards quality and patient-centered primary care. We must 
consider incentives such as loan forgiveness, scholarships and 
other things to draw young medical students into the primary 
care field. Additionally, we must assess the need for nurses, 
nurse practitioners and physician assistants and we must then 
invest in a proper way of ensuring that that carries forward. 
These professionals serve on the front line of care and play a 
critical role in primary care and prevention.
    We must address the persistent disparities in health care 
access and health outcomes for racial and ethnic groups. 
Numerous studies have shown that racial and ethnic minorities 
are consistently less likely to receive necessary care, even 
when controlling for other access-related factors. I believe, 
and I stress this, that health care is a right, not a 
privilege, and failure to address the root causes of these 
disparities is immoral.
    Finally, if it were not for Medicare, Medicaid and CHIP, 
many people would be among the ranks of the uninsured and 
underinsured. These public programs service one-third of U.S. 
populations. Any comprehensive reform must ensure the viability 
of these programs.
    I thank you, Mr. Chairman, and I yield back the balance of 
my time.
    Mr. Pallone. Thank you, Chairman Dingell.
    Next is our ranking member of the full committee, Mr. 
Barton.

   OPENING STATEMENT OF HON. JOE BARTON, A REPRESENTATIVE IN 
                CONGRESS FROM THE STATE OF TEXAS

    Mr. Barton. Thank you, Mr. Chairman. I appreciate you 
holding this hearing on issues related to improving access to 
care.
    This is the third hearing, and as the witnesses will 
testify, improving access to health care involves many issues 
such as getting more people into the provider workforce, the 
role of public health programs and perceived health 
disparities. I am particularly interested in hearing about the 
role of medical liability reform as it relates to health care 
access, also about the role physicians can play to increase 
access points in their communities.
    The current medical liability system in the United States 
affects the ability of patients to receive care when they need 
it. It is well documented that doctors are scaling back the 
care they provide or abandoning their practice altogether to 
avoid being sued. When you don't have providers, that can mean 
the difference between life and death for those patients who 
don't have a doctor.
    My home State of Texas is a perfect example of how medical 
liability reform improves people's health care. In 2003, Texas 
voters approved a constitutional amendment that included a 
limit on non-economic damages while continuing to allow injured 
parties to be fully compensated for economic damages. Prior to 
that reform, skyrocketing insurance premiums were forcing 
doctors to flee the State, quit medicine or cut back on 
complex, lifesaving procedures. At the height of the crisis, 
Texas ranked 48th out of the 50 States in per capita 
physicians. In the years since the reform was passed, Texas has 
been transformed from a State in turmoil to a model. Doctors 
are coming back to Texas, patients are getting better care. 
More doctors mean improved access, especially for those Texans 
that are living in poor and medically underserved areas. I 
would urge this committee, Mr. Chairman, to take a serious look 
at liability reform as we move into the overall issue of health 
care reform.
    I also believe that we should look at what is working in 
communities across this country to increase access to care. 
Last year we heard from a doctor in Louisiana whose community 
was ravaged by Hurricane Katrina. Hospitals were closed and 
residents were without access to needed medical services. 
Physicians in that community came together to run a physician-
owned hospital that provided the quality of medical care the 
residents so sorely need. Now, I know it is not the popular 
conventional wisdom to suggest that people helping their 
community can make a difference without the bureaucrats in 
Washington telling them what to do but it is true. Who knows 
what happens when communities actually work together themselves 
and don't look to Washington for the solution. It is certainly 
not the Washington elite who have all the answers. We should 
applaud the people who have stepped up to the plate and 
expanded access to quality medicine in their own neighborhoods. 
This committee has a long history of being involved in the 
issue of physician-owned hospitals. These facilities have 
consistently demonstrated that they provide high-quality care 
for patients and achieve high patient satisfaction. Patients 
like receiving their care at these facilities. Physicians and 
nurses like working at these facilities and these facilities 
continue to top the charts in terms of health care quality. You 
don't have to take my word for it. Visit any physician-run 
hospital and you can see for yourself. I would extend an open 
invitation to anybody on this committee to come to my district 
and visit a number of physician-owned hospital facilities in my 
district if they don't have them in their own district. When 
physicians have a stake in the system, they raise the standard 
of quality care to a level that patients then expect and demand 
from all providers. As we discuss access to care today, we need 
to keep this in mind. We should be expanding the number of 
providers, not limiting the number of providers.
    Again, I appreciate you, Mr. Chairman, for holding this 
hearing. I have a letter from a doctor-owned hospital in my 
district, USMD, dated yesterday to myself by the chairman of 
the board that I would like to submit for the record if we 
could get unanimous consent.
    Mr. Pallone. I am sorry. What is it that you want to 
submit?
    Mr. Barton. A letter from a physician-owned hospital in my 
district.
    Mr. Pallone. Without objection, so ordered.
    [The information was unavailable at the time of printing.]
    Mr. Barton. Thank you, Mr. Chairman.
    Mr. Pallone. Thank you, Mr. Barton.
    Our full committee vice chair, Ms. DeGette.

 OPENING STATEMENT OF HON. DIANA DEGETTE, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF COLORADO

    Ms. DeGette. Thank you very much, Mr. Chairman. This is a 
very important hearing in health care access on all levels, and 
I am looking forward to hearing the testimony from our panel.
    I wasn't going to talk about this but it appears to be in 
the talking points for my friends on the other side of the 
aisle so let me just mention that we did address the issue of 
medical malpractice reform and the concept of federalizing 
these traditionally State tort claims in the 109th Congress and 
we had a number of hearings in that Congress about this subject 
at which we took testimony, and frankly, there is absolutely no 
evidence that if we federalized these torts and we enacted caps 
on non-compensatory damages that that would help bring the cost 
of medical care down in any way.
    I do think though that we need to address the issue of what 
is happening with doctors' insurance rates because doctors' 
insurance rates have consistently increased over the years, 
even in States like my State and Texas and other States where 
we have had caps on non-economic damages for some years, and I 
think we need to put all of this into the mix, but I think it 
is unfair to try to claim that we haven't addressed this, that 
we haven't looked at it or that medical malpractice rates are 
causing the terrible cost overruns that we have in our system.
    Thank you, Mr. Chairman.
    Mr. Pallone. Thank you.
    The gentleman from Pennsylvania, Mr. Murphy.

   OPENING STATEMENT OF HON. TIM MURPHY, A REPRESENTATIVE IN 
         CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA

    Mr. Murphy of Pennsylvania. Thank you, Mr. Chairman, and 
thank you to all the doctors present here. We have enough to 
open up a sizable hospital, I guess. Who is minding the 
patients?
    All of our concern is to improve access to care and I 
believe that has to include----
    Mr. Pallone. Is your microphone not working?
    Mr. Murphy of Pennsylvania. It was going off and on, sir. I 
don't know. Maybe someone on that side of the aisle is----
    Mr. Pallone. All right.
    Mr. Murphy of Pennsylvania. But don't do that to me, 
because I agree. Hold the clock there too.
    Mr. Pallone. We will try it. Go ahead.
    Mr. Murphy of Pennsylvania. Thank you, Mr. Chairman.
    I am concerned about some of the inefficiencies that we put 
into the system itself which drive providers away, such as why 
aren't doctors more willing to be Medicaid and Medicare 
providers? Why are the rules we set forth a problem? Why does a 
person diagnosed with multiple sclerosis have to wait 2 years 
before they can be given medication? Why don't we pay for 
disease management of a diabetic but are willing to pay to have 
their legs amputated when they have complications? Why won't we 
pay an oncologist to do lab work on the day of chemotherapy if 
they are trying to determine if a patient can have the 
chemotherapy? There are so many questions that we have in this 
area that I think are barriers to access and I am hoping as 
part of the testimony we hear it will include how we can 
improve the health system the government runs through the 
Medicare, Medicaid and VA systems and learn to take down the 
barriers that stand in the way of access to care.
    Thank you very much.
    Mr. Pallone. The gentlewoman from California, Ms. Capps.

   OPENING STATEMENT OF HON. LOIS CAPPS, A REPRESENTATIVE IN 
             CONGRESS FROM THE STATE OF CALIFORNIA

    Ms. Capps. Thank you, Mr. Pallone, and thank you to each of 
our witnesses today. We have a stellar panel here and thank you 
for coming.
    This hearing is really central to our debate on how we are 
going to improve health care. If we can improve the way we care 
for the most marginalized in our society, then we can certainly 
improve the way we care for everyone. One of the barriers to 
access today is a lack of health professionals: nurses, 
physicians, dentists, a whole array of them. And contrary to 
what some of our colleagues on the other side have said about 
everyone supposedly being able to obtain health care at the 
emergency room, there aren't even enough health professionals 
to staff many emergency rooms 24/7 and 7 days a week. So as we 
talk about ways to improve access for everyone, let us talk 
about what else we can be doing to educate more health 
professionals and get them into the areas where they are needed 
most.
    I look forward to the testimony. I yield back.
    Mr. Pallone. Thank you.
    The gentleman from Michigan, Mr. Rogers.

  OPENING STATEMENT OF HON. MIKE ROGERS, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF MICHIGAN

    Mr. Rogers. Thank you, Mr. Chairman, and thanks to the 
panelists.
    Like you, I believe we must take action to provide more 
Americans with access to affordable, high-quality health 
insurance, but the details on how we get there are important. 
About 15 percent of Americans go without health insurance for 
some period of time every year. At the same time, 85 percent of 
Americans have health insurance, and for many of this 85 
percent they have good coverage that provides for their 
families' needs. We must focus on the 15 percent. Who are they? 
How can we ensure that they have access to affordable 
insurance? In reality, a large portion of this group is young 
and goes without insurance by choice. A large part of this 
group is already eligible for government programs but not 
signed up. How should we address these issues?
    In finding solutions to address the 15 percent problem, we 
must be careful not to destroy a system that does work for tens 
of millions of Americans. I am concerned that some proposals 
addressed today would do just that. Forcing millions of 
Americans who already have health insurance to accept fewer 
benefits, reduced access and higher costs is hardly a solution. 
I believe we can find solutions to provide universal access to 
health care, lower costs and better quality for all Americans. 
I believe we can strengthen critical safety net programs like 
Medicaid, Medicare and SCHIP but we must work together to 
achieve this goal.
    Mr. Chairman, I look forward to working with you and the 
members of this committee on this important issue, and I yield 
back the remainder of my time.
    Mr. Pallone. Thank you.
    The gentlewoman from Wisconsin, Ms. Baldwin.

 OPENING STATEMENT OF HON. TAMMY BALDWIN, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF WISCONSIN

    Ms. Baldwin. Thank you, Mr. Chairman. It is notable that we 
are holding this hearing on ensuring access to care during 
Cover the Uninsured Week.
    We are discussing two issues today that are very close to 
my heart, health disparities and primary care workforce 
shortages. On health disparities, the level of inequality in 
our health care system is a shocking injustice. Thanks to 
several of my colleagues, we have recently focused greater 
attention on racial and ethnic health disparities. I also want 
to draw attention to the fact that the lesbian, gay, bisexual 
and transgender community also experience significant health 
disparities. Most well known as an issue, of course, is HIV/
AIDS but the LGBT community experiences other health care 
disparities as well. We are far less likely to have health 
insurance compared to our straight counterparts. LGBTQ youth 
are up to four times more likely to attempt suicide than their 
heterosexual peers and we also know that many delay care due to 
fear of discrimination, leading to higher mortality rates from 
heart disease and cancer. To address these disparities, I am 
developing legislation that I will offer later this year.
    Let me quickly also express my strong concern about our 
existing and looming primary care shortages. To address one 
small aspect of this problem, I offer bipartisan legislation 
that would provide reimbursement for the costs of graduate 
degrees in nursing in exchange for a commitment to teach 
nursing for at least 4 years. Without the worry of educational 
debt, nurses will be able to devote time to training the next 
generation of the frontline primary care workforce.
    Thank you again, Mr. Chairman, and thank you to our 
witnesses today.
    Mr. Pallone. Thank you.
    The gentleman from Kentucky, Mr. Whitfield.

  OPENING STATEMENT OF HON. ED WHITFIELD, A REPRESENTATIVE IN 
           CONGRESS FROM THE COMMONWEALTH OF KENTUCKY

    Mr. Whitfield. Thank you, Mr. Chairman, and I want to thank 
the panel and particularly for listening to all of us this 
morning, and we have heard a lot of discussion today about 
liability insurance and whatever needs to be done to correct 
that problem, we may have differences of opinion about it but I 
think it is imperative that we focus on the fact that there is 
a problem.
    Members of the Kentucky Medical Association left my office 
just a few days ago and they referred to the study in 
Massachusetts that showed that 83 percent of doctors practiced 
defensive medicine and almost 28 percent of the tests, 
procedures, referrals and consultations were ordered to avoid 
lawsuits. And then almost half of America's medical students in 
their third or fourth year of medical school have indicated the 
liability crisis was a factor in their choice of specialty, 
threatening America's future access to high-risk medical 
services such as a surgery and other specialties, so I think it 
is something we must focus on as we move forward on health care 
reform. Thank you.
    Mr. Pallone. Thank you.
    The gentlewoman from the Virgin Islands, Ms. Christensen.

       OPENING STATEMENT OF HON. DONNA M. CHRISTENSEN, A 
       REPRESENTATIVE IN CONGRESS FROM THE VIRGIN ISLANDS

    Ms. Christensen. Thank you, Chairman Pallone, and thank you 
again for this series of hearings that continue to inform and 
guide us as we prepare to reform health care this year.
    Today we are looking at access and several barriers to it. 
It is important to understand that while providing coverage is 
the linchpin of reform, it is not the only thing that must get 
done to ensure access. We must have more and more diverse 
providers at all levels. We need to stop the way malpractice is 
increasing costs and forcing doctors out of practice, and as 
you will always hear from me, we must eliminate disparities and 
ensure that the system we create assures equal access to 
quality care for every America.
    I want to thank the panelists for the work that they have 
been doing to show us the way forward, and I look forward to 
your testimonies. I yield back.
    Mr. Pallone. Thank you.
    The gentleman from Georgia, Mr. Gingrey.
    Mr. Gingrey. Thank you, Mr. Chairman. Before I waive my 
opening remarks, I want to ask unanimous consent to submit for 
the record a letter, Mr. Chairman, from the Georgia Mutual 
Insurance Company to the Medical Association of Georgia on the 
question of is tort reform working in the State of Georgia; the 
response, most definitely. I ask unanimous consent to submit 
this letter for the record.
    Mr. Pallone. Thank you. Without objection, so ordered.
    [The information appears at the conclusion of the hearing.]
    Mr. Pallone. If all of you could give me these letters so 
we can take a look at them, I would appreciate it, because I 
know I am always concerned that we are going to have too much 
for the record, but I think you only had a few in each case.
    Mr. Deal. Mr. Chairman.
    Mr. Pallone. Yes, Mr. Deal.
    Mr. Deal. In that regard, I would ask unanimous consent to 
include in the record the American Medical Association two-page 
statement on medical liability reform and also a two-page 
letter from Richard Scott on behalf of Conservatives for 
Patients' Rights. I would ask unanimous consent to include 
those in the record.
    Mr. Pallone. Without objection, so ordered. Thank you.
    [The information was unavailable at the time of printing.]
    Mr. Pallone. Next is the gentlewoman from Florida, Ms. 
Castor.

  OPENING STATEMENT OF HON. KATHY CASTOR, A REPRESENTATIVE IN 
               CONGRESS FROM THE STATE OF FLORIDA

    Ms. Castor. Thank you, Mr. Chairman. First I want to say to 
the witnesses, I thought your written testimony was outstanding 
and very, very helpful as we proceed on our health care reform 
effort. I believe it shows that a consensus is building that 
broad-based, basic primary care reform, those simple visits to 
the doctors' offices and clinics will be central to providing 
affordable access to health care for all American families.
    Dr. Mullan, your workforce analysis was particularly 
terrific, I thought, and your recommendations to improve 
primary care professionals very helpful along with Dr. Harris's 
recommendations for a national health care workforce policy. 
Thank you for highlighting the arbitrary and outdated caps on 
physician resident slots that is really harming high-growth 
States like mine, the State of Florida. You also had 
constructive recommendations on the primary care pipeline. I 
want to thank your organization for endorsing my bill, the 
Primary Care Incentive Act, that provides that tuition 
reimbursement for folks that go and work in community health 
centers and clinics and devote a number of years of community 
service. Dr. Lavizzo-Mourey, you also had some very creative 
solutions, also picked up on a lot of the workforce issues that 
Congresswoman Capps has taken the lead on in nursing, physician 
assistants, and I appreciate that. Dr. Smedley, your analysis 
and statistics were very eye-opening and just demonstrated how 
health care is really our civil rights struggle for our time. 
Thank you.
    Mr. Pallone. Thank you.
    The gentlewoman from North Carolina, Ms. Myrick, who 
waives.
    Mr. Pallone. The gentleman from Connecticut, Mr. Murphy.

      OPENING STATEMENT OF HON. CHRISTOPHER S. MURPHY, A 
    REPRESENTATIVE IN CONGRESS FROM THE STATE OF CONNECTICUT

    Mr. Murphy of Connecticut. Thank you very much, Mr. 
Chairman. We are going to talk a lot over the course of the 
next few months about making sure that people have insurance 
but I know today we are going to spend time on what should be 
our second priority, making sure that people that have 
insurance actually have access to care, and I would like to 
just share one particularly important story from Connecticut.
    Last year in Tolland, Connecticut, in eastern Connecticut, 
about 190 dentists got together and decided to provide free 
care over the course of 2 days. The night before that clinic 
began, there were dramatic, torrential thunderstorms. Through 
the night, dozens of people lined up soaking overnight waiting 
for care the next morning, and their individual stories, which 
numbered 700 by the time that clinic was done, are shocking but 
unfortunately too common. There was a mother whose children 
insured through our State's SCHIP program, HUSKY, had been 
waiting 8 months to see a dentist for immediate care. There was 
a single woman who worked two jobs, had insurance but whose 
deductibles were so high she couldn't afford to see a dentist. 
And there were the unemployed workers there on COBRA whose 
employers never offered dental coverage in the first place.
    This is just one story not original to Connecticut but they 
do illuminate a point. Just because you have health insurance 
doesn't mean that you get to see a doctor, doesn't mean you get 
to see a dentist. Health insurance without real access is 
little better than no insurance at all.
    I thank the panel for being here and I look forward to your 
testimony today.
    Mr. Pallone. Thank you.
    The gentleman from Ohio, Mr. Space.

OPENING STATEMENT OF HON. ZACHARY T. SPACE, A REPRESENTATIVE IN 
                CONGRESS FROM THE STATE OF OHIO

    Mr. Space. Thank you, Mr. Chairman, for holding this 
important hearing, and specifically as it relates to rural 
health care disparities.
    I had a chance to review some of the testimony for today 
and I couldn't help but be struck by some of the statistics 
highlight by Dr. Kitchell from Iowa in his testimony. Twenty 
percent of the Nation's population resides in rural areas yet 9 
percent of our Nation's physicians reside in rural areas. Rural 
physicians see up to 30 percent more patients per physician. 
The cost of running a rural physician's practice is 
considerably higher than running an urban or suburban city 
physician practice, and the rural physicians' expenses, despite 
being greater, their Medicare reimbursements are far less. It 
is no wonder that some of the counties that I represent have 
one or two practicing physicians serving the entire county, 
requiring many of my constituents to drive long distances for 
basic care and that doesn't even cover the specialists. While 
the primary care focus is one that we need to be concerned 
with, it applies to other realms in the health care delivery 
field as well. Home health nurses, medical assistants and other 
professionals are in short supply.
    One of the critical elements of this issue is the impact 
that it will have on our economy. Developing and training a 
workforce to meet the needs that are glaring in rural American 
right now will not only enhance access to quality health care, 
it will provide an important avenue for economic opportunity in 
an area of the country that desperately needs it, so I would 
like to thank those who have come before the committee this 
morning and look forward to hearing all your testimony.
    Mr. Pallone. Thank you.
    The gentleman from Iowa, Mr. Braley.

OPENING STATEMENT OF HON. BRUCE L. BRALEY, A REPRESENTATIVE IN 
                CONGRESS FROM THE STATE OF IOWA

    Mr. Braley. Thank you, Chairman Pallone. I have been 
looking forward to this hearing because access to care is a 
primary care of mine and a primary concern of health care 
providers in Iowa and their patients.
    Our current system has built-in equities which result in a 
lack of access to care for residents in many rural States like 
Iowa, as my colleague from Ohio has just pointed out. A glaring 
example of this is the Geographic Practice Cost Indexes, or 
GPCIs. These antiquated formulas ensure that some parts of the 
country receive drastically lower Medicare reimbursement rates 
than other parts and that has led to a critical shortage of 
doctors in some parts of our country. Despite the well-
documented efficiency and quality of Iowa's health care system, 
Iowa health care providers still lose millions of dollars 
because they choose to care for Medicare patients. There is 
already a physician shortage in areas of Iowa and the existence 
of the GPCIs is a strong disincentive to those who often need 
it most, Medicare patients.
    Last Congress I introduced the Medicare Equity and 
Accessibility Act, which addresses the GPCI problems. I am 
going to continue fighting for a solution to the GPCIs but in 
fact this is only a Band-Aid for a broader problem of disparity 
of care in rural areas. I look forward to hearing more about 
access to care in rural areas in today's hearing.
    I also want to welcome my friend, Dr. Michael Kitchell, to 
the witness panel today. Dr. Kitchell is currently the 
president-elect of the Iowa Medical Society and someone I rely 
upon for sound advice on health care policy issues. He is also 
an expert on policies surrounding rural health care and I want 
to welcome him and look forward to his testimony. Thank you.
    Mr. Pallone. Thank you.
    The gentlewoman from California, Ms. Harman.

  OPENING STATEMENT OF HON. JANE HARMAN, A REPRESENTATIVE IN 
             CONGRESS FROM THE STATE OF CALIFORNIA

    Ms. Harman. Thank you, Mr. Chairman. There is obviously 
enormous expertise on the panel but there is expertise on this 
subcommittee too and I surely hope we will pull together and 
craft an excellent bill that addresses this important subject 
of access.
    Access is tough for the insured and uninsured, especially 
in California where low reimbursement for Medicaid is pushing 
more and more doctors out of the program. In my district, we 
are lucky to have places like the Venice Family Clinic that 
provide free quality health care to low-income minority 
population that lacks private coverage. Eighty-one percent of 
the patients seen at the clinic are minorities so the clinic 
places an emphasis on volunteer translator recruitment and 
medical tutorial programs. Remarkable volunteers are the 
arteries that keep the clinic going. My late father, a 
physician, devoted his time and passion to serving three 
generations of patients, like father, like daughter, and as a 
former VFC board member, I am a huge supporter of their work. 
As the Nation's largest free clinic, 24,000 patients last year, 
this is the only place for most of its patients to access care, 
helping them to avoid emergency room visits and other serious 
consequences. Unfortunately, many places in the country don't 
have Venice Family Clinics and that is a model that we should 
try to include as we draft the access part of the bill.
    Thank you, Mr. Chairman.
    Mr. Pallone. The gentleman from Georgia, Mr. Barrow.

  OPENING STATEMENT OF HON. JOHN BARROW, A REPRESENTATIVE IN 
               CONGRESS FROM THE STATE OF GEORGIA

    Mr. Barrow. Thank you, Mr. Chairman.
    When we talk about access to health care, we are talking 
about different things to different folks. In rural parts of 
the country, the problem is physical access. You got specialist 
doctors and nurses that don't want to practice in rural areas 
but you also have groups who live in those areas who are slower 
to seek care in the first place. You have a combination of an 
underserved community of high-risk patients. That is a bad 
combination. On the other hand, you have access problems that 
are financial in nature and we have different programs to try 
to make health care available to different groups of folks. We 
have Medicaid for the poor, we have Medicare for the elderly. 
We have programs like SCHIP for the kids and folks who make too 
much to qualify for Medicaid but not enough to get insurance on 
their own.
    There is another group that is underserved for whom the 
cost of health care isn't altogether out of reach but it is 
just out of reach, and as a result it might as well be 
altogether unavailable and that is folks who can't afford to 
pay the price differential that the insurance industry charges 
them because of the size of the groups to lump them into. If 
you are in a smaller group, it costs you more to get that same 
health care package of benefits than it does for folks who are 
members of larger groups. The legislation I introduced in the 
last Congress, the SHOP Act, the Small Business Health Option 
Program Act, addresses this price disparity in ways that I 
think will make health insurance available to more folks who 
can afford to kick in for the cost of care they are drawing out 
rather than drawing out care at the emergency room without 
kicking in at all, so I hope we can explore ways and means of 
making health care more affordable for folks just by 
eliminating the price differential that folks have to pay for 
the same benefits package.
    Thank you, Mr. Chairman. I yield back.
    Mr. Pallone. Thank you.
    The gentleman from Texas, Mr. Gonzalez.
    Mr. Gonzalez. Waive opening. Thank you, Mr. Chairman.
    Mr. Pallone. Thank you.
    I think we have covered everybody here for opening 
statements, so we will now go to our panel. I know you have 
been waiting patiently and we appreciate that. I want to 
welcome everyone, and let me introduce you starting on my left 
here, and they are all doctors, every one. Dr. Brian Smedley, 
who is vice president and director of the Health Policy 
Institute, the Joint Center for Political and Economic Studies; 
Dr. Michael John Kitchell, who is president-elect of the Iowa 
Medical Society, the McFarland Clinic; Dr. Michael Sitorius, 
professor and chairman of the Department of Family Medicine at 
the University of Nebraska Medical Center; and from my home 
State of New Jersey, welcome, Dr. Lavizzo-Mourey, who is 
president and CEO of the Robert Wood Johnson Foundation. And 
then we have Dr. Fitzhugh Mullan, Murdock head professor of 
medicine and health policy and professor of pediatrics at the 
George Washington University; Dr. Jeffrey Harris, president of 
the American College of Physicians; Dr. James Bean, who is 
president of the American Association of Neurological Surgeons; 
and Dr. Diane Rowland, who is executive director of the Kaiser 
Commission on Medicaid and the Uninsured. Now, I am told that 
you don't actually have a timer down there so you won't know 
when the 5 minutes are up. The only thing more dangerous is 
when we don't have timers up here. But please try to stick to 
the 5 minutes if you can and of course the statements become 
part of the record, and we will start with Dr. Smedley.

   STATEMENTS OF BRIAN D. SMEDLEY, PH.D., VICE PRESIDENT AND 
 DIRECTOR, HEALTH POLICY INSTITUTE, JOINT CENTER FOR POLITICAL 
 AND ECONOMIC STUDIES; MICHAEL JOHN KITCHELL, M.D., PRESIDENT-
ELECT OF IOWA MEDICAL SOCIETY, MCFARLAND CLINIC PC; MICHAEL A. 
 SITORIUS, M.D., PROFESSOR AND CHAIRMAN, DEPARTMENT OF FAMILY 
 MEDICINE, UNIVERSITY OF NEBRASKA MEDICAL CENTER; RISA LAVIZZO-
 MOUREY, M.D., M.B.A., PRESIDENT AND CEO, ROBERT WOOD JOHNSON 
 FOUNDATION; FITZHUGH MULLAN, M.D., MURDOCK HEAD PROFESSOR OF 
MEDICINE AND HEALTH POLICY, PROFESSOR OF PEDIATRICS, THE GEORGE 
   WASHINGTON UNIVERSITY; JEFFREY P. HARRIS, M.D., F.A.C.P., 
PRESIDENT, AMERICAN COLLEGE OF PHYSICIANS; JAMES R. BEAN, M.D., 
 PRESIDENT, AMERICAN ASSOCIATION OF NEUROLOGICAL SURGEONS; AND 
DIANE ROWLAND, SC.D., EXECUTIVE DIRECTOR, THE KAISER COMMISSION 
                 ON MEDICAID AND THE UNINSURED

                 STATEMENT OF BRIAN D. SMEDLEY

    Mr. Smedley. Thank you, Mr. Chairman. I appreciate the 
opportunity to provide testimony on racial and ethic 
disparities and health care access and quality.
    For nearly 40 years, the Joint Center for Political and 
Economic Studies has served as one of the Nation's premier 
think tanks on a broad range of public policy concerns for 
African-Americans and other communities of color. We therefore 
welcome the opportunity to comment on strategies for addressing 
health care disparities.
    As the committee has pointed out, health care disparities 
are differences in access to and the quality of health care 
experienced by racial and ethnic minorities, immigrants, those 
who aren't proficient in English, those who live in rural 
communities and many others relative to more advantaged groups. 
Left unaddressed, these disparities have the potential to 
unravel even the best efforts to contain health care costs and 
improve the overall quality of care. In addition, their 
persistence leaves U.S. health care systems poorly prepared to 
address the needs of some of the fastest growing segments of 
the population.
    This morning I would like to briefly examine the causes and 
consequences of racial and ethnic health care disparities and 
offer some policy strategies for their elimination. As I hope 
to illustrate, these disparities are unjust and avoidable. I 
will therefore refer to them as inequities throughout the 
remainder of my testimony.
    Health care inequities are not new. They are a persistent 
relic of segregation and historically inadequate health care 
for communities of color. Like access to other opportunities, 
health care for minorities suffered from government inattention 
for over 100 years after the end of the Civil War. Even less 
than 45 years ago, minorities routinely received inequitable 
care in segregated settings if care was received at all. Today 
health care is much more broadly available but the contemporary 
context remains shaped by this history.
    I want to note at the outset that while health care access 
and quality disparities are unacceptable, they are not the most 
important factors that contribute to the widely divergent 
health status of America's racial and ethnic groups. Some 
groups, particularly African-Americans, American Indians and 
Alaska Natives and Native Hawaiians and Pacific Islands 
experience poor health relative to national averages from birth 
to death in the form of higher infant mortality, higher rates 
of disease and disability and shortened life expectancies. The 
large and growing body of public health research demonstrates 
that to address these problems, we must improve the social and 
economic contexts that shape health. As the World Health 
Organization's report on social determinates of health states, 
inequities in health and avoidable health inequalities arise 
because of the circumstances in which people grow, live, work 
and age and the systems put in place to deal with illness.
    It is clear that many Americans, disproportionately racial 
and ethnic minorities, face health care access and quality 
inequities. Some of these inequities can be explained by 
socioeconomic factors while others cannot. The National 
Healthcare Disparities Report, which is prepared and released 
annually by the Agency for Health Care Research and Quality, 
has found that African-Americans, Hispanics, American Indians 
and Alaska Natives fare worse than whites on a preponderance of 
measures of health care access and quality. For example, the 
report finds that minorities are less likely to receive even 
routine evidence-based procedures and experience greater 
communication barriers.
    Now, the NHDR provides a window to the health care 
experiences of a diverse patient population but it does not 
disentangle the influences of race, income and insurance on 
health care. A substantial body of evidence, as has been 
pointed out, demonstrates that racial and ethnic minorities 
receive a lower quality and intensity of health care than white 
patients even when they are insured at the same levels and 
present with the same types of health problems. Many factors 
contribute to these inequities and these often interact in 
complex ways. I would like to focus on an important underlying 
factor in health care inequality and that is residential 
segregation. Racial and ethnic minorities are more likely than 
whites to live in segregated, high-poverty communities, 
communities that have historically suffered from a lack of 
health care investment. Institutes that serve communities of 
color are more likely to experience quality problems and have 
fewer resources for patient care than institutions serving non-
minority communities. Just as an example, a recent study of 
African-American and white Medicare patients found that the 
risk of admission to high-mortality hospitals was 35 percent 
higher for blacks than for whites in communities with high 
levels of residential segregation. Racial and ethnic 
segregation and inequality therefore set the stage for 
inequitable health care in the United States.
    To solve these problems, we must prioritize and invest in 
improving the health of communities that suffer from health 
care inequities. To make the largest gains, we should improve 
social and economic conditions for health. For example, the 
federal government should enforce provisions to address 
environmental justice in minority and low-income communities 
and should establish health empowerment zones in communities 
that disproportionately experience disparities in health status 
and health care. To improve health care access and quality for 
communities of color, the federal government should improve 
access to health care providers, as many on the committee have 
pointed out. We need to make special efforts to ensure that 
health care resources are better aligned with these 
communities' needs. We can do so by increasing the diversity of 
our health professional providers, supporting safety-net 
institutions, providing incentives for providers to serve in 
underserved communities, and addressing the geographic 
imbalance of health care resources like community health 
centers. We can also promote equal high-quality access to care 
by collecting and monitoring data on disparities and publicly 
reporting these data. We can also encourage the adoption of 
cultural and linguistic standards and encourage attention to 
disparities in quality improvement initiatives.
    Mr. Chairman, my time is short and these are but a few of 
the many ideas that will be put forward today, and we look 
forward to working with you as you craft legislation to address 
these issues.
    [The prepared statement of Mr. Smedley follows:]



    Mr. Pallone. Thank you, Dr. Smedley.
    Dr. Kitchell.

               STATEMENT OF MICHAEL JOHN KITCHELL

    Dr. Kitchell. Thank you, Chairman Pallone, Ranking Member 
Deal and Congressman Braley for inviting me. I practice 
neurology in a 167-member physician-owned multi-specialty 
clinic in central Iowa. We have offices in 21 different sites 
in rural Iowa and we have about 1 million patient visits per 
year.
    Maintaining access in rural America is difficult because of 
physician shortages, long distances to travel and fewer 
services that are available. You will hear other speakers today 
that will talk about the shortage of physicians in certain 
specialties, for example, internal medicine. In Iowa, we 
actually have 3.7 times fewer internal medicine physicians as 
the State of Massachusetts, and you aren't aware, Massachusetts 
has recently declared a critical shortage of 12 different 
specialties including internal medicine. So if those shortages 
in Massachusetts are critical when we have 3.7 times fewer 
internists, I would say we are just about comatose.
    The medical economic survey has actually shown that rural 
physicians practice expenses are higher in their survey. They 
are higher than inner city, suburban and urban physicians. The 
main reasons for practice expenses being higher in rural areas 
is the number of patients that we see. When you have half as 
many physicians in rural areas, you have to see a few more 
patients.
    Rural physicians are paid less by Medicare for our work 
despite the fact that we work longer hours. Medicare pays rural 
physicians less for practice expenses despite the fact that 
Medicare has never done a survey of the actual practice expense 
differences for physicians in rural areas. This has been going 
on for 17 years. Medicare pays us less for e-prescribing. You 
know, I looked for a geographic discount on electronic 
prescribing equipment and I couldn't find any geographic 
discounts. I looked for geographic discounts on office 
equipment, computers and yes, even electronic medical records 
and, you know, I couldn't find a geographic discount on 
electronic medical records.
    Medicare also pays us less for quality, and Congressman 
Braley has been kind enough to sponsor a bill to eliminate the 
devaluation of quality. Medicare pays quality for physicians at 
a lower rate in rural areas. I think that that devaluation of 
quality is the ultimate insult to rural physicians. Some rural 
Medicare fees are as low as one-third of what our private 
insurance payers are paying us. Some health care services are 
delivered at a loss in rural areas because Medicare pays so 
little. If Medicare expanded or if Medicare would cut their 
payments, obviously there will be more losses, more losses of 
dollars, more losses of service. You can't make up on volume 
when the cost of the service is greater than what you are paid.
    Congressman Braley, Senator Grassley and Senator Harkin 
have all sponsored legislation to eliminate or at least reduce 
these geographic penalties. President Obama in October also has 
come out in support of geographic equity. I hope that you will 
also come out in support of geographic equity.
    A lot of what is wrong in health care though is due to the 
physician payment system. This physician payment system is 
called the resource-based relative value unit system, that is, 
our payment system pays for resource use. It should be no 
surprise then when we pay for resource use that we have the 
most expensive health care system in the world. When we pay for 
more expenses rather than pay for the most effective care, we 
are going to get more expensive care and we won't get as much 
cost-effective care.
    We need to pay for value, not geography. We need to pay for 
things that matter to the patient. We need to pay for the right 
tests and treatment, not just more tests and treatment. Iowa is 
a good example of a high value in health care. It shows that 
high-quality health care doesn't have to be so expensive. The 
Commonwealth Fund has rated Iowa's health care system as number 
one in children's care and number two for care of adults. The 
Agency for Health Care Research on Quality, Dartmouth and other 
researchers have consistently shown that Iowa and Midwestern 
States take the lead in quality and cost-effective care. I 
testified 6 years ago at the Senate Finance Committee on the 
national health policy forum and I urged that Medicare pay for 
value, not volume. I urged that Medicare pay for quality, not 
quantity. Unfortunately, over the last 6 years there hasn't 
been much progress made in paying for value or paying 
physicians for quality. The Medicare payment system for quality 
is called Physician Quality Reporting Initiative, or PQRI. PQRI 
is definitely a failure. Only 8 percent of the Nation's 
physicians succeeded with this program. PQRI does not reward 
quality. It simply rewards reporting. The lowest quality 
physician in this country could report correctly on three 
quality measures that they never did any of those measures and 
they would get the bonus.
    Mr. Pallone. Doctor, I hate to interrupt but you are a 
minute over, so if you could wrap up?
    Dr. Kitchell. Medicare's Hospital Quality Rewards program 
is a success because it measures larger groups and systems. So 
what should Medicare do to reward quality and value for 
physicians? Another lesson that can be learned from Iowa is 
about coordinated care, teamwork and accountability. Quality 
measures should be based on teams, groups and systems. We need 
to encourage all physicians to be part of the system. Middlesex 
County, Connecticut, is a good example of independent 
physicians getting together, improving quality, improving value 
and being accountable. We need changes in the payment system 
for geographic equity to reduce cost and increase quality of 
value.
    Thank you, Mr. Chairman.
    [The prepared statement of Dr. Kitchell follows:]



    
    Mr. Pallone. Thank you.
    Dr. Sitorius.

                STATEMENT OF MICHAEL A. SITORIUS

    Dr. Sitorius. I would like to thank you, Mr. Chairman, for 
conducting this subcommittee hearing on the accessibility of 
health care.
    I am here to share information about the Bellevue Medical 
Center, which is currently under construction in Bellevue, 
Nebraska, a suburb of Omaha. The Bellevue Medical Center is an 
entirely different entity than anything we have seen across the 
country. It is going to be a full-service community hospital 
providing a wide array of services including emergency services 
24 hours to one of the largest communities in the United States 
without an acute care hospital. It is majority owned by the 
largest public hospital system in the State. It is expected to 
open in April of 2010. This medical center illustrates how 
hospitals, doctors and communities come together to enhance the 
access of health care to populations in need. I believe the 
Bellevue Medical Center represents the best in American health 
care. When we open our doors next spring, we will be an example 
of a public hospital system, a group of committed and talented 
physicians, a supportive city government and a thriving and 
responsive business community that came together to make health 
care accessible to an underserved population.
    Bellevue is the third largest city in Nebraska, it has 
about 45,000 residents, and it is home to Offutt Air Force Base 
and the United States Strategic Command. Approximately 10,000 
active-duty military personnel, 20,000 dependents and 11,000 
military retirees live in the Bellevue area, a very important 
asset to the Bellevue community. It may come as a surprise that 
Bellevue has not currently or has ever had a community hospital 
or emergency room in the city. The Offutt Air Force military 
hospital, Ehrling Bergguist, closed in 2005 as part of the Base 
Closure Realignment Commission. Though clinics remain at the 
Ehrling Bergguist Hospital, the remaining same-day surgery and 
evening urgent care clinics will be closing in the fall of 
2009. As a family physician, I can see firsthand the need for a 
hospital in Bellevue. There are approximately 180,000 people in 
eastern Nebraska and western Iowa who would benefit from the 
hospital, and will, in 2010.
    Currently, all the rescue squads in the Bellevue community 
leave that community for access to emergency care. Low-income 
individuals benefit from this full-service hospital as well. 
The UNMC Physician Group currently has a clinic in the Bellevue 
area which serves a significant low-income and Hispanic 
population which live in the near south Omaha area. This 
hospital will provide access to care that is currently not 
available to that population.
    Furthermore, I have a unique vantage point on the medical 
needs in this area. As chair of the Department of Family 
Medicine, we have had an affiliated family medicine residency 
training program with the Air Force since 1992. Unfortunately, 
with the closure of that base hospital in 2005, it has made 
difficult some of the training opportunities for one-fifth of 
the Air Force family medicine residents in their training 
programs. It is then important that we combine that military 
training need with the needs of the population to come up with 
the idea for the Bellevue Medical Center. The center is a 
creative solution to address the health care needs of the 
community of which it is serving. The Bellevue Medical Center 
is aligned with an academic medical center, the University of 
Nebraska Medical Center and the Nebraska Medical Center. 
Faculty physicians and community physicians meet community 
needs. When it opens in April of 2010, it will be a full-
service hospital delivering adult care, pediatric care, labor 
and delivery, emergency care, inpatient and outpatient surgery 
and intensive care. This represents a collaborative model 
involving public, academic community physicians and community 
leaders. The Bellevue Medical Center will hold strongly to the 
values of the existing Nebraska Medical Center for its 
excellence, innovation and quality patient care. In addition, 
it will serve as an educational mission for the medical center. 
It will train 20 percent of the Air Force complement of family 
practice resident physicians and will allow training in two 
different locations, the tertiary care academic medical center 
and the community-based Bellevue Medical Center in 2010.
    And in this time of economic downturn, this project also 
has created jobs. In addition to the hundreds of construction 
jobs already created, the Bellevue Medical Center will employee 
600 FTEs when opened.
    The Bellevue Medical Center has strong community support. 
In fact, the community is extremely engaged and led the effort 
to make this Bellevue Medical Center a reality. I believe the 
Bellevue Medical Center can serve as a health care model for 
other communities. The Nation's health care system needs to 
encourage innovation through partnerships, in our case, an 
academic medical center partnered with faculty physicians, 
community physicians and the community. I would encourage other 
academic medical centers to consider to replicate what the 
Nebraska Medical Center has done in the Bellevue community. 
Moreover, the Bellevue Medical Center is also a model as it 
relates to care of our military service members, their families 
and military retirees. It is our position that our military 
service members, their families and retirees deserve the best 
quality health care possible from a nearby community hospital. 
The Bellevue Medical Center will be able to provide that care. 
This center will also care for all of the benefits provided 
under the Tri-Care program. The Bellevue Medical Center will 
accept and look forward to working with the Tri-Care patients.
    In conclusion, as Congress begins to tackle health care 
reform, access to health care must be a significant part of any 
solution. I am proud to say that the Bellevue Medical Center 
stands ready to be part of that solution to expanding access to 
health care. We are excited that your subcommittee has asked us 
to share our story with you this morning.
    Thank you for your attention and interest and I would be 
happy to answer questions when we get to that point.
    [The prepared statement of Dr. Sitorius follows:]



    
    Mr. Pallone. Thank you, Doctor.
    Dr. Lavizzo-Mourey.

                STATEMENT OF RISA LAVIZZO-MOUREY

    Dr. Lavizzo-Mourey. Thank you, Chairman Pallone and Ranking 
Member Deal and members of the subcommittee for this 
opportunity to testify.
    As has been mentioned, it is Cover the Uninsured Week and 
communities all across the country are calling for fixes to our 
broken health care system. Expanding coverage must be a 
priority as Congress considers opportunities for health reform, 
but this alone will not fix the problem. In my written 
testimony, I have touched on issues of health care disparities 
and non-financial barriers to health but I would like to focus 
my oral remarks on the role of nurses in ensuring the access to 
high-quality care and opportunities for addressing the shortage 
of nurses and nurse faculty.
    If you have ever been hospitalized or had a loved one who 
was hospitalized, you know that nurses make a difference. 
Nurses' diligence keeps bad things from happening to patients. 
Their actions prevent medical errors and infections. They keep 
patients safe from falls and from the complications of extended 
bed rest. They also work in community settings to prevent 
disease, help patients manage their diseases better and avoid 
unnecessary hospitalizations. As Congresswoman Capps noted 
recently at the White House Forum for Health Reform, there is a 
projected shortage of 500,000 nurses by 2020. The nursing 
shortage results from a confluence of factors: A shortage of 
nurse faculty, too few nurses enrolling in nursing programs and 
turnover among experienced nurses. There is a vacancy rate of 
7.6 percent among nursing faculty which results in far too many 
qualified students being turned away. Solving this problem will 
require action at the national level and a commitment of 
resources both public and private. The results of our grantees' 
and partners' work suggest that the following steps must be 
taken.
    First, we need to increase the number of nurses with 
baccalaureate degrees to create a larger pool of nurses who 
will qualify to pursue faculty careers. Second, we need to 
increase financial assistance to enable more nurses to attend 
graduate school and obtain teaching qualifications. Third, 
encourage private sector to adopt evidence-based practices 
including the use of technology that will improve the retention 
of nurses in their clinical roles. And finally, we need to 
support research to demonstrate the nurse's role in improving 
the quality of patient care and improving outcomes. It is also 
essential that funding for workforce development not ebb and 
flow with yearly changes in appropriations to Title VIII 
programs.
    I want to highlight a few specific promising programs and 
strategies that address the nursing shortage and the faculty 
shortage. First, at our foundation we found scholarships to 
support accelerated nursing degrees for students who already 
have a degree in a discipline other than nursing. These are 
typically students that are ineligible for federal aid 
programs, and I can tell you, these scholarship programs are 
hugely oversubscribed. Second, we are providing career 
development awards to outstanding junior faculty. Third, there 
are many State partnerships of nurses, educators, consumers, 
business groups, government and philanthropy that are working 
together on practical creative solutions like using shared 
curriculum, online education, simulation centers for training, 
easing the transition from associate to baccalaureate programs 
and increasing the diversity of the nursing workforce. Taken 
together, these programs seem to increase the number of 
baccalaureate-prepared nurses, provide incentives and rewards 
for nursing faculty to educate the next generation of nurses, 
shorten the pipeline for providing nursing faculty and provide 
a new cadre of nursing leaders.
    Now, as we consider the critical task of ensuring that the 
education system can graduate new nurses, we must also retain 
experienced nurses. We have a demonstration project called 
Transforming Care at the Bedside that shows hospitals can 
successfully retain nurses through organizational reforms that 
do not add costs. I know that my colleague, Dr. Mullan, will 
focus on the shortage of primary care physicians, but nurse 
practitioners are an effective, high-quality way to fill the 
gap in primary care, particularly as we think about access in 
rural and other underserved settings.
    So in conclusion, as Congress addresses both the shortage 
of primary care physicians and the need to control spending, I 
encourage you think about opportunities to use nurse 
practitioners more widely and effectively.
    Thank you for this opportunity to testify today and for 
your attention to these issues that reach beyond ensuring 
health care coverage and allow us to strive for comprehensive, 
meaningful reform.
    [The prepared statement of Dr. Lavizzo-Mourey follows:]



    Mr. Pallone. Thank you, Doctor.
    Dr. Mullan.

                  STATEMENT OF FITZHUGH MULLAN

    Dr. Mullan. Chairman Pallone, Ranking Member Deal, members 
of the committee, colleagues, thank you for the opportunity to 
testify today. I will be talking about the clinical workforce, 
largely physicians but not limited to physicians. I started as 
a physician in the National Health Service Corps. I served for 
a period as the director of the National Health Service Corps, 
and in recent years I have worked in scholarly pursuits trying 
to understand the dynamics and policies related to the health 
workforce. So I have practiced it, I have run it and now I am 
studying it, and I am here to share that with you as much as I 
can and very expeditiously.
    Massachusetts has been cited as an example, and I will say 
to you, it is an example of my principal premise to you and 
that is that substantial reform and improvement in access and 
in health care in this country will not take place without 
substantial reform and improvement in the health workforce in 
this country, and the experience of Massachusetts has been when 
you provided expanded access, they did indeed come, and where 
they hit the first bump in the road was the absence of a good, 
strong primary care base, even in a State that is well endowed 
with physicians. So primary care is at the core of the reform 
of the health workforce.
    A few words about the shape and size of the health 
workforce. I offer you this graphic as a way to conceptualize 
what I consider the three phases of the life cycle of a 
physician and that would be medical school, graduate medical 
education and practice. Clearly, practice is a 30- to 40-year 
proposition and the others presumably are somewhat shorter but 
all three have a character and a legislative component and I 
suggest you consider those in that regard and we will go 
through them in a moment with the particular legislative 
potentials of each of those. In general, we do have problems in 
primary care. We have a smaller base compared to many other 
countries in terms of how we approach it. We have an inverted 
pyramid with a small base and a large wobbly superstructure of 
people engaging in specialty and subspecialty clinical roles. 
More important than this are the trends in primary care which 
for a variety of reasons ranging from reimbursement to what is 
in, folks are not going into primary care. That is a huge 
problem for the future and one that can be addressed both by 
investments and financially but also by statements by public 
bodies such as the Congress that this is important.
    Overall, my judgment would be in the somewhat contentious 
area of do we have enough doctors, I think we are in the right 
zone. We have a 30-year history now of increasing physician 
population ratio. We are at about 280 per 100,000. That puts us 
a little bit ahead of Canada and the United Kingdom, a little 
bit behind Germany and France. All these countries including 
ourselves are going to experience problems of aging population 
and I will address those in a moment.
    Our major problem, however, is that they are poorly 
distributed. Physicians tend to be urban. They tend to be in 
well-to-do areas and they tend not to go where the most severe 
problems are. That has continued to be a problem as we produce 
more doctors. They tend to continue to locate in similar areas. 
So we can make far better and more prudent use of our workforce 
if it was better distributed both in terms of geography and 
specialty, and we have two American inventions that are 
enormous assets in both what is happening now and what should 
and can happen in the future, and those, as referenced by Dr. 
Lavizzo-Mourey and others, are physician assistants and nurse 
practitioners, about 70,000 of the former, 100,000 of the 
latter. We invented them. Now the rest of the world is running 
to try to catch up but they have shown very effective use and 
they are effective not only in the primary care area but in the 
specialty area. A way to attenuate our need for more 
specialists is more collaborative work with non-physician 
clinicians including particularly nurse practitioner and 
physician assistants. We also have in place two very important 
programs that affect workforce and that is the Nation Health 
Service Corps as an incentive program and community health 
centers as a deployment mechanism to put folks to work. Those 
need to be invested in and continue to be recapitalized.
    Now, let us quickly go through this continuum. In medical 
school we are seeing expansion. New medical schools are coming 
online. Old schools are expanding their capacity. This is good. 
We have in addition two very important programs that impact 
medical education. The first is Title VII in the jurisdiction 
of this committee. It is an old program. It could use 
reconceptualizing and certainly reinvigorating but it is where 
the federal government offers or can offer incentives to 
medical schools and medical students for different kinds of 
careers and there is a lot that can be said about that 
important area of investment. And of course, the National 
Health Service Corps, which happily is receiving more 
attention. There are about 3,500 people in the service in the 
field today. About half of those are physicians. You are 
talking 1,700 physicians, 800,000 physicians in America. This 
is a very, very small but important program. It needs to get on 
the map in a more major way.
    Graduate medical education, a very important area, and 
primarily the jurisdiction of this committee because it is $8 
billion, $8.5 billion in Medicare funds that fund the GME 
largely. It is a huge program without, as I have characterized 
it, a brain. It is formulaic. It is not currently available to 
help with workforce redistribution. A great deal could be done 
with that. A great deal of attention needs to be paid to that. 
Modest activities would include incentivizing community-based 
and ambulatory training. More major would be realigning 
Medicare GME with national workforce needs with a better, more 
formal allocation system.
    And finally in practice, a lot could be done if you train 
them and put them out. In an environment that devalues primary 
care, they will find other ways to do other things and charge 
the system in other ways. So practice has to be realigned. We 
need payment reform. We need practice organization reform, 
primary care medical homes, and finally, health information 
systems which happily are getting attention will make all 
providers, particularly primary care, this information much 
more effectively.
    Finally, two ideas that I think need attention. One is, we 
function in an information-poor environment in terms of 
workforce planning. Data is not good. We need a national center 
for health workforce studies that would on a regular basis work 
on census issues, on analytic issues and on projection issues. 
And finally, a national health workforce commission, a 
deliberative body perhaps on the order of MedPAC that advises 
the Congress, the Administration and the American people on the 
issues of workforce, a very important, a very difficult, 
complex area. We need brains at work on that day in and day out 
with the sanction of the Congress that would help us think 
through these dilemmas.
    So I thank you for your time. I would be happy to engage in 
discussion and participate with the committee as you consider 
reform in this area. Thank you, Mr. Chairman.
    [The prepared statement of Dr. Mullan follows:]



    Mr. Pallone. Thank you, Dr. Mullan.
    Dr. Harris.

                 STATEMENT OF JEFFREY P. HARRIS

    Dr. Harris. Thank you, Chairman Pallone and Ranking Member 
Deal, for allowing me to share the American College of 
Physicians' views on primary care workforce and how it affects 
access.
    I am Jeff Harris, president of the ACP. Until recently, I 
practiced in a rural community with a population of 40,000 in 
Virginia. The office in which I practice focused on the 
delivery of primary care and nephrology. This year I have had 
the good fortune to be president of the American College of 
Physicians, representing 126,000 internal medicine physicians 
and medical students. The United States is experiencing a 
primary care shortage in this country, the likes of which we 
have not seen. The demand for primary care in the United States 
will grow exponentially as the Nation's supply of primary care 
dwindles.
    The reasons behind this decline in the supply of primary 
care physicians are multifaceted and complex. They include the 
rapid rise in medical education debt, a decrease in income 
potential for primary care physicians, failed payment policies 
and increased burdens associated with the practice of primary 
care. Many regions of the country already are experiencing 
primary care shortages. The Institute of Medicine reports that 
it would take about 16,000 additional primary care physicians 
to meet the needs in currently underserved areas. Two recent 
studies found that the shortage of primary care physicians for 
adults will grow to over 40,000, even after taking into account 
the important contributions of nurses, nurse practitioners and 
physician assistants as part of the primary care team. 
Approximately 21 percent of physicians who were board certified 
in the 1909s have left internal medicine compared to 5 percent 
who have departed from internal medicine subspecialties.
    Equally alarming is the fact that the pipeline of incoming 
primary care physicians is also drying up. In 2007, only 23 
percent of third-year internal medicine residents intended to 
pursue careers in general internal medicine. This was down from 
54 percent in 1998. Even more troubling, a recent survey found 
that only 2 percent of medical students plan to go into general 
internal medicine. ACP strongly supports the need to ensure all 
Americans have access to affordable health coverage. As more 
people are covered, though, the primary care workforce needs to 
grow to take on more patients. Primary care physicians are the 
first line of contact for individuals newly entering the health 
care system. If we do not increase the primary care workforce, 
it will become impossible in many communities for people who do 
not currently have a relationship with a primary care physician 
to find an internist, family physician or pediatrician who is 
taking new patients. In Massachusetts, where health insurance 
coverage was recently expanded and nearly 95 percent of the 
State's residents have coverage, the wait to see primary care 
physicians in Massachusetts has reportedly grown to as long as 
100 days. Yet Massachusetts has a higher physician-to-patient 
ratio than most other States.
    The cost of providing coverage to more than 46 million 
uninsured Americans will be much higher and the outcomes of 
care much poorer without more primary care physicians. More 
than 100 studies referenced in the ACP's recent paper, How is 
the Shortage of Primary Care Physicians Affecting the Quality 
and Cost of Medical Care, demonstrates that primary care is 
consistently associated with better outcomes and a lower cost 
of care. For instance, one study found that an increase of just 
one primary care physician per 10,000 population in a State was 
associated with a rise in the State's quality rank and a 
reduction in overall spending by $684 per Medicare beneficiary.
    The United States needs a comprehensive approach to ensure 
access to primary care. We should start with a national health 
care workforce process to set specific goals for educating and 
training a supply of health professionals including primary 
care to meet the Nation's health care needs. In the United 
States, the numbers and types of health care professionals 
being trained are largely determined by the availability of 
training programs, the number of applicants and inpatient 
service needs of academic medical centers. But institutional 
service needs are poor indicators of national health workforce 
requirements, particularly as patient care has continued to 
shift from inpatient to outpatient settings.
    The Institution of Medicine has recommended ``a 
comprehensive national strategy to assess and address current 
and projected gaps in the number, professional mix, 
geographical distribution and diversity'' of the health care 
workforce. Secondly, we need to fund programs to cover the cost 
of medical education for students who agree to pursue careers 
in primary care and subsequently practice in areas of the 
Nation with greatest needs. Third, Medicare payment policies 
need to be reformed. The career choices of medical students and 
young physicians should be largely unaffected by considerations 
of differences in earnings expectations, yet Medicare payment 
policies systematically undervalue the comprehensive, 
longitudinal, preventive and coordinated care that is the 
hallmark of primary care. Currently the average primary care 
physician earns approximately 55 percent of the average 
earnings for all other non-primary care physician specialties. 
Studies show that this compensation gap is among the most 
significant reasons for the growing shortage of primary care 
physicians. To eliminate this differential as a critical factor 
in medical student and resident choice of specialty, the 
average net compensation for primary care physicians would need 
to be raised by Medicare and other payers to be competitive 
with other specialties. We recommend that Congress institute a 
process that would result in such targeted annual increase in 
Medicare fee schedule payments to make primary care competitive 
with other specialties over a five-year period beginning next 
year. The funding for such payments should take into account 
primary care's contribution to reducing overall Medicare cost 
associated with preventable hospital, emergency room and 
intensive care visits, many of which are reimbursed under 
Medicare Part A. Although it may appear to some that our call 
to increase Medicare payments to primary care is self-serving, 
the fact is that almost half of the ACP's membership practices 
in subspecialties, not general internal medicine, yet they 
share our belief that having a sufficient primary care 
workforce is essential if patients are to have access to high-
quality, effective and affordable care.
    Finally, we need new payment models that align incentives 
for accountable, coordinated patient-centered care including 
continued expansion of the patient-centered medical home. The 
Commonwealth Fund's Commission on High-Performing Health Care 
Systems recently issued a report----
    Mr. Pallone. Dr. Harris, I didn't stop you because I was 
interested but you are 3 minutes over, so you have to wrap up.
    Dr. Harris. I apologize.
    Mr. Pallone. That is all right.
    Dr. Harris. One last paragraph. In conclusion, the United 
States faces a critical shortage of primary care physicians for 
adults. We believe that it is imperative for all Americans to 
be provided with access to affordable coverage. We also know 
that coverage alone will not ensure that patients have access 
to high-quality and affordable care if there are not primary 
care physicians available to meet those needs.
    Thank you for your patience.
    [The prepared statement of Dr. Harris follows:]



    Mr. Pallone. Thank you.
    Dr. Bean.

                   STATEMENT OF JAMES R. BEAN

    Dr. Bean. Thank you, Chairman Pallone and Ranking Member 
Deal and members of the Health Subcommittee for the opportunity 
to address you about patient access to medical care. My name is 
Jim Bean. I practice neurosurgery in Lexington, Kentucky, for 
the past 29 years. I serve currently as president of the 
American Association of Neurological Surgeons, and this is a 
member organization of Doctors for Medical Liability Reform, 
the Health Coalition on Liability and Access, and the Alliance 
of Specialty Medicine.
    Access to effective medical care depends on a number of 
factors and we have talked about them, but one that is too 
often neglected is a barrier to access that is created by a 
malfunctioning medical liability system. I think it is safe to 
say there is near-universal agreement among physicians, 
patients and policymakers that our medical liability system is 
broken. Defining how is the issue. In 2005, Senators Hillary 
Clinton and Barack Obama acknowledged this when they co-
sponsored medical liability legislation to deal with the 
mounting access-to-care crisis. A 2008 white paper, Call to 
Action, released by Senate Finance Committee Chair Max Baucus, 
also acknowledges that the current legal environment leads to 
the practice of defensive medicine and calls for alternatives 
to civil litigation so that the administrative costs associated 
with litigation, which account for 60 percent of malpractice 
premiums, can be reduced. Those at the forefront of health care 
reform understand that it will do little good to achieve 
universal insurance coverage if the doctors who actually supply 
critical aspects of care are either driven from practice or 
retire early or simply shun the lifesaving procedures that need 
to be done because of uncontrolled risk.
    The problem of access to care is especially critical for 
high-risk specialties. We have been talking a lot about primary 
care but we should not forget that the specialty care has to be 
rendered in a safe system. Specialties such as neurosurgery, 
obstetrics, orthopedics, general surgery, emergency medicine 
and others, these specialties have been hit particularly hard 
by lawsuits and rising insurance premiums and they are the same 
ones who provide critical emergency services, and when they 
leave, they leave enormous gaps. The crisis persists despite a 
clear record of successful reform in some States. Mississippi 
and West Virginia both faced critical loss of medical services 
because of a doctor exodus because of skyrocketing liability 
costs. Mississippi lost a substantial number of obstetricians. 
Both States, West Virginia and Mississippi, lost enough 
neurosurgeons to endanger their emergency care system. 
Liability State reforms dramatically reversed the trend and 
doctors have begun to return. All States should have the same 
advantage. Perhaps the most dramatic example is Texas. We have 
heard about it. Before reform in 2003 doctors fled the State. 
Texas ranked 48th out of 50 States in physician manpower, and 
since medical liability reform, 69 underserved counties have 
seen a net gain in emergency physicians and a number of other 
specialists. Access to care was clearly improved.
    While we strongly believe that comprehensive reforms passed 
in Texas should be applied nationwide, other proposed reforms 
may help as well. They include early offers, specialized health 
courts and a presumptive defense by using evidence-based 
medicine. The President endorsed such an approach in a New 
England Journal of Medicine articled printed online. It was 
entitled Modern Health Care for All Americans, and it was 
published during the presidential campaign on September 24, 
2008. I have a copy if you would like. He wrote that he would 
be open to additional measures to curb malpractice suits and 
reduce the cost of malpractice insurance and he further wrote, 
``I will also support legislation dictating that if you 
practice care in line with your medical society's 
recommendations, you cannot be sued.'' We strongly support the 
President's announced position and look forward to its 
implementation as policy.
    Our President and this Congress are dedicated to reforming 
our health care system and ensuring access to care, but access 
to quality care must come first and ensuring patient access to 
care means acting out to fix a critically ill medically 
liability system.
    Mr. Chairman, thank you.
    [The prepared statement of Dr. Bean follows:]



    Mr. Pallone. Thank you, Dr. Bean.
    Dr. Rowland.

                   STATEMENT OF DIANE ROWLAND

    Ms. Rowland. Thank you, Chairman Pallone and Ranking Member 
Deal and members of the committee, for the opportunity today to 
participate in this hearing on making health care work for 
American families. My testimony today will address the role 
public programs have played in improving access and helping to 
reduce health care disparities. Indeed, health care coverage 
matters. It may not be enough to assure access, but without it, 
access to care suffers and disparities rise.
    Together today, Medicare and Medicaid provide coverage to 
over a quarter of our population, 80 million Americans, our 
oldest, our poorest, our most disabled and among our sickest 
residents. Both programs for over 40 years have been central to 
our Nation's efforts to improve access to care and the health 
care of the American people. Medicare has helped to provide 
access to care for the elderly by easing the financial burden 
for care and opening up access to the broad range of medical 
services and new technology that has helped to both extend life 
and promote better care. Medicare has helped not only to 
improve access to medical care but also to reduce racial 
barriers to care, both through the enforcement of the civil 
rights legislation that led to the desegregation of health care 
facilities and by providing equal benefits to all beneficiaries 
without regard to health status, income, racial or ethnic 
identity or State of residence.
    Medicaid is the workhorse today of the U.S. health care 
system, providing coverage for almost 60 million Americans left 
out of private health insurance and with very special health 
care needs. Medicaid coverage of the low-income population 
provides access to a comprehensive scope of benefits with 
limited cost sharing that is geared to meet the health needs 
and limited financial resources of Medicaid's beneficiaries who 
tend to be both sicker and poorer than the privately insured 
low-income population. Medicaid also helps to address racial 
and ethnic disparities and access to care. Because minority 
Americans are more likely than whites to be low income and 
without access to job-based coverage, Medicaid provides an 
important safety net, today covering one in four non-elderly 
African-Americans and Latinos. In fact, minority populations 
compose over half of the Medicaid beneficiaries. The 
comprehensive scope of Medicaid benefits is critical, given the 
low incomes and complex health needs of the population Medicaid 
services including the chronically ill and people with severe 
disabilities. When the health needs of the beneficiaries on 
Medicaid are taken into account, Medicaid is in fact a low-cost 
program. Both adult and child per capita spending are lower in 
Medicaid than under private health insurance. Medicaid 
enrollees, however, tend to fare as well as the privately 
insured on important measures of access to primary care. 
Uninsured children have significantly higher rates of no usual 
source of care. Compared to only 4 percent of publicly insured 
children and 3 percent of privately insured children, one 
third-of uninsured children have no usual source of care. There 
have been great gains in reducing the share of low-income 
children who are uninsured through the expansion of Medicaid 
and CHIP demonstrating that public programs can provide a solid 
platform from which to expand coverage.
    As the Nation moves forward to consideration of how to 
provide coverage to the over 45 million uninsured Americans 
today, Medicaid's role for the low-income population provides a 
strong platform on which reform efforts can be build as 
evidenced by the recent experience with children's coverage. 
One must recall that the uninsured population is predominantly 
low income, two-thirds with incomes below 200 percent of 
poverty, or roughly $44,000 for a family of four a year. 
Medicaid provides a strong and tested foundation upon which to 
build these health reform efforts but it could play indeed a 
stronger role if coverage of the low-income population was 
improved through expanded eligibility and reduction of 
enrollment barriers through addressing payment rates and 
administrative burden to help boost provider participation and 
promote greater access to primary care especially and through a 
stabilization of financing so that the periodic cuts in the 
program that affect reimbursement to providers and coverage for 
beneficiaries do not need to occur.
    In summary, the Medicaid program has an established track 
record in providing the scope of benefits and range of services 
to meet the needs of low-income population including those with 
chronic illness and severely disabling conditions. Drawing on 
Medicaid's experience in already substantial coverage of the 
low-income population offers an appropriate starting point for 
extending coverage to the low-income uninsured population 
through health care reform. While health insurance coverage is 
essential to open the door to the health care system for these 
individuals, broader measures as you have heard discussed today 
need to also be put in place as a complement to assure that the 
coverage card is not an empty promise. Thank you.
    [The prepared statement of Ms. Rowland follows:]



    Mr. Pallone. Thank you, Dr. Rowland, and thank all of you. 
I know it is a large panel, but you covered a lot of very 
important areas and we appreciate it. We now have questions 
from the members and I will start with myself for 5 minutes.
    I am going to start with Dr. Mullan and I am going to throw 
a few things at you here. I don't know if you will have time to 
answer them all but I am very concerned about the financing of 
medical education, you know, the whole idea of Medicare 
financing GMEs. If you were to suggest to me that we probably 
should have an alternative financing mechanism and not maybe 
even use Medicare, I would like to hear that. But even more 
important, my concern is about, you said 30 percent of the 
doctors are educated abroad. To me, that makes no sense and I 
don't think any effort is being made to reverse that. If 
anything, it seems to me that we will probably see a situation 
where more of our physicians are educated abroad, and that 
makes no sense to me. You know, I talk about how I attend 
events in my district with medical doctors who are raising 
money for Caribbean medical schools rather than for UMDNJ in 
New Jersey. There were reports in the media a few months ago 
about foreign medical schools raising money and buying 
essentially residencies at hospitals in the New York 
metropolitan areas so that their students would have preference 
for residencies over graduates of American medical schools. 
What does this all mean in terms of the quality of physicians 
that so many are educated abroad, be they Americans that go 
abroad or immigrants? I mean, where are we going? Some of these 
schools, they seem to be opening more and more overseas. A lot 
of them are private, not even government run. I don't know what 
kind of controls they have. Should we reverse this? I am not 
even talking about the impact on other countries, potential 
brain drain on other countries. That concerns me less. Maybe I 
should be concerned about it but I am not so much. Would you 
address that? Because I hear about it every day at home. I know 
it is a lot to ask you but----
    Dr. Mullan. Well, I will try to give the 2-minute synopsis 
on international medical graduates and how we have gotten to 
where we have gotten and what we can do about it. Very quickly, 
we have chronically undertrained. We have not trained 
sufficient physicians in our medical schools, and over the 
years we have put a lot of investment from the Congress in 
particular and from State governments into medical education at 
the medical school level in the 1960s and 1970s and this had a 
very good response. We doubled the output of medical schools 
between 1965 and 1980. At that point everybody said whoa, we 
are going to overshoot, and funding was throttled back. Schools 
remain where they were. So between 1980 and 2005, we lost one 
medical school, a net loss of one, and the graduating class, 
16,000, 16,500, every year was the same. Meanwhile over time, 
the residency opportunities grew, reflecting somewhat the needs 
of the country, and the opportunity for international graduates 
who took exams like the U.S. exams, today they take exams that 
are exactly the same to come and fill residency positions and 
then remain in practice, grew. So that today about 27 percent 
of our residents and 25 percent of our doctors in practice are 
graduates of international schools. A minority of these, about 
20 percent today, come from schools in the Caribbean, which are 
essentially designed for U.S. students to go abroad and come 
back as international medical graduates. That is because the 
need for medical education was not being made onshore. We 
didn't have enough placements.
    Mr. Pallone. But Doctor, should we be reversing this? I 
mean, my fear is the quality is good. Is this a way for us to 
save money so we should say great, let us have everybody 
educated abroad because the cost is less and let that burden be 
passed onto someone else? Does it matter? Are we doing anything 
to change it?
    Dr. Mullan. The answer is yes, we should be reversing it. 
That is good domestic policy. It is good foreign policy both. 
It gives more opportunity to domestic students if we have 
opportunities for them to train onshore and it diminishes the 
brain drain, which is bad foreign policy around the world. Many 
governments are resenting the fact that we are pulling their 
doctors here. The way it is happening and it is happening in a 
somewhat spontaneous fashion, is that medical schools are now 
growing again, increasing the opportunities. It is estimated 
that the medical school positions over the next 3 or 4 years 
will grow by 25 percent, and what will happen by all estimates 
is, that as more U.S. graduates come out, they will be selected 
for residency positions and de facto or in passing, the 
international medical graduates will have less opportunities. 
They will be less drawn from abroad. The problem----
    Mr. Pallone. But is that true? I mean, was this an 
aberration that I read in the New York Times where these 
foreign medical schools are now essentially buying residencies?
    Dr. Mullan. The foreign medical schools you refer to are 
the Caribbean commercial schools that are training largely U.S. 
students abroad and they did conclude--one of them concluded a 
large agreement with the New York Health and Hospitals 
Corporation for medical student places on their wards. It is 
unclear what will happen. U.S. New York-based schools that have 
placed their students there are in competition for those. 
Traditionally they have not paid for them. And it will be 
interesting to see how that plays out. But I think the point 
is, if the opportunities for practice in the United States for 
international medical graduates diminish because more and more 
of our positions are being filled by our own graduates, that 
business will diminish and we will not be so reliant on foreign 
graduates, whether they are U.S. citizens to begin with or 
international citizens.
    Mr. Pallone. So you think we are reversing this policy and 
we shouldn't worry much about it?
    Dr. Mullan. I think we should remain concerned about it. I 
think we are in a period where it is going to diminish. Now, we 
should understand that the number of residency positions in the 
country has remained relatively fixed. In round numbers, about 
100,000 people are in residency every year, about 24,000, 
25,000 new people in a residency each year. If we increase GME 
funding, graduate medical education Medicare funding, we will 
increase the opportunities and that will again begin to draw on 
the rest of the world. So right now where the physicians are 
capped under Medicare, that is Medicare reimbursement is 
capped, we are not creating more residency positions so the 
increased number of U.S. medical school graduates will go into 
a fixed number of positions, and by doing that it will diminish 
the number of international graduates that we bring into our 
country.
    Mr. Pallone. Thank you.
    Mr. Deal.
    Mr. Deal. Thank you.
    I would like to follow up on that too. I had a constituent 
that I asked him what his doctor told him. He said I don't 
know, I didn't understand a word he said, and that is a 
continuing problem. I didn't realize the percentages were as 
great until I read your testimony. With regard to the New York 
situation that you talked about, if we are funding graduate 
medical education through Medicare and the hospitals are now 
entering into private negotiated purchases of those slots, are 
we in effect funding slots through public funding that are now 
being in effect sold to foreign medical colleges?
    Dr. Mullan. That is a good question. I think the answer is 
no, because as I understand the agreement in New York, it is 
for the training of medical students, not for graduate medical 
education. The residency slots which Medicare funds remain the 
same. They are filled by both U.S. graduates and international 
medical graduates. Remember, I said we graduated about 16,000. 
If you add in osteopathic medical schools, U.S. based, we 
graduate about 18,000 every year. We offer 24,000 internship 
positions, post-graduate year one. So the difference between 
the 18,000 we graduate and the 24,000 that are offered are 
filled by international graduates, U.S. international graduates 
and non-U.S. international graduates. As the U.S. graduate 
numbers rise with the 24,000 positions to be filled, the 
international medical graduate numbers will diminish.
    Mr. Deal. Let me go to Dr. Harris because on a related 
subject to those residency slots, you make the point that we do 
not have enough residents in their post-graduate education 
going into the primary care internal medicine slots. How do we 
correct that? Is that something that the funding should be 
channeled more in the direction of those residency slots rather 
than the others, or how would you suggest we fix that?
    Dr. Harris. Well, we do recommend that there be focused GME 
funding on expanding the number of primary care spots. We feel 
that you need to be attentive to that. But the answer comes 
when you interview young people and ask them why are you not 
choosing primary care for a career, and the answers are three. 
One, it gets back to the question about medical education. You 
can argue that fundamentally there is a design flaw with 
medical education in that most medical schools in this country 
are centered around tertiary care centers where most ill people 
in the States are sent for their care while the most exotic 
illnesses are sent for very focused care. It is intellectually 
wonderfully satisfying, it is a wonderful place to spend 4 
years, but there is precious little exposure to what the 
majority of health care is in this country, namely outpatient 
ambulatory care. So one of the things you need to do is 
increase that exposure to show young people that following 
patients longitudinally, knowing them for years, if not 
decades, is a pleasure. The second thing has to do with the 
pace and that gets back to the notion of this medical center 
home or funding for bundled care that allows the expansion of 
the team that gives physicians time with their patients. 
Remember, 20 percent of the Medicare population in this country 
has five or more chronic illnesses.
    Mr. Deal. Let me stop you because my time is running out. I 
understand that. I think your point is well made that the 
traditional residency is in a hospital environment whereas the 
primary care whereas the primary care physicians that we need 
to be attracting, their practice is not going to be necessarily 
in that hospital environment. We need to have a different 
environment in which for them to complete that exposure. Is 
that what you are saying?
    Dr. Harris. We need to increase their exposure to 
ambulatory medicine during their training.
    Mr. Deal. But doesn't that have to be done under the 
auspices of a hospital that is providing the residency program?
    Dr. Harris. Yes.
    Mr. Deal. Okay. Let me go back to Dr. Mullan just a second.
    We know that NIH funding has been significantly boosted as 
a result of the stimulus input. You made a statement in your 
written testimony talking about the rise in NIH funding from 
$2.4 billion in 1970 to $16.3 billion in 2004, and you say 
creating a robust culture of research at medical schools that 
dominates medical school finances, faculty values and school 
culture. Now, with this huge influx of new money into NIH, is 
that going to exacerbate this problem about the focus of 
medical schools and focus it away from increasing primary care 
training or is it going to help it? Which way it is, or 
neither?
    Dr. Mullan. Good question. The stimulus money is focused in 
very practical ways and I think would probably be more 
practice-friendly perhaps than traditional NIH funding but the 
point is well taken, and I am not here to talk against NIH 
funding. I am here to talk for balance and we need to think if 
our medical schools are being endowed with enormous research 
money, creating a culture that values research and specialism 
when the problems in the country are generalism, we need to 
think about how to rebalance that and medical schools and 
funding for generalist research is important as well.
    Mr. Pallone. Ms. Christensen.
    Ms. Christensen. Thank you, Mr. Chairman. I didn't expect 
you to come to me that quickly.
    I thank all of the panelists as I said, for not only your 
testimony today but for the work that you have been doing over 
the years.
    Dr. Smedley, and I will probably also ask Dr. Rowland to 
answer, I am an advocate of building on the public programs to 
expand coverage but I have a concern that as we reform the 
system that we don't perpetuate a two-tiered system of care. 
There have been several studies that I have seen that have 
shown that despite the increased access that Medicaid patients 
have to services, they don't have as good outcomes. They have 
about the same outcomes as the uninsured. So why do you think 
this is and how can we fix the problem? And is there a role for 
the public plan that we are talking about in all of this? Dr. 
Smedley?
    Mr. Smedley. Sure. First, I agree with Dr. Rowland's 
statement that Medicaid has been vitally important for low-
income communities and communities of color. I have no doubt 
that without Medicaid, many more people would have suffered 
unnecessarily and we would have had many more premature deaths. 
By the same token, we know there are some things that need to 
be fixed and so it is important that we try to address the fact 
that we have tiered health care insurance systems, and so to 
the extent that people of color are disproportionately in 
lower-tier systems, this in itself can be one of the many 
causes of health care inequality and it is important that we 
take steps to strength Medicaid so that it is not stigmatizing 
to be a Medicaid patient. I was sharing with you earlier a 
story. I was surprised to walk into a county health clinic in 
one of our northeastern States. I walked into a waiting room 
that was approximately 20 feet by 30 feet, a very small waiting 
room where you could your name if you were called, but yet 
along one of the walls there was a sign that said ``Medicaid 
patients only.'' This was surprising to me because it further 
stigmatizes Medicaid patients and so to the extent that 
Congress can take steps to ensure that all of our public plans 
are comparable to private plans in terms of coverage, quality, 
quality incentives and performance incentives, I think this 
will go a long way toward reducing that inequality.
    Ms. Christensen. Dr. Rowland, we want to make sure that the 
card isn't an empty promise. It just seems to me that when you 
have a Medicaid card and another card, you know, it just opens 
the door for bias.
    Ms. Rowland. I think there are two things to note here. One 
is that many of our low-income population live in medically 
underserved areas so much of the discussion we have had today 
about bringing more resources into that area is important. I 
think the second thing to note, however, is that we can do more 
to make Medicaid payment rates more equalized with the rest of 
the health care system and that unfortunately as we gave States 
greater flexibility over their programs, many of them have used 
that flexibility when they need to cut costs to reduce payment 
rates, although we do see States improve those payment rates 
whenever their resources are more abundant. So over the last 
few years before this economic downturn, many States moved to 
up their payment rates. I think that the most important thing 
is to make sure that the card provides people with access to 
physician services and to primary care service and I think we 
should note that within the Medicaid program over the last few 
years the advance of managed care and the use of primary care 
networks has helped to really secure a better access, so I do 
worry that in some cases the providers willing to participate 
in those networks are not the same as the providers willing to 
provide care to the privately insured.
    Ms. Christensen. Thank you.
    Dr. Lavizzo-Mourey, thank you for the work that Robert Wood 
Johnson has done, and I was really interested in the family 
nurse partnership program as well as the others, but we hear an 
argument and we asked the CBO director, several of us did over 
and over again about savings that would be realized by 
prevention and you talk about a savings that you see in the 
family nurse partnership program. Their argument is that we 
will spend more money on prevention and so we won't realize any 
savings and I find this a major obstacle to getting done what 
we need to get done and making the investment. How would you 
respond to that?
    Dr. Lavizzo-Mourey. Thank you for this question. When 
people talk about prevention, they often lump a number of 
issues together that really should be separated. First, you 
referenced the nurse family partnership program. That is a 
program, for those who don't know, that invests in the 
relationship between nurses and moms-to-be or young mothers 
that teaches them how to navigate the health care system but 
also how to provide better health for themselves and their 
babies so it is an investment in health that happens in the 
community. The benefits that accrue from that investment happen 
over a number of years, not 2 or 3 but really over 10 to 15 
years. We continue to see savings up until the child is in 
their adolescence. So one has to look for the savings over a 
long enough period of time, first of all, in order to really 
understand whether there are savings.
    Secondly, we often talk about prevention and we are really 
referring to clinical services, screening tests and the like, 
and there frankly the results are mixed on whether it is going 
to provide savings. However, we do know it almost always 
improves health and produces a better value, but one has to 
also separate from that prevention that occurs at the community 
level, community-based investments such as reducing obesity, 
improving physical activity, reduction of tobacco use. These 
have been shown time and time again in large public health 
studies to reduce the overall costs of care because they 
improve the health, and we really need to focus those three 
separately if we are going to answer the question of whether 
prevention saves money.
    Mr. Pallone. The gentleman from Illinois, Mr. Shimkus.
    Mr. Shimkus. Thank you. I am going to try to be quick. It 
is a huge panel. I appreciate you all coming and I apologize 
for being in and out like we all have to do when there is 
business. Let me ask a question, and if you can answer briefly 
and I will try to get the whole panel. It depends on how quick 
you answer. You know, Senator Baucus on the other side's basic 
premise is Medicaid for all, cover the uninsured. Would you 
support that, Dr. Smedley? We are hearing some bad comments on 
Medicaid here.
    Mr. Smedley. I believe it was Medicare for all, if I am not 
mistaken, which----
    Mr. Shimkus. Okay. Well, let us assume that we want to 
cover the uninsured through Medicaid. Would you support that?
    Mr. Smedley. Well, it is important that we ensure that 
everyone has comprehensive care and that----
    Mr. Shimkus. So would you support current State-run 
Medicaid system insuring the uninsured today?
    Mr. Smedley. I would support as broad a pool as possible.
    Mr. Shimkus. So would you support State Medicaid programs 
covering the uninsured of each State?
    Mr. Smedley. That is an option that can work in many 
States. I am sorry I cannot give you a definitive answer.
    Mr. Shimkus. Dr. Kitchell?
    Dr. Kitchell. Yes, I think that Medicaid should be expanded 
but I also think that we should maintain private insurance for 
patients who need it.
    Mr. Shimkus. Okay. Thank you.
    Dr. Kitchell. As we----
    Mr. Shimkus. That is good. I really want to go quick and I 
don't want to be disrespectful.
    Dr. Sitorius.
    Dr. Sitorius. I am going to second Dr. Smedley. In some 
States it will work, in others it may not.
    Mr. Shimkus. Okay.
    Dr. Sitorius. I am not answering your question. I 
understand that.
    Mr. Shimkus. All right. That is good to know when you are 
on the record because that makes a statement about the current 
Medicaid system.
    Ma'am, I don't want to butcher your name. I am sorry.
    Dr. Lavizzo-Mourey. Lavizzo-Mourey. It is a mouthful, I 
know. Our foundation does not advocate for specific plans but 
we do have principles that suggest that there are a broad array 
of ways to, as Dr. Smedley says, ensure that we can increase 
the number of----
    Mr. Shimkus. Okay, but my focus is on Medicaid system in 
States as we know today. Covering the uninsured through 
Medicaid system in States, is that a way to insure the 
uninsured?
    Dr. Lavizzo-Mourey. It is one way among others.
    Mr. Shimkus. So you are not going to answer either.
    Sir, I don't see your nametag. I apologize.
    Dr. Mullan. Mullan. I would agree it is one of a number of 
options. It would not be my preferred option.
    Mr. Shimkus. Great.
    Dr. Harris.
    Dr. Harris. Congressman, in our paper we felt that----
    Mr. Shimkus. Quicker, please.
    Dr. Harris [continuing]. Consideration should be given up 
to 200 percent of the federal poverty limit for covering 
people. That would capture a sizable number of these people.
    Mr. Shimkus. So you are saying yes for 200 percent of 
poverty?
    Dr. Harris. As part of this overall pool of people. That 
will in no way capture all of the uninsured.
    Dr. Bean. No. The benefits are wide but the pay is so low, 
you won't get participation.
    Mr. Shimkus. Dr. Rowland.
    Ms. Rowland. For the low-income population, two-third of 
the uninsured, expanding Medicare would make a lot of sense.
    Mr. Shimkus. For the uninsured?
    Ms. Rowland. Yes.
    Mr. Shimkus. Okay. Let me go with this question. Would you 
trade your current insurance policy for a Medicaid policy, Dr. 
Smedley?
    Mr. Smedley. No.
    Mr. Shimkus. Just go down the table. Dr. Kitchell?
    Dr. Kitchell. As I said, some private insurance----
    Mr. Shimkus. Would you trade yours for a Medicaid policy?
    Dr. Kitchell. No.
    Dr. Sitorius. No.
    Dr. Lavizzo-Mourey. My plan has things that Medicaid does 
not have in it.
    Mr. Shimkus. So that is a no?
    Dr. Lavizzo-Mourey. That is a no.
    Mr. Shimkus. Thank you.
    Dr. Mullan. No.
    Dr. Harris. No.
    Dr. Bean. No.
    Ms. Rowland. Yes.
    Mr. Shimkus. Thank you. We may give you that opportunity to 
do that.
    Ms. Rowland. Medicaid has low cost sharing and 
comprehensive benefits and covers a lot of services that 
private insurance doesn't.
    Mr. Shimkus. Obviously with the doctor's question about, or 
your question about someone going into a clinic, being casted 
as Medicaid only this line versus other lines, that is why I 
asked that question. It is really a follow-up.
    I am really involved, this is my district. I have about 14 
community health clinics. They service--Illinois services 1.3 
million Medicaid, uninsured, Medicare and for-pay folks. It has 
been very successful. When I first got elected to Congress, I 
had zero in my district. Now, the benefits of community health 
clinics are what? The people who practice there are protected 
by the Federal Tort Claims Act. It has allowed them to provide 
health care to the uninsured. Do you think that some model, 
talking about what happened with Texas, what happened in 
Illinois, although our legislation is being reviewed by the 
Supreme Court--we had medical liability reform for my 
neurologist. There was a time when we did not have a single 
neurologist south of Springfield because of medical liability. 
Would moving on a Federal Tort Claims Act provision on medical 
liability be helpful in access to care and keeping costs down? 
Dr. Smedley?
    Mr. Smedley. I don't know if the evidence speaks to that. 
Community health centers are successful not solely because of 
tort issues but because of----
    Mr. Shimkus. So you are saying that the fact that they 
don't have liability costs because they are protected, that 
doesn't affect the way they charge individuals?
    Mr. Smedley. No, they are--community health centers have 
done a marvelous job targeting the needs of low-income and 
underserved communities. I believe that is the primary reason 
that they are successful.
    Mr. Shimkus. I would beg to differ.
    Dr. Kitchell.
    Dr. Kitchell. Yes, I think community health centers are a 
good idea. We have actually----
    Mr. Shimkus. I am talking about the Federal Tort Claims Act 
protection on community health centers.
    Dr. Kitchell. That would help, yes.
    Dr. Sitorius. Yes.
    Dr. Lavizzo-Mourey. I practice in a community health 
center. I have to agree with Dr. Smedley that the reasons that 
they are successful have much more to do with other issues.
    Mr. Shimkus. Do you pay any liability insurance when you 
practice in the community health center?
    Dr. Lavizzo-Mourey. No, I do not.
    Mr. Shimkus. Okay. Thank you.
    Dr. Mullan. Health centers are distinctly successful for 
other causes. Is the tort protection afforded to provides there 
useful? Yes.
    Mr. Shimkus. Dr. Harris.
    Dr. Harris. I simply agree with Dr. Mullan.
    Dr. Bean. Yes, it would help.
    Ms. Rowland. I agree with Dr. Mullan.
    Mr. Shimkus. Thank you, Mr. Chairman. I think tort issues 
should be part of this health care debate. I yield back.
    Mr. Pallone. Thank you.
    Mr. Braley.
    Mr. Braley. Dr. Kitchell, I want to follow up on some of 
the points you raised in your opening statement, especially 
dealing with geographic reimbursement inequities. You mentioned 
the Geographic Practice Cost Index, also commonly referred to 
as GPCI, reduced fees for physicians because of where they 
live. In your best estimate, what is the differential in 
Medicare fees between the highest GPCI areas and the lowest 
GPCI areas?
    Dr. Kitchell. The differential is 34 percent between North 
Dakota, Arkansas, and then the highest area is in California.
    Mr. Braley. And then to follow up on your point, when you 
are out looking to replace equipment and looking for durable 
medical equipment that you use in your practice, have you found 
a similar inequity of what the cost of that equipment is based 
upon geographic differences?
    Dr. Kitchell. No. In fact, about 2 years ago when we 
decided to buy an electronic medical record, that cost of $21 
million for our clinic is exactly the same as anywhere in the 
country.
    Mr. Braley. Can you explain in further detail how it is 
that these reimbursement inequities built upon a flawed GPCI 
formula impact access to care in rural areas?
    Dr. Kitchell. Well, there are some services that are not 
even paid as much as the cost of delivering those services. Let 
me give you an example of a cardiac defibrillator implant. The 
Medicare reimbursement for that is actually less than the cost 
of the device. So the payment for the labor, the payment for 
the rent, the payment for all the other services that that 
patient needs, Medicare pays less than the cost of that 
machine.
    Mr. Braley. Now, one of the solutions that has been 
proposed is putting a floor on GPCI inequities and we know that 
by enacting a 1.0 floor on work GPCIs we reduce the inequity 
even though there is still this 8 percent differential you 
mentioned in your testimony. Do you feel that a 1.0 floor on 
practice expense GPCIs would also decrease rural health care 
disparities?
    Dr. Kitchell. Yes, that would be our best solution.
    Mr. Braley. Earlier this year I spoke in this committee 
about the need for a reimbursement system that rewards quality. 
Can you explain how a model system might look to provide 
quality-based reimbursements to physicians?
    Dr. Kitchell. Yes. As I said, the PQRI program is flawed. 
The hospital system is doing a good job of rewarding quality. 
Quality needs to be rewarded for teams, groups and systems. 
Quality is team-based care. The medical home model, the bundled 
systems, the shared savings, they rely upon physicians working 
together with non-physicians in teams so we should be 
encouraging, we should be incenting physicians to be part of 
teams, groups and systems, and as I mentioned, the Middlesex, 
Connecticut, example is a great example where independent 
physician practices have gotten together in an accountable care 
organization and they have increased their quality and reduced 
the costs of care. I think a key point for Americans is to 
understand that by working together, physicians and non-
physicians working together, we can improve quality and we can 
reduce costs.
    Mr. Braley. All right. Dr. Bean, I am going to follow up a 
little bit on your testimony because one thing that was 
noticeably absent from your testimony was a discussion of 
preventable medical errors and there has been a lot of 
testimony from the panel about the importance of an Institute 
of Medicine finding relating to access to health care but no 
one has mentioned the seminal Institute of Medicine study in 
2000 and the follow-up study identifying the acute problem of 
preventable medical errors and the costs they impose on the 
system. So do you agree that the most effective way to reduce 
malpractice costs in this country is by reducing or eliminating 
preventable medical errors?
    Dr. Bean. I am afraid I don't agree that is going to 
eliminate the malpractice crisis in the areas where malpractice 
is used or abused. I will agree with you that the focus on 
preventing medical errors is not only laudable but highly 
necessary.
    Mr. Braley. Well, can you explain why the existing 
framework for health quality oversight that is in place in this 
country primary through the Joint Commission on Accreditation 
of Health Care Organizations that is hospital specific has 
failed to make a measurable decrease in preventable medical 
errors despite the fact that their sentinel-event program has 
been in place for over a decade, and if you take the IOM 
numbers of 44,000 to 98,000 preventable medical errors 
resulting in deaths in hospitals every year and compare that to 
the sentinel-event statistics from JACO which show that on 
average only 300 sentinel-event reports are filed per year, 
don't you agree that there is a gross example of underreporting 
of the problem and a failure on the part of the community to 
address it?
    Dr. Bean. No, not at all. First of all, if you look back at 
the studies that were done where the 44,000 to 98,000 figures 
were drawn from, these were extracted from hospital charts in 
about 1982 or 1983. That is almost 30 years ago. So there has 
been a substantial change in hospital practices and events 
since then. When that extraction was done, they were 
extrapolated from acute charts and assumed that this was 
happened around the country and the medical errors and 
negligence were equated and that is not necessarily so at all. 
There are things that do happen that are not negligence so 
saying that the medical liability system is going to handle--is 
necessary to prevent all that is wrong. I think that the proper 
way to do it is what we are doing. We are looking at quality 
events, and in fact if the reporting is low, maybe that review 
should be done again to see if that is the reason. Maybe there 
has been a change over the past 30 years.
    Mr. Braley. Do you think there are only 300 preventable 
medical errors a year happening in hospitals in this country? 
Is that your testimony?
    Dr. Bean. No, I think that, number one, if you are asking 
hospitals to report things or doctors to report things in the 
face of a medical liability system where they can be sued for 
millions of dollars, your incentive to be open is blunted 
considerably. Change the liability system. Make it possible 
like airlines to report things without being so open to suits 
that can run you out of practice, and we can have a better 
system for finding and correcting errors.
    Mr. Braley. Thank you, Mr. Chairman. I would just like to 
point out that the reporting system I am referring to at JACO 
is a closed system that is not open to the public.
    Mr. Pallone. Thank you.
    The gentleman from Texas, Mr. Burgess.
    Mr. Burgess. Thank you, Mr. Chairman, and that is an 
excellent point, Dr. Bean, and I am so glad you made it because 
the IOM study was in fact published 10 years ago and it was 
from data collected 20 and 30 years ago. It is high time, Mr. 
Chairman, we asked the Institute of Medicine to update that 
study. The sentinel reporting techniques have been around for 
10 years. Maybe we should look again and see whether we have 
made any progress. I suspect we have, because even then the 
data from 1982 and 1983 and the data from 1992 showed 
significant improvement between that 10-year span and that was 
not accounted for in the publication, To Err is Human.
    Since Mr. Shimkus took my questions, Dr. Rowland, let me 
just ask you, you described a Medicaid program that I just 
scarcely recognized. In my practice, it wasn't a workhorse, it 
was more like a Trojan horse and all the people got inside and 
then you were in trouble. But let us think about it for just a 
minute. You were the only one who answered affirmatively to 
changing what you had now for what would be available in the 
Medicaid system. I offered an amendment during our SCHIP debate 
and I may well offer it as stand-alone legislation that would 
allow members of Congress the option of entering the Medicaid 
system so perhaps they could see for themselves firsthand what 
patients encounter. Would that be a good idea?
    Ms. Rowland. Well, first of all, I think, sir, that you 
come from the State of Texas and that Medicaid programs are 
different in different States and so one of the issues that 
needs to be addressed if one is going to build on the Medicaid 
foundation is to perhaps make the program more standard.
    Mr. Burgess. But we had no other member from Texas on the 
panel here today but everyone declined the opportunity for 
taking an adventure into the Medicaid system. I just offer that 
for what it is worth. Do you think I will get many cosponsors 
on that legislation from Members of Congress?
    Ms. Rowland. I actually doubt it.
    Mr. Burgess. Yes, I do too.
    Ms. Rowland. But I think that it does point out that the 
program does need improvement as a building----
    Mr. Burgess. There is no question that the program needs 
improvement and I did take Medicaid patients in my obstetrics 
practice, and the biggest problem I had was finding a 
specialist to whom to refer a patient when she had a problem 
that was beyond my scope and capabilities, and that I think 
really speaks to the problem that many primary care doctors 
have when they open their doors to Medicaid patients. If they 
get a complicated abscess, if they get a complicated cardiology 
patient, they literally have no place to send that patient, and 
as a consequence they may be practicing well over their heads, 
and that is a patient safety issue that really should not go 
unaddressed.
    Dr. Bean, I want to thank you too for your comments about 
the medical liability system. Texas has I think done an 
excellent job. I can't take any credit for it. I have 
introduced the Texas legislation in Congress. The bill number 
is 1468, for anyone keeping scoring at home. This bill actually 
scores as a savings by the Congressional Budget Office. It is 
$3.8 billion over 4 years. It is not a huge savings. We spend 
trillions of dollars at the drop of a hat now. But still, $3.4 
billion to $3.8 billion means something to someone somewhere 
and I just offer this, Mr. Chairman, as a gift to help balance 
the budget wherever it might be helpful. I will be glad to make 
my modest little Texas medical liability bill available so that 
other States can in fact enjoy some of the things that have 
happened in Texas.
    Dr. Kitchell, in my remaining time, I couldn't help but 
notice that your notes were handwritten so I assume you haven't 
purchased that $21 million record system that is available to 
you?
    Dr. Kitchell. We are in the process of phasing it in, yes.
    Mr. Burgess. I understand why because even from across the 
street, I can tell that your partners cannot read your 
handwriting. Let me just ask you a couple of questions because 
you have some great testimony about the PQRI which I thought 
was a mistake when our side pushed it at the end of 2006. You 
say it doesn't actually reward quality it rewards reporting. 
There was a great article in the Journal of the American 
Medical Association a little less than a year ago. I 
unfortunately don't remember the author. It was tongue in 
cheek. It recommended that we diagnose liberally, don't be 
stingy with your diagnoses. If you make more people in your 
patient panel class 2 diabetics, your hemoglobin A1Cs are going 
to look a lot better and as a consequence you are going to get 
a better--your payment is going to improve. You reward, you 
incent the wrong type of behavior when you go down the PQRI 
road but I do wonder, and you have the statement that there are 
methodological problems, are these fatal flaws or could these 
be corrected? And of course, one of the biggest problems with 
PQRI is, we didn't pay a darn thing for anyone to gather the 
data. It was more expensive to try to participate than any 
bonus that you would get at the out end on PQRI but are the 
problems inherent in PQRI, are they so fatal that the program 
cannot be salvaged and we just need to move to a different 
scheme?
    Dr. Kitchell. Let me just preface this slightly. The 
American Medical Association physician consortium for 
performance improvement is developing measures of quality so we 
cannot only measure, we can reward quality. The AMA should take 
a lot of credit for developing this. They have taken the lead 
in measuring and rewarding quality. The PQRI program has chosen 
to use individual measures. The consortium is now working on 
more team and system measures. That is where I think we need to 
go. The problem with the individual measures as a physician, we 
don't want to be profiled. We don't want to be tiered. We don't 
want to be rated individuals because our patients vary. 
Sometimes three physicians are seeing one patient so who gets 
the credit, who gets the blame. That is an attribution problem. 
So these individual measures continue to promote fragmentation 
of care rather than coordination of care by teams and systems. 
We need to think about how we deliver care and we will do 
better with raising quality, giving patients safety, improving 
the value of their care if we measure by teams, groups and 
systems. So my proposal would be to change the focus of PQRI to 
get away from reporting. Let us do measures. And we have some 
composite measures now and some groups, accountable care 
organizations are willing to be accountable for quality and for 
cost. It is time we allowed those groups of physicians who are 
willing to be accountable for quality and willing to be 
accountable for their costs to let them do that.
    Mr. Burgess. Are these along the lines of the physician 
group practice demonstration model that CMS has been doing?
    Dr. Kitchell. Yes.
    Mr. Burgess. And I would----
    Mr. Pallone. Dr. Burgess, just one more and then----
    Mr. Burgess. I would very much favor us considering in the 
Medicare system, which is a federal program, if a group 
practice is under that accountable model, to allow them, allow 
that group for their Medicare patients coverage under the 
Federal Tort Claims Act and I think we can go a long way 
towards pushing what is I think a very effective policy and 
getting doctors to buy in, and I will yield back the balance of 
my time.
    Dr. Kitchell. Can I just----
    Mr. Pallone. You can answer.
    Dr. Kitchell. One last comment, and just so you understand, 
the physician group practice demonstration project also 
included independent physicians. They were not a group, a 
formal group. They were independent practicing physicians and 
they got together in groups.
    Mr. Pallone. Thank you.
    The gentleman from New York, Mr. Weiner.
    Mr. Weiner. Thank you, Mr. Chairman.
    Some of my colleagues on the other side have been engaged 
in a furious process of erecting straw men and then burning 
them down. So let me just clarify a couple of things with your 
help. First of all, my understanding is, the proposal by some 
is Medicare for all, the idea being that it is a model that 
people are somewhat comfortable with. It is in some 
interpretations this problem with this debate is that some 
people have gotten stirred about the idea of socialized 
medicine, forgetting that in fact what the social compact in 
Medicare has been with the exception of problems with cost 
reduction and things that need to be fixed, it has been a 
success that people appreciate. The other false choice that has 
been offered to us is the idea that not whether Members of 
Congress should be offered Medicaid but whether Medicaid 
citizens should be offered what Members of Congress have. That 
is the choice that we confront. What we are trying to do is 
trying to take programs that are obviously deficient and 
replace them with models that work better. So perhaps my 
colleague from Texas should offer legislation offering anyone 
on Medicaid the same plan that Members of Congress have. That 
would truly be a constructive step forward. It is the premise 
of our entire discussion that the Medicaid system doesn't work 
very well and it doesn't treat people as well as it should or 
treat physicians the way it should or reimburse States the way 
it should. That is a given, and to set the straw man up that, 
oh, well, we have to have Medicaid for everyone, wouldn't that 
be a terrible thing, yes, it probably would not be anyone's 
desired outcome and I don't think any of the collective wisdom 
of the panelists would suggest that that is the seminal 
question despite the somewhat overly yes, no, get your answer 
ready kind of inquisition.
    Let me just now ask a question, if I could. It strikes me 
that Medicaid is a pretty good deal for hospitals and 
physicians when compared to no insurance. We actually have an 
experience in New York City that when there is a Medicaid 
patient coming in the door, a lot of the hospitals in New York 
are gleeful. At least they have someone with some kind of 
coverage, some kind of predictable repayment, some kind of a 
process that they know that they are going to get compensated. 
So yes, Medicaid looks pretty problematic to a lot of 
physicians except when compared to what a lot of people have, 
which is no coverage at all. But I want to ask a question about 
the impetus to get more physicians to go into primary care. It 
seems to me that the market is not functioning efficiently, 
that while there is a demand for more of those, while there are 
more hospitals that are looking and more of our system seems to 
want it, it doesn't seem like the incentives are getting built 
in properly. As we figure out how to contract the incentives 
differently in the context of a national health care plan, 
should we be saying we will pay you more? Should we be saying 
we will pay more of your medical education if you go into 
primary care? Should we say we are going to penalize you if you 
decide to be a dermatologist? I mean, what would be the model 
if we are going to start from scratch which to some degree we 
are. What would be the model that would be--and Dr. Mullan, you 
were the one who I heard speak most articulately about it. What 
do you think that we should be doing to structure it so that 
being a primary care physician seems like a better deal?
    Dr. Mullan. I think the important thing to know is 
unfortunately there is not a single prescription, a single 
diagnosis and single prescription here, and it is along this 
continuum. I think there are things that need to be done in the 
pipeline. There are things that need to be done in practice. 
And as you rightly observed, the market is not working. The 
market is not calibrated in practice to support people very 
well in primary care and that is a financial matter in terms of 
reimbursement. It is also a structure model in terms of the 
hamster in the maze or hamster on the runner-type environment 
that has been created by the need to churn out as many patients 
as possible simply to pay the rent. So the restructuring of 
primary care with incentives from federal payers as well as 
others will be hugely important to creating a primary care 
environment which is attractive to make the market better. But 
if you don't have the pipeline geared to do that, you will have 
ill-prepared people coming and therefore the investments, Title 
VII, how do we--what do we do about the medical school 
environment, the culture to make it more friendly to primary 
care, community medicine, ambulatory care and the like, and 
with graduate medical education how do we get more people 
training in those areas with very heavy federal investment in 
that area.
    Mr. Weiner. Can I squeeze in one more question? Is there a 
whole different tier of health care that we maybe need to 
create on the preventive side, on the diagnostic side, on the 
nutritional side, on the testing side? I mean, should we not 
think about maybe having kind of clinics or mobile things or 
something that go out and find people before they would go 
and--who might be disinclined to go into a doctor's office or a 
hospital? You know, we have a whole collection of senior 
centers, for example, in New York City that seem like a perfect 
place to kind of capture people, you know, in a non-medical--I 
don't know exactly what I am describing. I guess it is 
something before even primary care, you know, to kind of be a 
gateway thing that would--you know, we seem to all worship at 
the altar of getting people early, doing more diagnostic, 
nutrition, all these different things, but should we maybe just 
think about a non--I know it is tough asking, you know, a panel 
of doctors, but should we be thinking about maybe an extra 
medical type of structure that grabs people in a way that maybe 
gets them to do the things that might keep them out of even 
primary care? I don't know who is best equipped to answer that.
    Dr. Lavizzo-Mourey. I will make a couple of points and I am 
sure my colleagues will as well. One of the things that we know 
about improving the health of people is that if you can take 
interventions to where they live and work and learn, you can do 
a much better job of improving their overall health. We have 
learned this through school-based health clinics. We know it 
through community-based investments in prevention, some of 
which I have referenced before, investments in increasing 
people's physical activity, reducing obesity and so on. So I 
would agree with you that there is an investment that needs to 
be made in going to where people actually spend the bulk of 
their time, which is not in a doctor's office or a health care 
setting.
    The other point I would like to just make is that we have 
talked a lot about reimbursement and adjusting that. We haven't 
really talked about the ways in which medical practice has 
changed and needing to keep up a reimbursement system that 
mirrors that. Patients want to get care, not visits. They want 
to get phone calls, e-mails and other ways to allow them to 
manage their own care outside of a doctor's office. We don't 
really have a reimbursement system that encourages and incents 
that.
    Mr. Weiner. Thank you.
    Mr. Pallone. The gentleman from Georgia, Mr. Gingrey.
    Mr. Gingrey. Mr. Chairman, I thank you. I just want to say 
before I get into the questions that this straw man scenario 
that my friend from New York said we Republicans have adopted 
has been taken to perfection by the Democratic majority 
including President Obama, and I think it is probably time for 
both sides to stop doing that as we work in a bipartisan 
fashion to try to solve this health care reform issue. It is 
hugely important, and I think we can do it. I sincerely believe 
that we can do it.
    With that, let me turn to Dr. Bean actually. Dr. Bean, in 
your testimony you noted in his health care reform white paper, 
Senator Baucus acknowledged that the current legal environment 
leads to the practice of defensive medicine. That was his 
quote. I would like for you to elaborate on what constitutes 
defensive medicine and discuss the costs associated with this 
practice. If you remember, during the debate between former 
President Bush and candidate Senator John Kerry, in one of the 
debates that was brought up, and Senator Kerry said well, you 
know, the actual premium cost of malpractice insurance is 
although high for the individual doctor, not a significant 
number, but that is not the real cost and I wish you would 
explain to my fellow colleagues on the committee and those in 
the room what the real costs are in regard to that.
    Dr. Bean. Mark McClellan did a study back in the 1990s, I 
think it was. The Health and Human Services used that as a 
basis of a 2003 study and found that the excessive tests 
prescribed to be certain and protect yourself from liability 
would cost at that time somewhere between about $45 to $129 
billion. Now, that updated--
    Mr. Gingrey. Per year?
    Dr. Bean. Per year in the health care system. That updated 
today would be about $170 billion, and the study is debated but 
I think it is difficult truly to tell what is in the back of a 
doctor's mind. There is the diagnostic thing but there is the 
fear that is lingering in the back that if you don't cover 
everything, you are subject to unmerciful liability, 
unprotected liability. If this were taken care of, I think 
there would be a substantial reduction. The other issue about 
the premium, it is quoted to be a half percent of medical 
costs. Of course it is trivial because it is just a small 
proportion of doctors with population sustaining it. It is that 
bigger cost, if it is a cost issue that can be saved.
    Mr. Gingrey. Dr. Bean, thank you, and I am going to turn 
now to Dr. Harris because I actually back in 2005 when I 
introduced liability reform, tort reform here in the House, I 
got a letter from American College of Physicians and it said of 
course supporting my position on medical liability reform 
legislation. The American College of Physicians stated that 
there is ``strong evidence that the health care liability 
crisis resulted in many patients not receiving or delaying 
much-needed medical care.'' Dr. Harris, could you please 
explain to us how the medical liability crisis has negatively 
impacted access to needed medical care for millions of 
Americans?
    Dr. Harris. Well, I think that gets to the point that Dr. 
Bean was making and whether there is an element of apprehension 
about doing things by virtue of the threat of malpractice. I 
mean, it is our belief that liability reform should be part of 
this large effort to reform the health care system in this 
country, and as you know, we favor putting a cap on non-
economic damages but we also think that in the middle of all 
this there needs to be some thought and look at the potential 
for other options. As you are all aware, the testing of expert 
courts is one that has been considered, but before making such 
a momentous step, we would applaud looking broadly to see what 
are the other options.
    Mr. Gingrey. Thank you, Dr. Harris.
    And in my remaining time--Mr. Chairman, remember I did 
waive my opening statement--Dr. Rowland, in your testimony you 
talked about the Medicaid program and that you recommended 
maybe Medicaid as a platform for extending coverage to the 45 
million or so uninsured and maybe not quite that many who are 
underinsured. You know, when I practiced, I can tell you that 
there is a bias against Medicaid recipients. Of course, some 
doctors won't even accept Medicaid because of the low payment, 
but even though they do, I think that there probably is a 
stigma, and certainly if we use the best Medicaid program in 
the country, of course, all 50 are different but if you took 
the best as the model to offer to those who are uninsured, how 
do you get beyond that stigma? Maybe in the brief time, I guess 
I have at least another minute, for you to respond to that 
question?
    Ms. Rowland. Thank you. What we have seen in the 
implementation of the CHIP program as a companion to Medicaid 
and many States restructured, renamed their Medicaid program 
and tried to eliminate some of the stigma attached with it 
being a heritage program from the welfare days and have found 
that in Connecticut, for example, the HUSKY program was very 
popularly received and people didn't distinguish it. When we do 
surveys of the individuals who have uninsured children and ask 
them about access to public programs, they say they would 
enroll if they were eligible. They aren't always aware that 
they are eligible and perceive these programs to be a good 
program. I think the other point though that one has to make is 
that when we look at all the survey research over the years, 
Medicaid and private insurance do relatively the same in terms 
of access to care and access to care measures for the 
populations they serve always far better obviously than being 
uninsured. So while we have a provider participation issue and 
that could be corrected obviously by improving the way in which 
providers are paid and we have a primary care delivery system 
now that is being used in many States to promote better care, 
it is important to really look at the overall structure and 
eliminate some of these State-by-State variations so that it is 
a better base program for those low-income individuals for whom 
private insurance with high deductibles and large amounts of 
cost sharing may not be adequate, but especially for the 
population that Medicaid now serves, those with severe 
disabilities and chronic illness where the scope of benefits 
for Medicaid is equally important to the fact that it has low 
levels of cost sharing. So I think you really need to look at 
the population being served. And finally, I would say you also 
need to recognize that Medicaid is far more than a health 
insurance program and that the majority of its dollars are 
spent on long-term care and assistance to the elderly and 
people with disabilities that go well beyond what we are 
talking about in terms of the federal health insurance benefit 
plan or any other private health insurance plan.
    Mr. Gingrey. Dr. Rowland, thank you, and Mr. Chairman, 
thank you for your indulgence.
    Mr. Pallone. Thank you.
    Ms. Capps.
    Ms. Capps. First of all, let me thank the panel for your 
persistence and endurance, I guess, with this long morning, and 
I was called many other places but I couldn't miss coming back 
to address your statement, Dr. Lavizzo-Mourey. Thank you for 
highlighting the role of nurses and our nursing shortage. It is 
not the only topic on the table but it is often not on the 
table so I want to thank you for being here and to present that 
large element in health care. In your written testimony you 
mentioned the need to increase the number of nurses with 
baccalaureate degrees to create larger pools of nurses who 
would qualify among other things for careers in teaching. What 
efforts do we need to do? I would like to really zero in on 
this, and then one other topic, school-based health clinics 
that I know you are very good at as well to bring to our 
attention and get on the record here. What efforts need to 
occur at the federal level to increase the proportion of nurses 
with this level of education?
    Dr. Lavizzo-Mourey. One of the key issues is funding for 
scholarships and other financial aid programs for nurses at the 
baccalaureate level and for nurses who are transitioning from 
associate to baccalaureate. We know that these programs over 
the last 20 years have decreased and in the past have been a 
major source of financial support for nurses and I would 
encourage every effort to be made to enhance those.
    Ms. Capps. Thank you, and it is so clear that given the 
cost-of-living increases, we have less money from federal 
dollars in nursing education today than we did in the 1970s, 
and with our shortage, this is something I hope we can do our 
part in remedying. Of course, recruitment and financial aid is 
one piece of it. Retention is another. You mentioned, I would 
love to have you explain a little bit more for all of us, the 
need to retain newly licensed nurses at the bedside and 
particularly the work of the Robert Wood Johnson Foundation in 
the area that you are calling Transforming Care at the Bedside 
project. Briefly describe this because I still want to get to 
school-based health clinics so that we can understand that this 
is a very important example and there are other examples as 
well as to how we can keep nurses engaged in the delivery of 
health care.
    Dr. Lavizzo-Mourey. One of the things we recognize is that 
the pipeline for nurses entering the field is being eroded by 
the number of nurses that are leaving the field and these are 
often among the most experienced clinicians and they have 
demonstrated, particularly when they are trained at the 
baccalaureate or above level, that it decreases medical errors, 
poor outcomes and the like. So efforts that will enhance the 
retention of experienced nurses will directly impact the 
shortage.
    The program that you mentioned, Transforming Care at the 
Bedside, really focuses on trying to develop a cadre of nurses 
who understand the needs at the bedside and can make changes at 
the nursing level but then also disseminate those changes 
throughout the hospital and to other hospitals that empower 
nurses to do the best for patients, improve the patient 
centeredness and in the process improve the quality of care. So 
it really speaks to the issues that nurses often give for 
leaving the profession or leaving a particular institution that 
are non-financial, that is, not being able to deliver the 
quality of care that they feel they were trained to deliver. 
That is really the core issue that Transforming Care at the 
Bedside addresses.
    Ms. Capps. It is very important, thank you, that we have 
this ingredient really strong front and center in our efforts 
to reform health care delivery. One other thing, you mentioned 
the work of the Robert Wood Johnson Foundation in addressing 
health care needs of our Nation's children by investing in 
school-based centers across the country. I have long felt this. 
It is not just a bias because I have been a school nurse for so 
many years. Families trust their neighborhood schools. They 
will come there, not just the schoolchildren but the whole 
family. That is a good place to delivery care and we should be 
thinking about this as a cost-effective means and I would like 
to have you address it, because one of the problems is--and I 
know this very personally--is the shortage of school nurses and 
others. Nurse practitioners can deliver great care within the 
school setting but that is exactly where we are short supply.
    Dr. Lavizzo-Mourey. Your points are very well taken. There 
are 1,500 school-based clinics around the country and they have 
demonstrated that by providing care in the local environment, 
the school is a local environment, it is a trusted area that is 
close to where people need to get care, you can improve mental 
health services, you can improve primary care services and 
other services that the children and, as you mentioned, their 
families would not otherwise receive. So these are cost-
effective ways of delivering care in the community that 
addresses, I think, some of the issues that Dr. Smedley was 
mentioning. People need to be able to get care close to where 
they live.
    Ms. Capps. Thank you, and I only wish I had time to ask 
some of the others on the panel for your thoughts because it 
seemed like I picked the one person who talked about nurses but 
I think there might be other agreements among the panel members 
that these are areas that we should rightly pursue. Thank you 
very much.
    Mr. Pallone. Thank you.
    The gentleman from Maryland, Mr. Sarbanes.
    Mr. Sarbanes. Thank you, Mr. Chairman. Thanks to the panel. 
Congresswoman Capps, you needn't have worried that the topic 
won't be continued because I am going to ask you the same 
questions, particularly about school-based health clinics. It 
is great that we have 1,500 school-based clinics across the 
country but that is a complete drop in the bucket in terms of 
what we could use them for, and Representative Weiner 
introduced this concept of sort of creating a different kind of 
infrastructure for delivering certain kinds of care. I am very 
interested, and the school-based health clinic falls right 
within this, in the concept of place-based health care, and I 
think you addressed this, but let us go where people are. I 
mean, we can walk down the hall here and there is a clinic. 
There is a nursing station suite that we can stop into and it 
makes perfect sense to have those resources on site where you 
can capture certain populations. It is so obvious to me and 
clearly other members of the committee as well and members here 
in Congress that our schools represent a huge opportunity to do 
this. I practiced health care law for 18 years but for 8 of 
those years I was part time as a health care attorney and part 
time working 20 hours for the State superintendent of schools 
so I was in schools, and of course what I kept seeing was the 
impediments to education that were represented by the health 
status of so many of the students and the need they had to get 
these services.
    So I would like any others who would like to join this 
conversation to talk about this concept of place-based health 
care, and we can we also view it--I would like you to speak in 
terms of addressing the workforce issues, internships, 
residencies and other things that are associated with those 
structures, and I would add as well the concept of medical home 
which is typically talked about when you are addressing the 
individual's care but I think we should be thinking in terms of 
the medical home for certain communities, so in other words, 
the medical home for a school is that clinic. The medical home 
for a naturally occurring retirement community where people are 
aging in place, you know, in significant levels would be a 
clinic. In the school, it could be a clinic that is being 
staffed by not just nurses but pediatricians so you can get the 
workforce issue there. In a clinic where people are aging in 
place, it is a way to expand the geriatrician workforce, et 
cetera, et cetera. So speak to place-based health care as 
really potentially being a revolution in the way we address a 
lot of these needs and the public health needs. Anybody who 
wants to jump in?
    Mr. Smedley. Congressman, I would just echo your thoughts. 
A focus on place and on communities can help us to really think 
more creatively about how to prevent illness in the first place 
and as a result lower health care costs. The examples that 
Representative Weiner gave of beginning to emphasize prevention 
are critically important. One of the things that we haven't 
talked about is good community-based primary prevention. A 
recent report by the Prevention Institute showed that if we 
invest just $10 per person per year for 5 years, we can save 
$16 billion in health care costs by helping people to avoid 
illness in the first place.
    Mr. Sarbanes. Anyone else? Yes.
    Dr. Harris. The American College of Physicians I don't 
believe has policy per se about community-based clinics. 
However, obviously the notion of primary care physicians in 
schools, pediatricians and then the family practitioners and 
internists in settings in adult settings, we have said that the 
patient-centered medical home is not the only solution, that we 
may need to redefine, and the ultimate product will be quite 
different and perhaps along the lines that you are suggesting.
    The last point which I believe is relevant to this is what 
was alluded to, the role of nurses or nurse practitioners in 
this outreach program. The American College of Physicians met 
with much of the leadership of the nurse practitioner community 
last July to talk about we can work collaboratively to try and 
expand in this team-based concept, and Mr. Sarbanes, as you may 
be aware, we just published a paper in which we felt that this 
Medicare demonstration projection with the notion that homes 
may in certain areas be headed by a nurse practitioner, not 
necessarily a physician, obviously within the scope of practice 
of nurse practitioners, but it does get to the idea that the 
end product of this discussion will probably be a very varied 
set of options and not one simple solution to our health care 
needs.
    Mr. Sarbanes. Thank you all. The other day I was thinking 
about which level of schools is it most important to have these 
health centers in, so elementary, you think about elementary 
and it is obvious why you should have that kind of resource 
there. Then you think about middle school and it is absolutely 
obvious why you would need it there. And think you think about 
high school and it is beyond obvious why you would need it 
there. So 1,500, like I said, it is a starting point and we 
also have to make sure that the financing mechanism for these 
centers is one that is not subject to the typical way education 
gets funding because then they will just sort of come and go 
depending on the situations that the schools face. So anyway, 
we will continue to pursue this topic. Thank you for your 
testimony.
    Mr. Pallone. The gentlewoman from Florida, Ms. Castor.
    Ms. Castor. Thank you very much.
    Just picking up on what Mr. Sarbanes and Ms. Capps were 
saying, I want to ask a quick SCHIP question. Years ago the 
precursor to SCHIP started in Florida under Governor Lawton 
Chiles. It was conceived early on as making it as easy as 
possible for parents to enroll their children in health 
insurance when they started school, when they started the 
school year. Unfortunately, in the intervening years the 
political leadership in Florida changed and folks there saw 
enrolling kids as a cost rather than an investment and we lost 
a lot of ground and we lost that link between the start of 
school and signing up children for health insurance, making 
sure they got their checkups and immunizations. Are States 
across the country, do other States still have that link?
    Ms. Rowland. Many states really use and the Johnson 
Foundation has helped to promote through its Covering Kids 
initiative the first day of school as a real day to try and 
alert parents to the fact that their children may be eligible. 
There is more than can be done to use the schools as an 
enrollment facility and to simplify the enrollment but it has 
been one of the main outreach focuses for many of the States in 
their efforts to enroll more children and I think it is a very 
critical place in the community for people to come. One of the 
things I was going to note is in New Orleans where Katrina 
destroyed so much of the health care system, they are 
rebuilding it community by community and using the schools as 
really the focus for where they put their clinics and for where 
they organize their services which will also help contribute to 
more people being able to gain access and participate.
    Dr. Lavizzo-Mourey. I would just add that there are other 
ways for people to find out about SCHIP but there are other 
areas, other locations where people naturally gather than can 
be used to increase enrollment and tying enrollment to other 
kinds of services like school lunch programs and the like, 
makes it easier for parents to make that linkage and not have 
to go to extraordinary ends to actually get enrolled and stay 
enrolled.
    Ms. Castor. Yes, I was surprised to learn when I had my 
local housing authority director paying a visit on a totally 
separate topic, he said back a few decades ago the housing 
authorities used to have very expansive clinics in some urban 
areas. That makes a lot of sense. In my urban county in Tampa, 
Florida, it is Hillsborough County, it is about 1.2 million 
people, about 15 years ago there was a fork in the road. They 
were paying for very expensive care in our emergency rooms out 
of property taxes. I said there must be a better way, and said 
instead, let us shift from property taxes to a different 
revenue source. We would take a half-cent sales tax and develop 
this collaborative effort with the hospitals and doctors and 
community health centers and have established a number of 
neighborhood clinics that really out in the neighborhoods. Some 
community health centers and then other hospitals have their 
own clinics where their doctors have to take turns and teaching 
hospitals, a lot of the residents from the University of South 
Florida are there, and it is a model program, and I know there 
are some other models in San Antonio and I believe in Oakland. 
How do we--as part of this health care reform effort, how do we 
incentivize these communities? What is going to be the role? I 
don't want health care reform to happen in a vacuum. There are 
some good things going on out in the world.
    Dr. Lavizzo-Mourey. I am familiar with some of those 
programs because our foundation helped fund many of them, and I 
think before I address the issue of incentives, let me just 
speak to one of the major disincentives that was operational in 
many of those programs. They were, as you say, locally 
generated, addressed the needs of the local population but many 
of them found that they could not sustain themselves because 
the base was not large enough to cover the costs of people's 
insurance and health needs over a longer period of time, and 
that is really one of the things that has made us favor federal 
programs that can ensure that these locally generated programs 
actually have the funding base to provide care not just in 
prosperous times but also in times when the community is not as 
prosperous.
    In terms of the incentives, I think one of the things we 
saw in putting out applications for these kinds of programs is 
that communities do know the kinds of services that they need 
and they will come together and organize to provide those kinds 
of services, so I think that providing that kind of a mechanism 
is going to be a valuable incentive.
    Ms. Castor. And it takes money. The administrative costs 
are very low. They aren't any HMOs involved. It is administered 
by the county and the hospitals love it because they are 
getting compensated for medical services that otherwise would 
go uncompensated and charity care. But if you have some other 
ideas and examples of communities that have programs like that 
that are working, I would appreciate it.
    Thank you, Mr. Chairman.
    Mr. Pallone. Thank you. I think that concludes our 
questions but I really want to thank you all for being here 
today. I know it was a large panel, it covered a lot of things, 
but it was very worthwhile in our efforts to put together 
reform legislation. The way it works, you may get additional 
questions in writing and then we would ask you to respond in 
writing, I think within the next 10 days or so. But again, 
thank you for your input. As you can see, there is really a lot 
to cover here but we are determined to move forward with reform 
this year.
    So without objection, the meeting of the subcommittee is 
adjourned.
    [Whereupon, at 1:10 p.m., the subcommittee was adjourned.]
    [Material submitted for inclusion in the record follows:]






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