[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]


                  THE PRESIDENT'S AND OTHER BIPARTISAN
                      PROPOSALS TO REFORM MEDICARE

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

                                 HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                      COMMITTEE ON WAYS AND MEANS
                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED THIRTEENTH CONGRESS

                             FIRST SESSION

                               __________

                              MAY 21, 2013

                               __________

                          Serial No. 113-HL04

                               __________

         Printed for the use of the Committee on Ways and Means
         
         
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                      COMMITTEE ON WAYS AND MEANS

                     DAVE CAMP, Michigan, Chairman

SAM JOHNSON, Texas                   SANDER M. LEVIN, Michigan
KEVIN BRADY, Texas                   CHARLES B. RANGEL, New York
PAUL RYAN, Wisconsin                 JIM MCDERMOTT, Washington
DEVIN NUNES, California              JOHN LEWIS, Georgia
PATRICK J. TIBERI, Ohio              RICHARD E. NEAL, Massachusetts
DAVID G. REICHERT, Washington        XAVIER BECERRA, California
CHARLES W. BOUSTANY, JR., Louisiana  LLOYD DOGGETT, Texas
PETER J. ROSKAM, Illinois            MIKE THOMPSON, California
JIM GERLACH, Pennsylvania            JOHN B. LARSON, Connecticut
TOM PRICE, Georgia                   EARL BLUMENAUER, Oregon
VERN BUCHANAN, Florida               RON KIND, Wisconsin
ADRIAN SMITH, Nebraska               BILL PASCRELL, JR., New Jersey
AARON SCHOCK, Illinois               JOSEPH CROWLEY, New York
LYNN JENKINS, Kansas                 ALLYSON SCHWARTZ, Pennsylvania
ERIK PAULSEN, Minnesota              DANNY DAVIS, Illinois
KENNY MARCHANT, Texas                LINDA SANCHEZ, California
DIANE BLACK, Tennessee
TOM REED, New York
TODD YOUNG, Indiana
MIKE KELLY, Pennsylvania
TIM GRIFFIN, Arkansas
JIM RENACCI, Ohio

        Jennifer M. Safavian, Staff Director and General Counsel

                  Janice Mays, Minority Chief Counsel

                                 ______

                         SUBCOMMITTEE ON HEALTH

                      KEVIN BRADY, Texas, Chairman

SAM JOHNSON, Texas                   JIM MCDERMOTT, Washington
PAUL RYAN, Wisconsin                 MIKE THOMPSON, California
DEVIN NUNES, California              RON KIND, Wisconsin
PETER J. ROSKAM, Illinois            EARL BLUMENAUER, Oregon
JIM GERLACH, Pennsylvania            BILL PASCRELL, JR., New Jersey
TOM PRICE, Georgia
VERN BUCHANAN, Florida
ADRIAN SMITH, Nebraska


                            C O N T E N T S

                               __________

                                                                   Page

Advisory of May 21, 2013 announcing the hearing..................     2

                               WITNESSES

Joseph R. Antos, Ph.D., Wilson H.Taylor Scholar in Health Care 
  and Retirement Policy, American Enterprise Institute...........     6
Joe Baker, President, Medicare Rights Center.....................    24
Alice M. Rivlin, Ph.D., Co-Leader, Bipartisan Policy Center 
  Health Care Cost Containment Initiative, Senior Fellow, 
  Economic Studies, Brookings Institution........................    15

                       SUBMISSIONS FOR THE RECORD

AARP, statement..................................................    59
AFSCME, statement................................................    63
Alliance for Retired Americans, statement........................    66
American Association of Bioanalysts, statement...................    69
Center for Medicare Advocacy, statement..........................    71
National Association for Home Care & Hospice, statement..........    82
National Association of Chain Drug Stores, statement.............    93
National Committee to Preserve Social Security and Medicare, 
  statement......................................................    98
Pam Casper, statement............................................   100
Partnership for Quality Home Healthcare, statement...............   102
Partnership for the Future of Medicare, statement................   109
Robert N. Young, statement.......................................   112
Shannon Dwyer, statement.........................................   116
St. Joseph Health, statement.....................................   117
Texas Association for Home Care and Hospice, statement...........   119
Torchmark Corporation, statement.................................   121
United Auto Workers, statement...................................   124
United Steelworkers, statement...................................   127
Virginia Association for Home Care and Hospice, statement........   131
Visiting Nurse Associations of America, statement................   133

 
                  THE PRESIDENT'S AND OTHER BIPARTISAN
                      PROPOSALS TO REFORM MEDICARE

                              ----------                              


                         TUESDAY, MAY 21, 2013

             U.S. House of Representatives,
                       Committee on Ways and Means,
                                    Subcommittee on Health,
                                                    Washington, DC.

    The Subcommittee met, pursuant to call, at 10:03 a.m., in 
Room 1100, Longworth House Office Building, Hon. Kevin Brady 
[Chairman of the Subcommittee] presiding.
    [The advisory announcing the hearing follows:]

ADVISORY

                 FROM THE COMMITTEE ON WAYS AND MEANS

                         SUBCOMMITTEE ON HEALTH

                                                CONTACT: (202) 225-3943
FOR IMMEDIATE RELEASE
Tuesday, May 14, 2013
No. HL-04

                  Chairman Brady Announces Hearing on

                  the President's and Other Bipartisan

                      Proposals to Reform Medicare

    House Committee on Ways and Means, Subcommittee on Health Chairman 
Kevin Brady (R-TX) today announced that the Subcommittee on Health will 
hold its first in a series of hearings to explore the bipartisan 
proposals, including those contained in President Obama's Fiscal Year 
2014 Budget to reform Medicare. This hearing will focus on review of 
proposals to change cost-sharing for services received under the 
Medicare program. The hearing will take place on Tuesday, May 21, 2013, 
in 1100 Longworth House Office Building, beginning at 10:00 a.m.

      
    In view of the limited time available to hear from witnesses, oral 
testimony at this hearing will be from invited witnesses only. However, 
any individual or organization not scheduled for an oral appearance may 
submit a written statement for consideration by the Committee and for 
inclusion in the printed record of the hearing. A list of witnesses 
will follow.

      

BACKGROUND:

      
    Created in 1965, the Medicare benefit was originally modeled on the 
Blue Cross Blue Shield plans that were prevalent throughout the Nation 
at that time. However, since its creation, Medicare's cost-sharing has 
been largely unchanged and has not kept up with changes in the growth 
of the Medicare population or how health care is delivered. The current 
Medicare spending trajectory is unsustainable and has led the Medicare 
trustees to estimate that the Part A trust fund will be bankrupt in 
2023 and insolvent in 2024. The Medicare Health Insurance (HI) trust 
fund has not met the trustee's formal test of short-range financial 
adequacy since 2003. The Supplemental Medical Insurance (SMI) trust 
fund is considered adequately financed, however, this is a result of 
the SMI trust fund being reliant on general revenue transfers. By 2037, 
the Medicare trustees estimate general revenue transfers will account 
for 56 percent of Medicare outlays.

      
    To address these and other concerns, the Obama Administration has 
identified several key policies to modify cost-sharing within the 
Medicare program. In the President's FY14 budget, the Administration 
focused on three key cost-sharing policies: (1) increasing income-
related premiums for Medicare Parts B and D; (2) increasing the annual 
Medicare Part B deductible; and (3) establishing a home health copay. 
The President's FY14 budget estimates that these three policies will 
save $54 billion over 10 years. In addition to the President's budget, 
several other bipartisan policy organizations, such as the Bipartisan 
Policy Center, The Moment of Truth project, and the Medicare Payment 
Advisory Commission, have collectively made recommendations to alter 
Medicare's cost-sharing policies as a means of extending the longevity 
of the program.

      
    In announcing the hearing, Chairman Brady stated, ``The current 
Medicare spending trajectory is unsustainable. There is bipartisan 
recognition that modifying seniors' cost-sharing is appropriate and can 
be done in a way that maintains access to critical healthcare services. 
Medicare is fast going broke and the time to act to save this program 
is now.''

FOCUS OF THE HEARING:

      
    The hearing will review policies that modify beneficiary cost-
sharing within the Medicare program.
      

DETAILS FOR SUBMISSION OF WRITTEN COMMENTS:

      
    Please Note: Any person(s) and/or organization(s) wishing to submit 
for the hearing record must follow the appropriate link on the hearing 
page of the Committee website and complete the informational forms. 
From the Committee homepage, http://waysandmeans.house.gov, select 
``Hearings.'' Select the hearing for which you would like to submit, 
and click on the link entitled, ``Click here to provide a submission 
for the record.'' Once you have followed the online instructions, 
submit all requested information. ATTACH your submission as a Word 
document, in compliance with the formatting requirements listed below, 
by the close of business on Tuesday, June 4, 2013. Finally, please note 
that due to the change in House mail policy, the U.S. Capitol Police 
will refuse sealed-package deliveries to all House Office Buildings. 
For questions, or if you encounter technical problems, please call 
(202) 225-1721 or (202) 225-3625.
      

FORMATTING REQUIREMENTS:

      
    The Committee relies on electronic submissions for printing the 
official hearing record. As always, submissions will be included in the 
record according to the discretion of the Committee. The Committee will 
not alter the content of your submission, but we reserve the right to 
format it according to our guidelines. Any submission provided to the 
Committee by a witness, any supplementary materials submitted for the 
printed record, and any written comments in response to a request for 
written comments must conform to the guidelines listed below. Any 
submission or supplementary item not in compliance with these 
guidelines will not be printed, but will be maintained in the Committee 
files for review and use by the Committee.
      
    1. All submissions and supplementary materials must be provided in 
Word format and MUST NOT exceed a total of 10 pages, including 
attachments. Witnesses and submitters are advised that the Committee 
relies on electronic submissions for printing the official hearing 
record.
      
    2. Copies of whole documents submitted as exhibit material will not 
be accepted for printing. Instead, exhibit material should be 
referenced and quoted or paraphrased. All exhibit material not meeting 
these specifications will be maintained in the Committee files for 
review and use by the Committee.
      
    3. All submissions must include a list of all clients, persons and/
or organizations on whose behalf the witness appears. A supplemental 
sheet must accompany each submission listing the name, company, 
address, telephone, and fax numbers of each witness.
      
    The Committee seeks to make its facilities accessible to persons 
with disabilities. If you are in need of special accommodations, please 
call 202-225-1721 or 202-226-3411 TDD/TTY in advance of the event (four 
business days notice is requested). Questions with regard to special 
accommodation needs in general (including availability of Committee 
materials in alternative formats) may be directed to the Committee as 
noted above.
      
    Note: All Committee advisories and news releases are available on 
the World Wide Web at http://www.waysandmeans.house.gov/.

                                 ---------
                                 
    Chairman BRADY. Subcommittee will come to order. I want to 
welcome everyone to today's hearing on the President's budget 
and other bipartisan proposals to reform Medicare. This is the 
fourth hearing for our Subcommittee this Congress, and the 
second Ways and Means Committee hearing in a series focused on 
proposals to reform Medicare and Social Security. During our 
first hearing of Congress we focused on redesigning the 
Medicare benefit package to make it more rational, more 
responsive to seniors and Medicare patients. Today's discussion 
is an extension of that hearing discussing the details around 
these three specific policies:
    One, increasing income-related premiums for Medicare Parts 
B and D; two, increasing annual Medicare Part B deductibles, 
and three, establishing a home health copay. We focused on 
these three policies because they are included in the 
President's 2014 budget and supported by several bipartisan 
organizations. All too often recently, discussions surrounding 
finding Medicare savings have come under the context of a 
``grand bargain'' or a ``super committee.'' As the committee of 
jurisdiction over these critical topics, we have an obligation 
to discuss them publicly and determine how best to craft policy 
in these areas. That is why we are holding this hearing today.
    The President's budget estimates that these three policies 
will save $54 billion over 10 years. These are real savings for 
a program that is facing bankruptcy in 10 short years. Asking 
seniors to pay more when they have the means to do so is not a 
new concept. In 2003, Republicans led the charge with income-
related premiums for Medicare Part B in the Medicare 
Modernization Act, which ensured that seniors have access to 
accessible, affordable, high-quality medicines through free 
market competition for their business.
    In 2010, Democrats included income-related premiums in the 
Medicaid program, Health Exchanges, and increases for Medicare 
Part D in the Affordable Care Act, known as ObamaCare. 
Throughout Federal programs, there has been recognition that 
some seniors can contribute more and some seniors need 
additional assistance. The growth of the retiree population has 
been and will continue to be a tremendous source of stress on 
Medicare's finances.
    When Medicare was enacted in 1965, the average life 
expectancy was 70.2 years. It was anticipated that Medicare 
would cover an average person's health expenditures for the 
last 5.2 years of their life. In 2010, the average American 
lived to the age of 78.4, which means Medicare covered the last 
13.5 years of life, a 158 percent increase. Yet, we have not 
made changes to the Medicare benefit structure to address this 
increase.
    Now, I know that some may want to reject these policies out 
of hand and may suggest that the overall Medicare spending for 
seniors has decreased. They may contend that this means there 
is less of a need to find Medicare savings. But I, too, am glad 
to see Medicare spending is down, but the program is headed 
toward bankruptcy in 10 short years. Burying our heads in the 
sand and waiting for the looming crisis to overwhelm us will 
only force future Congresses to take more drastic measures.
    Even the Medicare trustees recognize the growing challenges 
of Medicare's financial future as the baby boomers enter 
Medicare. Even if per-senior spending decreases, that will not 
help the sustainability of the trust fund when the number of 
new seniors coming into the program begins to dramatically 
increase.
    And simply cutting providers is not the answer. In fact, 
the Medicare trustees warn because of cuts already in law, 15 
percent of our Part A providers will be unprofitable by the end 
of this decade. Roughly 40 percent would be unprofitable by 
2050. The actuaries warn that these cuts will force providers 
to withdraw from providing services to our Medicare seniors and 
patients.
    Finally, instead of simply focusing on how much money a 
policy might save Medicare or how many more beneficiaries will 
pay more, I challenge this Committee and our witnesses today to 
think differently. The question we should be asking ourselves 
is, how can we act now, this year, to extend Medicare solvency? 
If not permanently, how about for an additional 10 years beyond 
2023? Why not extend its life an additional 20 years? We owe it 
to current and future seniors to examine and pursue these 
critical goals. It will require hard decisions, yes. But making 
them now will ensure a vibrant Medicare for generations to 
come.
    Before I recognize Ranking Member McDermott for the 
purposes of an opening statement, I ask unanimous consent that 
all Members' written statements be included in the record. 
Without objection, so ordered.
    I now recognize Ranking Member McDermott for his opening 
statement.
    Mr. MCDERMOTT. Thank you, Mr. Chairman.
    There was a time in the Congress when the procedure was 
that the President proposed and the Congress disposed. And so I 
would just put a caveat on anything that has been proposed by 
the White House that that is not holy writ brought down from 
the mountain by Moses. That is to be looked at by the Congress 
and we will make a decision.
    The Majority keeps holding hearings on supposedly 
bipartisan reform ideas, but over and over it is the same song: 
Cut the benefits, shift the costs to the poor and the elderly. 
These reforms were offered by the President in a spirit of a 
grand, balanced bargain. That package has shared sacrifice and 
included some spending cuts and revenue increases, but when it 
is cherry picked, when you catch the low-hanging fruit, they 
are nothing more than partisan cuts. How many times and how 
many ways can we rehash the same old idea? We have been trying 
to get blood from a stone.
    Fifty percent of the Medicare beneficiaries in this country 
have annual incomes at or below $22,500. Our seniors, our 
parents, our grandparents, 50 percent of them are living barely 
above the poverty line. They should not be our go-to source for 
savings.
    We are long overdue on fixing the physician payment system 
and I sincerely hope we can work in a bipartisan way to do it. 
In particular, we need to address inequities in payment for 
primary care physicians, and we need to do it in a way that 
encourages the most efficient delivery of health care so we can 
be pushing more of the right kind of care, not just more care 
overall.
    Now let me be clear, and I am speaking as a physician here: 
It is the physicians who are driving the healthcare utilization 
in the system, not the beneficiaries. The notion that 
beneficiaries have to have more skin in the game to encourage 
smart healthcare shopping is ridiculous. When your doctor tells 
you you need an extra test, or to come back in 2 weeks, how 
many of you poll other doctors to see if they agree? Of course 
not. There is a major information asymmetry between doctors and 
patients and a necessity to trust the physician's judgment. Few 
beneficiaries can distinguish between necessary and unnecessary 
care, and in the face of more cost-sharing, they may forego 
both.
    I would like to submit for the record a recent letter from 
the National Association of Insurance Commissioners in which 
they state that they were unable to find evidence that cost-
sharing encouraged appropriate use of healthcare services. In 
fact, they found that cost-sharing would result in delayed 
treatments that could increase costs and result in negative 
health outcomes.
    As it is, Medicare households pay nearly 15 percent of 
their income on health care as compared to non-Medicare 
households, which pay 5 percent. As one of our witnesses, Joe 
Antos, points out in his testimony, higher income Medicare 
beneficiaries already pay more into the system, both through 
higher premiums and because they have paid more payroll taxes 
over the course of their working lives.
    As for the notion of home healthcare deductible, these 
beneficiaries are some of the frailest individuals in Medicare. 
Why do Republicans insist on using this Committee to go after 
them rather than building on the ACA's tools to fight fraud in 
this section?
    It is fundamentally untrue that we have to cut Medicare in 
order to save it. If we are looking for offsets, we could focus 
on pharmaceutical companies' windfall from the Republicans' 
Part D drug benefit. Creating a drug rebate to capture that 
windfall would save $141 billion, the entire cost of the SGR 
fix. We could look to the providers with higher Medicare 
margins. MedPAC tells us that those margins mean payment rates 
are too high. Or we could look to the savings from winding down 
the wars in Afghanistan and Iraq. There are plenty of other 
savings to be found that don't involve jeopardizing the health 
and security of some of our most vulnerable Americans.
    I look forward to this hearing and the witnesses' 
testimony. I think that we are faced with a question that we 
are going to have to face at some point. That is, how do you 
control costs in the healthcare system? I yield back.
    Chairman BRADY. Thank you.
    And without objection, the document will be included in the 
record.
    Today we will hear from three witnesses, Joseph Antos, the 
William H. Taylor Scholar in Health Care and Retirement Policy 
at the American Enterprise Institute; Alice M. Rivlin, the 
Senior Fellow of Economic Studies at the Brookings Institution; 
and Joe Baker, President of the Medicare Rights Center.
    I want to thank you all on behalf of Mr. McDermott and 
myself, thank you all for being here today. I look forward to 
your testimony. You will all be recognized for 5 minutes for 
the purposes of providing your oral remarks.
    Mr. Antos, we will begin with you.

 STATEMENT OF JOSEPH R. ANTOS, PH.D., WILSON H. TAYLOR SCHOLAR 
   IN HEALTH CARE AND RETIREMENT POLICY, AMERICAN ENTERPRISE 
                           INSTITUTE

    Mr. ANTOS. Thank you, Mr. Chairman.
    Medicare is on a fiscally unsustainable path. Seventy-six 
million members of the baby boom generation will turn 65 and 
enroll in Medicare over the next 2 decades. According to AARP, 
that is about 8,000 baby boomers every day. The resulting costs 
will place a heavy strain on the Federal budget, crowding out 
other spending priorities and burdening younger generations, 
and for that matter burdening older generations who will have 
to pay the rising costs of the Medicare program.
    Comprehensive reforms are needed to ensure that Medicare 
will be able to continue to meet the needs of its beneficiaries 
over the long term. Bipartisan commissions, including the 
Bowles-Simpson commission, the Bipartisan Policy Center, the 
Medicare Payment Advisory Commission, and the Engelberg 
Center's Bending the Curve project concur on several principles 
that should form the basis of Medicare reform. One of those 
principles is addressed today, and that is the need to reform 
cost-sharing responsibilities to promote cost awareness and 
improve equity in the program.
    Today's hearing focuses on three proposals advanced by the 
President: raising the Part B deductible, adding a copayment 
for some home health episodes, and increasing premiums for 
higher income beneficiaries. These proposals, as the Chairman 
said, these proposals yield $54 billion in budget savings over 
the next decade. That is less than 1 percent of the $7.9 
trillion that Medicare will spend over the same period.
    These are modest changes, certainly financially, but they 
could lead to bipartisan discussions of broader reforms to 
protect Medicare for future generations. Medicare reform should 
create a benefit that is easy to understand and that protects 
seniors from catastrophic costs. That is a principle that I 
think is almost universally agreed, but the Medicare program is 
the way it is today for historical reasons.
    The bipartisan commissions support proposals to simplify 
traditional Medicare's confusing benefit structure. If patients 
know what a health service will cost them, they will be more 
informed about their alternatives and will be better able to 
decide, with their physicians, about the best course of action. 
Replacing the multiple deductibles and complicated copayment 
structure in traditional Medicare with a simpler design typical 
of private insurance is one step in this reform. Limiting what 
Medigap plans cover so that beneficiaries pay some of the 
upfront costs themselves is another part of this reform.
    The President's budget proposals are much narrower. The 
Part B deductible would be increased 75 years over 3 years. The 
new copayment would be levied on certain home health episodes 
that were not preceded by an inpatient stay. Both proposals 
would apply only to new Medicare enrollees as of 2017. Those 
proposals have been criticized as imposing a burden on 
beneficiaries. But in fact 90 percent of beneficiaries have 
supplementary coverage through Medigap, retiree plans, or 
Medicaid. Consequently, most beneficiaries have nearly complete 
coverage against out-of-pocket costs.
    That fosters inefficiency in Medicare and adds to the costs 
of the program, which are borne by beneficiaries and taxpayers. 
I might add that for those who buy Medigap policies, they are 
simply paying it through another mechanism. They are still 
paying the cost.
    So a more equitable phase-in than the President proposes 
would provide further protection for beneficiaries who do not 
already have supplementary coverage. The cost-sharing provision 
should be applied to all beneficiaries, not only to new 
enrollees, but exceptions could be made based on a 
beneficiary's ability to pay or health status, rather than the 
year of their enrollment.
    The third proposal increases income-related premiums under 
Part B and Part D. This extends the principle that those with 
greater means should provide more support for the program, a 
principle embraced by Republicans and Democrats alike. This 
principle was embodied in Medicare at its beginning in 1965. 
High earners pay more in payroll taxes, as Mr. McDermott 
pointed out, and income taxes throughout their work lives. That 
started in 1966, and we still have this principle today.
    How much they should pay is an ethical judgment, but if the 
budget resources are not available to maintain an adequate 
level of Medicare benefits for every senior, then we should 
care first for those who cannot afford to cover the costs 
themselves.
    Increasing premiums reduces the fiscal pressure faced by 
Medicare, but it does not address the fundamental defects that 
drive up program costs. Higher premiums do not change the 
financial incentives of fee-for-service Medicare. They do not 
change the way beneficiaries use services, or the way services 
are delivered. More fundamental reforms that address Medicare's 
cost drivers are needed.
    Any significant Medicare reform will take time to develop 
and implement. It is better to start that process now rather 
than delay until the fiscal crisis is upon us. Abrupt actions 
forced by crisis harm seniors and risk the long-term stability 
of the program. Proposals advanced by the President, as well as 
proposals from the independent commissions, potentially provide 
a basis for bipartisan agreement and the start of a process 
that can preserve and improve Medicare for future generations. 
Thank you.
    [The prepared statement of Mr. Antos follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT] 
    
                                 --------
    Chairman BRADY. Thank you, Mr. Antos.
    Ms. Rivlin.

  STATEMENT OF ALICE M. RIVLIN, PH.D., CO-LEADER, BIPARTISAN 
 POLICY CENTER HEALTH CARE COST CONTAINMENT INITIATIVE, SENIOR 
        FELLOW, ECONOMIC STUDIES, BROOKINGS INSTITUTION

    Ms. RIVLIN. Thank you, Chairman Brady and Ranking Member 
McDermott.
    Let me start with a basic question: Why reform Medicare? 
The main reason for reforming Medicare is not that the program 
is the principal driver of future Federal spending increases, 
although it is. The main reason is not that Medicare 
beneficiaries could be receiving much better coordinated and 
more effective care, although they could. The most important 
reason is that Medicare is big enough to move the whole 
American health delivery system away from fee-for-service 
reimbursement, which rewards the volume of services, and toward 
new delivery structures which reward quality and value. 
Medicare can lead a revolution in healthcare delivery that will 
give all Americans better health care at sustainable cost.
    This Committee knows very well that health care in the 
United States is expensive and getting more so. Moreover, 
quality is uneven, and much care is duplicative, wasteful, and 
uncoordinated. For decades, however, reformers have focused 
less on cost containment and quality improvement than on 
closing the gaps by widening healthcare insurance coverage. But 
now that the near universal coverage has been ensured by the 
Affordable Care Act, attention should shift to improving 
quality and value of healthcare delivery for all and containing 
cost growth.
    I recently had the privilege of co-leading with former 
Senators Daschle, Domenici and Frist the Bipartisan Policy 
Center's report on the future--on cost containment in health 
care. We reached a consensus on a comprehensive package of 
reforms that span the entire healthcare system with a 
particular focus on Medicare and Federal health-related tax 
policy. We believe that if enacted together, and that is 
important, these reforms will improve healthcare quality for 
patients and families and lower overall spending throughout the 
healthcare system.
    Budget savings were not our primary objective, but we 
believe that these reforms would achieve approximately $300 
billion in net savings over the next 10 years and about a 
trillion in the following 10 years. These saving estimates are 
net of the cost of fixing the dysfunctional sustainable growth 
rate physician payment formula.
    Now, as has been noted, our bipartisan foursome were not 
mavericks working in isolation. The Simpson-Bowles commission, 
the Bending the Curve project at Brookings, and indeed the 
President's budget have endorsed many of the same proposals. It 
seems that a bipartisan consensus is emerging on using Medicare 
and tax reform to lead the transition of the health system away 
from fee-for-service and toward quality and value-based care.
    Briefly, our recommendations included preserving the 
guaranteed health coverage promised in traditional Medicare; 
modernizing the benefit package for Medicare to create a cap on 
beneficiary cost-sharing, a catastrophic cap which we don't now 
have; combining the Part A and B deductibles; and exempting 
physician visits from the deductible and preventive care from 
all cost-sharing. We would limit Medicare supplemental 
coverage, and we would protect low-income beneficiaries by 
helping them with cost-sharing up to 150 percent of the poverty 
line. We would raise Part B premiums for higher-income 
beneficiaries in a slightly different way than the President 
does.
    Most importantly, we would create Medicare networks, an 
improved version of the affordable care organization 
demonstrations in the Affordable Care Act. Medicare networks 
would be provider-led and enrollment-based, and would better 
provide coordinated care. Beneficiaries and providers would 
have incentives to join them, and reimbursement would be 
increasingly reflective of measures of quality and value.
    We would replace the SGR with a better structure, and we 
would increase competition among health plans in Medicare 
Advantage by implementing a new competitive bidding structure 
that would result in lower payments and helping beneficiaries 
navigate plan choice on a user-friendly website.
    We would also limit the tax-favored treatment of expensive 
health insurance products by capping the exclusion of employer-
paid benefits. And we would have a cumulative limit on the 
increase in Medicare spending for each of the three categories 
that we propose.
    This would not be an easy set of reforms to enact or 
implement, Mr. Chairman, but we believe it would improve the 
care delivery under Medicare and save money at the same time.
    [The prepared statement of Ms. Rivlin follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                                 -------
    Chairman BRADY. Thank you, Ms. Rivlin.
    Mr. Baker.

                    STATEMENT OF JOE BAKER, 
               PRESIDENT, MEDICARE RIGHTS CENTER

    Mr. BAKER. Thank you, Chairman Brady, Ranking Member 
McDermott, and distinguished Members of the Subcommittee on 
Health, for the opportunity to testify this morning about 
proposals to modify Medicare cost-sharing. Medicare Rights 
Center is a national nonprofit organization dedicated to making 
sure that people with Medicare get access to affordable health 
care. We counsel about 15,000 people a year and their families 
and through our education initiatives help about 700,000 
others.
    Proposals to increase the Medicare Part B deductible, 
introduce a home health copayment, and further income-relate 
Medicare premiums share a common pernicious theme: Each plan 
achieves savings by shifting cost to the very people Medicare 
was designed to protect.
    Cost shifting to Medicare beneficiaries doesn't solve the 
underlying problem with our healthcare system: the long-term 
challenge of systemic healthcare inflation and costs, which 
threatens both the public and the private spheres. We believe 
that Congress should focus its attention on reforms that 
diminish wasteful Medicare spending and encourage the 
transformation of our healthcare system from one that rewards 
high-volume care to one that rewards high-value care.
    To this extent, we support the proposals that would shift 
no costs, like advancing some of the delivery system reforms in 
the Affordable Care Act, restoring Medicare drug rebates, 
equalizing reimbursements to Medicare Advantage plans, and 
other proposals.
    Today, as Ranking Member McDermott said, half of all people 
with Medicare, 25 million older adults and people with 
disabilities, are living on annual incomes of $22,500 or less 
and spending about 15 percent of their household income on 
healthcare costs as opposed to 5 percent for those under age 65 
who are not on Medicare. These people with Medicare cannot 
afford to pay more for health care. Indeed, the most common 
call to our help line comes from a Medicare beneficiary having 
difficulty affording a treatment or a medicine. Further, 
forcing so-called wealthy beneficiaries to pay more for 
Medicare translates into a premium hike on middle-class 
retirees and people with disabilities while also fracturing one 
of our Nation's most successful social insurance programs.
    Added cost-sharing leaves many beneficiaries with no choice 
but to self-ration care. Faced with higher upfront costs, 
beneficiaries living on fixed incomes are likely to forego 
doctor's visits, a decision made on affordability, not on 
healthcare needs. Almost 40 years of data consistently 
demonstrates that while higher out-of-pocket costs certainly 
deter healthcare utilization, it deters utilization of needed 
care as well as unneeded care indiscriminately. The equation is 
simple: Higher out-of-pocket costs will require many Medicare 
beneficiaries to go without, either going without heating or 
rent payments, or going without needed medical care. And in the 
long run, reduction in the use of medically necessary care can 
increase healthcare spending through the increased likelihood 
of emergency room visits, ambulance rides, and hospital stays.
    Increasing the Medicare Part B deductible, either alone or 
by combining the Part A and Part B deductible, is one of 
several proposals that adhere to the faulty logic that added 
cost-sharing is an appropriate tool to limit healthcare service 
use. Most alarming about this proposal is that these added 
costs would impose greater hardship on beneficiaries with low 
fixed income. And with regard to the point about supplemental 
insurance covering this, many who would also increase the 
deductible would also decrease the level of coverage in Medigap 
or other Medicare supplemental plans.
    Similarly, introducing a home health copayment would be 
most damaging to the most vulnerable--the poorest, the oldest 
and the sickest. The typical home health user is an older, 
lower-income woman with one or more common or chronic 
conditions. Beneficiaries who need ongoing care to remain in 
their homes and not be institutionalized in nursing homes or 
other types of care are most at risk of skipping needed care if 
forced to pay this copayment.
    Many policymakers suggest that wealthier beneficiaries can 
contribute more in Medicare costs, specifically through higher 
premiums. Yet higher-income beneficiaries already pay higher 
premiums, as we have heard. Achieving savings of any scope 
under these proposals requires reaching down the income 
spectrum. Recent analysis shows that individuals making $47,000 
per year would pay more under current proposals. And that is a 
slippery slope. It could get lower and lower as this is looked 
at.
    So we implore you to reject proposals that fail to build a 
better healthcare system, instead only achieve ephemeral 
savings by shifting costs to people with Medicare. Thank you 
for this opportunity to testify.
    [The prepared statement of Mr. Baker follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
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    Chairman BRADY. Thank you, Mr. Baker.
    First to Mr. Antos, Ms. Rivlin. Medicare is so important. 
It is in deep trouble. Lawmakers like to bury their heads in 
the sand on these tough issues. How important is it that we act 
this year to either save Medicare for the long-term or to take 
meaningful steps to extending its life, for example, another 20 
years or more? Mr. Antos. Ms. Rivlin.
    Mr. ANTOS. Well----
    Chairman BRADY. Act now.
    Mr. ANTOS. Acting now is a critical matter. Congress has 
had plenty of opportunity to take appropriate actions over 
many, many years. But in fact we still face the fiscal problems 
and the risk to the Medicare program.
    Chairman BRADY. I have a couple more questions for you, so 
your point is act now?
    Mr. ANTOS. Act now, but act responsibly.
    Chairman BRADY. Got it.
    Ms. Rivlin.
    Ms. RIVLIN. I would say act now, but for the principal 
reason that you can use Medicare to reform the whole system.
    Chairman BRADY. Yeah. Yeah. Do you see, as you look at 
these issues and the President's policies in his budget, 
income-related premiums for Medicare Parts B and D, the Part D 
deductible establishing a home health copay? The President has 
suggested this begin 4 years from now, 2017. Ms. Rivlin, do you 
see any reason we should wait that long?
    Ms. RIVLIN. I don't think you need to wait until 2017. You 
need a little time to get them in place and----
    Chairman BRADY. Yeah. Set them up.
    Ms. RIVLIN. Set them up. So it can't be 2014. I think we 
suggested 2016 as a reasonable year. But again, I wouldn't do 
these in isolation. Do them as a package.
    Chairman BRADY. Got it, makes sense.
    Mr. Antos, you emphasized broad reforms of combining 
Medicare Parts A and B. This important topic, the Subcommittee 
has been looking at and will continue to explore. Would you 
consider the policies we are discussing today to be smaller 
reforms on the pathway to perhaps bigger ones?
    Mr. ANTOS. Well, they could be on the pathway to a 
discussion about combining A and B and more sensible reforms of 
Medicare. But these specific proposals I don't think take us in 
that direction. They are simply budget cuts.
    Chairman BRADY. Got it.
    Ms. Rivlin, you--and Mr. Antos, you both recommended 
establishing a home health copay so that patients determine the 
value of those services that are being provided to them. Some 
critics have warned it would deter many vulnerable Medicare 
beneficiaries from accessing needed care, maybe increase 
returning to hospitals. Can you respond to those criticisms?
    Mr. ANTOS. Well, certainly, the President's proposal 
follows the Medicare Payment Advisory Commission's precaution 
and restricts this to episodes that have at least five visits 
and are not preceded by an inpatient stay.
    Chairman BRADY. So you are not coming from the hospital.
    Mr. ANTOS. You are not coming from the hospital. 
Nonetheless, this is a serious matter. And the problem with a 
lot of Medicare policy is that it is very heavy-handed. We need 
to have a more subtle policy or we need to have a better 
management of patient care.
    Chairman BRADY. Should we adjust it to the income of the 
Medicare senior?
    Mr. ANTOS. We certainly should recognize the extra burden 
that this is going to cause on the minority of patients who 
don't have the money.
    Chairman BRADY. Ms. Rivlin, your thoughts?
    Ms. RIVLIN. Home health care is liable to abuse, and I 
think that some cost-sharing is appropriate. In our plan, we 
actually help the lower-income beneficiaries cope with total 
cost-sharing, including any new cost-sharing, so it wouldn't be 
subject to that criticism.
    Chairman BRADY. Yeah. And your belief is we are looking at 
value over volume. Is Washington the best one to determine what 
that value of service is, or are patients actually using them, 
you know, who have some role in some cost-sharing, small or 
large, according to ability to pay? Is that where we see value 
more likely to be determined?
    Ms. RIVLIN. Well, when we talk about value and quality, we 
envision a set of measures that will eventually govern the 
reimbursement as we get more experience with them. I don't 
think you entirely rely on patients, as Dr. McDermott has 
suggested, to sort out what is quality. The point of cost-
sharing is to give patients some reason to stop and think, 
unless they are very low income, about whether they need to go.
    Chairman BRADY. That makes sense.
    Mr. Baker, I just want to understand: You absolutely reject 
the President's proposals to begin some of these reforms in 
Medicare?
    Mr. BAKER. Yes, we think that the cost-sharing as set is a 
blunt instrument and one that would visit some harm on 
beneficiaries.
    Chairman BRADY. Okay. Thank you.
    Mr. McDermott.
    Mr. MCDERMOTT. Thank you, Mr. Chairman.
    I didn't take economics and so I am always pleased with the 
chance to learn from economists how they think. You take the 
average person is 78 years old, and he or she is living on 
$22,000 and spending about $3,000 on average, 15 percent, on 
their medical expenses, okay. So they are already spending a 
big chunk out of it.
    Now, we are going to impose a tax on them. We are going to 
tax them--we are going to call it a premium increase, but it is 
a tax. It is a tax on the seniors that we are putting on here. 
And I want to understand from the economist's point of view how 
imposing that tax on a 78-year-old senior who is living on 
$22,000 and spending $3,000 already on health care, how is that 
going to change the delivery of the healthcare system to 
deliver quality instead of quantity?
    I mean, I am trying to think of Mr. Johnson sitting there 
and saying, well, the doctor said I should come back and have 
my blood pressure checked, and it is going to cost me X number 
of dollars and so forth, and so I am not going to go. Or I am 
going to go because the doctor told me to. How does this change 
the cost of overall Medicare by putting a tax on seniors of 
another 50 bucks a month?
    Ms. RIVLIN. That proposal is not what I--tax on seniors of 
50 bucks a month is not what I am advocating.
    Mr. MCDERMOTT. You are not talking about the melding of the 
Part A and Part B?
    Ms. RIVLIN. We are.
    Mr. MCDERMOTT. You are. So that means that the money that 
they pay will be more per month, right?
    Ms. RIVLIN. Let me finish. We do not propose a net increase 
in beneficiary cost-sharing. The package that we would have, 
and it is a package, would reduce the cost-sharing for low-
income beneficiaries, increase it at the top. It would also 
make some very important changes in the benefit package that 
would say no deductible for going to the doctor ever, and no 
cost-sharing at all for preventive care, and a cap on out-of-
pocket spending. All of that is helpful to your average and 
below beneficiary.
    Mr. MCDERMOTT. So then you are going to put it all on the 
richer people, that is the idea. Since it is not going to cost 
the poor people more, it has to cost the richer people more, is 
that it? So you are putting the tax on the people above----
    Ms. RIVLIN. Well, we are increasing the Part B premium, 
yes, for higher-income people. There is already an income 
relation, and we would lower the thresholds for that, but not 
to levels where people are in need.
    Mr. MCDERMOTT. When does it tip over into being a welfare 
system? If you are poor you get it for free; if you are rich, 
you have to pay for it. I mean, that is what we have now in the 
healthcare system in this country. If you are poor, you go to 
Medicaid, right? Or you just walk into the emergency room and 
get taken care of. The rest of us pay for it, and we are paying 
1,000 bucks a year for the cost of the uncompensated care, 
presently. What you are doing is just shifting it to the top, 
is that what you are saying?
    Ms. RIVLIN. That is part of what I am saying, but remember, 
we don't pay for Part B. Right now the premiums cover only 25 
percent of the cost of Part B. We would like the premiums to 
cover a somewhat higher share, and we would do that by raising 
the premiums for people like me. I am a beneficiary of Medicare 
who can afford to pay it.
    Mr. MCDERMOTT. Mr. Baker, your view of this whole process?
    Mr. BAKER. Well, I think whenever you are talking about 
shifting the benefit, especially in the context of deficit 
reduction or for paying for other things, you are looking for 
savings. And in that context, even if you are protecting lower-
income people----
    Mr. MCDERMOTT. You are looking for savings or you are 
looking for more revenue?
    Mr. BAKER. Well, you are looking for revenue for the 
Federal budget, of course.
    Mr. MCDERMOTT. So it is basically a tax.
    Mr. BAKER. It is a tax.
    Mr. MCDERMOTT. You are taxing somebody to get more revenue 
into the system.
    Mr. BAKER. It gets more revenue into the system, and I 
think that the problem is, it doesn't solve the underlying 
problem, as I said, which is the healthcare costs themselves 
and inflation in that market, and it is kind of a slippery 
slope. So once you start charging, say, people at $60,000 or 
$85,000 a year or more, and you can argue whether that is a 
wealthy individual when you look at our Tax Code, not 
necessarily as wealthy, of course, as someone at 450 or a 
million dollars where tax rates start to go up. But even for 
folks that are in that middle-income range, they do not qualify 
for low-income protection. They are strapped.
    So, you know, you are looking at folks that are the most 
vulnerable, that have the least control over their utilization 
of health care, because as you had mentioned, once they get to 
the doctor and they are in the healthcare system, they are 
moving through that system. They are following doctor's orders. 
And I think that is where the incentives need to be placed on 
controlling care, through accountable care organizations, some 
other mechanisms I think we all see as appropriate.
    Mr. MCDERMOTT. Thank you.
    Chairman BRADY. Thank you.
    Mr. Roskam is recognized for 5 minutes.
    Mr. ROSKAM. Thank you, Mr. Chairman.
    You know, it is interesting to take a step back and look at 
the trend and the history of this discussion. So the trend 
would suggest that income-related premiums and the discussion 
around them are here to stay. If you look at 2003, the decision 
by House GOP at that point to move forward on Part D and Part 
B; the decision by the Democrat majority in 2010 to move 
forward with similar themes as it relates to Medicaid and 
health exchanges in Part D; the decision of the Obama 
Administration, even if it is de minimis, they are 
acknowledging in their budget that it is here to stay.
    So, Mr. Baker, I think that you are making yesterday's 
argument. Yesterday's arguments, they are nostalgic, but I 
think that the entire question, these numbers are so big, they 
have really eclipsed. Mr. McDermott raised this question about 
the economics of this, and that is sort of the wonder of it 
all, isn't it? That if you give patients choices, and not 
cutting out the legs from underneath the vulnerable that he is 
defending today, as well he should, but you look at the success 
of Part D, for example, a lot of the themes that we have heard 
in terms of criticisms of income-related premiums, we have 
heard those echoes in the past, and that was the claim that 
Part B was going to sort of lead to a very difficult situation, 
when as we all know, the data suggests just the opposite. 
Incredibly high satisfaction rate among seniors, you know, 
savings that have come in well under, you know, by 45 percent 
under the expectations. So that is part of the power of giving 
people choices and the ability to move forward.
    Mr. McDermott mentioned a minute ago the idea of a senior 
being told, well, chase this down, you know what I mean, and 
come back and double-check with your physician. Part of the 
other story, though, to complete the picture is, many times if 
you are told by a physician to get an MRI, or whatever it 
happens to be, right now the system doesn't create an 
environment where you have much interest in trying to figure 
out who is doing the most efficient MRI. Where is the best, 
cheapest, and easiest, as opposed to the one that you just end 
up in?
    Dr. Rivlin, can I ask you a question? With that sort of 
predicate, you made an interesting statement, and you said that 
the driving opportunity right now take the debt--and it is a 
pretty provocative thing. You said the debt is a big question; 
set it aside. A more effective healthcare system is 
interesting; sort of set it aside. But you are telling this 
Committee and this Congress that you have such a big 
opportunity right now that you can have a transformational 
moment as it relates to Medicare. What did you mean by that?
    Ms. RIVLIN. The rising costs are not just in Medicare. They 
are in the whole system. And one of the culprits is the fee-
for-service reimbursement system, which does, not surprisingly, 
reward more services, more volume, rather than coordinating 
care and rewarding value and quality.
    We think that the accountable care organizations, we all 
think that accountable care organizations should be 
strengthened, provider-led networks that will take care of the 
whole patient, coordinates the care, and we think do it on a 
better, a higher quality basis, and at a lower cost.
    Now, time will tell whether that is right, but there is a 
strong feeling among health policy analysts that it is time to 
use Medicare to move the whole system off of fee-for-service.
    Mr. ROSKAM. Thank you. I yield back.
    Chairman BRADY. Thank you.
    Mr. Pascrell is recognized for 5 minutes.
    Mr. PASCRELL. Thank you, Mr. Chairman.
    Ms. Rivlin, I think you have hit the nail on the head when 
you talk about Medicare and the whole system. Because I think 
one of the major problems we had in putting the ObamaCare 
together, in writing out the law, and it is voluminous pages, 
we have all heard, was that we often lose track that the person 
who is over 65 years of age many times has the same kinds of 
problems that a couple of 45 years of age have. And we have 
missed the point on this thing. When you shift costs, when you 
are shifting costs, as you laid out, you are not changing the 
cost, you are not lowering the cost. It is like the person who 
doesn't look at his hospital bill because it is covered, 
because I have insurance.
    This moves the cost higher as well. I mean, many medical 
people don't want us to be knowledgeable of what is in the 
bill. And let's face it and let's say it like it is. I 
understand my colleagues on the other side continue to say that 
these proposed additional costs to beneficiaries are bipartisan 
proposals, I will have you know. But we must remember that the 
President offered the proposal in the context of a broad, large 
deficit-reduction package that requires both spending cuts and 
increased revenues.
    We also need to remember that reform to the Medicare 
program is already underway. Why we will not admit to that, 
some on my side, and some on the other side, is beyond me. When 
we put the Affordable Care Act together, the purpose of that 
was to look at, one of the specifics was Medicare and to reduce 
the cost.
    And already, already, what we have done is the following: 
We have had entitlement change. We won't admit it. If you have 
Medicare, you qualify for an annual wellness visit, mammograms, 
other screenings for cancer and diabetes, important preventive 
care. Medicare Advantage plans that give better quality care 
receive additional bonus payments. Plans must use some of the 
bonus money to offer you added health benefits. Medicare 
Advantage plans cannot change--or charge people more than the 
original Medicare pays for certain services. These services 
include chemotherapy administration, renal dialysis, and 
skilled nursing care. The law cracks down on waste, on fraud 
and abuse, a major part of that ObamaCare. Nobody refers to 
this. We have selective memory about what we want to think 
about or talk about in this legislation. And we guard against 
medical identity theft, et cetera, et cetera. It improves long-
term care services.
    Why not target when you say that we have to move away from 
fee-for-service, not just for seniors, for everybody? For 
everybody? Can we say it enough times, Ms. Rivlin, for 
everybody? Because the costs are too high. And if we don't 
change those costs and find a way to do it without cost 
controls, then we are not going to have any system at all, not 
just we will reduce the propensity of Medicare and the strength 
of Medicare.
    Overall health spending has been constrained. Per capita 
Medicare spending was 0.4 percent of GDP in 2012, last year. 
And CBO projects Medicare cost growth will remain low 
throughout the decade. There is a reason for this. Are there 
less people going into Medicare? Heck no. And overall health 
inflation has been at historic lows for 3 years in a row.
    There is a report that came out this morning, I don't know 
if you saw it. Senior poverty is much worse than you think due 
in part to such burdens. The new Kaiser Family Foundation 
report finds that the SPM poverty rate for seniors is actually 
higher than the official rate, 15 percent versus 9 percent. And 
here we are talking about shifting costs, even if it is to the 
higher income. We better be darn careful about this, because if 
we don't understand the situation that seniors are in, we are 
in big trouble.
    Mr. Baker, if I can get a quick question in. I think we are 
trying to go in a new direction here. I agree we should always 
be open to new ideas. I think my colleagues need to take a look 
at the work happening today that is moving Medicare; more 
important the quality than the quantity. Can you discuss the 
ways in which affordable health care has helped the solvency of 
the Medicare program directly? Can you answer the question?
    Chairman BRADY. If I may, because time has expired, Mr. 
Baker, could you perhaps answer in another question or provide 
Mr. Pascrell an answer in writing. Thank you.
    Mr. PASCRELL. Thank you for your consideration.
    Chairman BRADY. Thank you, Mr. Pascrell.
    Mr. Gerlach is recognized for 5 minutes.
    Mr. GERLACH. Thank you, Mr. Chairman. Thank you for having 
this hearing today.
    Today's hearing is focused on the reform of Medicare's 
benefit structure, so your suggestions are very welcome and 
very helpful. Thank you very much. But in addition to the 
benefit structure itself, success and cost-effectiveness of the 
program is also based on how it is administered every single 
day. Currently, the Medicare program has a pay-and-catch system 
for improper payments. A few years ago, the GAO put out a 
report that concluded that there is about $50 billion a year in 
improper payments made in the Medicare program, both 
unintentional payments, erroneous, mistaken, or intentional 
fraudulent-based payments due to stealing the identification 
numbers of physicians and other fraudulent activities.
    So based on the fact that that $50 billion a year in 
improper payments in the Medicare program over 10 years would 
be half a trillion dollars, and based on the fact that that is 
about 10 percent of the total expenditure in the program each 
year, what do you each believe would be the single-most 
important step that Congress could take now to reduce and 
ultimately eliminate $50 billion a year in improper payments in 
the program in addition to all of the other suggestions you 
have given us about benefits restructuring? But specifically 
what could be done today to reduce and eliminate $50 billion in 
improper payments just because of the way the program is 
administered on a daily basis?
    Start with Mr. Antos.
    Mr. ANTOS. Well, certainly, the idea about Medicare 
verifying who the providers are would be the first step. Don't 
pay unless the provider is a legitimate provider. Don't pay 
unless the provider is providing appropriate services. The idea 
of having information about the quality of care should extend 
also to traditional Medicare. It doesn't exist there right now.
    Mr. GERLACH. Thank you. Is there a specific kind of 
technology or system, programming that could be utilized to 
make that happen?
    Mr. ANTOS. Well, so in terms of measuring quality, there 
are literally scores of different measures that measure very 
specific results or very specific activities in health care. 
They don't necessarily represent quality. They represent things 
we can measure. And so I think the first step is to do a better 
job of developing the kinds of measures that really reflect not 
what goes into the patient, but what comes out. In other words, 
patient outcomes.
    Mr. GERLACH. Ms. Rivlin.
    Ms. RIVLIN. I agree with that, and I think more money for 
more vigorous prosecution of fraud would actually help. That is 
happening, but probably not enough. And better information for 
the patient to enable a patient to say, wait a minute, I never 
saw that doctor. It is hard now for a patient to monitor that 
kind of thing.
    Mr. GERLACH. Mr. Baker.
    Mr. BAKER. I would agree with all that has been said. We 
get a lot of complaints on our help line saying I didn't see 
this particular doctor, and we do refer them to the fraud tip 
lines, et cetera, but sometimes it is the pathologist in the 
hospital that no one ever sees. That kind of education is 
important.
    I think one of the things that we do have to guard against 
is one of the justifications for home health copayments is, oh, 
it will help combat fraud efforts. And I think putting 
financial cost-sharing on consumers to have them help identify 
fraud is not necessarily the best way to go, but rather, some 
of the ideas that we have been talking about here, and really 
providing administrative resources to not only our law 
enforcement personnel, but also to the Center for Medicare and 
Medicaid Services to really oversee this program. We always 
brag about Medicare having a low administrative cost, but maybe 
it should have a little bit of a higher level of administrative 
cost so that it can pursue some of these initiatives against 
fraud.
    Mr. GERLACH. Do either of you have a debit card on you 
today?
    Mr. BAKER. Yeah.
    Mr. GERLACH. And you pull that card out, is there an 
identification number on that?
    Mr. BAKER. Yes, there is.
    Mr. GERLACH. And if you took it downstairs to the credit 
union and you want to get money, you would type in a few 
numbers, would you not, that are unique to you and unique to 
that identification number, is that correct?
    Mr. BAKER. Yes.
    Mr. GERLACH. And so why don't we have that system in 
Medicare right now? Why don't we have a smart card technology 
in our system that identifies that provider and that patient at 
the same time before the service is undertaken? Has anybody 
considered that as part of your review of the program?
    Ms. RIVLIN. Sounds like a good idea.
    Mr. GERLACH. Okay.
    Mr. BAKER. We certainly could consider that.
    Mr. GERLACH. I know when to end my questioning. Thank you, 
Mr. Chairman. I yield back.
    Chairman BRADY. Stop when you get the answer you want.
    Mr. Price is recognized for 5 minutes.
    Mr. PRICE. Sounds like a bill is coming, Mr. Chairman. 
Thank you. Thank you so much. And I want to thank the panel 
members.
    This is a remarkably important topic, but it is also just 
part of a hugely complex system. And I am struck most often 
when we have the topic of health care come up in this 
Committee, and appropriately so, we are talking about money, 
not about patients. And when you talk just about money and not 
about patients, then I think that we miss really the focus of 
where we ought to be. We ought to be talking about patients.
    And as a physician taking care of patients for over 20 
years, I know that the patients of this country, especially the 
Medicare patients of this country, are extremely frustrated 
with the current system. Access is being diminished to care. I 
have said this before, if you are a new Medicare patient, you 
turn 65, your physician that has been taking care of you isn't 
seeing Medicare patients, which is more and more frequent.
    Even in large metropolitan areas, the opportunity or the 
ability that you have to find a doctor who is taking new 
Medicare patients is minimal. One in three physicians in this 
country has limited the number of Medicare patients that they 
are seeing. One in eight physicians who would normally see 
patients of Medicare age is not seeing any Medicare patients. 
And that is only getting worse. And the ACA is making that 
worse, not Dr. Price's, Tom Price's opinion. That is the 
opinion of the Medicare trustees, that access to care will be 
diminished because of the laws that we have already passed.
    Mr. Antos, you talked about Medicare oftentimes instituting 
policies in a heavy-handed way, and it is that heavy-handedness 
that I believe harms patients.
    So there is huge pressure within the system, and I want to 
touch on a couple specific areas. And I know that the fee-for-
service system has been bashed, and, you know, it isn't worth a 
doggone thing, according to some folks. But one of the 
antiquated notions of the fee-for-service system is that a 
patient can choose a physician that he or she desires to take 
care of them and that that care can be delivered.
    So I would ask you, Mr. Antos and Ms. Rivlin, do you 
believe that whatever system we come up with, should patients 
and doctors be able to practice outside of that system? Should 
they be free to take--the doctor take care of a patient outside 
of that system if voluntarily the patient and the doctor desire 
to do so?
    Mr. ANTOS. Well, under the Medicare program right now 
physicians are allowed to opt out, in essence. There are 
potentially substantial financial losses associated with that.
    Mr. PRICE. How about for an incident of care right now?
    Mr. ANTOS. For an incident of care, that is not possible. 
You are either in----
    Mr. PRICE. Should it be?
    Mr. ANTOS. It runs certain risk. I believe that this----
    Mr. PRICE. The freedom runs the risk.
    Mr. ANTOS. Freedom runs the risk. That is right. The 
question is, will the physician have the patient's best 
interest at heart or will the physician----
    Mr. PRICE. Have you ever read the Hippocratic Oath?
    Mr. ANTOS. I have read it, but there are plenty of ways to 
interpret it. And the question is----
    Mr. PRICE. Can one interpret the Hippocratic Oath to not be 
in the interest of the patient?
    Mr. ANTOS. It needs to be in the interest of the patient, 
but the financial system that the physician is under in 
Medicare works across purposes oftentimes to the patient's----
    Mr. PRICE. But coercion to the physician is not to provide 
the best care to the patient.
    Mr. ANTOS. The financial system promotes oftentimes 
services that are not useful or not very useful to the patient.
    Mr. PRICE. That is not the physician's design, that is the 
system's design.
    Mr. ANTOS. That is the system's design, and so we need to 
reform the system in order to make that relationship between 
the doctor and patient much more productive.
    Mr. PRICE. And maybe a little freer.
    This is going in an interesting direction. So my time is 
about to run out and I want to get to this other issue. We seem 
to be having contradictory themes. We say that the government 
control will produce value, push value--that is what we want, 
we want value--yet some of the things like home health care 
that provide some of the highest value for patients or care in 
ambulatory surgery centers that provides some of the highest 
value for patients, this proposal and others dis-incentivizes 
the use of those. So you have to ask the question, whose value? 
Is it the patient's value or the government's value?
    Ms. Rivlin, whose value should we be talking about here, is 
it the government's value or the patient's value?
    Ms. RIVLIN. We should be trying to measure the value to the 
patient and rewarding that. It is not easy. And the question of 
home health care I think is a good example. Clearly it is 
valuable to many, many patients and you don't want to 
discourage it, but you don't want abuse either, and you have to 
weigh the advantages and disadvantages of a copay.
    Mr. PRICE. Complex issue, Mr. Chairman. Thank you.
    Chairman BRADY. Thank you.
    Mr. Buchanan is recognized for 5 minutes.
    Mr. BUCHANAN. Thank you, Mr. Chairman. I want to also thank 
our panelists today for taking your time to be with us.
    I represent a community in Florida, Sarasota, but it is 
pretty much the demographics of Florida when you look across 
it, 700,000 people we all represent, 300,000 55 and older. But 
I went to, probably a month back, went to an assisted-living 
facility in our area, these were seniors, very capable, active 
and engaged, and I usually go there once a year to talk to this 
group, 300 residents. So on the way in they mentioned to me, 
Vern, I would like to have you come meet a few of the 
residents, and very coherent. But I would say of the four I 
met, one was 108, there were three or four others in the 
assisted-living facility over 100. Another assisted-living 
facility in Venice, Florida, the average age, the guy had been 
there 40 years, it is a Lutheran organization that runs that 
out of Wisconsin, I think Wisconsin or Minnesota. He said the 
average age there today is 90, and he said 20 years ago it was 
72.
    So maybe it is just the sunshine in the State of Florida, I 
don't know, but I can tell you I am very concerned just looking 
forward from the viability as people are living longer. I think 
the statistics, the numbers used to be, people lived, when they 
put the program in place, I think it was 5 years. Today they 
claim 13.4 years. Have we looked down the road the next 10 
years or so at what the age is that people are expected to live 
to or how many more years that is and are we factoring in the 
idea that the program, Medicare, is going to go broke in 10 
years, Mr. Antos?
    Mr. ANTOS. Well, certainly, the Medicare actuaries take 
longevity into account. But longevity isn't the principal issue 
here, I don't think, it is the rising cost of health care, it 
is the rising use of services.
    Mr. BUCHANAN. Well, you mentioned this, just real quick, 
how many people did you say come a day, are coming into the 
program at 65?
    Mr. ANTOS. According to AARP it is about 8,000 a day.
    Mr. BUCHANAN. Yeah, I have heard 8,000, 10,000, 12,000, 
somewhere in that range, every day for the next 30 years.
    Mr. ANTOS. Well, for the next 20 anyway.
    Mr. BUCHANAN. Yeah, for the next 20. But go ahead, 
continue, what were you going to say?
    Mr. ANTOS. They are youngsters. When you turn 65 you are 
basically a healthy person. It is at the other end of life 
where the money is being spent. And I think the issue here is 
not so much, we are not going to have people stop turning 65 
and joining the Medicare program. The issue is how do we get 
unnecessary spending under control? How do we get better 
treatment for these patients?
    Mr. BUCHANAN. Ms. Rivlin, did you have any comments on 
those about longevity?
    Ms. RIVLIN. No, I agree with that. It is certainly 
increasing. But as Mr. Antos said, it is the rising cost per 
patient combined with the longevity, but the rising cost per 
patient is really the driving force.
    Mr. BUCHANAN. The other thing I think that a lot of seniors 
are concerned about is the fact that we are not doing much 
about it. There is a 10-year window ideally. What is your 
opinion of waiting and not dealing with this in a real way? I 
mean, we are talking about some adjustments and things that we 
might be able to do today, but in the scheme of things long 
term it doesn't seem like it is going to have a huge impact in 
terms of the overall dollars. By waiting, what happens from 
that standpoint? How long can we wait and not deal with it in a 
big way? Ms. Rivlin.
    Ms. RIVLIN. Every year you wait makes it more difficult. We 
have waited too long already on many of these things and I 
would include Social Security. We need to put all of these 
programs on a firmer basis.
    But with respect to the healthcare programs it is a 
question of moving to better, more effective, more cost-
effective delivery systems that is the most important. And the 
faster we can do that the better, although it is going to take 
time to transition.
    Mr. BUCHANAN. Thank you, Mr. Chairman. I yield back.
    Chairman BRADY. Thank you.
    Mr. Smith, you are recognized for 5 minutes.
    Mr. SMITH. Thank you, Mr. Chairman. And thanks to our 
witnesses for sharing your time today. I appreciate the 
testimony and your insight. And I think the urgency cannot be 
overstated. And yet we want to build on what we know works, and 
we want to do what we can to eliminate that which we know does 
not work.
    I get a little concerned when the term ``fraud'' that we 
should all be concerned about is often used to describe what 
might have been an innocent mistake amidst a bureaucracy in 
piles and piles of paperwork, and we don't want the heavy hand 
of government to overreact. But I am curious to know what you 
might have to suggest about States coming up with innovative 
solutions. One thing we do know is that with our 50 States they 
are different among themselves. I know that, representing rural 
Nebraska, the definition of rural has a different application 
in different parts of the country. And so if you might, any of 
you, elaborate on perhaps how we could maybe rely on the States 
for innovation and incentives to increase the effectiveness of 
care and access. Not all at once, but go ahead.
    Mr. ANTOS. States obviously have a very strong fiscal 
interest in this question because of course they are 
responsible for about 42 percent of the cost of the Medicaid 
program. The Medicaid program, many Medicaid people are 
essentially young, relatively healthy people. But the older 
Medicaid beneficiaries are among the sickest and among the most 
expensive patients that we have. Many of them are dual 
eligibles in Medicare.
    So States are very concerned about improving delivery of 
health care. I think in terms of rural America the idea of 
being able to bring modern electronics out there where you if 
can't get a doctor, let's get somebody who is trained at the 
local level and have communications back with a medical center.
    In addition, States, I don't think States are rushing to do 
this, but increasingly we are going to need to look at the 
personnel who provide healthcare services. We are going to have 
a doctor shortage, there is no question about that. We are 
going to have a lot more people who will be demanding care, we 
are not going to be producing that many more physicians, 
because it takes so long to produce a physician, a good 
physician. So we are going to have to look at expanding the 
scope of practice for nurse practitioners, for example, 
physician's assistants. States control that, they need to take 
a look at that issue.
    Mr. SMITH. Okay.
    Ms. Rivlin.
    Ms. RIVLIN. I would agree with that. It is the Medicaid 
program which you ought to look to for giving States the most 
flexibility. And the potential is there. The situation now with 
waivers is much too complex, and it would be important, I 
think, to provide a more uniform system where States can take 
the measures that they think are most cost effective and are 
rewarded for that, but don't have to go through a very 
complicated waiver process.
    Mr. SMITH. Mr. Baker.
    Mr. BAKER. I would agree. I think some of the 
experimentation that is happening under the ACA but also 
outside of it with regard to dual eligibles, people that are 
eligible for both Medicare and Medicaid, and there the States 
really are pushing the envelope in many instances in combining 
those funding streams and coming up with creative ways to 
manage their care. The typical statistic is these are the 20 
percent of people that generate 80 percent of the costs. If we 
can control those costs better, much of it through better 
coordinated care, managing that care better, breaking down 
those silos. And States have been doing that. And I think we 
need to continue to encourage that.
    It is less possible in true rural areas that are sparsely 
populated, but some of the other ideas around allied 
professionals getting involved with physicians and others to 
kind of bring that care to the areas. Many times folks don't 
need that intensive medical care, they need kind of social 
supports or other supports, kind of to live in their 
communities and stay healthy. And I think those are important 
initiatives that States are engaged in right now.
    Mr. SMITH. And, Mr. Baker, I think you touched briefly on 
perhaps cost-sharing with emergency room or other areas. Could 
you elaborate on that?
    Mr. BAKER. Well, my point there was that if we increase 
cost-sharing up front, many times people don't access the kind 
of primary care or preventative care that they need. In many of 
the proposals preventive care would be covered first dollar up 
front, but other primary care would still need a copayment or a 
deductible to get through. So what happens is people put off 
care, end up in emergency rooms, or higher, more expensive care 
settings.
    Mr. SMITH. Okay. Thank you, Mr. Chairman.
    Chairman BRADY. Thank you.
    Mr. Kind is recognized for 5 minutes.
    Mr. KIND. Thank you, Mr. Chairman. I want to thank our 
panelists for your testimony today. Mr. Chairman, I hope this 
is the first of many more hearings that we can do to explore 
avenues of bipartisan cooperation on reforming a healthcare 
system that is in desperate need of reform. And I guess one of 
the frustrating things sitting here and listening even to 
today's conversation, is that there are so many of those tools 
that are currently a part of the Affordable Care Act right now.
    Ms. Rivlin, delivery system reform, getting to a more 
integrated, coordinated, patient-centered healthcare delivery 
system. There are tools in the Affordable Care Act right now to 
drive the system in that direction, including payment reform. 
Demanding value-based payments, quality reimbursements, as 
opposed to volume is already in the Affordable Care Act right 
now and vast experimentation taking place. Would you agree with 
that assessment?
    Ms. RIVLIN. I agree with that, and I said that actually. 
And we want to strengthen and build on what is already going on 
and accelerate it.
    Mr. KIND. And I applaud the work the Bipartisan Policy 
Center has come up with additional recommendations on reform. 
In fact, the New Democrat Coalition just had Bill Hoagland and 
Chris Jennings before us to walk us through a lot of the 
recommendations, and many of which we embrace.
    If there is one concern or one criticism I might have about 
the Bipartisan Center is you do maintain fee-for-service in a 
hybrid type of form, but nevertheless it is still there out in 
future years. And I happen to believe that we are going to have 
to kill this thing, we are going to have to have a date certain 
on fee-for-service so there will be institutional pressure from 
all over to maintain a fee-for-service or volume-based payment 
system that we are never going to be able to slay and get rid 
of.
    Ms. RIVLIN. I think we kill it with incentives to move away 
from it, but we do preserve a choice so that no one can say we 
are destroying Medicare as we know it.
    Mr. KIND. Well, and again on the whole topic of Medicare 
fraud, and I look forward to working with my good friend from 
Pennsylvania because I think he has some good ideas to bring to 
the table how we can do a better job. But, Mr. Antos, I don't 
know if you are sure, if you looked at the Affordable Care Act, 
but pay-and-catch is no longer the law of the land, it is a 
system of verification. And regional offices now have stepped 
up enforcement and funding to crack down or Medicare fraud. In 
the first 2 years we were able to recapture over $15 billion in 
fraudulent payments made in the Medicare system because of what 
is in the Affordable Care Act already. And that is moving 
forward. And maybe we need more personnel on the ground and 
more resources to do it, but again, as part of the Affordable 
Care Act, there has been a stepped-up measure to crack down on 
Medicare fraud. And I don't know, your testimony made me 
believe that you weren't aware that pay-and-catch is no longer 
allowed under Medicare.
    Mr. ANTOS. Oh, I didn't address it in my written statement. 
It is not allowed but it still happens. It is great that CMS 
has been able to take actions, but obviously the problem isn't 
solved. The problem will never be solved.
    Mr. KIND. Well, again, I think we can continue working in a 
bipartisan fashion on what stepped-up enforcement are needed. 
There would be wide bipartisan support because no one is going 
to be here defending fraudulent practices, especially in the 
Medicare program.
    But, Mr. Baker, I also notice that you have been one of the 
panelists on the second Institute of Medicine panel trying to 
change volume to value-based payments. My only encouragement to 
you and the panel, I know it is hard with peer review with IOM, 
you have high standards, but you have to go bold and you have 
to go courageous. And if you guys can't come up with a path to 
get to a fee-for-value-based reimbursement system it is going 
to be very hard for this institution to embrace something as 
well. So I don't know if you want to give us a quick update 
where IOM 2 is going right now, but soon you are going to be 
reporting out.
    Mr. BAKER. Well, we are in the peer review process so I 
can't really talk specifically about it. But I think that, as 
you saw from our interim report, we are very concerned about 
the present system. And I think you will be seeing some ideas 
about moving forward some of the value-based reforms that are 
already in the ACA. I think we are all agreed that those kinds 
of things and the kind of delivery system reform that we have 
all been talking about is key.
    I would point out that, and I do believe that we need to 
move away from fee-for-service, as we have been talking about, 
but we also have to recognize that within some of these hybrid 
or some of these even in classic managed care fee-for-service 
is still used and still might be appropriate to encourage the 
provision of some services. So I think it is a hybrid system 
and one that definitely needs to move away----
    Mr. KIND. I will need to be educated on the value of doing 
that, but I also agree with Mr. McDermott, if at the end of the 
day all we are doing is talking about cost shifting, that is 
not the path forward because that is not the reform that we 
need to create the right incentives to get better value at a 
better price within the healthcare system. I think we are all 
in agreement on that. And my concern is with SGR fix and 
everything else that this cost--and time is of the essence. The 
Ryan bill does nothing to reform Medicare for 10 years because 
they exempt the first 10 years of entrants into the program. So 
if time is of the essence, I don't know why we are repealing 
the Affordable Care Act 37 times and then trying to move 
forward on a plan that does nothing for the next 10 years when 
10,000 seniors are joining Medicare every single day in this 
country.
    My time has expired, Mr. Chairman, thanks for your 
indulgence.
    Chairman BRADY. Thank you.
    Mr. Thompson is recognized for 5 minutes.
    Mr. THOMPSON. Thank you, Mr. Chairman. I want to thank all 
the witnesses for being here today and for your longstanding 
commitment to making health care work in this country.
    I want to pick up where Mr. Kind left off, where Mr. 
McDermott started, and that is with the whole issue of cost 
shifting. And one provision I would like to explore a little 
bit is found in the President's budget as it relates to a copay 
for home health care. And I, too, am worried about the idea 
that we would be cost shifting. And while the President's 
program saves close to $800 million--I don't know if it does 
save that, but it is scored at saving $800 million--and I just 
want to be very, very careful that we do the scoring correctly, 
because my concern is if this copay discourages folks from 
doing what they should be doing in regard to health care, it 
could end up costing us a lot more.
    Specifically, if people don't get the care and they become 
more ill or they become injured and have to go into the 
hospital, that is a direct cost to Medicare and the Federal 
Government, or it could even turn out to be a cost shift to the 
specific States.
    And on that note I would like to ask unanimous consent that 
we put in the record two letters from two different States who 
share the same concern, one from Governor O'Malley, a Democrat 
from Maryland, and the other from Governor Deal, a Republican 
and former colleague of ours from Georgia.
    Mr. Chairman.
    Chairman BRADY. Without objection.
    Mr. THOMPSON. And I think that is important to note that, 
and I would like to know what your thoughts are on that, and we 
can start with whomever. Mr. Baker.
    Mr. BAKER. Okay. Yes, I think that is a potential. I mean, 
in 1972 Congress actually took out copayment amount for the 
home health benefit after finding that it had led to increased 
hospital usage and institutionalization in other kind of more 
expensive and restrictive care settings. And I do believe that 
most of the savings that are scored there in the President's 
proposal don't come from collecting the actual copayments, but 
come in from analysis about the utilization being tamped down 
and folks just not accessing the benefit at all.
    And particularly the way this copayment is structured, as 
has been mentioned, is for people that have not had a 
hospitalization that need extended or longer-term care, even 
though Medicare doesn't cover long-term care per se. Some folks 
can get ongoing home health care needed in order to stay in 
their homes through the Medicare benefit. And those are the 
folks that are at risk of either hospitalization or of 
deterioration of their condition either leading to 
hospitalization or nursing home care.
    So I think it is misguided, I think it is penny wise and 
pound foolish, as they say, and certainly to the extent it has 
the potential to lead to higher health costs, that was 
recognized in the early 1970s and I think that lesson should be 
relearned.
    Mr. THOMPSON. Anyone else?
    Ms. RIVLIN. I think it is a difficult balancing act to the 
extent that there are people using home health care that don't 
really need it because there is no copay and you might as well. 
We need to discourage that and be careful that it doesn't hurt 
people who have very low income or who really need the care.
    Mr. THOMPSON. Ms. Rivlin, I am glad that you raised that 
issue, because I suspect a lot of that savings is directed at 
detecting fraud abuse and getting away from that. But MedPAC 
has noted that there are patterns of abuse in home health care, 
primarily found in 25 different counties in Texas and Florida. 
So it seems to be a pretty focused issue or for the most part 
focused, and a pretty wide, sweeping way to deal with it. Is 
there a better way?
    And I am glad that Mr. Gerlach raised the issue of going 
after the fraud because I am one who believes that we can 
accomplish a lot in fixing the system if we are able to nail 
the fraud stuff. Is there a better way to go after the fraud 
than the copay?
    Ms. RIVLIN. Well, there may be, but I think the copay would 
probably help.
    Chairman BRADY. Thank you, Mr. Thompson.
    Mr. Blumenauer is recognized for 5 minutes.
    Mr. BLUMENAUER. Thank you, Mr. Chairman. And I do 
appreciate an opportunity for a conversation like this, zeroing 
in on what actually can happen. And I want to follow up on 
comments from both my colleagues Mr. Thompson and Mr. Kind 
because I think we have embedded in the Affordable Care Act 
some opportunity to change the delivery mechanism. We are doing 
some experimentation in Oregon, and we are optimistic globally 
that it can have some significant effects. What Mr. Thompson 
said about being able to identify outliers, counties in a 
couple of States that are clearly having a pattern that screams 
abuse, the same way that we have had some pill mills where 
there are a handful of pharmacies that are responsible for 
certain narcotic drugs that find their way into the system. And 
I am a proud cosponsor of Mr. Gerlach's legislation for the 
secure card, which I think could help us get at that.
    I am open to other systematic adjustments, some of which 
have been proposed, Mr. Chairman, by some of your colleagues, 
some from the Administration. But I am hopeful that we are able 
to focus on the big picture, things that we can do now that 
clearly attack problems of abuse and mismanagement that should 
share broad bipartisan support. And I am hopeful, Mr. Chairman, 
that our Subcommittee could zero in on a few of these proposals 
that have bipartisan support on the Committee, that aren't 
going to solve everything overnight, but will make a 
significant difference improving the system.
    I am of the opinion that the more we can do on some of 
these smaller things that will make a difference, that are 
bipartisan, that are not particularly controversial except for 
some people who are taking advantage of the system, will help 
us establish a foundation for what we are going to have to do 
for the next half dozen years as the nature of healthcare 
changes in this country.
    And I will wrap up, we have things to do. I don't want to 
debate particularly some of these modest points, although I 
would put on the table one other bipartisan proposal that will 
give people better health care, what they want, and will 
actually save money. And that deals with letting people know 
what they face at the end of life, that Medicare will pay 
untold billions to give hip replacements to 92-year-old people 
in the last months of life, it will hook them up to machines, 
it will do anything, but it won't pay to have a conversation 
with the medical professional of their choice about what they 
face.
    There is a reason why doctors actually consume less health 
care in their final months of life, because they know what they 
are facing, they know what works, they know what doesn't, and 
they have a way of making those decisions and making sure 
whatever the decisions are that they are respected.
    And I would hope that there would be an opportunity for us 
to deal with legislation like that, that is bipartisan, that 
will make a difference, that surveys tell us over 90 percent of 
the American public wants, that will not just save money but 
will give people a better quality of care.
    I appreciate your commitment to make the Subcommittee zero 
in on some of the big picture, some controversial, some not. 
But I hope that we can circle around to some of the stuff that 
doesn't have to be controversial which will save money and 
bring the Committee together while, above our pay grade, 
certain things are battled out. Thank you, Mr. Chairman.
    Chairman BRADY. Thank you, Mr. Blumenauer.
    Ms. Black for the final question.
    Mrs. BLACK. Thank you, Mr. Chairman. And I appreciate being 
able to sit here on the Committee and for being given an 
opportunity to ask a question.
    My question is going to go to two pieces here. One is the 
solvency and the other is the quality. And being a healthcare 
provider, as Dr. Price talked about, the quality is very 
important to me as well, but making sure that we have a system 
at the end of the day that is solvent, that we can actually 
have a system.
    So the current Medicare spending trajectory is 
unsustainable and we know that. It has actually led the 
Medicare trustees to estimate the Part A trust fund will go 
bankrupt in 2023 and insolvent in 2024. So that has already 
been established. But recent data has showed that Medicare 
spending is actually lower and some have suggested that this 
means that we don't need to make any changes to the program. 
And so I ask the panelists, and starting with you particularly, 
Mr. Antos, and then working down the line, wouldn't you agree 
that this is the wrong way to look at this?
    And then, second to that, instead of waiting should we be 
acting now to extend the solvency of this program? And if we 
make those changes now would you agree that the changes would 
be smaller now rather than waiting? And then the end piece of 
that, can you discuss how you think a well-designed Medicare 
program would benefit the outcomes for our beneficiaries? So, 
Mr. Antos, can you go to that?
    Mr. ANTOS. Thank you. What is lower now is not Medicare 
spending, what is lower is the last 2 or 3 years of growth per 
beneficiary. But of course the number of beneficiaries is 
growing every year. So in fact Medicare spending is continuing 
to grow, just at a somewhat slower rate than in the past. But 
we only have evidence for the last 3 years of slower Medicare 
spending. So I think it is way premature to announce victory 
and to hang up our hats.
    Clearly, the sooner we take responsible actions to shore up 
Medicare financing and to improve the program so that it 
actually does a good job for patients, the easier the 
transition will be to whatever the new Medicare program will 
be. I tend to agree with many of the suggestions of the 
Bipartisan Policy Center and the other groups, certainly in 
general terms, and they all imply changes in the way patients 
act, physicians act, health plans act, and the traditional 
Medicare program acts. That is a lot of change, and that takes 
a lot of time. The sooner we start on that the more successful 
we will be without having what could be a disastrous experience 
for vulnerable people.
    Mrs. BLACK. Thank you.
    Ms. Rivlin.
    Ms. RIVLIN. I agree with all of that. I don't think it is 
the bankruptcy of the Part A trust fund that should drive this 
primarily. You can always put more general revenues in the 
trust fund and you are doing that already in Part B. But the 
opportunity that you have now to change the way Medicare 
reimburses organizations and to incent more cost-effective 
delivery systems seems to me just major, and you ought to take 
it right away and push on that continuously.
    There is no one thing you can do to fix the whole thing, we 
will all be back here again. But there is a big opportunity now 
to accelerate the reforms, many of which are already in the 
Affordable Care Act, to improve the delivery system for 
Medicare and the rest of the health system.
    Mrs. BLACK. And might I add to that, because I think I 
heard you say earlier that one of the things you think is a 
benefit of this is that the quality of care is actually going 
to increase.
    Ms. RIVLIN. Yes, absolutely.
    Mrs. BLACK. Mr. Baker, in my little bit of time I have 
left.
    Mr. BAKER. Of course. I think I agree with a lot of what 
has been said. I think the crisis isn't as acute a crisis as it 
has been because of the slowdown in growth in Medicare costs. 
And if you are looking 10 years ahead we do have this window 
now where, if this projection keeps up--and projections are 
projections, right--but we feel that there is some breathing 
room. That doesn't mean we should be complacent. Definitely, as 
we have all discussed, not only in our Medicare program, but 
also in our private health insurance and private coverage 
schemes we need to be looking at how to save money and, as you 
are saying, increase the level of quality of care and get 
higher value.
    And so we think once again that some of the reforms in the 
Affordable Care Act, some of the things that are happening in 
the private sector that mirror that, and I agree with Ms. 
Rivlin that those things coming together and Medicare working 
shoulder to shoulder can drive a lot of good change. I mean, 
Medicare has had that role in the past and can have it now. I 
think my concern is that some of the cost-sharing that we see 
here isn't driving in that direction.
    Mrs. BLACK. Thank you, Mr. Baker.
    Yield back.
    Chairman BRADY. Thank you. On behalf of Mr. McDermott and 
myself, I would like to thank all three of our witnesses for 
their testimony today on the President's budget proposals. Your 
experience and ideas on how to reform Medicare to keep it 
solvent for our Nation's seniors are constructive, and your 
continued thoughts and feedback will be very helpful as we move 
forward with these efforts in the coming months.
    As a reminder, any Member wishing to submit a question for 
the record will have 14 days to do so. If any questions are 
submitted, I ask the witnesses respond in a timely manner, as I 
know you will.
    With that, the Subcommittee is adjourned.
    [Whereupon, at 11:35 a.m., the Subcommittee was adjourned.]
    [Submissions for the Record follow:]
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