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




 
       EXAMINING THE IMPACT OF OBAMACARE ON DOCTORS AND PATIENTS

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

                                HEARING

                               before the

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

                                 of the

                         COMMITTEE ON OVERSIGHT
                         AND GOVERNMENT REFORM

                        HOUSE OF REPRESENTATIVES

                      ONE HUNDRED TWELFTH CONGRESS

                             SECOND SESSION

                               __________

                             JULY 10, 2012

                               __________

                           Serial No. 112-183

                               __________

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


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



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              COMMITTEE ON OVERSIGHT AND GOVERNMENT REFORM

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

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

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

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


                            C O N T E N T S

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

                               WITNESSES

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

                                APPENDIX

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


       EXAMINING THE IMPACT OF OBAMACARE ON DOCTORS AND PATIENTS

                              ----------                              


                         Tuesday, July 10, 2012

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

                       WITNESS STATEMENTS

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

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

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

            STATEMENT OF RICHARD A. ARMSTRONG, M.D.

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

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

                    STATEMENT OF RON POLLACK

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

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

                    STATEMENT OF SALLY PIPES

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

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

                 STATEMENT OF ERIC NOVACK, M.D.

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

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

               STATEMENT OF KELVYN CULLIMORE, JR.

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

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

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