    [Senate Hearing 112-865]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 112-865

                          IS POVERTY A DEATH SENTENCE?

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

                                    HEARING

                                   BEFORE THE

                    SUBCOMMITTEE ON PRIMARY HEALTH AND AGING

                                     OF THE

                        COMMITTEE ON HEALTH, EDUCATION,
                              LABOR, AND PENSIONS

                              UNITED STATES SENATE

                          ONE HUNDRED TWELFTH CONGRESS

                                 FIRST SESSION

                                       ON

                               EXAMINING POVERTY

                                   __________

                               SEPTEMBER 13, 2011

                                   __________

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              COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                           TOM HARKIN, Iowa, Chairman

    BARBARA A. MIKULSKI, Maryland        MICHAEL B. ENZI, Wyoming
    JEFF BINGAMAN, New Mexico            LAMAR ALEXANDER, Tennessee
    PATTY MURRAY, Washington             RICHARD BURR, North Carolina
    BERNARD SANDERS (I), Vermont         JOHNNY ISAKSON, Georgia
    ROBERT P. CASEY, JR., Pennsylvania   RAND PAUL, Kentucky
    KAY R. HAGAN, North Carolina         ORRIN G. HATCH, Utah
    JEFF MERKLEY, Oregon                 JOHN McCAIN, Arizona
    AL FRANKEN, Minnesota                PAT ROBERTS, Kansas
    MICHAEL F. BENNET, Colorado          LISA MURKOWSKI, Alaska
    SHELDON WHITEHOUSE, Rhode Island     MARK KIRK, Illinois
    RICHARD BLUMENTHAL, Connecticut

                        Daniel E. Smith, Staff Director
                      Pamela Smith, Deputy Staff Director
         Frank Macchiarola, Republican Staff Director and Chief Counsel

                                     ______

                    Subcommittee on Primary Health and Aging

                          BERNARD SANDERS (I), Vermont

    BARBARA A. MIKULSKI, Maryland        RAND PAUL, Kentucky
    JEFF BINGAMAN, New Mexico            RICHARD BURR, North Carolina
    ROBERT P. CASEY, JR., Pennsylvania   JOHNNY ISAKSON, Georgia
    KAY R. HAGAN, North Carolina         ORRIN G. HATCH, Utah
    JEFF MERKLEY, Oregon                 LISA MURKOWSKI, Alaska
    SHELDON WHITEHOUSE, Rhode Island     MICHAEL B. ENZI, Wyoming (ex
    TOM HARKIN, Iowa (ex officio)        officio)

                    Ashley Carson Cottingham, Staff Director

                    Peter J. Fotos, Minority Staff Director

                                      (ii)

                                C O N T E N T S

                                   __________

                                   STATEMENTS

                          TUESDAY, SEPTEMBER 13, 2011

                                                                       Page

                               Committee Members

    Sanders, Hon. Bernard, Chairman, Subcommittee on Primary Health
      and Aging, opening statement...................................     1
    Paul, Hon. Rand, a U.S. Senator from the State of Kentucky.......     3
    Whitehouse, Hon. Sheldon, a U.S. Senator from the State of Rhode
      Island.........................................................    17
    Merkley, Hon. Jeff, a U.S. Senator from the State of Oregon......    48

                                Witness--Panel I

    Kemble, Sarah, M.D., MPH, Practitioner and Founder, Community
      Health Center of Franklin County, Turners Falls, MA............     6
        Prepared statement...........................................     7
    Hulsey, Tim, M.D., Practitioner of Cosmetic and Plastic Surgery,
      Bowling Green, KY..............................................    10
        Prepared statement...........................................    12
    Adams, Garrett, M.D., MPH, Practitioner and Founder, Beersheba
      Springs Medical Center, Beersheba Springs, TN..................    13
        Prepared statement...........................................    15

                               Witness--Panel II

    Braveman, Paula, M.D., MPH, Professor of Family and Community
      Medicine, University of California San Francisco, Director,
      UCSF Center on Social Disparities in Health, San Francisco, CA.    22
        Prepared statement...........................................    24
    Cannon, Michael F., Director of Health Policy Studies, The Cato
      Institute, Washington, DC......................................    31
        Prepared statement...........................................    33
    Zolotorow, Phyllis, Ellicott City, M.D...........................    38
        Prepared statement...........................................    40

                                     (iii)

                          IS POVERTY A DEATH SENTENCE?

                                  ----------

                          TUESDAY, SEPTEMBER 13, 2011

                                           U.S. Senate,
                      Subcommittee on Primary Health and Aging,
           Committee on Health, Education, Labor, and Pensions,
                                                        Washington, DC.
        The subcommittee met, pursuant to notice, at 10:08 a.m. in
    room SD-430, Dirksen Senate Office Building, Hon. Bernard
    Sanders, chairman of the subcommittee, presiding.
        Present: Senators Sanders, Whitehouse, Merkley, and Paul.

                      Opening Statement of Senator Sanders

        Senator Sanders. Thank you all very much for coming. We
    expect other Senators to be entering. There they are. OK. Thank
    you very much for coming for what is going to be, I think, an
    extremely interesting and important hearing. And I want to
    thank everybody for being here, especially the witnesses who
    are taking time from very busy schedules and have come from
    different parts of the country.
        The reason that I called this hearing this morning is that
    the issue that we are discussing today gets far too little
    public discussion. It's something I just wanted to bring up and
    get out before the public.
        It is very rarely talked about in the media and it's talked
    about even less in Congress, yet it is one of the great
    economic, and more importantly moral issues, moral issues
    facing our country.
        Today, there are nearly 44 million Americans, living below
    the poverty line, and that is the largest number on record.
    Since the year 2000, nearly 12 million more Americans have
    slipped into poverty.
        Now, I understand that, generally, from a political point
    of view, it's not terribly wise to be talking about poverty.
    Poor people don't vote in many cases. Poor people certainly do
    not make campaign contributions.
        So from a political point of view, we kind of push them
    aside as not being relevant. But that's not what I think this
    country is supposed to be about.
        According to the latest figures that I have seen from the
    OECD--and that's the Organization for Economic Cooperation and
    Development--the United States has both the highest overall
    poverty rate and the highest childhood poverty rate of any
    major industrialized country on Earth.
        This also comes at a time when the United States has, by
    far, the most unequal distribution of wealth and income of any
    major country on Earth, with the top 1 percent earning more
    income than the bottom 50 percent, top 400 individuals owning
    more wealth than the bottom 150 million Americans.
        According to the latest figures from the OECD, published in
    April 2011, 21.6 percent of American children live in poverty.
    This compares to 3.6 percent in Denmark, 5.2 percent in
    Finland, 5.8 percent in Norway, 6.7 percent in Iceland, etc,
    etc, etc.
        I suppose we can take some comfort in that our childhood
    poverty rates are not quite as bad as Turkey, 23.5 percent, and
    Mexico, 25.8 percent.
        When we talk about poverty in America, I think a lot of
    thoughts go through our minds. We think about people who may be
    living in substandard housing. Maybe they're homeless. We think
    about people who live with food insecurity, and worry about how
    they're going to feed their families today or tomorrow.
        We think about people who, in States like mine where the
    weather gets very cold, are worrying right now how they can
    stay warm in the coming winter. We think about people who
    cannot afford health insurance or access to medical care.
        We think about people who cannot afford an automobile or
    transportation to get to work or get to a grocery store. We
    think about senior citizens, who often have to make a choice
    between buying prescription drugs or the groceries they need.
        Today, however, I want to focus on one enormously important
    point. And that is that poverty in America leads not just to
    anxiety, it leads not just to unhappiness, or discomfort, or a
    lack of material goods.
        It leads to death. Poverty in America is, in fact, a death
    sentence. And tens and tens of thousands of our people are
    experiencing that reality.
        Now, let me just toss out some facts. At a time when, as
    everybody knows, we are seeing major medical breakthroughs in
    cancer and other terrible diseases for the people who can
    afford those treatments. The reality is that life expectancy
    for low-income women has declined over the past 20 years in 313
    counties in our country. Women are dying at a younger age than
    they used to.
        In America today, people in the highest income group level,
    the top 20 percent, live, on average, at least 6\1/2\ years
    longer than those in the lowest income group, 6\1/2\ years. If
    you're poor in America, you will live 6\1/2\ years less than if
    you're wealthy or of the middle class.
        In America today, adult men and women who have graduated
    from college can expect to live at least 5 years longer than
    people who have not finished high school. In America today,
    tens of thousands of our fellow citizens die unnecessarily,
    because they cannot get the medical care they need.
        According to Reuters, September 17, 2009,

              ``Nearly 45,000 people die in the United States each
            year, one every 12 minutes, in large part because they
            lack health insurance and cannot get good care, Harvard
            medical researchers found, in an analysis released on
            Thursday.''

        That's dated September 17, 2009. Forty-five thousand
    Americans die because they lack health insurance.
        In 2009, the infant mortality rate for African-American
    infants was twice that of white infants.
        Now, I recite these facts because I believe that, as bad as
    the current situation is with regard to poverty, it will likely
    get worse in the immediate future. As a result of the greed,
    and recklessness, and illegal behavior of Wall Street, we are
    now, as all of you know, in the worst recession since the Great
    Depression of the 1930s. Millions of workers have lost their
    jobs, and have slipped out of the middle class, and into
    poverty.
        Further, despite the reality that our deficit problem has
    been caused by the recession, and declining revenue, two unpaid
    wars, and tax breaks for the very wealthy, there are some in
    Congress who wish to decimate the existing safety net which
    provides a modicum of security for the elderly, the sick, the
    children, and lower-income people.
        Despite an increased poverty, there are some people in
    Congress who would like to cut or end Social Security,
    Medicare, Medicaid, food stamps, LIHEAP, nutrition programs,
    and help for the disabled and the elderly.
        To the degree that they are successful, there is no
    question in my mind that many more thousands of Americans will
    die earlier than they should. In other words, they are being
    sentenced to death without having committed any crime, other
    than being poor.
        What is especially tragic and reprehensible is that with
    the kind of childhood poverty rates we are seeing today, unless
    we turn this vicious circle around, we are dooming a
    significant part of an entire future generation to unnecessary
    suffering and premature death.
        This is not what America is supposed to be about and we
    must not allow that to happen.
        Senator Paul.

                           Statement of Senator Paul

        Senator Paul. Thank you, Senator Sanders, for holding these
    hearings. I agree with you that poverty is an important issue.
    I also agree that we need to understand what causes poverty and
    what causes prosperity, or we won't be able to fix the problem.
        Kwashiorkor is a condition in which the abdomen swells
    because fluid leaks from the vascular space. Kwashiorkor is a
    phenomenon associated with starvation and lack of protein.
    We've all seen the sad and horrific pictures of famines in
    Africa.
        Kwashiorkor is no longer present in the United States.
    Capitalism in our country vanquished starvation along with
    smallpox and polio. Anyone who wishes to equate poverty with
    death must go to the third world to do so. Anyone wishing to
    equate poverty with death must seek out socialism and tyranny.
        Those who wish to see death from poverty in our country are
    blind to the truth. While we all hope to lessen the sting of
    poverty, we need to put poverty in America into context.
        Robert Rector, of the Heritage Foundation, recently put
    together a profile of the typical poor household in America.
    The average poor household has a car, air conditioning, two
    color televisions, cable or satellite TV, a DVD player, and an
    Xbox. Their home is in good repair and is bigger than the
    average non-poor European.
        The average poor person reports that, in the past year,
    that they were not hungry. They were able to obtain medical
    care and had sufficient funds during the past year to meet all
    essential needs. This is the average poor person in America.
        An American citizen can expect to live a decade longer than
    the world average and nearly twice as long as some African
    countries. Infectious diseases such as AIDS decimate third-
    world countries, while American citizens are often immunized
    from disease or easily treated for these conditions.
        While more than 750,000 people around the world die each
    year from malaria, the United States has zero deaths from
    malaria. At the turn of the last century, life expectancy in
    the United States was about 46 years of age. Life expectancy
    now approaches 80. By all measures, this is a great success.
    Mortality due to infectious diseases affects 50 percent of
    children in Africa and is now less than 1 percent in America,
    an extraordinary success.
        One of our witnesses today, Michael Cannon, will explain
    how, over time, poor Americans became healthier than wealthy
    Americans of a previous generation. Only in America would we
    label it as a death sentence for the children of poor families,
    to have a reasonable expectation of growing up healthier than
    the adults of wealthy families did in the immediately preceding
    generation.
        To the extent that poverty is a social determinant of
    health, much of it can be attributed to behavioral factors.
    Over 30 percent of those living below the poverty line smoke,
    compared to 19 percent of the rest of the population. Consider
    that it costs between $1,500 and $2,000 per year to smoke a
    pack of cigarettes a day. This is nearly 20 percent of an
    individual's income at the poverty line.
        Obesity rates among the poor are higher than the general
    population. We're not talking about kwashiorkor in our country.
    We're talking about obesity, an unimaginable problem for those
    starving in North Korea or Somalia.
        An interesting example of culture's influence on health is
    known as the Hispanic health paradox. According to a National
    Institute of Health study, despite higher poverty rates, less
    education, and worse access to healthcare, health outcomes
    among many Hispanics living in the United States today are
    equal to or better than those of non-Hispanic whites.
        Researchers do not argue that the Hispanic health paradox
    has anything to do with genetics. In fact, most researchers
    believe the differences in smoking habits and a strong family
    support structure explain much of the so-called Hispanic health
    paradox.
        This context, while important, does not negate the fact
    that there are truly needy Americans. We all want to halt
    poverty. We all want to help those in need. I am suggesting
    today, though, that with a national debt of $14.3 trillion, we
    must be more precise in how we talk about poverty in America
    and whom we should target with scarce Federal resources.
        We need to ask, are we targeting Federal programs to those
    most in need? Are Federal programs accomplishing their goals?
    Are we doing what's needed and are we doing it appropriately?
    Are some programs creating unnecessary and unhealthy dependence
    on government?
        We have limited resources. We have to ask these questions.
    We also need to understand that poverty is not a state of
    permanence. When you look at people in the bottom fifth of the
    economic ladder, those at the bottom, only 5 percent are there
    after 16 years. People move up. People do. The American dream
    does exist.
        In a University of Michigan study of 50,000 families, 75
    percent of those in the bottom fifth make their way up to the
    top 20 to top 40 percent on the socioeconomic ladder. The rich
    are getting richer, but the poor are getting richer even
    faster. U.S. Treasury statistics showed that 86 percent of
    those in the bottom 20 percent of the economic ladder move to a
    higher level.
        We need to be proud of the American dream and promote
    policies that encourage the economic growth that allows so many
    to rise up out of poverty.
        In the half of the century since LBJ's war on poverty
    began, we have spent $16 trillion to fight poverty. We now
    spend over $900 billion a year and have over 70 means-tested
    welfare programs under 13 government agencies, yet thanks or no
    thanks to the Federal Government, we now have more poverty, as
    measured by the government, than we did in the 1970s.
        An all-time high, 40 million Americans depend on food
    stamps and 64 million are enrolled in Medicaid. If poverty is a
    death sentence, it is a big government that has acted as the
    judge and jury, conscripting poor Americans to a lifetime of
    dependency on a broken and ineffective Federal Government.
        One of the fastest growing poverty programs is food stamps.
    The cost of the food stamp program has doubled just since 2007.
    There is evidence that the program actually leads to higher
    rates of obesity. An Ohio State University researcher has
    calculated that, controlling for socioeconomic status, all
    things being equal, women who receive food stamps were more
    likely to be overweight than nonrecipients.
        When we've tried to place restrictions and say, ``you can't
    buy junk food,'' Federal Government has said, ``no, we can't
    place restrictions on food stamps.'' A recent article pointed
    out that 30 percent of the inmates in Polk County, IA were
    receiving food stamps illegally. In Wisconsin, fraud is so
    rampant, prosecutors have given up going after the common cause
    of abuse, such as selling food stamp cards online.
        There's so much of it they can't even keep up with it.
    Leroy Fick won $2 million--I'm pretty close to finishing up; I
    have just another minute or 2, please--won $2 million in the
    lottery, and yet he still gets food stamps because there is no
    limit to food stamps based on assets.
        In America, capitalism has been so successful in
    alleviating poverty, that our doctors travel around the world.
    Doctors today that are here, such as Dr. Tim Hulsey, not only
    help indigent patients in this country, but travel to, many
    times, Guatemala to repair children with cleft palate.
        As a physician, both Dr. Hulsey and I have treated children
    from Central America. We have treated children from around the
    world. Not only are we doing such a good job treating poverty
    in our country, we're able to send our efforts around the world
    to help thousands of cataract patients, thousands of those with
    cleft palate.
        So what I would say here today is that not only is poverty
    not a death sentence in our country, capitalism has done such
    wonderful things to lift people out of poverty, that we are now
    helping the world, that really, there are still true pockets of
    poverty around the world.
        So I think, rather than bemoan or belabor something that
    really, truly is something that is overwhelmingly being treated
    in our country, we should maybe give more credit to the
    American system, the American dream, and give credit to what
    capitalism has done to draw us up out of poverty in this
    country. Thank you very much.
        Senator Sanders. Thank you very much. We have a wonderful
    and distinguished panel. Let me introduce our first witness,
    and that is Dr. Sarah Kemble, who is a practicing physician and
    founder of the Community Health Center of Franklin County in
    Turners Falls in Northfield, MA.
        In addition to providing direct care to the medically
    underserved population of Franklin County, Dr. Kemble is a
    hospitalist and vice-president of the medical staff at Bay
    State Franklin Medical Center and past chair of the department
    of medicine.
        Dr. Kemble, thanks very much for being with us. And why
    don't you take about 6 minutes each, if you could, please?

    STATEMENT OF SARAH KEMBLE, M.D., MPH, PRACTITIONER AND FOUNDER,
     COMMUNITY HEALTH CENTER OF FRANKLIN COUNTY, TURNERS FALLS, MA

        Dr. Kemble. Thank you. I very much appreciate this
    opportunity to address the question, is poverty a death
    sentence? Since time is short, today, I'll just share a few
    clinical stories from my experience in Franklin County, MA,
    where I founded a rural community health center in 1995.
        One of our first board members was a woman in her 50s who
    was very committed to our health center. She was also our
    patient, having spent more than a decade uninsured and without
    access to routine medical care.
        On her first routine exam, there was a large irregular
    abdominal mass. She died a year later from colon cancer, a
    preventable disease that we routinely screen for in primary
    care. She would not have died if diagnosed earlier.
        This patient taught me one important point about access to
    care for the working poor. She and many of our patients came to
    us because the health center was open to all. She felt that she
    was both using, but also contributing, to a community resource,
    not asking for charity. And she was correct.
        Many working people make this distinction and will not seek
    charity care. Another case was a man in his 50s with aortic
    stenosis. Aortic stenosis is a common degenerative heart valve
    disease in which the valve becomes sclerotic and stiff over
    time. Eventually, it will no longer open, despite the heart's
    increasing efforts to pump against it.
        When this occurs, the patient experiences chest pain
    followed by sudden loss of consciousness. Usually, death
    follows within minutes. Medicine alone is useless for this
    condition and can even be harmful in the late stages. The only
    treatment for aortic stenosis is surgery to replace the damaged
    valve.
        This patient worked for a local transportation company
    which did not provide paid sick leave or health insurance. When
    he first came to our office, he could barely walk and used a
    cane. The diagnosis was easy to make on the first visit. Within
    a few weeks, medicines were effective at removing over 40
    pounds of fluid from his body.
        This gave him significant relief from his fatigue,
    swelling, and shortness of breath. He was able to get rid of
    the cane and said he hadn't felt so good in years. I insisted,
    at each visit, that he needed valve replacement surgery or he
    would die. He allowed me to refer him to the cardiothoracic
    surgeon and he learned what the surgery and rehab would entail.
        More than once, he considered scheduling the operation,
    only to postpone it, as he could not figure out how he would be
    able to afford the out-of-pocket cost or the time off from
    work. About 2 years after his diagnosis, he died one morning at
    work.
        Today, I understand there is discussion here about shifting
    even more costs onto patients. You can see, from my
    perspective, this makes no sense. For anyone lacking resources,
    the natural consequence of any out-of-pocket cost is that they
    withhold needed care from themselves with devastating clinical
    consequences and at high cost to society.
        I will end with one more patient. This was a young man in
    his 40s, admitted to the intensive care unit with a massive
    heart attack. His cardiogram and blood work indicated the heart
    attack had started a couple of days earlier. He admitted he'd
    tried to tough out the chest pain at home, but could no longer
    do so once he found himself unable to breathe.
        The disease had most likely destroyed a large area of his
    heart muscle. He reminded me that a couple of years earlier, he
    had seen me once in our office, where I'd advised him to take a
    low-dose aspirin and prescribed a blood pressure-lowering beta
    blocker. Both of these are inexpensive medications with good
    evidence that they protect patients from stroke and heart
    attack.
        He was a truck driver with no benefits or health insurance
    and he could neither afford his medicines, nor take time off to
    follow up with his care. Paradoxically, without routine medical
    care and a couple of generic medications that might have
    prevented his heart attack, this patient would most likely
    become disabled, never again able to resume his occupation.
        In concluding, these are just three patient stories, but
    there are many, many more. Any rural primary care doctor could
    tell you hundreds of their own and I think our urban colleagues
    might have a slightly different twist, but the moral of the
    story is the same.
        Our healthcare system can do much better for our people of
    this country. I wish you all the best in your efforts to enact
    better healthcare and social policies for us all, and I thank
    you for this opportunity to provide my perspective today. I
    look forward to your questions.
        [The prepared statement of Dr. Kemble follows:]
                 Prepared Statement of Sarah Kemble, M.D., MPH
        The title of my presentation today is borrowed from medical slang,
    ``Found down'' is a frequently documented reason why patients,
    particularly the elderly, are brought to hospital emergency
    departments. I will say more about this later, but want to begin and
    end by saying that our health care system, in particular our primary
    care, should also be ``found down'' by you today.
        I appreciate the opportunity to come before you in order to address
    the urgent question: ``Is poverty a death sentence? '' As a rural
    general internist I can tell you that in my experience of the last 15
    years, in many instances, it is.
        The World Health Organization* has shown in a recent extensive
    study that the underlying health of any population is primarily due to
    social determinants. Health status is generally predictable for
    individuals based on their level of education, income, occupation,
    geography and gender. Poverty is one of the most powerful predictors of
    poor health status and outcomes. Dr. Braveman's presentation today
    describes some of the biological mechanisms for this. I will share my
    clinical observations from my experience spent caring for poor and
    underserved populations in Franklin County, MA, where I founded a
    community health center in 1995.
    ---------------------------------------------------------------------------
        * World Health Organization Final Report on the Social Determinants
    of Health, Geneva, Switzerland, 2008.
    ---------------------------------------------------------------------------
        While the poor literally start life with the cards stacked against
    their health and longevity, my life's work of creating access to care
    has convinced me that having access to medical care can mitigate, and
    lacking access can aggravate these predetermined disparities.
        Our health center was started with a planning grant from the State
    Medicaid agency. At that time there were large numbers of patients in
    our community who were enrolled Medicaid recipients but they
    nonetheless had no access to actual care, because there were almost no
    local physicians accepting Medicaid insurance. This showed me early on
    that access to insurance and access to care were not the same thing.
        Six months after opening the practice, we found that 75% of our
    patients were uninsured. Many were extremely sick. I remember a woman
    who came in complaining of rib pain. I only saw her once, as she died
    almost immediately of widespread lung cancer after receiving the
    diagnosis from a simple chest x-ray that she had not previously been
    able to afford.
        Another woman was brought in by her family over her increasingly
    feeble objections after she became nearly comatose. She had end stage
    liver disease and also died within weeks.
        One of our first board members was a woman in her 50s who was very
    committed to the health center. She was also our patient, after years
    being uninsured and having no medical care. On her first routine exam
    in years there was a large, irregular abdominal mass. She died about a
    year later from colorectal cancer--a condition that we routinely screen
    for in primary care, and should detect in time to treat effectively in
    almost all cases.
        An elderly man came to the health center with extremely disfiguring
    basal cell carcinoma of the face that had been present for over 20
    years. Basal cell carcinoma is the most curable cancer of the skin, and
    the slowest growing. It never spreads through the blood, only locally
    and only after decades when left untreated does it become capable of
    destroying adjacent tissue. This patient, a logger who lived in the
    woods, had come of age during the depression and never accepted
    anything for which he could not pay. When I met him his entire nose and
    left eye were destroyed by tumor, and he wore a patch over the left
    side of his face to conceal his gruesome appearance. He died soon after
    of overwhelming infection and encephalitis after the tumor finally
    spread through his eye socket, opening up a direct pathway for
    infection to reach his brain.
        This case illustrates an important point about access to care for
    the working poor. This patient only came to see me because the
    community health center was open to all regardless of income or ability
    to pay. The patient felt he was using a community resource, not asking
    for charity, and he was correct. Many people make this distinction.
        Most community health centers provide primary medical, dental,
    behavioral and pharmacy services, and we take the simple approach that
    dignified, high quality health care is a right in any wealthy and
    civilized society. Many of our patients sought help from us with this
    understanding, even after going for years or even decades without
    seeking care before our health center came into existence.
        Other community health center workers have had the same experience.
    Even so, for the patients who come to us with advanced cancers or
    surgical diseases, we can only bear helpless witness as, in many cases,
    they die.
        A relatively young woman who was unable to afford routine
    gynecologic care for nearly 20 years died of a huge tumor which was
    technically not even malignant, but had grown so large it had already
    destroyed numerous gastrointestinal and pelvic organs before she came
    to our office. This was not a subtle problem, and the patient knew that
    she had it for years. She obviously could have gone to an emergency
    room at any time. But she was so worried about financial catastrophe
    for her family, she kept this problem a secret until it was too late.
        There is literally an odor of death that we learn to recognize in
    our work. The odor hit me when I first walked into the exam room with
    this young woman, before I even said hello. Since health centers do not
    usually employ surgeons or oncologists, my job was to refer her to
    those specialists, where her worst nightmare--not death, but financial
    ruin for her family--came true.
        Two other patients illustrate the same point. Both had aortic
    stenosis, a common degenerative heart valve disease in which the valve
    becomes stiff and finally, will not open despite the heart's increasing
    efforts to pump against it. When this happens, the patient experiences
    chest pain, sudden loss of consciousness, and usually death follows
    immediately. Medicine alone is useless for this condition, and can even
    be harmful. The only treatment for aortic stenosis is valve replacement
    surgery, which in most cases restores people to a level of functioning
    that they have not felt in months or years. The recovery time for this
    surgery takes months, and in most cases patients require close followup
    and lifelong blood thinner medicine with frequent blood tests.
        One of my patients with aortic stenosis was a man in his late 50s.
    He worked for a local transportation company which did not provide paid
    sick leave or health insurance. When he first came to my office, he
    could barely walk, and used a cane. The diagnosis was easy to make on
    the first visit. Within a few weeks, medications were effective at
    removing over 40 pounds of fluid, thereby giving him significant relief
    from his fatigue, swelling and shortness of breath. He was able to get
    rid of the cane, and said he had not felt so good in years. He wanted
    to believe he was ``fixed'' but I insisted at every visit that he
    absolutely required surgery or he would die. He did let me refer him to
    the cardiothoracic surgeon and he learned what the surgery would
    entail. Once or twice he considered scheduling the valve replacement,
    only to postpone it as he could not figure out how he would be able to
    afford either the direct monetary cost or the time off from work. He
    died suddenly at work one day, waiting for the right time, about 2
    years after receiving his diagnosis.
        I remember another patient who also tried to wait with aortic
    stenosis. She actually made it to the emergency department when she
    passed out while driving on the day when her valve finally, inevitably
    no longer worked. She underwent emergency valve replacement surgery and
    lived to become bankrupted and disabled by depression.
        The financial fears that lead so many patients, including this one,
    to withhold medical care from themselves, are neither irrational nor
    trivial. Her husband committed suicide by burning their home with
    himself in it after it was lost to foreclosure.
        Since this is the subcommittee on primary care and aging, I would
    also like to talk a little about older patients, by returning to the
    title of my presentation. ``Found down'' is common medical shorthand
    used to describe a patient, usually elderly, who has been brought to
    the hospital after having lost consciousness at an unknown time, for an
    unknown reason, while alone.
        This scenario is not rare. When it happens, the first thing we try
    to figure out is the duration of the ``down time,'' as this is
    inversely related to the patient's chances of having reasonably
    functioning kidneys, liver, heart and brain tissue. This in turn
    generally determines whether survival can be expected. The last case I
    had was only a couple of weeks ago. The patient never woke up before
    dying days later in the intensive care unit after withdrawal of the
    ventilator that it turned out she had not wanted in the first place.
        Every day in our country, seniors are found down. The risk factor
    for ending life in this way is being old, sick and alone. Aging and
    illness are not necessarily preventable, but in our society, being
    alone at this time of life is widespread. Who among us could not easily
    end our days in just this way? Most need to pay for simple personal
    care out-of-pocket and they simply cannot afford it. Seniors all have
    medical insurance, but Medicare does not cover low-cost home care which
    would keep them safely and securely in their homes. This could save
    their loved ones the anguish of never being able to know what happened,
    or how much pain and suffering was involved.
        Today I understand there is discussion about shifting even more
    cost onto seniors themselves. This makes no sense. You can see from my
    perspective that for anyone lacking resources, the natural consequence
    of any cost shifting or out-of-pocket costs is that they simply
    withhold needed care from themselves, often with devastating
    consequences.
        Our primary care system itself may soon be found down. In case this
    happens, here is my prediction for explaining the scenario: we will
    have to admit that we were not able to maintain our primary care work
    force due in part to this heartbreaking experience of being forced to
    watch our patients suffer and even die needlessly, even as we knew and
    advised what they needed, but they could not afford access to the most
    inexpensive and basic care.
        Home care services, dental care, eye care and behavioral health
    services are among the other types of highly cost-effective support
    services that can make the difference for many working people between
    disability and being able to function as contributing members of
    society.
        Let me end with one more patient. This was a young man in his 40s,
    whose name was not familiar to me when I admitted him to our intensive
    care unit with a massive heart attack. His cardiogram and blood work
    showed that the heart attack had started a couple of days earlier, and
    he admitted he had tried to tough it out at home until he was not only
    in pain but also found himself unable to breathe. The disease had
    likely destroyed a large area of his heart muscle, which meant he was
    doomed to being a cardiac cripple.
        I was listed as his primary care doctor and he seemed to remember
    me. He said a couple of years earlier I had seen him once in the office
    and advised him to take a low-dose aspirin and beta blocker (blood
    pressure pill) each day. Both are inexpensive, generic medicines that
    have been shown to protect patients at risk from stroke and heart
    attack. He explained that he was a truck driver with no benefits or
    health insurance, and he could neither afford his medicines nor take
    time off from work to follow up with his care. Yet to not being able to
    afford routine care and a couple of generic medicines that might have
    prevented this heart attack, he would most likely never again work in
    his occupation.
        In conclusion, although I have altered identifying details to
    protect my patients' privacy, the medical facts of these stories are
    all true. There are many, many more just like them. Any rural primary
    care doctor could tell you hundreds of their own. Urban doctors might
    have a slightly different version, but the moral of the story is this:
    our health care system and our society can do much better for the
    people of this country.
        I wish the members of this committee all the best in your efforts
    to create better health and social policies for us all, and thank you
    very much for the opportunity to provide my perspective today.

        Senator Sanders. Thank you very much, Dr. Kemble. Our
    second witness on this panel is Dr. Tim Hulsey, a practicing
    physician of cosmetic and plastic surgery in Bowling Green, KY.
    In addition to his work in private practice, he is a member of
    the medical staff of Hospital Corporation of America, Greenview
    Hospital, and the Medical Center at Bowling Green.
        Dr. Hulsey works with the Commission for Children with
    Special Needs and Children of the Americas. Dr. Hulsey, thanks
    for being here.

      STATEMENT OF TIM HULSEY, M.D., PRACTITIONER OF COSMETIC AND
                   PLASTIC SURGERY, BOWLING GREEN, KY

        Dr. Hulsey. My pleasure. In 1982, after 12 years of post-
    graduate training at Vanderbilt University, I opened a practice
    in Bowling Green, KY, a town of about 50,000 with about 300
    physicians in a Commonwealth with about 2.2 physicians per
    1,000 people.
        I have been operating on patients for 37 years and have
    been in solo practice for almost 30 years, treating some
    cosmetic surgery patients, but more patients with cancer,
    burns, trauma, and patients in need of reconstructive surgery.
        My policy has been to see Medicare and Medicaid patients,
    as well as to see those without resources to pay for their care
    at no charge, when that was appropriate. Since 1984, we have
    run a cleft, lip, and palate clinic through the Commission for
    Children with Special Health Care Needs, and this serves a
    large portion of our Commonwealth.
        These clinics are available in most States and are
    available to anyone, regardless of their ability to pay. There
    is no excuse for a child in the Commonwealth of Kentucky, or
    any other State that has these clinics available, to go without
    care because of lack of monetary resources.
        I made a choice, as many physicians do, to use part of my
    expertise and time to treat those without health insurance
    coverage. And I am only one of 900,000 physicians in this
    country who have done the same thing to make sure that services
    are there for those who can't afford them.
        There are 100,000 churches in this country and innumerable
    civic organizations who have mandates, by faith or by choice,
    to provide care to those who are in need. These include people
    with need of medical care problems.
        Those people are aggressive and active in their seeking out
    patients who need their help. St. Jude's Children's Research
    Hospital is only one of the cancer treatment resources
    available to all comers.
        Emergency rooms in our country are mandated by Federal law
    to evaluate and stabilize any patient that arrives at their
    door, with regard to the ability to pay as insignificant.
        This certainly is a less-than-efficient manner to provide
    healthcare. Between doctors, nurses, hospitals, churches, civic
    organizations, free clinics, and individual citizens willing to
    dedicate a portion of their time and expertise, there is really
    no reason in this country for lack of ability to pay to be a
    death sentence.
        Mr. Chairman, I've had the opportunity to see the type of
    poverty that frequently is a death sentence. I've spent a
    significant amount of time delivering medical care in Central
    America.
        There, you can find the kind of poverty that, for millions
    of people, means living in a cardboard house on the side of an
    unstable, steep ravine with no water, other than local polluted
    streams, no electricity, no sanitation, where meals are cooked
    over an open, unvented fire, and where lighting an open cup of
    gasoline is the only means to have light at night, where
    children run around, barely clad and unwashed, where clothes
    can only be washed in nearby streams, which are usually sewage-
    contaminated.
        I have seen adults and children living in multiacre, deep
    ravines full of trash, picking through the trash to recycle
    things for a pittance and picking out things to eat. The
    children run among the feral horses, pigs, dogs, cats, of
    course, rats, and a few feral human beings. They're exposed to
    drug addicts and the occasional human body part.
        They are surrounded by all manner of infectious diseases
    and with access only to clinics where there are no medications,
    supplies, or vaccines. There are incidences of significant
    infectious diseases among this population, including malaria,
    typhoid, Dengue fever, and fatal diarrheal diseases.
        The incidence of congenital defects is about tenfold what
    it is in the United States, defects of all categories. And of
    course, my experience has been mostly with cleft, lip, and
    palate, and burn scars. This is because of the local
    environment, lack of prenatal care, poor maternal nutrition, as
    well as a factor of genetics.
        Infant mortality rate there is 28 to 38, depending on the
    source, whether you trust the UN or the CIA more. And this is
    four to six times what it is in the United States.
        Added to this is the position these poor people now stand
    in, between armies, and police, and the drug cartels, and there
    is also a significant poverty of justice, in that 96 percent of
    crimes in that area go unpunished.
        This is certainly the kind of poverty that can be a death
    sentence. In the United States of America, if people living in
    poverty cannot avoid health problems by adopting a healthy
    lifestyle, they can choose, actively, to seek care through the
    myriad resources I have mentioned, and certainly, some that I
    have forgotten to mention.
        That care is best delivered locally by private individuals
    and practitioners who can act as the patient's advocate without
    extraneous pressures. In other words, there is little reason,
    other than failure to seek care, that poverty should be a death
    sentence in this country. Thank you, Mr. Chairman.
        [The prepared statement of Dr. Hulsey follows:]
                     Prepared Statement of Tim Hulsey, M.D.
        My name is Tim Hulsey. I opened my practice in Plastic Surgery in
    Bowling Green, KY, in 1982, after 12 years of post-graduate training at
    Vanderbilt University. Bowling Green has a population of about 50,000,
    with about 300 physicians. The Commonwealth of Kentucky has about 2.2
    physicians per 1,000 people, slightly less than the national average of
    2.6.
        I have been operating on patients for 37 years and have been in
    solo practice for almost 30 years, treating some cosmetic surgery
    patients, but more patients with cancer, burns, trauma, and patients in
    need of reconstructive surgery--both adults and children. My policy has
    been to see Medicaid and Medicare patients, because many of them need
    specialized care that would otherwise only be available hundreds of
    miles away or across State lines. I also see patients who are uninsured
    and without resources. These patients are referred by other physicians,
    the free clinic, by a friend or family member, or a charitable
    organization.
        Since 1984, an othodontist, an oral surgeon, a pediatrician, and I
    have run a Cleft Lip and Palate/Plastic Surgery Clinic through the
    Kentucky Commission for Children with Special Health Care Needs in
    Bowling Green. This clinic has been available to anyone regardless of
    their ability to pay for the services. Such services are available in
    other States, as well. There is no excuse for a child in the
    Commonwealth of Kentucky, or any other State where these clinics exist,
    to go without care because of lack of monetary resources.
        I made a choice to use part of my time and expertise to do things
    for those with no means to bear the expense for it, and I am one of
    over 900,000 doctors in this country.
        Since 1995, Commonwealth Health Corporation, which runs one of our
    local hospitals, opened the Commonwealth Health Free Clinic to provide
    Medical and Dental care to the working uninsured. There are about 1,200
    free clinics throughout this country. These supplement the community
    health departments available across all 50 States.
        My friend, Dr. Andy Moore, a plastic surgeon in Lexington, KY, runs
    a program called ``Surgery on Sundays'' that provides surgical services
    to those without health insurance coverage. This is only one of
    thousands of individual efforts by physicians across the country to
    make sure that medical services are available for those who cannot pay.
        There are about 100,000 churches in this country. Most religions
    mandate a service to those in need, including those in need of medical
    care. You have no difficulty seeing this in action around our Nation
    daily.
        One source sites civic organizations in the United States as ``too
    many to list.'' These entities have mandates to provide service to the
    people in their communities, many related specifically to medical care.
    Shriner's Hospitals, numbering about 20 in the United States alone, are
    well-known for providing some of the most expert treatment in the world
    at no charge. The Lions Club commitment to eye problems is another
    well-known example. These organizations actively and aggressively seek
    out patients for their programs.
        Hospitals such as St. Jude Children's Research Hospital provide
    expert cancer treatment to any child regardless of ability to pay for
    it.
        As I said, I am only one physician. Let's be extremely
    conservative, as I want to be, and say that only half of U.S.
    physicians are inclined to practice as I do, volunteering services for
    those unable to cover the cost. That amounts to 450,000 doctors
    providing non-remunerated care. If you add in all the other entities
    that I mentioned above, plus others that I have certainly left out,
    that amounts to a vast resource for anyone in need of medical care in
    this country, regardless of their financial situation.
        Mr. Chairman, I have had an opportunity to see the type of poverty
    that is frequently a death sentence. I have spent a significant amount
    of time delivering medical care in Central America. There you can find
    the kind of poverty that means living in a cardboard house on the side
    of an unstable ravine, with no electricity, running water, or
    sanitation where meals are cooked over an open fire, and where lighting
    an open cup of gasoline is your only means of producing light at night;
    where the children run around barely clad and frequently unwashed. I
    have seen children and adults living in multi-acre trash dumps, making
    a pittance for digging out trash to recycle, living amongst feral
    horses, pigs, dogs, cats, and, of course, rats; exposed to glue
    sniffers and the occasional human body part; with access only to
    medical clinics where there are no medications or supplies. This, Mr.
    Chairman is the type of poverty that can be and frequently is a death
    sentence.
        In the USA, poor or not, if people cannot avoid medical problems by
    adopting a healthy lifestyle to prevent disease, they can choose to
    actively seek care and treatment when they have a health problem, and
    that medical care is best delivered at the local level, in an
    individualized format by private practitioners who can act as the
    patient's advocate without extraneous pressures. In other words, there
    is little reason, other than failure to seek out treatment, for poverty
    to be a death sentence in this country.

        Senator Sanders. Thank you very much, Dr. Hulsey. Our final
    witness on this panel--and we have another panel to follow--is
    the founder of and physician at the Beersheba Springs Medical
    Clinic, a comprehensive ambulatory clinic in Beersheba Springs,
    TN.
        Trained as a pediatrician, Dr. Adams retired from full-time
    faculty at the University of Louisville School of Medicine,
    where he was chief of pediatric infectious diseases and medical
    director of communicable diseases at the Louisville Metro
    Health Department in Louisville, KY.
        He currently serves as president of Physicians for National
    Health Program. Dr. Adams, thanks very much for being with us.

        STATEMENT OF GARRETT ADAMS, M.D., MPH, PRACTITIONER AND
     FOUNDER, BEERSHEBA SPRINGS MEDICAL CENTER, BEERSHEBA SPRINGS,
                                   TN

        Dr. Adams. Thank you, Senator Sanders, Senator Paul, and
    members of the committee. Senator Sanders, thank you for
    understanding the great health threats that more and more
    Americans suffer because of poverty. You do a wonderful service
    by giving them a voice.
        I dedicate this testimony to those for whom poverty is, has
    been, or will be a death sentence, and also to those for whom
    illness is a poverty sentence.
        These are people I have known, all of whom failed or are
    failing to get life-saving healthcare because they can't afford
    it. Most are or were impoverished.
        Others were not, but they died waiting for approval by a
    health insurance company of a life-saving procedure that never
    came or came too late, such as David Velten, a 32-year-old
    school bus driver from Louisville, KY, married, two sons. He
    had liver failure. A transplant was denied by the insurance
    company, but due to public pressure, the company eventually
    relented, but it was too late. He died several months after the
    transplant.
        And Cheryl Brawner, 50, a legal secretary from Louisville
    with acute leukemia--she achieved remission and was awaiting
    approval from the insurance company for a bone marrow
    transplant when her leukemia relapsed and she died.
        Clay Morgan, an automobile mechanic in Henry County, KY,
    owned his own business. He got malignant melanoma, was treated,
    improved, and thought to be cured, but now was bankrupted.
    Cancer returned. Depressed and unwilling to bring more medical
    debt on his family, Clay went into the backyard and took his
    own life.
        Velinda Anderson, whom you see in this photograph, I met on
    Oak Street in Louisville in March. She had surgery to remove
    blockage in her leg arteries. She was employed, but couldn't
    afford Plavix, an expensive medicine to keep arteries open.
    Here, she begs for help for medicine.
        Grundy County in Tennessee is the poorest county and ranks
    the lowest in overall health. Median household income is
    $25,000. Two-thirds of schoolchildren qualify for free lunch.
    Nineteen percent of the population is illiterate. The ratio of
    population to primary care provider is 7,000 to 1, 11 times the
    national ratio.
        On the Cumberland Plateau in Grundy County of Appalachia is
    the community of Beersheba Springs. My family has vacationed
    there for six generations. Confronted with seeing my mountain
    friends suffer without medical care and being forced to pay
    unfair bills to profiteering hospitals, I established a medical
    clinic, a free medical clinic.
        The following patients are from Grundy County. Charlotte
    Dykes had an obstruction to the main intestinal artery with
    stent placement in Chattanooga. We diagnosed a severe blockage
    of the main artery in her right arm and a 70 percent carotid
    artery blockage.
        The surgeon will not operate unless she pays up front
    because she still has not paid her bill from the previous
    surgery. A walking time bomb, she'll be 65 in December when
    she'll be eligible for Medicare, if she lives that long. In
    giving permission to tell her story, Charlotte said to me, you
    speak out for me.
        Charlene, 54, hasn't seen a doctor in over 20 years. We
    diagnosed an acute heart attack in May. She was airlifted to
    Nashville, treated, and discharged, but didn't fill her
    discharge prescriptions, including Plavix, and didn't go to
    cardiac rehab because she couldn't afford either. She's doing
    poorly now and has a recent dementia, due to small strokes.
        Doris, 58, and her husband operated a small local
    restaurant before her illness forced them to close the
    restaurant. Estimated annual income, $13,000, no insurance, no
    medical care. She heard we offered free mammograms. We
    diagnosed breast cancer.
        Paula, 32, cervical cancer surgery 2 years ago, but no
    follow-up because of no insurance and no money.
        Billy Campbell, a 54-year-old tree farmer and carpenter,
    makes $12,000, has stage-three colon cancer, no health
    insurance. He needs a PET scan, but the hospital won't do it
    because he can't pay the $1,500 fee, disability denied three
    times. This past Friday night, there was a barbecue benefit on
    the mountain to raise money for Billy's PET scan.
        Bob has double hernias. A surgeon agreed to fix them for
    $500, but Bob can't afford the hospital cost of $8,000. His
    hernias will not be fixed.
        I saw a 64-year-old woman with a crooked arm and a limp.
    She fell in March, suffering a serious arm and leg fracture. A
    surgeon agreed to repair her arm in spite of no insurance, but
    the hospital would not allow use of the operating room because
    she couldn't pay. Her arm will not be fixed.
        And finally, a woman with blood sugar greater than 500
    milligrams percent, life-threatening hyperglycemia, five times
    normal. She knew she had diabetes and she owned a glucometer,
    but she could not afford the strips to test her blood sugar.
        Thank you for this opportunity to speak for those without a
    voice, who have died or will die as a result of our country's
    unwillingness to acknowledge that healthcare is a human right
    and to provide affordable high quality healthcare to every
    resident.
        And this is just a microcosm, a drop in the ocean, of all
    the people, and much worse in minorities. We need social
    justice in America, not charity. Thank you.
        [The prepared statement of Dr. Adams follows:]
                 Prepared Statement of Garrett Adams, M.D., MPH
        Senator Sanders, Senator Paul, members of the committee, I am very
    grateful to Senator Sanders for his sensitivity to the grave health
    threats that a large portion of the American population currently
    suffers because of poverty. He does a wonderful service to these people
    by giving them a voice to our leaders, so that you can better
    understand the perilous health care situation so many Americans find
    themselves in because of their poverty. I dedicate this testimony to
    all those Americans for whom poverty is, has been, or will be a death
    sentence. And also to those Americans for whom illness is a poverty
    sentence.
        According to the Institute of Medicine, 45,000 Americans die every
    year because of lack of health insurance, a stark figure. Surgeon
    General Julius Richmond, however, reminds us that, ``Statistics are
    people with the tears wiped dry.'' Today I will tell you about some of
    those people whom I know or have known, all of whom failed or are
    failing to get necessary life-saving health care because of financial
    constraints--most impoverished; others not yet impoverished, but who
    died waiting for approval by a health insurance company of an expensive
    life-saving procedure that never came or came too late. The first cases
    I describe are Kentuckians.
                                    kentucky
        David Velten--Louisville. 32 years old. School bus driver. Wife,
    two young sons. Chronic liver failure. I met David in June 2006. He was
    initially denied a liver transplant by his insurance company, but due
    to public pressure, the company relented and allowed it. But it was too
    late. He died in 2007 several months after the transplant.
        Cheryl Brawner--Louisville. 50 years old, Legal secretary, avid
    bicyclist, friend. Acute leukemia. Advised at Fred Hutchinson Hospital
    in Seattle to have a bone marrow transplant. Was in remission awaiting
    approval from the insurance company for the transplant. She waited and
    waited and waited. Cheryl relapsed and died of her leukemia, while
    waiting for approval.
        Clay Morgan--Henry County. Automobile mechanic, owned his own
    business. Malignant melanoma. Received treatment, improved, thought to
    be cured, but now was bankrupted. His cancer returned. Depressed and
    unwilling to bring more medical debt on his family, Clay went into the
    back yard and took his own life.
        Velinda Anderson, ``Help Needed for Medicine'' (see attached
    picture) Oak Street, Louisville, March 2011. She was employed. Velinda
    had had endarterectomy (removal of artery blockage) in her legs, but
    could not afford the expensive medicine, Plavix, prescribed to keep her
    arteries open. She had left her usual neighborhood to beg, so that she
    would not be seen begging by friends. She had not told her daughter
    that she was doing it.

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                               grundy county, tn
        Grundy County is the poorest county in Tennessee, 95th out of 95.
    The median household income is $25,619. Sixty-six per cent of school
    children qualify for free lunch. Nineteen per cent of the population is
    illiterate. Correspondingly, it has the lowest county rank in overall
    health. The ratio of population to primary care provider is 7,122 to 1,
    compared to the national ratio of 631 to 1.
        Beersheba Springs is on the Cumberland Plateau in Grundy County--
    Appalachia. We have a vacation home there. In the early winter of 2008,
    Josephine, an 87-year-old friend, stopped by. She was holding her red,
    swollen face and was bent over in pain. She had an acute sinusitis that
    required quick, aggressive treatment. I urged her to get to a doctor
    immediately. She bounced around several places, but eventually got
    treated. However, her bill was over $2,000, money she didn't have, and
    she did not have Medicare. I decided to establish a free medical clinic
    for my mountain friends in Beersheba Springs. The Beersheba Springs
    Medical Clinic, an all-volunteer, not-for-profit clinic opened in
    November 2010 (www.beershebaclinic.org).
        Charlotte Dykes--64 years old. Works odd jobs when able; husband is
    a carpenter. Peripheral vascular disease. Past history of obstructed
    mesenteric artery (main artery to intestines) with stent placement in
    Chattanooga. This spring we diagnosed severe blockage of her right
    subclavian artery and a 70 percent carotid artery blockage. Surgeon
    refuses to operate unless she pays up front, because she still has not
    paid her bill from her previous surgery. Charlotte is a walking time
    bomb. She will be 65 in December, when she will be eligible for
    Medicare, if she lives that long. In giving permission for me to tell
    her story, Charlotte said to me, ``You speak out for me.''
        Charlene--54 years old. We saw her in May. She had not seen a
    doctor in over 20 years. We diagnosed an acute myocardial infarction
    (heart attack). She was air-lifted to Nashville, treated and
    discharged, but did not fill her discharge prescriptions (including
    Plavix--see Velinda Anderson) and did not go to cardiac rehab as
    directed, because she could not afford either. She is doing very poorly
    and has a recent dementia, probably due to small strokes.
        Doris--58 years old. She and her husband operated a small local
    restaurant before her illness forced them to close the restaurant.
    Estimated annual income: $12,948. Came to our clinic because of a lump
    in her breast. She had heard we offered mammograms. We diagnosed breast
    cancer. Because she had breast cancer, she was able to get TennCare to
    pay for her mastectomy and treatment, but the coverage is only for the
    cancer treatment.
        Billy Campbell--54 years old. Work: Tree farming and carpentry.
    Estimated income in 2009: $12,000; 2010: $17,000. No health insurance.
    Colon cancer, Stage 3. Oncologist recommends PET scan. Hospital refuses
    to allow it because he cannot pay the $1,500 fee. TennCare denied.
    Disability denied three times. Barbecue benefit to raise money for
    Billy's PET scan was last Friday night, Sept. 10, 2011.
        Paula--32 years old. Cervical cancer surgery 2 years ago. No
    followup, because of no insurance and no money. We arranged for
    specialist care at no charge.
        Bob--Double hernias. Surgeon agreed to fix for $500, but hospital
    charge will be $8,000. He can't afford it. His hernias will not be
    fixed.
        Woman with broken arm--64 years old. No insurance. I saw this woman
    about 3 weeks ago. She had a crooked left forearm and limped. She had
    fallen in March, breaking her left arm and her left leg. She went to a
    hospital emergency room where she was seen by an orthopedic surgeon,
    who recommended surgery to properly fix her arm. The surgeon agreed to
    do it in spite of the lack of insurance, but the hospital refused to
    allow use of the operating room since she couldn't pay.
         Woman with blood sugar > 500 mg percent. The normal value is
    around 100 mg percent. Her's was a life-threatening level of
    hyperglycemia. We sent her to a hospital emergency room. She knew she
    had diabetes. She owned a glucometer, but could not afford the strips
    to test her blood sugar!
         Thank you for this opportunity to speak for those without a voice,
    who have died or will die as a result of our country's unwillingness to
    acknowledge that health care is a human right and to provide
    affordable, high quality health care to every resident.

        Confidentiality Note. All patients with first and last names have
    given me permission to tell their story. Charlene, Doris, Paula, and
    Bob are fictitious names. All Grundy County patients, except for Billy
    Campbell, were seen in the Beersheba Springs Medical Clinic.

        Senator Sanders. Thank you very much. Thank you very much,
    Dr. Adams. Senator Sheldon Whitehouse of Rhode Island has
    joined us. Senator, would you like to make a brief statement
    for the record?

                        Statement of Senator Whitehouse

        Senator Whitehouse. I'm fine. I'll hold until the questions
    and we can go on through the hearing, but I appreciate it. This
    is an important hearing, and I thank you and the Ranking Member
    for holding it. Thank you.
        Senator Sanders. OK. Let me begin by asking what I think is
    the $64 question, coming from the testimony of the panelists,
    and Senator Paul, and myself. We have heard that yes, longevity
    in America today is better than it was in the past. We have
    learned that, in the United States of America, healthcare is
    better than it is in some of the poorest, most desperate
    countries in the world.
        But frankly, I think that gives cold comfort to millions
    and millions of people. It almost speaks to the rather poor
    shape that we're in, when we're comparing ourselves to third-
    world countries, who are much, much poorer than we are.
        We have heard from Senator Paul and Dr. Hulsey that,
    essentially, as I understand it, people can access healthcare
    if they want it. On the other hand, we have heard from Dr.
    Kemble and Dr. Adams that, that is not the case. I have quoted
    a report from Reuters, which discusses a Harvard University
    study that says 45,000 people in this country die each year
    because they lack health insurance and cannot get good care.
        So the question that we're asking now, is it, in fact, true
    that people can get all the medical care they need, the
    prescription drugs that they need, the hospitalization that
    they need, anytime they really want it? Or in fact, are we
    having a situation in this country, where millions and millions
    of people--and let's remember, we have 50 million people who
    are uninsured--are not able to get to the doctor, or the
    hospital, or afford it, and in fact, are dying or suffering
    unnecessarily?
        That seems to be the question and we have a strong
    difference of opinion about that, so let me throw it out to all
    three panelists. Dr. Kemble, what's your thought?
        Dr. Kemble. Sure. Well, I think that the nature of our
    system is that most physicians who have a heart do volunteer
    and do give some of their time in these voluntary efforts. I
    think all three of us here have done that. In my experience,
    actually, before we started the health center, there was a free
    clinic in our community. And I was a participating physician in
    that effort.
        I also was very curious about what were the real costs and
    benefits of that model. And I wrote a paper about that in
    Public Health Reports. It was published 10 years ago. And
    really, to cut to the bottom line, we did find that the actual
    cost--these free clinics are not free. Someone pays the
    administrative costs of running them, for sure, and it's not
    only that--it's not possible for good-hearted doctors to just
    show up and do their service without a lot of other organizing
    efforts taking place in the community.
        I was curious about what the actual cost of that was. In
    our community at that time, it was during the managed care era,
    so I was comparing the cost of caring for people in the free
    clinic to what we would normally expect to be paid on a per-
    member, per-month basis from the managed care companies.
        And the cost of the free, so-called free, care actually
    exceeded routine care through an HMO.
        Senator Sanders. OK. Dr. Hulsey.
        Dr. Hulsey. Well, I'm honored to be on a panel with such
    distinguished folks here who have a big heart and give a lot to
    patients for no remuneration. I would be willing to bet you
    that the lady that was in this photograph over here with that
    sign would have no trouble getting people to stop right there
    on the street to offer her help for that problem, had she taken
    that sign to her local health department, had she taken that
    sign to her local civic organizations, to her local medical
    society.
        I have a feeling that she could also have gotten some
    response to that situation. There are multiple, generic, cheap
    drug programs available through many of our retailers. I do
    think that the resources are available out there.
        There is really no reason for a patient not to find a
    doctor who will take care of their problem with no
    remuneration, and I think that many of those doctors have the
    wherewithal to go to their hospitals and find that those
    entities will also give time for those patients.
        I have had that personal experience and, certainly,
    hospitals are worried about making a living, just like I am.
    But very frequently, I have gotten patients operated on at no
    cost to them by going to the hospitals and pleading the case
    for them.
        Now, I'm not saying it's fun to be poor in any country. But
    in the countries that I've been to outside of the United
    States, there certainly was no Xbox and the only game being
    played was, what am I going to have for dinner tonight?
        Senator Sanders. Thank you.
        Dr. Adams.
        Dr. Adams. Velinda Anderson, who is pictured there, Dr.
    Hulsey, had exhausted her avenues of regress. I did talk to her
    about that and she was a smart person. She was employed. She
    had done everything she could think of and had actually made
    these opportunities.
        Generally, it seems that physicians are more open to
    helping. Physicians are naturally sympathetic, but now, with
    the for-profit hospitals and with the closing of public
    hospitals, the hospitals in our area, that we can refer to, are
    part of chains, large, large, highly profitable chains that
    sell their stock on the New York Stock Exchange, and they're
    out for profit, and I haven't had success in twisting their
    arms to get them to do the surgeries to open their ORs or their
    PET scan units.
        Another point that Dr. Kemble made, I think, is a very
    important one. And that is dignity. And I have seen the
    patients in the emergency room and the Children's Hospital in
    Louisville. And they come in and the clerk says, ``have you got
    your card?''
        Have you got your card? It's a demeaning way to address a
    person. We need something that provides everyone equal dignity,
    an egalitarian system in this country, which provides equal
    healthcare for everyone, just as we see in other developed
    countries.
        I think we tend to want to compare ourselves to other
    developed countries. I think a comparison with--but in fact, in
    some respects, we have slipped down into the third-world area,
    in terms of infant mortality, immunizations, and life
    expectancy.
        Senator Sanders. OK. Thank you.
        Senator Paul.
        Senator Paul. In our town, we have two hospitals. We have a
    for-profit hospital, HCA, and before we throw all the for-
    profit hospitals under the bus, HCA has actually been very good
    at allowing us to do free surgery. I've done free surgery there
    on children from Guatemala. So has Dr. Hulsey on numerous
    occasions, over many years.
        We have a doctor who lived in Guatemala, Dr. Schwank, who's
    a neurosurgeon, who's done many surgeries, also in the
    hospital. So I think, really, we can't make any blanket
    statement that for-profit hospitals are unwilling to help
    people.
        We also have a not-for-profit hospital in town that
    provides a free clinic, as well as free drugs. Actually, one of
    the main things that they do is, when people come in, they're
    able to help them with getting free drugs.
        Every drug company that I've ever dealt with has an
    indigent program. I have not come across one that didn't have a
    program, that you could fill out a card, and send in, and get
    assistance on your medications.
        Everybody over 65 already has assistance. We have Medicaid
    and has assistance also. When we talk about people--and a lot
    of the stories were very tragic that you presented--for every
    story that you presented, every physician in the country can
    present equally as many so that are real tragedies of people
    who all had insurance, and still died, and had horrible
    tragedies.
        We have a good friend, of Dr. Hulsey and I, who died from
    colon cancer. She was an OB-GYN and she had every resource. She
    had every resource possible, health insurance, physician, PET
    scans, everything.
        And she still died, and it's a horrible tragedy, but the
    tragedies are sometimes the disease and not necessarily the
    poverty. My question is for Dr. Hulsey when I ask it. Have you
    ever seen anybody, any patient, who died in Kentucky, in your
    30 years in practice, for lack of healthcare?
        Dr. Hulsey. No, sir. I have not.
        Senator Paul. One of the other follow-up questions would be
    that, when you see sort of patients who are not getting their
    Plavix and they say it's because of health cost, have you also
    seen that in patients who have government insurance, who have
    Medicaid, who then are noncompliant, even though it is paid
    for?
        Dr. Hulsey. Yes, sir. Compliance is a problem in all
    financial groups of patients.
        Senator Sanders. Thank you.
        Senator Whitehouse. Thank you, Chairman. I think, when
    we've heard the experiences of Dr. Kemble and Dr. Abrams, it
    may be true that charity helps some people without insurance
    and it may also be true that illness claims with insurance.
        But that doesn't take away from the fundamental problem,
    that a great number of people who don't have access to health
    insurance have health consequences in their lives from not
    having health insurance. In some cases, as Dr. Kemble and Dr.
    Adams have described, those consequences are fatal.
        What's tragic about this is that it's not for lack of
    funding into the healthcare system that this takes place. The
    healthcare system burns 18 percent of the gross domestic
    product of this country. The closest competitor that we have is
    around 12 percent, which means we're 50 percent more
    inefficient than the next-most inefficient industrialized
    Nation in the world at delivering healthcare.
        When we look at outcomes around our population, they're no
    better than some countries that we think of, really, as
    substantially less modern and industrialized than our own,
    virtually third-world countries.
        So we have this enormous expenditure and we have moderate,
    at best, results, and that plays out down where the rubber hits
    the road, where you all live, in the lives of the patients that
    you described, who simply don't survive an illness because they
    couldn't access the care.
        I hope that that's an issue that we can work on. There
    should be no Democratic or Republican value in a massively
    inefficient healthcare system.
        My guess is that about 10 cents of every insurance dollar
    gets spent on trying to deny and delay payment. You probably
    have seen that, Dr. Kemble, in your clinic. We have a Cranston
    community health center in Cranston, RI. And when I was last
    there, they said that half of their personnel were dedicated
    not to providing healthcare, but to trying to get paid for the
    healthcare that the other half of the staff provided. I see you
    nodding your head.
        They also have a $200,000-a-year contract to try to keep up
    with the tricks and traps that are used to delay and deny
    payment. Then, when they do that, the doctors have to hit back,
    as your community health center probably did, as the Cranston
    community health center did, as doctors across this country do,
    hire experts to do their billing, and to organize all of that.
        They can't be as efficient at fighting back at the
    insurance industry, as the insurance industry is denying and
    delaying payment. So it's got to be more than 10 cents worth,
    although I haven't seen good figures on their side.
        That would imply that 20 cents of every healthcare dollar
    is spent fighting over getting paid and not over actually
    providing healthcare.
        Then we have the quality issues of hospital-acquired
    infections, which cost billions of dollars and should be
    ``never'' events, but they're not.
        There are just a lot of ways in which there's no value in
    that fight between insurers and providers. There's no
    healthcare value. There's no healthcare value in a hospital-
    acquired infection that was avoidable. These are things where I
    think we ought to be able to work together and try to design a
    more efficient healthcare system so that the resources that
    we've already put into the system can get to the people who you
    see day to day.
        I just thank you for your courage and determination,
    whether through charity work, or through community health
    centers, or through your volunteer work in trying to reach out
    to those people who our healthcare system, for all its vast
    expense, overlooks and abandons. Thank you very much.
        Dr. Adams. Yes, may I comment on your remark, Senator
    Whitehouse, about the cost of billing? There's a recent article
    in Health Affairs to that effect, which compares the cost for
    physicians in Canada to bill compared to the United States.
        And it's four times in the United States, the cost for
    billing and amounts to some $80 billion. And 20 hours per
    patient, per week, the average American physician spends doing
    the billing.
        That 10 percent adds onto the 20 percent of the health
    insurance companies' overhead, so we're wasting 30 cents out of
    every dollar on the market-based system in this country.
        Senator Sanders. OK. Let me thank all of the panelists for
    excellent testimony. And now, we hear from the second panel.
    Thank you very much. I think we have three excellent panelists
    and I thank all of you for being with us.
        We're going to begin with Dr. Paula Braveman, a professor
    of family and community medicine at the University of
    California at San Francisco and director of the University
    Center on Social Disparities in Health.
        Dr. Braveman is a member of the Federal Institute of
    Medicine. She has studied socioeconomic, and racial, and ethnic
    disparities in maternal and infant health and healthcare for
    two decades.
        Dr. Braveman, a pediatrician and family specialist, has
    previously worked with the World Health Organization staff to
    develop and direct a WHO global initiative on equity in health
    and healthcare. Dr. Braveman, thanks for being with us.

    STATEMENT OF PAULA BRAVEMAN, M.D., MPH, PROFESSOR OF FAMILY AND
      COMMUNITY MEDICINE, UNIVERSITY OF CALIFORNIA SAN FRANCISCO,
      DIRECTOR, UCSF CENTER ON SOCIAL DISPARITIES IN HEALTH, SAN
                             FRANCISCO, CA

        Dr. Braveman. Thank you very much. Good morning. It's a
    pleasure to be here. I'm going to discuss the current State of
    the science that can shed light on the question, is poverty a
    death sentence.
        A link between poverty and health has been observed for
    centuries, but a body of knowledge has accumulated in the past
    15 to 20 years, that I believe makes it very different to
    consider this issue now than previously.
        First, the connection between poverty and lifespan, and
    between poverty and virtually every health indicator has been
    established repeatedly. For example, recent studies using
    national data from the CDC have shown that the poor can expect
    to live around 7 years less than people with incomes at least
    four times the poverty, who I will call higher income.
        Next slide, please. Poor children are seven times as likely
    to have ill health as children in higher income families. Poor
    adults--next slide, please. Poor adults are four times as
    likely to have ill health and the pattern holds for scores of
    indicators.
        Next slide, please. Because health data in the United
    States have typically been reported by race or ethnic group and
    not by income, some people assume that differences in health by
    income primarily reflect racial or ethnic differences.
        But income differences in health are at least as striking
    when we look separately within each racial or ethnic group. In
    other words, differences in health according to income are not
    due to racial or ethnic differences. Most racial or ethnic
    differences in health disappear or are greatly reduced after
    considering income.
        But is poverty actually the cause? Some economists have
    ascribed the poverty health link to loss of income due to
    sickness, and that happens, but by now, a large body of
    research shows that poverty, because of multiple disadvantages
    associated with it, indeed causes ill health and shortened
    life.
        Poverty makes people sick. It's true that sickness makes
    some people poor, but the main direction is from poverty to
    sickness.
        Next slide, please. So how does poverty make people sick?
    It's not just through medical care. Behaviors are involved, but
    it is definitely not just through behaviors. I want to give you
    a few examples.
        Your income affects the quality of the housing you can buy
    or rent, which affects whether your kids are exposed to
    crowding, lead, asbestos, dust, mites, or mold, all of which
    have harmful health effects.
        A healthy diet costs more. Regular exercise is easier if
    you can afford to belong to a gym or live where it's safe to
    exercise outdoors. Low income is stressful. The strain of
    trying to cope with daily challenges without adequate
    resources, and I'll return to the topic of stress in a moment.
        We have learned that the health damaging effects of poverty
    reach across generations. Parents' income can shape the next
    generation's income by determining who can afford to live in
    neighborhoods with good schools or pay for private schools.
        School quality affects children's ultimate educational
    attainment, which then determines the jobs they can get, which
    in turn, drives their income. Low income and education are
    linked in many ways that I haven't mentioned.
        Poverty in one generation leads to poverty and ill health
    in the next, and this is very well-documented. Next slide,
    please. Many poor neighborhoods lack stores selling healthy
    food. Children in poor neighborhoods are more likely to be
    exposed to unhealthy norms and role models for behaviors like
    smoking and drinking.
        Poor neighborhoods are more polluted, they're more violent,
    they're more stressful. Next slide, please. Recent advances in
    neuroscience show multiple ways in which chronic stress can
    affect health and they show that it plays a major role in
    chronic disease.
        For example, stress can cause one part of the brain to send
    a signal to another part of the brain, which then signals the
    adrenal glands to produce a hormone called cortisol.
    Chronically high cortisol levels can lead to inflammation,
    suppression of the immune system, and premature aging.
        Other systems and even chromosomes can be affected. Acute,
    time-limited stress is not necessarily harmful, but repeated,
    chronic stress can damage multiple bodily organs and systems,
    resulting in chronic disease, premature aging, and premature
    death.
        Next slide, please. So who has the most stress? Some stress
    is inescapable, regardless of income. But higher income means
    more resources to cope with challenges.
        For example, as income rises among pregnant women, the
    prevalence of major stressors such as divorce or separation,
    involuntarily job loss, domestic violence, and food insecurity
    goes down.
        One of the most important scientific discoveries recently
    is that chronic poverty in childhood appears to contribute
    toward heart disease and other chronic disease among adults,
    partly through stress.
        If we care about chronic disease and premature mortality
    among adults, we need to do something about chronic poverty in
    childhood. Finally, the last one, please.
        In summary, a critical mass of very compelling scientific
    evidence shows that poverty, particularly chronic poverty in
    childhood, is a major cause of disease and premature death
    overall in the United States and of racial disparities in
    health in the United States.
        Scientific advances help explain how that happens, how
    poverty damages health through, for example, exposure to
    unhealthy physical and social environments, denial of
    educational opportunities, chronic stress, and multiple
    obstacles to health.
        I'd like to close by acknowledging that much is still
    unknown, but we know enough now about what works to act, to act
    now. Lack of knowledge isn't the obstacle. The obstacle is
    political will. Thank you.
        [The prepared statement of Dr. Braveman follows:]
                Prepared Statement of Paula Braveman, M.D., MPH
        My testimony has two main components:

        I. The text (below) that accompanies the attached Powerpoint
    presentation; and
        II. Broadening the focus, a paper published in the American Journal
    of Preventive Medicine 2011.*

        * The Broadening the focus paper referred to may be found at http:/
    /files.meetup.com/1697878/To%20read%20Braveman%20-
    %20broadening%20focus%20-%20soc%20determ%20-%20
    AJM.pdf.

        Is poverty a death sentence? What does science tell us? (numbers
    ---------------------------------------------------------------------------
    below refer to the slides in the accompanying Powerpoint file).

        1. I'm going to discuss what current scientific knowledge tells us
    about poverty & health. A large body of knowledge has accumulated in
    the past 15 to 20 years that makes it very different to consider this
    issue today than previously.
        2. I'm going to show you a series of slides using national data
    illustrating how poverty and health are related. In each slide, as you
    look from left to right, income increases. On the far left are the
    poor--those under the Federal Poverty Line (FPL). On the far right are
    those with incomes at least 4 times the FPL, who make up around 40
    percent of the U.S. population. This slide shows how the number of
    additional years of life one can expect to live at age 25 increases as
    income increases. The poor live around 7 years less than the group with
    incomes at least 4 times the FPL.

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        3. This slide shows how ill health among children varies by income.
    Ill health among children goes down stepwise as income increases. We
    looked at scores of indicators and all age groups and found this
    pattern with most health conditions among whites and blacks. In
    biological science, this pattern--suggesting a ``dose-response''
    relationship--adds to a wealth of other evidence indicating that
    income--or factors tightly associated with it--actually causes the ill
    health and shortened life.

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        4. Poor adults are more than 4 times as likely to have ill health
    as affluent adults.

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        5. Here is the same health measure, but looking separately at
    different racial/ethnic groups. The stepwise pattern, with dramatically
    worse health among the poor, is at least as striking WITHIN each
    racial/ethnic group as when you look overall. This illustrates that the
    differences in health by income cannot be explained by race or ethnic
    group. At a given income level, the racial/ethnic differences are
    modest. And other research has shown that most racial/ethnic
    differences in health disappear or are greatly reduced after
    considering income.

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        6. What could explain these patterns? Here are some examples of how
    poverty affects health, for which there is plentiful evidence. Income
    can influence who gets timely medical care, but that is probably not
    the largest piece of the puzzle. Your income determines the kind of
    housing you can buy or rent, which can determine whether your kids are
    exposed to lead, asbestos, dust, mites and mold, all of which have
    serious harmful health effects. A healthy diet costs more than an
    unhealthy diet. Regular physical activity is a lot easier if you can
    afford to belong to a gym or live in a neighborhood where it's safe to
    exercise. Many poor neighborhoods are food deserts, without any stores
    selling fresh, healthy food. And low income is stressful--the challenge
    of trying to cope with daily challenges without adequate resources.
    [I'll return to this point.]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Parents' income can shape the next generation's education & income,
    by determining who can afford to buy or rent in neighborhoods with good
    schools, or pay for private schools. School quality affects children's
    ultimate educational attainment. And education determines the kind of
    job people can get, which in turn drives income. [And you see the
    vicious cycle.]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        7. I mentioned that our income shapes our options for where to
    live. Studies show how neighborhood conditions can shape health--this
    slide lists some of those ways, including stress.
        8. I've mentioned stress. How does stress get into our bodies?
    Recent advances in science show multiple ways in which chronic stress
    can affect health. This illustrates just one--by causing one part of
    the brain to send a signal to another part of the brain which then
    signals our adrenal glands to pump out a hormone called cortisol. Acute
    stress is not necessarily harmful. But chronic stress is linked with
    damage to multiple organs and systems in the body, resulting in chronic
    disease, premature aging, and premature death. Chronic stress in
    childhood appears to be an important factor in who develops heart
    disease & other chronic disease in adulthood.

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        9. Who has the most stress? Some stress is inescapable regardless
    of income. But higher income means more resources to cope with
    challenges. This slide shows you what percent of pregnant women in
    California experienced divorce or separation, according to income. We
    found a similar pattern looking at 10 other major stressors. Other
    studies have found the same patterns.

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        10. In summary:

        a. Compelling scientific evidence shows that poverty--particularly
    chronic poverty in childhood--is a major cause of disease and premature
    death, and of racial disparities in health.
        b. Recent advances in science help explain how poverty damages
    health, through, e.g.:

        i. Exposure to hazardous environments;
        ii. Parent's income limiting their children's educational
    attainment which then limits the latter's job options and hence income
    in adulthood; and
        iii. Chronic stress.

        And finally, I would like to add, that although there is much we
    still do not know, we know enough about what works to act now. All we
    need is the political will. I'm hoping you will create that.

        Senator Sanders. Thank you very much, Dr. Braveman.
        Our second witness is Michael Cannon. He is the director of
    health policy studies at the Cato Institute in Washington, DC.
    Previously, he served as a domestic policy analyst for the U.S.
    Senate Republican Policy Committee under Chairman Larry Craig,
    where he advised the Senate leadership on health education,
    labor, welfare, and the 2d Amendment. Mr. Cannon, thanks very
    much for being with us.

       STATEMENT OF MICHAEL F. CANNON, DIRECTOR OF HEALTH POLICY
              STUDIES, THE CATO INSTITUTE, WASHINGTON, DC

        Mr. Cannon. Thank you for having me, Mr. Chairman, and
    Senator Paul. This is an incredibly important issue and I share
    the Chairman's commitment to reducing poverty in the United
    States and around the world, in large part, because of the link
    between poverty and health.
        But to identify the problem is not to solve it and there
    are serious disagreements about how to combat poverty. So I'd
    like to begin with a little perspective, which is that poverty
    is actually the natural human condition. It has been the
    dominant human condition throughout most of human history.
        So really, the question for us is not what causes poverty,
    but what causes prosperity? And on that question, the jury is
    in, a market economy with the greatest anti-poverty program
    ever designed, or maybe I should say discovered by humans.
        The market economy continuously makes goods and services
    that the wealthiest individuals could not afford 10, 50, or
    even 20 years ago, including life-saving goods and services,
    available to people who, previously, could not afford them,
    including the poor.
        In my written testimony, I show how markets have done so
    with items like refrigerators, air conditioning, mobile phones,
    and other goods. The same is also true of education and other
    crucial services.
        The benefits of the market process can be seen in U.S.
    health statistics. Figure two in my written testimony shows the
    actual and projected survival rates of men after age 60 from
    the top and bottom halves of the earnings distributions from
    two birth cohorts.
        Those are men born in 1912 and then born in 1941. One
    interesting feature of these data is that the gap in survival
    rates between the top and bottom halves of the earnings
    distributions is larger for men born in 1941 than for men born
    in 1912.
        But differently, the gap in survival rates between higher
    and lower income males is growing, but that's not even the most
    interesting characteristic of these data. Much more interesting
    is that men born in 1941, who are in the lower half of the
    earnings distribution, are projected to live longer than men in
    the top half of the earnings distribution, for men--among those
    born in 1912.
        In other words, the lower income males born in 1941 are
    living longer than the higher income males born 29 years
    earlier, and we should all be able to celebrate this progress.
    Higher income workers are living longer. Lower income workers
    are living longer. And today's lower income workers are living
    longer than yesterday's upper income workers.
        As a threshold matter, then, governments should not pursue
    policies and should eliminate existing policies that inhibit
    economic exchange and wealth creation. Unfortunately,
    governments the world over adopt policies that reduce economic
    activity, and thereby perpetuate poverty, often for the benefit
    of a privileged few.
        These such policies include government-imposed barriers to
    trade, which leave all nations poorer, and trap particularly
    third-world residents in lives of privation far worse than that
    known to the U.S. poor.
        These policies also include high marginal tax rates. In the
    United States, excessive marginal tax rates destroy anywhere
    from 25 cents to $1.65 of economic activity for every dollar of
    tax revenue the Federal Government collects. Excessive tax
    rates mean fewer jobs, less opportunity, and fewer goods and
    services for Americans to consume.
        Our first task, then, and our first duty to the poor is not
    to do anything to interrupt the market process that has pulled
    billions of people out of poverty and continues to do so every
    day--to pull people out of poverty every day.
        Put differently, our first duty to the poor is not to add
    to their numbers. Yes, poverty is a death sentence, but only in
    the sense that life itself is a death sentence. To abuse the
    metaphor further, if what you want is a stay of execution so
    that more people can enjoy a long and healthy life, your most
    effective tool is a free-
    market economy.
        Your task, as stewards of the public fiscal, is not to
    create a new government anti-poverty program for every
    perceived need, but to ascertain whether existing programs are
    wise investments of taxpayer dollars at all.
        Now, ideally, that research would capture all of these
    programs' costs, which go far beyond outlays and include the
    economic activity destroyed by the taxes that finance them and
    economic activity destroyed by the incentive such programs
    create not to climb the economic ladder.
        I talk a little bit more about these effects in my written
    testimony, but a good place to start this process would be to
    build upon the Oregon Health Insurance Experiment by allowing
    other States to conduct similar experiments.
        This is the first scientifically rigorous study ever
    conducted of the effects of the Medicaid program, and health
    insurance broadly, on such outcomes as health and financial
    security.
        I submit that rather than expanding Medicaid eligibility to
    all Americans under 138 percent of the Federal poverty level,
    as the recently enacted Patient Protection and Affordable Care
    Act requires, States could use a lottery to extend Medicaid
    coverage to a pre-determined number of residents with incomes
    below that threshold, and then measure the results.
        Armed with that information, policymakers could determine
    whether they would save more lives by expanding Medicare,
    Medicaid, or by funding smaller programs targeted at vulnerable
    populations with highly effective treatments, for example,
    programs offering hypertension screening and treatment to low-
    income adults.
        Such experiments would cost the Treasury far less than the
    Medicaid expansion mandated by the new healthcare law and could
    yield further savings while helping to save lives.
        I thank you very much for the opportunity to share my
    thoughts and I look forward to your questions.
        [The prepared statement of Mr. Cannon follows:]
                  Prepared Statement of Michael F. Cannon \1\
        Thank you, Chairman Sanders and Ranking Member Paul for the
    opportunity to speak with you today about the relationship between
    poverty and health, and how government should address these goals.
        Any sincere effort to grapple with the problems of poverty must
    begin with the understanding that poverty has been the natural state of
    affairs throughout human history. Only in the past few hundred years
    have humans struck upon the antidote to poverty. Rather than begin our
    inquiry with the question, ``What are the causes of poverty and how can
    we eradicate them? '', we must instead begin by asking, ``What are the
    causes of prosperity and how may we promote them? ''
        This was the very aim of Adam Smith's volume An Inquiry into the
    Nature and Causes of the Wealth of Nations--known to most as The Wealth
    of Nations--published in 1776. Smith demonstrated that trading with
    others leads to enormous gains in innovation and productivity, and
    thereby greater wealth. Figure 1 illustrates how rapidly the United
    States' market economy has made new and often life-saving products
    available to people who previously could not afford them.
        U.S. households officially classified as ``poor'' today have access
    to amenities that not even the wealthiest people in the world could
    access just 100, 50, or even 20 years ago. Nearly all of the U.S. poor
    (99.6 percent) have refrigerators, 78 percent have air conditioning, 65
    percent have one or more DVD players, 62 percent have clothes washers,
    55 percent have cellular phones, 53 percent have clothes dryers, and
    17.9 percent have big-screen televisions.\2\ To highlight these numbers
    is not to deny that poverty is a problem. It is to highlight that a
    market economy is the remedy.

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        The benefits of this market process can be seen in U.S. health
    statistics. Figure 2 shows the actual and projected survival rates of
    men after age 60 in both the top and bottom halves of the earnings
    distribution from two birth cohorts: men born in 1912 and men born in
    1941.\3\ One interesting feature of Figure 2 is that the ``gap'' in
    survival rates between the top and bottom halves of the earnings
    distribution is larger for men born in 1941 than for men born in 1912.
    Put differently, the gap in survival rates between higher- and lower-
    income males is growing. But that is not even the most interesting
    aspect of Figure 2.
        Much more interesting is that men born in 1941 who were in the
    lower half of the earnings distribution (the dashed line) are living
    longer than did men in the top half of the earnings distribution among
    those born in 1912 (the solid line). In other words, the lower-income
    males born in 1941 are living longer than the higher-income males born
    29 years earlier. We should all be able to celebrate this progress:
    both upper- and lower-income workers are living longer; and today's
    lower-income workers are living longer than yesterday's upper-income
    workers.
        As a threshold matter, then, governments should not pursue policies
    (and should eliminate existing policies) that inhibit economic exchange
    and wealth creation.\4\ Unfortunately, governments the world over
    maintain policies that reduce economic activity and thereby perpetuate
    poverty, often for the benefit of a privileged few. Such policies
    include government-imposed barriers to trade, which leave all nations
    poorer and trap Third World residents in lives of privation far worse
    than that known to the U.S. poor. These policies also include high
    marginal tax rates. In the United States, excessive marginal tax rates
    destroy anywhere from 25 cents to $1.65 of economic activity for every
    dollar of tax revenue the U.S. government collects.\5\ Excessive tax
    rates mean fewer jobs, less opportunity, and fewer goods and services
    for Americans to consume.

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                               poverty and health
        If we seek to improve lives by improving population health, it is
    not sufficient to identify a social factor that is associated with
    health outcomes and throw taxpayer dollars at it. We must first
    identify the causal relationships between various factors and health
    outcomes. Second, we must identify policies that yield improvements in
    those factors and whose benefits exceed the costs.
        Figure 3, created by economist David Meltzer, demonstrates the
    difficulties inherent in the first task. The economic literature shows
    a correlation between poverty and health, but this relationship is
    complex. The existence of a correlation between A and B does not tell
    us whether A causes B, whether B causes A, or whether some third factor
    causes both. Poverty may cause some people to suffer poor health, while
    poor health may drive some people into poverty. And indeed many other
    factors are also correlated with health, including education, social
    status, health behaviors (e.g., smoking, exercise), genetics, access to
    medical care, and more. The arrows in Figure 3 show the causal
    connections between the many factors associated with health. Factors
    such as income, insurance status, education, and health behaviors not
    only influence health status but are influenced by health status. These
    factors may also exert an influence on each other.

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        With so many complex interactions between the factors associated
    with health, establishing the relative influence of any one factor
    requires controlling for all the others. In complex phenomena like
    human health, that means conducting a randomized trial. Such trials are
    expensive and often impractical. Yet without them, policymakers who
    attempt to maximize health by focusing on factors with which it is most
    correlated may neglect other factors that have a greater causal
    influence on health.
        Even if policymakers can overcome this hurdle, it is not sufficient
    to create new government programs that would deliver improvements in a
    known determinant of health. Policymakers must also ensure that the
    benefits of such programs exceed their costs, and that they deliver the
    greatest improvement in health per dollar spent. Most important, in
    judging the efficacy of anti-poverty programs, policymakers must look
    at all of the program's effects, both seen and unseen.\6\
    Unfortunately, such accounting is usually lacking.
        On the benefits side, this means not looking solely at the
    consumption that the program enabled. We must also subtract the private
    charity and self-help for which the program substituted. Crowd-out is a
    persistent phenomenon with government anti-poverty programs. Economist
    Jonathan Gruber has estimated that, in effect, 6 out of every 10 new
    enrollees in Medicaid and the State Children's Health Insurance Program
    would have had health coverage anyway.\7\ If the aim of these programs
    is to expand health insurance coverage, only 4 of those 10 new
    enrollees count toward that goal. Elsewhere, Gruber has estimated that
    ``church spending fell by 30 percent in response to the New Deal, and
    that government relief spending can explain virtually all of the
    decline in charitable church activity observed between 1933 and 1939.''
    \8\
        Likewise, the costs of government programs go far beyond the tax
    dollars required to fund them. The costs also include the economic
    activity destroyed by those taxes, other behavioral changes the
    programs produce, and any additional economic distortions.
        Programs that offer subsidies to those with low incomes or assets
    also withhold those subsidies when incomes or assets exceed certain
    thresholds, for example. The potential loss of subsidies can discourage
    individuals from climbing the economic ladder. Gruber has estimated
    that the Medicaid program encourages low-income households to reduce
    their asset holdings by $1,600 to become eligible for the program.\9\
    The ``Patient Protection and Affordable Care Act'' of 2010 (PPACA)
    offers large subsidies to help low-income households purchase health
    insurance. But because those subsidies shrink or disappear when
    household income exceeds certain thresholds, the law creates effective
    marginal tax rates in excess of 100 percent on low-income
    households.\10\ Those implicit marginal rates are far higher than the
    marginal tax rates faced by the wealthiest Americans.
        The behavioral changes that such programs encourage can have the
    perverse effect of expanding poverty if they induce Americans not to
    climb the economic ladder. The fact that the 1996 welfare reforms led
    to a vast reduction in the number of Americans receiving cash
    assistance yet was not accompanied by an increase in poverty (which
    actually fell) suggests that government anti-poverty programs can have
    very high off-budget costs.
        Unfortunately, the political system as an institution does not take
    the care to identify which social factors promote health, much less
    target those factors for improvement in a cost-effective way.
        The highest-profile example of this is PPACA. President Obama
    claimed this law will ``save lives.'' Yet the most reliable research to
    date suggests that the Federal Government's last great expansion of
    health insurance coverage--Medicare--did not save a single life in at
    least its first 10 years of operation.\11\ Congress rushed PPACA into
    law without bothering to wait for the results of the one study--the
    randomized, controlled Oregon Health Insurance Experiment \12\--that
    might inform policymakers about PPACA's benefits and enable them to
    ascertain whether they could deliver even greater gains in health and
    financial security for the same or less money.
                                   conclusion
        As stewards of the public fisc, your first task is not to create or
    expand government anti-poverty programs in response to every perceived
    need, but to ascertain whether existing programs are wise investments
    of taxpayer dollars at all. Ideally, that research would capture all of
    these programs' costs, which go far beyond outlays to include the
    economic activity destroyed by the taxes that finance them and by the
    incentives such programs create not to climb the economic ladder.
        A good place to start would be to build upon the Oregon Health
    Insurance Experiment by allowing other States to conduct similar
    experiments. Rather than expand Medicaid eligibility to all Americans
    under 138 percent of the Federal poverty level as PPACA requires,
    States could use a lottery to extend Medicaid coverage to a
    predetermined number of residents with incomes below that threshold,
    and measure the results.
        Armed with those results, policymakers could determine whether they
    would save more lives by expanding Medicaid or by funding smaller
    programs targeting vulnerable populations with highly effective
    treatments (e.g., programs offering hypertension screening and
    treatment for low-income adults). Such experiments would cost the
    Federal treasury less than the Medicaid expansion mandated by PPACA,
    would reduce future deficits, and could yield further savings while
    helping to save lives.
                                   References
        1. The Cato Institute is a nonpartisan, nonprofit, tax-exempt
    educational foundation organized under Section 501(c) 3 of the Internal
    Revenue Code. The mission of the Cato Institute is to increase the
    understanding of public policies based on the principles of individual
    liberty, limited government, free markets, and peace. In order to
    maintain its independence, the Cato Institute accepts no government
    funding. Cato receives approximately 82 percent of its funding from
    individuals, 10 percent from foundations, 1 percent from corporations,
    and the remainder the sale of publications. Cato's fiscal-year 2009
    revenues were over $20 million. Cato has approximately 105 full-time
    employees, 75 adjunct scholars, and 23 fellows, plus interns.
        2. Robert Rector and Rachel Sheffield, ``Air Conditioning, Cable
    TV, and an Xbox: What is Poverty in the United States Today? ''
    Heritage Foundation Backgrounder no. 2575, July 19, 2011, http://
    www.heritage.org/Research/Reports/2011/07/What-is-Poverty.
        3. Hilary Waldron, ``Trends in Mortality Differentials and Life
    Expectancy for Male Social Security-Covered Workers, by Socioeconomic
    Status,'' Social Security Bulletin, Vol. 67, No. 3, 2007, http://
    www.ssa.gov/policy/docs/ssb/v67n3/v67n3
    p1.html.
        4. See generally, Johan Norberg, In Defense of Global Capitalism
    (Washington: Cato Institute, 2003), http://africanliberty.org/pdf/
    GLOBAL%20CAPITALISM.pdf.
        5. Christopher J. Conover, ``Congress Should Account for the Excess
    Burden of Taxation,'' Cato Institute Policy Analysis no. 669, October
    13, 2010, http://www.cato.org/pubs/pas/PA669.pdf.
        6. ``There is only one difference between a bad economist and a
    good one: the bad economist confines himself to the visible effect; the
    good economist takes into account both the effect that can be seen and
    those effects that must be foreseen.'' Frederic Bastiat, That Which Is
    Seen, and That Which Is Not Seen, 1850.
        7. Jonathan Gruber and Kosali Simon, ``Crowd-out 10 years later:
    Have recent public insurance expansions crowded out private health
    insurance?'' Journal of Health Economics 27 ( 2008): 201-17; http://
    econ-www.mit.edu/files/6422.
        8. Jonathan Gruber and Daniel M. Hungerman, ``Faith-Based Charity
    and Crowd-Out During the Great Depression,'' Journal of Public
    Economics 91(2007): 1043-69; http://www.religionomics.com/old/erel/S5-
    ASREC/REC05/Gruber%20-%20Hun
    german%20-%20Faith-based%20Charity.pdf.
        9. Jonathan Gruber and Aaron Yelowitz, ``Public Health Insurance
    and Private Savings,'' Journal of Political Economy 107, no. 6, part 1
    (December 1999): 1259.
        10. Michael F. Cannon, ``Obama's Prescription for Low-Wage Workers:
    High Implicit Taxes, Higher Premiums,'' Cato Institute Policy Analysis
    no. 656, January 13, 2010, http://www.cato.org/pubs/pas/pa656.pdf.
        11. David Jackson, ``Obama: `On the precipice' of health care
    change, though `differences' remain,'' USA TODAY, Dec. 15, 2009, http:/
    /content.usatoday.com/communities/theoval/post/2009/12/obama-on-the-
    precipice-of-health-care-reform-though-differences-remain/1. Amy
    Finkelstein and Robin McKnight, ``What Did Medicare Do? The Initial
    Impact of Medicare on Mortality and Out of Pocket Medical Spending,''
    Journal of Public Economics 92, July 2008, 1644-68.
        12. Michael F. Cannon, ``Oregon's Verdict on Medicaid,'' National
    Review (Online), July 7, 2011, http://www.nationalreview.com/articles/
    271252/oregon-s-verdict-medicaid-michael-f-cannon.

        Senator Sanders. Thank you. Thank you very much, Mr.
    Cannon. Our final witness is Phyllis Zolotorow, a Maryland
    resident and certified medical coding specialist, who has spent
    the last 26 years caring for her son, whose complex medical
    conditions have necessitated many surgeries and specialized
    treatments.
        Her husband suffered a serious heart attack 6 years ago and
    Phyllis herself has chronic health conditions. She will share
    with us today a glimpse into her life, navigating her medical
    bills while caring for her disabled husband and son, as she
    struggles to keep her family financially afloat.
        Ms. Zolotorow, thank you very much for being with us.

           STATEMENT OF PHYLLIS ZOLOTOROW, ELLICOTT CITY, MD

        Ms. Zolotorow. Thank you for inviting me here today. My
    experience with our healthcare system is as a mother of a 26-
    year-old son whose serious chronic illnesses started at age 2,
    my husband's cardiac disability of 6 years, and my own chronic
    diagnoses.
        My husband, Mike, had a serious injury at work, requiring
    two surgeries and 2 years of physical therapy, paid by workers'
    comp. After the first year, Mike's employer canceled his health
    insurance and workers' comp paid for treatment of his injury
    only.
        Mike felt sick in September 2005, but refused to go to the
    emergency room due to the cost, since he was no longer insured.
        Ten days later, he had a massive, near-fatal heart attack
    with permanent, severe damage to his heart, requiring three
    surgeries, and is permanently disabled. If a national health
    insurance plan had been available, Mike would have been
    diagnosed at the first sign of illness, had a cheaper surgery,
    and treatment for milder heart disease, and like most heart
    patients, would have been working several months later, adding
    to the tax base.
        The hospital applied for Medicaid and SSDI for Mike, and
    Medicaid covered his expenses associated with catastrophic
    illness and insured his eligibility for placement on the heart
    transplant list, a life-saving privilege denied any person
    without health insurance in the United States.
        To be eligible for full Medicaid coverage without a spend-
    down deductible in the State of Maryland, the net income
    standard for a family of two adults with no dependent children
    is $392 a month. Mike had to accrue a deductible of $3,500
    every 6 months before Medicaid started paying his medical bills
    for that time period.
        Five months after his heart attack, Mike received
    confirmation of eligibility for SSDI. But as per Federal
    regulations, there is a 24-month wait for eligibility for
    Medicare. My spousal eligibility for Medicaid ended when Mike's
    Medicare coverage began in 2008.
        During the 2-year wait for Mike's Medicare approval, I had
    been forced to choose between applying for jobs without health
    insurance benefits and losing financial eligibility for
    Medicaid if hired, most likely resulting in Mike's death or not
    working and being forced into an unwanted life below the
    poverty level, thus qualifying him for partial Medicaid
    benefits and transplant eligibility.
        I chose my husband's life over earned income. I have
    Crohn's disease and diabetes. I was overcome with exhaustion in
    2008, unable to get out of bed without feeling faint many days
    of the week. With the constant stress of being the caretaker
    for my family and financial worries, I thought I was suffering
    from depression.
        Without health insurance or a job, I felt I could not
    afford an office visit and assumed I could just think my way
    out of depression. After a year of suffering, I finally went to
    the doctor. Being a type II, noninsulin-dependent diabetic, she
    took a finger-stick glucose level. My supposed depression was
    actually a glucose level of 500.
        I was now a type II, insulin-dependent diabetic and working
    my way up to a diabetic coma. Contrary to popular belief, most
    uninsured people don't go to the emergency room for minor
    illness. Who wants to spend 4 to 8 hours sitting in an
    emergency room?
        We go when we are sick enough to be frightened for our
    lives. And for those people who think the uninsured are well
    cared for in any emergency room for any illness, the emergency
    room will diagnose and stabilize you, but they do not treat
    chronic illness.
        Between Mike's old medical bills and my recent bills, all
    totaling over $26,000, we get calls from medical collection
    agencies starting at 8:30 a.m. to 8:30 p.m. 7 days a week.
        Since access to healthcare in the United States is
    dependent upon employment status, I am still uninsured. In
    2009, I went back to school. I passed a 6-hour national medical
    coding certification exam and I still can't get a job. I'm not
    lazy. I spend hours each day in front of the computer, filling
    out applications and sending resumes the 21st century way to
    search for jobs.
        Healthcare and employment are so tightly intertwined, they
    cannot be separated. Getting people employed, and consequently
    healthy, is what your constituents want from you now. We also
    want you to defend and protect the new health law that will
    soon loosen the ties that bind healthcare coverage to
    employment status. Thank you.
        [The prepared statement of Ms. Zolotorow follows:]
                    Prepared Statement of Phyllis Zolotorow
                          is poverty a death sentence?
        I would like to thank Chairman Bernard Sanders, Ranking Member Dr.
    Rand Paul, and the members of the subcommittee for holding this hearing
    today.
        My husband Mike and I are the parents of a 26-year-old son whose
    numerous chronic life threatening illnesses started in 1987, at age 2
    when he was diagnosed with Common Variable Immunodeficiency, a mild
    form of the ``Boy in the Bubble Syndrome'' requiring expensive monthly
    intravenous infusions for his lifetime. When he was 3 my husband's
    employer-based health insurance company, changed the physician's
    diagnosis from Common Variable Immunodeficiency to AIDS, for the sole
    purpose of rationing Craig's health care by denying future claims. The
    Maryland State Commissioner of Insurance convinced them to change the
    diagnosis back to CVID by threatening their ability to do business in
    the State of Maryland.
        Craig had 7 surgeries in 3 years, Nephrogenic Diabetes Insipidus,
    Anemia, atypical Anorexia, fevers up to 105 degrees 5-15 times a month
    for years, acute kidney failure four times, Meningitis and many more
    diagnoses. During his childhood, he was followed by 12 specialists at
    The Johns Hopkins Children's Center. At age 10, Craig was diagnosed
    with Hodgkins Lymphoma. He was treated for cancer with my UFCW union
    health insurance coverage. While getting chemotherapy, it was
    discovered, during a crisis, that he had an Adrenocorticotrophic (ACTH)
    Deficiency. During treatment for a serious reaction to his previous
    round of chemotherapy, an insurance company clerk told Craig's Johns
    Hopkins Pediatric Oncologist to discharge him from the hospital because
    the ``for-profit" health insurance company did not pay for pediatric
    oncology inpatient stays without active chemotherapy infusions. We took
    Craig home but 3 hours later he was readmitted through the emergency
    room with a fever of 104 and complications that could have killed him.
    Because of his diagnoses and our 20 percent co-pay of a $250k medical
    bill in 1995, Craig became eligible for SSI with Medicaid co-
    eligibility, as his secondary insurer. Two years later, at age 12,
    Craig reached his lifetime maximum on my health insurance, so Medicaid
    became his primary and only insurer. By 1999, I had to leave my job to
    take care of Craig and his ever-increasing diagnoses.
        My husband, Mike, was seriously injured at work in December 2003,
    requiring 2 surgeries and 2 years of rehabilitation therapy. A year to
    the day after his injury, Mike's employer cancelled his health
    insurance and Worker's Comp Insurance paid for medical treatment of his
    injury only. In September 2005, Mike felt very sick while taking a
    walk. I wanted to take him right to the Emergency Room, but because he
    no longer had health insurance he refused to go due to the cost. Ten
    days later he had a massive, near fatal heart attack with severe damage
    to his heart and had a Defibrillator surgically implanted. Six months
    later when his condition worsened he had emergency quintuple bypass
    surgery. If a Medicare-like insurance plan had been available, (health
    insurance not dependent on employment status), Mike would have been
    diagnosed at the first sign of illness, had a much cheaper surgery and
    treatment for milder heart disease and would most likely have been
    working several months later adding to the tax base, instead of being
    permanently disabled.
        The hospital applied for Medicaid and SSDI (Social Security
    Disability Income) for Mike and Medicaid covered his medical expenses
    associated with catastrophic illness. As soon as he received Medicaid
    approval Mike was eligible to be placed on the Heart Transplant list
    (without any insurance, public or private, a human being in the United
    States is denied the ``privilege'' of a life saving transplant.) To be
    eligible for FULL Medicaid coverage without a spend-down (deductible)
    in the State of Maryland, the net income standard for a family of 2
    adults (with no dependent children) is $392.00/mo. Mike's monthly SSDI,
    our only income, was too high to qualify for full Medicaid without a
    spend-down. He had to accrue a deductible of paid or unpaid medical
    expenses of $3,500.00 every 6 months after which Medicaid picked up
    medical bills for the rest of that 6-month period. By the time that
    deductible was met, he ended up with coverage only every other 3 months
    or so, with uncovered expenses we may never be able to pay off.
        Five months after his heart attack, Mike received confirmation of
    eligibility for SSDI. But unlike Craig's SSI with co-eligibility for
    Medicaid, with SSDI, as per Federal regulations, there is a 24-month
    wait for eligibility for Medicare. Why? Only the most seriously ill are
    considered for SSDI. We have no choice but to believe that the Federal
    Government wanted Mike to die so Medicare didn't have to pay his
    medical expenses. Mike survived and is now submitting bills to
    Medicare. My spousal eligibility for Medicaid ended when Mike's
    Medicare coverage began in February, 2008, so I became and continue to
    be uninsured. From the time of Mike's heart attack, I knew I would be
    the permanent head of household. I immediately started looking for
    employment. I checked the biggest online employment Web sites on the
    Internet including that of Maryland's largest employer, THE STATE OF
    MARYLAND, but all the jobs I qualified for were contractual, no
    benefits. I had been forced to choose between applying for jobs I was
    qualified for, without health insurance benefits, thereby losing
    financial eligibility for Mike's Medicaid if hired, most likely
    resulting in his death, or not working and being forced into an
    unwanted life below the poverty level, thus qualifying him for partial
    Medicaid benefits and eligibility for a place on the transplant list. I
    chose my husband's life over earned income.
        I have had Crohn's Disease for most of my life and I was diagnosed
    with Type II non-insulin dependent Diabetes in 2001. I was overcome
    with exhaustion in 2008, unable to get out of bed without feeling faint
    many days of the week. With the constant stress of being the caretaker
    for my very ill family and financial worries, I thought I was suffering
    from severe depression. Without health insurance or a job, I felt I
    could not afford an office visit and assumed I could just think my way
    out of my depression. After a year of suffering, I finally gave in and
    went to my doctor. Being diabetic, she took a finger stick Glucose
    level. My supposed depression was actually a Glucose level of 500. I
    was working my way up to a diabetic coma. I am now a Type II Insulin
    Dependent Diabetic. During that office visit in 2009, I found out I was
    eligible for Maryland's PAC (Primary Adult Care) program. It allows me
    to see a family doctor only, and pays for my medications.
        Contrary to popular belief, most uninsured people don't go to the
    emergency room for minor illness. Who wants to spend 4-8 hours sitting
    in an emergency room? We go when we are so sick or in such pain we are
    frightened into believing that our lives are in jeopardy. And for those
    people who think the uninsured are well cared for in any emergency room
    for any illness, the emergency room will diagnose and stabilize you,
    but they do not treat chronic illness. I have had two hospitalizations
    in the last 2 years with bills totaling over $12,000. With no insurance
    and without the ability to pay out-of-pocket and with Mike's 2005-8
    deductibles of $15,000+, we get calls from medical collection agencies
    starting at 8:30 a.m. to 8:30 p.m., 7 days a week.
        With pre-existing illnesses, even with the Affordable Care Act's
    regulation of no pre-existing conditions clause forcing insurance
    companies not to refuse to insure us and out-of-pocket spending limits
    of $11,000 per year for a family, private coverage is still financially
    unaffordable for us. Even after passage of the ACA we find that care is
    still rationed by for-profit insurance companies that threaten our
    health. Two weeks ago my husband tried to refill his Lipitor, covered
    by the Medicare Part D insurer, Anthem--Wellpoint, that they have
    covered for the last 6 years. Lipitor limits Coronary Artery Disease,
    the main cause of my husband's heart attack and lessens the possibility
    of strokes. I called the insurer to find out why coverage was denied. I
    was told Lipitor was no longer part of their covered formulary and I
    needed to have the doctor fill out a Formulary Exemption form.
        The doctor's office called for, received the fax and filled out the
    formulary exception form, but there was no return fax number on that
    form. Mike was now 10 days without his medication. I called the insurer
    to ask what was going on and was told the doctor was faxed the wrong
    form. In anger, I told them if my husband had any medical issues due to
    their mistake, we would be filing a malpractice suit and I was
    contacting the Washington Post as soon as I hung up. I was then told
    the doctor could call in a pre-authorization (new information I was
    never told about with Mike's past medication formulary exemption
    changes) and they would approve his Lipitor within 72 hours. The
    pharmacy called later that day to let us know his prescription was
    ready for pick-up. Over the last 24 years I have become an expert at
    fighting for coverage and overturning insurance denials for my family.
        In 2009, I went back to school and in August, 2010, I passed a 6-
    hour national medical coding certification exam. I was employed by an
    MRI facility from December 2010 through April 2011, but was laid off
    when my employer lessened their patient case load by dropping patients
    insured by one insurance company due to reduced insurance
    reimbursements for MRI's in this region. I have been searching for a
    job since April and I still can't find employment. I'm not lazy, I have
    been a full-time but unpaid, medical case manager for Craig for the
    last 24 years and now for Mike, too. I spend hours each day in front of
    the computer filling out applications and sending resumes, the 21st
    century way to search for jobs with very little success. I have heard
    there are at least 1,000 resumes for every job listed!
        We have not always been uninsured. In my lifetime, I have had just
    about every kind of health insurance available in the United States. As
    a young single woman, I had an affordable individual private insurance
    policy, then, my husband's employer-based family insurance, for 7 years
    during some of my son's worst illnesses (I was a rooming in parent
    while Craig was a cancer inpatient and worked part-time evenings) I was
    a UFCW union member so my family had insurance through my union, we've
    had Medicaid and my husband is now on Medicare/Medicaid. I can't tell
    you how frustrating access to care is without one single affordable
    national health insurance option. Our easiest and fullest access to
    health care has been with government-funded but privately administered
    (Medicare and Medicaid) healthcare coverage.
        We are not a rare occurrence in the United States. Our friends,
    formerly upper middle class, are small business owners. With the
    economy of the last several years, their business has fallen
    considerably. They were forced to drop their individual family coverage
    due to the cost of $26,000/yr in premiums with 50 percent-60 percent
    co-insurance, co-pay and deductible out-of-pocket expenses for medical
    care and are now uninsured. Another friend, a nurse, who had to stop
    working because of medical disabilities, had an individual single
    insurance plan and was paying $700/month for about 50 percent co-
    insurance, co-pay and deductible out-of-pocket coverage. She was
    finally sick enough to qualify for SSDI and is now on Medicare. Even
    with an AARP Medicare Supplemental insurance plan, its a great
    financial relief for her.
        Although my son Craig has the intelligence and capacity to earn an
    unlimited income, unless he can find a permanent job with benefits, not
    a contractual job offering no health insurance benefits, he will be
    limited to a salary of less than $30,000/yr so as not to jeopardize his
    much-needed Medicaid coverage. He will never achieve the American Dream
    of home ownership but then, of course, he will never lose his home to
    medical bankruptcy, either. Why not let people earn as high a salary as
    their capabilities allow, paying into the tax base and pay a premium,
    based on their income, into the Medicaid program helping to keep it
    funded while keeping their lifesaving coverage?
        Under the status quo, since access to health care in the United
    States is dependent upon employment status, jobs and health are so
    tightly intertwined they cannot be separated. It's cheaper for the
    United States to make sure all of its citizens have access to
    affordable, quality health care. A citizen able to access care is
    healthier. Healthy people work and add to the tax base and seek less or
    no social service assistance from the State or Federal Governments. A
    healthy working citizen adds to the economic growth of the United
    States.

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Senator Sanders. Thank you very much, Ms. Zolotorow. Let me
    start off with a question for Dr. Braveman. And I hope Senator
    Paul will correct me if I'm misstating what I believe his
    position to be. But we have heard testimony today that,
    essentially, anybody in Kentucky, I gather, or maybe in
    America, can get access to a doctor, access to a hospital,
    access to prescription drugs when they need it, regardless of
    income. Is that your understanding of reality, Dr. Braveman?
        Dr. Braveman. There is a huge body of evidence that says
    that that's not true.
        Senator Sanders. Do you want to elaborate on that?
        Dr. Braveman. There, you can look at evidence that comes
    out of the National Center for Health Statistics, out of the
    Agency for Healthcare Research and Quality. I know there's the
    Federal agency's data that are examined on an annual basis. And
    there's evidence of lack of access to care among certain
    portions of the population.
        I do want to emphasize, though, just in case this point
    gets lost, that poverty is a death sentence, but it's not----
        Senator Sanders. Right.
        Dr. Braveman [continuing]. Just because of the lack of
    medical care.
        Senator Sanders. And you made that point extremely well.
        Let me ask Mr. Cannon and Ms. Zolotorow. Mr. Cannon, do you
    believe that it's true that anybody in America, regardless of
    income, can access doctors, hospitals, prescription drugs?
        Mr. Cannon. No. I'm sorry. Sorry, Mr. Chairman. No. I think
    that cost is a barrier to access to medical care for people who
    are uninsured. But I think the same thing is also true, or at
    least my answer is also no when it comes to people who are
    enrolled in government programs like Medicaid.
        There are people in the Medicaid program who cannot access
    a doctor. There have been deaths of people in the Medicaid
    program because they cannot access a doctor. I think it's
    crucial to recognize, when we're wrestling with these
    questions, that there is no such thing as perfection here.
    Perfection is not an option.
        A healthcare system is going to be maintained by humans, no
    matter how it's designed, and so we will always have--and
    former Senate majority leader Tom Daschle makes this point well
    in his book, Critical--we will always have people falling
    through the cracks, whether it's a completely free market
    system or whether it's a completely government-run system.
        I think what we have to focus on is, what system does the
    best job of preventing people from falling through the cracks,
    filling those cracks in so that we minimize the number of
    people who fall through the cracks.
        Senator Sanders. Ms. Zolotorow, based on your experience,
    do you think it's true that anybody in America can access a
    doctor, a hospital, or get the prescription drugs they need,
    regardless of income?
        Ms. Zolotorow. No. I can't see a specialist for my Crohn's
    disease. I can't see an endocrinologist. I am extremely lucky
    to live in the State of Maryland, because I am in the PAC
    program. It's a program----
        Senator Sanders. Please explain what the PAC program is. Is
    that a State of Maryland program?
        Ms. Zolotorow. Yes. It is.
        Senator Sanders. Yes.
        Ms. Zolotorow. If you cannot qualify for Medicaid, it is
    kind of a partial Medicaid. You can see your family doctor and
    you can have your prescriptions covered. But you cannot see a
    specialist to be treated for any other condition. Luckily,
    there is a free clinic at the Wilmer Eye clinic in Baltimore at
    Johns Hopkins.
        And I am tested once a year for a diabetic retinitis, which
    Dr. Paul must have expertise in. And without these programs, I
    would most likely be one of the 45,000 Americans who die each
    year. I wouldn't be here talking to you.
        Senator Sanders. Dr. Braveman, you make a very important
    point, and your point is not just that people are dying, or
    suffering, or losing limbs because they can't get to a doctor
    when they should. But you're talking about the whole life
    cycle, of what it means to be poor, the kinds of diet that one
    has, the kind of stress that one lives under, which contributes
    to illness.
        Can you just compare, for a moment--and I think that's an
    enormously important point that goes above and beyond access to
    medical care, which is also enormously important. Can you give
    us a snapshot? Somebody is upper middle class, earns a good
    income, has health insurance. Somebody is poor. And maybe
    especially the impact on the children--what happens? What does
    it mean that over 21 percent of our kids are living in poverty?
    What does that mean for the future?
        Dr. Braveman. Let me give you an illustration. So here's a
    person over here who earns a good living, have kids, kids in
    childcare. They work. And here's a person over here who also
    has kids, and works, and does not earn a good living, is poor,
    is really on the edge.
        And for both of them, something happens that makes their
    childcare arrangements fall through. The person over here has
    the resources to find an alternative. They keep their job. They
    are not experiencing the stress of wondering what's happening
    with their kids.
        The person over here is in a situation where there's
    tremendous stress involved in trying to figure out a way
    without the resources to come up with a suitable arrangement.
    They may take chances and leave their kids in situations that
    are not healthy, situations where the kids don't get the kind
    of nutrition, or stimulation, or even that aren't safe.
        But in addition, the person without the resources is much
    more likely to lose their job because of this problem with
    childcare. And situations like that, with a million variations
    play themselves out, literally, every day and account for a
    difference in the levels of stress. And as I had mentioned
    earlier, what we've learned about the way that the physiology
    of stress is how it gets under the skin.
        We know it's not just cortisol. There are cytokines
    involved. And we know something about telomere length. There's
    a lot that we don't know, but we now understand the physiology
    of stress and how it gets under the skin. So that's just one
    minor example.
        Senator Sanders. I've exceeded my time. I'm going to give
    Senator Paul an equal amount of time, but let me ask my last
    question. I began my discussion by pointing out that countries
    like Denmark, Finland, Norway, Iceland, Slovenia, and Sweden
    have substantially lower childhood poverty rates, substantially
    lower. And I might add that they have, also, refrigerators, and
    air conditioning. I was there. They even have electric lights,
    you know. They're able to do all those things.
        What does it mean for the future of the country--I'm going
    to let everybody take a shot at this--that 21 percent of our
    kids are living in poverty, that the number in the midst of
    this terrible recession might very well rise? What does it mean
    for the future of our country? Dr. Braveman, and then others,
    take a shot at that.
        Dr. Braveman. Now, I'll tell you, it's a time bomb. I mean,
    it's already true that in the United States, we rank at or near
    the bottom, consistently, year after year, and getting worse.
    Among industrialized countries, we rank at or near the bottom
    in life expectancy, as well as in infant mortality.
        I think the current science tells us that, most likely, to
    explain that lower ranking on life expectancy, we need to look
    at childhood poverty. The growing childhood poverty is going to
    translate into more and more chronic disease in adulthood and
    lives cut short.
        The business roundtable a few years ago took a very strong
    position, calling for the need for universal, government-
    supported, high quality early childhood development programs,
    sort of high quality early Head Start-type programs, based on
    the implications for a productive workforce and future medical
    costs for employers.
        Senator Sanders. Good. Thank you very much.
        Mr. Cannon, you want to take a shot at that?
        Mr. Cannon. If I may back up to 1996, I think there's a
    lesson in that year for when we look at childhood poverty and
    poverty overall. In 1996, Congress eliminated the Federal
    Entitlement to Cash Assistance under the old AFDC program. They
    effectively removed lots of people from the cash assistance
    rolls.
        The predictions were, from critics, that this would lead to
    an increase in poverty, an increase in child poverty. People, a
    million children dying of starvation, I think, was one of the
    predictions.
        In fact, what happened was, poverty fell for every age and
    income group, and only this year has the overall poverty rate
    risen to the level it was back in 1996.
        Now, I don't mean to suggest that eliminating that
    entitlement and cutting back the Federal Government's--this
    anti-poverty program necessarily caused that reduction in
    poverty.
        But it was followed by a reduction in poverty. It did not
    cause the increase in poverty that some had predicted, and so I
    think the lesson from that is that sometimes, government
    efforts to combat poverty can actually induce people to become
    dependent on that assistance and can perpetuate poverty.
        And I fear, moving forward, now that the poverty rate has
    climbed in this recession back up to the levels--to pre-1996
    levels, I am concerned that, moving forward, and especially in
    2014, we are going to trap even more people in poverty and in
    low-wage jobs, because the recently enacted healthcare law does
    contain subsidies to help low-income individuals purchase the
    mandatory health insurance, that this law requires nearly every
    American to buy.
        But those subsidies disappear as income rises. In fact, it
    creates what economists call low-wage traps that will impose
    upon low-
    income households effective marginal tax rates that exceed 100
    percent, far beyond the actual tax rates that even the
    wealthiest Americans pay.
        That can discourage low-income families from climbing the
    economic ladder, so I'm very concerned about the poverty rate
    in the future.
        Senator Sanders. OK. This is Ms. Zolotorow.
        Ms. Zolotorow. I feel that children who are sick, hungry--
    they just cannot get educated as well as a child who is well-
    fed and well, medically. And these children are someday going
    to be the adults that are going to take care of us when we are
    no longer able to take care of ourselves. And I sure would like
    to hope that they are all as well-educated, and healthy, and
    intelligent as they possibly can be.
        Senator Sanders. Thank you. I have exceeded my time.
    Senator Paul.
        Senator Paul. Yes. The disease of Kwashiorkor, or
    malnutrition, the swollen babies, the swollen bellies that we
    see in the third world, you don't see in the United States. You
    don't see famine in the United States.
        Life expectancy has doubled. Around 1900, people lived
    about 46 years. I remember, in medical school, them talking
    about menopause being a disease that was not evolved for--or a
    condition not evolved for because no one lived that long.
        It's a hundred years that we have nearly doubled our life
    expectancy. We should be proud, where we've come. Childhood
    mortality, infant mortality, infectious disease mortality have
    all been reduced 200-fold in our country.
        These are great successes of capitalism. We need to be
    proud of our economic system. We need to be proud of who we are
    as a country. The poor among us are infinitely better off than
    the middle class in most countries. The poor among us are able
    to get healthcare at a rate that greatly exceeds the vast
    majority of the world.
        We have had developed nations that have had malnutrition
    and famine. These developed nations were like the Soviet Union,
    that plummeted into the depths of famine and malnutrition
    because of their economic system, because of socialism.
    Socialism doesn't work.
        We have countries like Zimbabwe that have great natural
    resources and great wealth. And it is squandered because they
    don't have the rule of law. They don't have a constitution that
    protects private property. Their leaders run off with their
    money and the poor have nothing. They have no running water.
    They have extensive infectious disease, despite having wealth.
        So we need to be proud of many of the things we have in our
    country. And my question for Mr. Cannon is, I really enjoyed
    when you said, what are the causes of prosperity. It's more
    important than knowing anything else.
        The people on the lowest end of the life expectancy curve,
    one generation ago, now exceed the ones who are rich at that
    time. So in one generation, we've allowed the poorest among us
    to live longer than the rich did a previous generation. That's
    an amazing statistic and something we should be enormously
    proud of.
        My question for Mr. Cannon is, how important is it, the
    type of economic system you choose, as far as trying to
    alleviate poverty in this country?
        Mr. Cannon. Thank you, Senator. I think it's incredibly
    important. The examples you highlighted are on point. To the
    extent that economic activity in a nation is directed by
    political systems rather than by markets and market actors,
    there's a degree of irresponsibility because the political
    system, the actors in that system are not spending their own
    resources. They don't spend them as wisely.
        And they also are not able to capture all of the
    information that a market system can capture, through the price
    system and other mechanisms, to harness the new ideas that
    people bring to bear on this problem of, how do we make
    resources more abundant and bring them into the hands of people
    who cannot afford these resources right now.
        So I think that if economic history has taught us anything,
    it is that a market economy does a much better job of solving
    the problem of poverty than an economy driven by political
    systems.
        Senator Sanders. Senator Merkley--Senator Paul, are you
    finished with your questioning?
        Senator Paul. Yes, thank you.
        Senator Sanders. Senator Merkley has joined us and I would
    like to ask a few more questions, but Senator Merkley, please.

                          Statement of Senator Merkley

        Senator Merkley. Thank you very much, Mr. Chair, and thank
    you all for your testimony. Mr. Cannon, you note in your
    testimony that Congress rushed the Affordable Care Act into law
    without waiting for the results of one study, the randomized,
    controlled Oregon Health Insurance Experiment.
        That was a situation in which, essentially, there wasn't
    enough money to cover everyone who was eligible for Medicaid in
    Oregon, the Oregon Health Plan. And so a lottery was held, and
    therefore, gave us one of the first real comparable control--
    groups type studies.
        I wanted to give you a chance to expand a little bit on
    your observations on that. My understanding is that we only
    have 1 year's results at this point, and that involves a study
    of the use of healthcare, the financial strain on the families,
    and overall health. All is self-reported. In the second year,
    there's going to be hard data regarding cholesterol, blood
    sugar, blood pressure, obesity, and so forth, that will be
    better scientific information.
        But what is your sense of the type of insights this might
    provide to us?
        Mr. Cannon. I'll try to keep my answer brief. There is a
    lot to be said about it. The first part of the answer is that
    it's very difficult to know the actual impact that extending
    Medicaid coverage to a population has on that population's
    health or financial security, because just extending coverage
    to these people in the control, and then looking at similar
    individuals, and trying to make comparisons that way may miss
    important characteristics that are different between those two
    groups, that might also be accounting for the differences that
    you're seeing.
        So it's important to----
        Senator Merkley. Such as? Just help us understand it.
        Mr. Cannon. If you look at people enrolled in Medicaid and
    people not enrolled in Medicaid, you might say, ``oh, well, the
    people enrolled in Medicaid are sicker.'' Therefore, Medicaid
    must make people sick, or give them worse health outcomes, when
    really, the reason they enrolled in Medicaid is because they're
    sick.
        You might have health behaviors that's a confounding
    variable. There are all sorts of confounding variables, so the
    challenge is to isolate the one variable you're trying to test,
    which is Medicaid coverage, from all the others, and the way
    you do that is with what Oregon did, somewhat inadvertently,
    which is randomization, randomly assigning some people to
    receive Medicaid.
        So you're correct. There's only been 1 year of results so
    far. It's only self-reported health. There are measures of
    self-reported health. There was a mortality measure which was
    not able to discern any difference between the Medicaid group
    and the nonMedicaid group. The authors of the studies believe
    it was statistically underpowered. You just didn't have a large
    enough group or enough years to detect mortality differences
    yet, but we'll have to see.
        There are also financial security measures. Now, I would
    say, there are improvements in financial security. There are
    improvements in self-reported health. And you know, people
    defer about whether those are larger or modest.
        I would say that one of the self-reported health measures
    is a little harder than the others, which is that people
    enrolled in the Medicaid arm had, I think, 10 restricted
    activity days per month, due to the mental or physical
    problems, which is a pretty--you can say that's a subjective
    health measure. It's a pretty important one and there was some
    improvement on that score, a half-day improvement.
        So the importance of this study is that it, really, for the
    first time, measures the effect of Medicaid in a scientifically
    rigorous way. And it's important. That's important to do, not
    just to establish that there are benefits to expanding Medicaid
    coverage to new populations, but also so that policymakers can
    compare the benefits of expanding Medicaid to other
    interventions that might improve health or financial security,
    and because I think the only responsible way to approach this
    is to say, ``OK, for a given amount of money, what is it that
    we're trying to maximize?''
        If it's health, then we should be putting that money into
    whatever gets us the most health per dollar spent. There are a
    lot of economists who believe that programs like the one I
    mentioned in my testimony--a discreet program to go into low-
    income neighborhoods, and screen, and treat people for
    hypertension--would save a lot more lives for the money than
    would expanding Medicaid, say, up to all low-income
    individuals.
        My recommendation is that before Congress expand any
    programs, that Congress do more such testing so that they can
    really find out what works. Otherwise, we might be wasting an
    awful lot of money on ineffective strategies to promote what
    we're trying to promote.
        Senator Merkley. Thank you. I appreciate your point. I do
    share the perspective that anytime we can actually collect data
    on what works and what doesn't makes sense, that we can then
    utilize our resources in a far more effective manner.
        I do think I want to really draw attention to this study
    because I think, as additional results come out, if it's
    carefully followed up on, it will provide a lot of valuable
    insights. The self-reporting was striking. The reduction in
    financial strain was substantial, folks reported a 40 percent
    decrease in the probability of having unpaid medical bills,
    increased access to preventative care. They reported feeling
    healthier, and putting themselves in good and excellent health,
    an increase in 25 percent.
        It's just kind of a taste of the information that we'll get
    as we continue to study that process and understand how that
    applies to providing cost-effective healthcare in America.
        Mr. Cannon. If I may respond just briefly, unfortunately,
    we're only going to get one more year's worth of data out of
    that Oregon experiment, which is why I recommend doing the same
    in other States, especially large States.
        Senator Merkley. OK.
        Or continuing to study the Oregon experiment a few more
    years into the future.
        Mr. Cannon. Well, there will only be 2 years of data
    collection, because I believe Oregon expanded Medicaid to
    everyone who had previously been excluded.
        Senator Merkley. Correct. Thanks.
        Senator Sanders. All right. Let me just close. I am sorry
    that Senator Paul had to leave. But I just wanted to ask one
    more brief question, and Senator Merkley could participate as
    well, of course. Senator Paul made a statement--and I think
    I've got it right here. I always hesitate to quote somebody
    who's not here. But he said something like, the poor can get
    healthcare better in the United States than in any other
    country. Dr. Braveman, is that true?
        Dr. Braveman. That is not true and there's a tremendous
    amount of data to support that. And you know, what that brings
    up for me is, you know, we said we rank--I mean, we are No. 1
    in child poverty among the industrialized countries.
        There's another thing we're No. 1 on, which is spending on
    medical care. And yet, we consistently rank at or near the
    bottom on measures of health, like infant mortality and life
    expectancy. And many experts believe that it's because of child
    poverty. That's the biggest thing.
        It's not about the medical care. It also is a statement
    about the inefficiency of the medical care that probably can't
    be made up from within the medical care system, because the
    inefficiency is based on the poverty.
        Senator Sanders. All right. Let me ask you another
    question. Senator Paul also made the point, which is obviously
    correct, as longevity has improved, we live a lot longer than
    people did 50 years ago, 100 years ago, and so forth, and so
    on.
        But I think the real comparison--and I would say this to
    Mr. Cannon also--is not necessarily how we compare to people
    living a while back, with all of the growth, and medical
    technology, and medicine and so forth, but how we compare to
    other countries in the year 2011.
        Dr. Braveman, how are we comparing, in terms of life
    expectancy, to other countries around the world? Are we No. 1?
        Dr. Braveman. We have been consistently at or near the
    bottom among the industrialized countries.
        Senator Sanders. OK.
        Dr. Braveman. I mean, that's where the most valid
    comparison is. I would also like to comment that I think it's a
    moral issue, whether you say, I'm going to compare the health
    of the poor now to the health of the poor 25, 50 years ago, and
    say, you're doing great, they're doing better, or whether the
    moral obligation is not to say, I'm going to compare the health
    of the poor with the health that is possible----
        Senator Sanders. Right.
        Dr. Braveman [continuing]. The health potential that is
    there. And at a minimum level, that is indicated by the health
    of socially advantaged people within this country. Even if we
    say, ``OK, we're not going to compare to other countries,''
    because that would be a relatively low standard--to the health
    of the affluent within our country, on many measures, is worse
    than the health of lower income people in some other countries.
        But certainly, I think one can say that the health of the
    affluent in this country represents a standard that should be
    possible for everyone. There is no medical reason why everyone
    shouldn't attain that and----
        Senator Sanders. OK. Let me ask Mr. Cannon. Mr. Cannon,
    I've enjoyed your testimony and I certainly agree with you,
    that when we spend public dollars, we want to make sure that,
    that money is used as cost effectively as possible. And we
    certainly don't always do this.
        But I don't want to be provocative and put words in your
    mouth. I wish Senator Paul was here. But I heard--I'm not
    really quite that familiar with the--all of what's going on in
    Zimbabwe. I know it's bad news, but I trust you do not believe
    that those countries that have substantially lower childhood
    levels of poverty, such as Denmark, Finland, Norway, Iceland,
    etc, are socialist tyrannies. I trust you don't believe that.
        Mr. Cannon. I don't----
        Senator Sanders. Or do you believe that?
        Mr. Cannon. I don't know that I would call them tyrannies.
    But I think socialist is probably a closer description. But
    let's keep in mind what socialism is, it is the government
    assuming control of more of the resources that are available in
    society, and to the extent the government asserts that control
    takes that control away from individuals.
        Senator Sanders. Correct. But the result is----
        Mr. Cannon. And the result is--which results in----
        Excuse me.
        Mr. Cannon [continuing]. Less freedom----
        Senator Sanders. I'm going to give you----
        Mr. Cannon [continuing]. For those individuals.
        Senator Sanders. Do you think it causes less freedom? So do
    you think, when children in Denmark have a 3.6 percent rate of
    poverty, compared to 21 percent plus in the United States, our
    poor kids are freer than those enslaved children in Denmark?
        Mr. Cannon. Well, then those enslaved children are--OK. So
    you mean under the socialist system. Freedom, as I use the
    term, when in discussions like these--let me back up. There are
    multiple definitions of freedom.
        If, by freedom, you mean the freedom to purchase whatever
    you want, the freedom to go where--to have the resources to do
    whatever you want, if that's what you mean by freedom, then
    actually, automatically, whoever has more resources is more
    free.
        Senator Sanders. No. But my question was----
        Mr. Cannon. When I----
        Senator Sanders. I'll give you a chance to respond. Please
    let me ask the question.
        Mr. Cannon. Well, I think I am answering the question.
        Senator Sanders. My question is, you're not suggesting that
    the people of Denmark, and Finland, and Sweden are not free, by
    the conventional definition of the word?
        Mr. Cannon. Economically, I believe they are less free. The
    conventional definition of the word is, do you have the freedom
    to do what you want with your life without being subject to
    physical restraint by others? And that could be the State. That
    could be other individuals, other than the State.
        Senator Sanders. And you think that is the condition in
    Scandinavia?
        Mr. Cannon. Well, let me ask you this. If you had to pay--
    --
        Senator Sanders. I'm asking you the questions.
        Mr. Cannon. Well, but I'm a good Irishman, I'm going to
    answer a question with a question. If the government charged
    you a 100 percent tax rate, would you be free, if the
    government then provided you all of the material needs that an
    individual would want?
        Senator Sanders. I am not aware their governments or this
    government is charging people----
        Mr. Cannon. Well--but to answer your question----
        Senator Sanders. I'll--excuse me.
        Mr. Cannon [continuing]. I'm asking you----
        Senator Sanders. You can ask the questions when you get
    elected and I'll be over there, but at this moment, I'm asking
    the questions, OK? I think that's a hypothetical that is not
    terribly sensible.
        Mr. Cannon. Well, then let----
        Senator Sanders. This is----
        Mr. Cannon. Well, no.
        Senator Sanders  This is----
        Mr. Cannon. I think it is.
        Senator Sanders. OK, OK.
        Mr. Cannon. I think it illustrates----
        Senator Sanders. Mr. Cannon, excuse me, please. Ms.
    Zolotorow, would you like to answer the question?
        Mr. Cannon. I would appreciate the opportunity to answer
    your question.
        Senator Sanders. All right. You've had a considerable
    amount of time. I'll get back to you. But Ms. Zolotorow, would
    you like to answer the question?
        Ms. Zolotorow. Well, I think, if you're talking about
    freedom, when it comes to healthcare, if you are uninsured, you
    are not--you don't feel free to just get access to care. It is
    a job in itself. And you are penalized when you are sick and
    you are uninsured.
        When you go to the emergency room, if you are admitted into
    the hospital, if you are insured, the hospital receives no
    compensation for the time you spent there, the emergency room,
    because they're an outpatient facility and the coding guideline
    is, if you are admitted from an outpatient facility, they
    forfeit their payment and the hospital gets paid, because the
    care you got there is considered the first initial hospital
    day.
        But if you are uninsured, I get the bill for that. So I not
    only get the hospital bill from when I was admitted through the
    emergency room to the hospital. I got the bill for the
    emergency room, that an insured patient will not get. I get the
    hospital bill. I get all the doctors' bills. And I feel that
    that's a detriment to my freedom.
        Senator Sanders. OK. Thank you. Senator Merkley, you want
    to say something?
        Senator Merkley. Thank you, Mr. Chair, and I think this is
    an important conversation. It takes me to my town halls. I have
    36 town halls, one in each county each year, and I am one short
    of completing that for my third year.
        I can't tell you how many times people come up to me and
    say, here's where I'm at: I'm in my late 50s, early 60s. I'm
    just trying to figure out how to bridge the gap until I can be
    under Medicare because my health problems and my inability to
    pay for them--basically dominate my life.
        And we know, from many studies, that people delay, if you
    will, addressing their problems because they can't afford to.
    And then Medicare picks up the problems when they're more
    advanced and more troubling.
        If we think of this in terms of quality of life, there's an
    awful lot of folks out there who feel like they could pursue
    what they'd like to pursue in life better if they didn't have
    the millstone of the costs of an extraordinarily expensive
    healthcare system around their neck.
        And so I think there is kind of a double-edged sword here.
    We're arguing two sides of that issue. And I think it's a good
    discussion. I do want to end on the note, though, that the
    common ground that I feel is the point that Mr. Cannon made. We
    should be smart in studying what works. Oregon has been a
    leader in this. They've had some very controversial discussions
    about ranking, what procedures work the best, are most cost-
    effective, so that at any given level, you can afford to invest
    in insurance. You get the maximum public health effect from
    that.
        That's a hard conversation for folks to have. People like
    to polarize the debate, but the fact is, every insurance policy
    has limits on what you cover and being smart about cost-
    effectiveness is an area that merits a lot of exploration. And
    I thank you all for your testimony on what is really such an
    important conversation to the quality of life in America.
        Senator Sanders. OK. Let me thank the panelists. And Mr.
    Cannon, maybe we will continue our discussion on the nature of
    human freedom at some other point. But thank you all very much
    for coming. Thank you.
        [Whereupon, at 11:52 a.m., the hearing was adjourned.]