[Senate Hearing 112-865]
[From the U.S. Government Publishing Office]
S. Hrg. 112-865
IS POVERTY A DEATH SENTENCE?
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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?
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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.
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* World Health Organization Final Report on the Social Determinants
of Health, Geneva, Switzerland, 2008.
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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.]