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



 
          OBAMACARE'S IMPACT ON PREMIUMS AND PROVIDER NETWORKS

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


                                HEARING

                               before the

                         COMMITTEE ON OVERSIGHT

                         AND GOVERNMENT REFORM

                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED THIRTEENTH CONGRESS

                             FIRST SESSION

                               __________

                           DECEMBER 12, 2013

                               __________

                           Serial No. 113-86

                               __________

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


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                      http://www.house.gov/reform




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              COMMITTEE ON OVERSIGHT AND GOVERNMENT REFORM

                 DARRELL E. ISSA, California, Chairman
JOHN L. MICA, Florida                ELIJAH E. CUMMINGS, Maryland, 
MICHAEL R. TURNER, Ohio                  Ranking Minority Member
JOHN J. DUNCAN, JR., Tennessee       CAROLYN B. MALONEY, New York
PATRICK T. McHENRY, North Carolina   ELEANOR HOLMES NORTON, District of 
JIM JORDAN, Ohio                         Columbia
JASON CHAFFETZ, Utah                 JOHN F. TIERNEY, Massachusetts
TIM WALBERG, Michigan                WM. LACY CLAY, Missouri
JAMES LANKFORD, Oklahoma             STEPHEN F. LYNCH, Massachusetts
JUSTIN AMASH, Michigan               JIM COOPER, Tennessee
PAUL A. GOSAR, Arizona               GERALD E. CONNOLLY, Virginia
PATRICK MEEHAN, Pennsylvania         JACKIE SPEIER, California
SCOTT DesJARLAIS, Tennessee          MATTHEW A. CARTWRIGHT, 
TREY GOWDY, South Carolina               Pennsylvania
BLAKE FARENTHOLD, Texas              TAMMY DUCKWORTH, Illinois
DOC HASTINGS, Washington             ROBIN L. KELLY, Illinois
CYNTHIA M. LUMMIS, Wyoming           DANNY K. DAVIS, Illinois
ROB WOODALL, Georgia                 PETER WELCH, Vermont
THOMAS MASSIE, Kentucky              TONY CARDENAS, California
DOUG COLLINS, Georgia                STEVEN A. HORSFORD, Nevada
MARK MEADOWS, North Carolina         MICHELLE LUJAN GRISHAM, New Mexico
KERRY L. BENTIVOLIO, Michigan        Vacancy
RON DeSANTIS, Florida

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


                            C O N T E N T S

                              ----------                              
                                                                   Page
Hearing held on December 12, 2013................................     1

                               WITNESSES

Mr. Jeffrey English, M.D., Neurologist, The Multiple Sclerosis 
  Center of Atlanta
    Oral Statement...............................................     6
    Written Statement............................................     9
Ms. Patricia McLaughlin, M.D., Ophthalmologist, New York City
    Oral Statement...............................................    12
    Written Statement............................................    15
Eric N. Novack, M.D., Orthopaedic Surgeon, Orthoarizona
    Oral Statement...............................................    21
    Written Statement............................................    23
Avik S.A. Roy, M.D., Senior Fellow, Manhattan Institute for 
  Policy Research
    Oral Statement...............................................    63
    Written Statement............................................    66
Judith Feder, Ph.D., Professor of Public Policy, McCourt School 
  of Public Policy
    Oral Statement...............................................    71
    Written Statement............................................    73
Mr. Edmund F. Haislamaier, Senior Research Fellow, Health Policy 
  Studies, The Heritage Foundation
    Oral Statement...............................................    79
    Written Statement............................................    81

                                APPENDIX

Admendment to Testimony of Patricia A. McLaughlin, M.D...........   102
Statement of The National Association of Chain Drug Stores.......   106
Statement of America's Health Insureance Plans...................   109
Submitted for the record by Chairman Issa, a Wall Street Journal 
  article ``Juking the ObamaCare Stats''.........................   122
Submitted for the record by Chairman Issa a Bloomberg article 
  entitled ``Recession Not Health Law May Be Responsible For Cost 
  Curb''.........................................................   124


          OBAMACARE'S IMPACT ON PREMIUMS AND PROVIDER NETWORKS

                              ----------                              


                     Wednesday, December 12, 2013,

                  House of Representatives,
      Committee on Oversight and Government Reform,
                                           Washington, D.C.
    The committee met, pursuant to call, at 9:30 a.m., in Room 
2154, Rayburn House Office Building, Hon. Darrell E. Issa 
[chairman of the committee] presiding.
    Present: Representatives Issa, Mica, Turner, Duncan, 
Jordan, Chaffetz, Walberg, Lankford, Gosar, DesJarlais, 
Farenthold, Woodall, Collins, Meadows, Bentivolio, DeSantis, 
Cummings, Maloney, Tierney, Clay, Lynch, Connolly, Speier, 
Cartwright, Duckworth, Davis, Cardenas, Horsford, Lujan 
Grisham, and Kelly.
    Staff Present: Brian Blase, Majority Senior Professional 
Staff Member; Molly Boyl, Majority Deputy General Counsel and 
Parliamentarian; Lawrence J. Brady, Majority Staff Director; 
Sharon Casey, Majority Senior Assistant Clerk; John Cuaderes, 
Majority Deputy Staff Director; Brian Daner, Majority Counsel; 
Adam P. Fromm, Majority Director of Member Services and 
Committee Operations; Linda Good, Majority Chief Clerk; 
Frederick Hill, Majority Deputy Staff Director of 
Communications and Strategy; Christopher Hixon, Majority Chief 
Counsel for Oversight; Mark D. Marin, Majority Deputy Staff 
Director for Oversight; Matthew Tallmer, Majority Investigator; 
Sharon Meredith Utz, Majority Professional Staff Member; 
Rebecca Watkins, Majority Communications Director; Krista Boyd, 
Minority Deputy Director of Legislation/Counsel; Courtney 
Cochran, Minority Press Secretary; Jimmy Fremgen, Minority 
Policy Advisor; Susanne Sachsman Grooms, Minority Deputy Staff 
Director/Chief Counsel; Jennifer Hoffman, Minority 
Communications Director; Chris Knauer, Minority Senior 
Investigator; Una Lee, Minority Counsel; Juan McCullum, 
Minority Clerk; Jason Powell, Minority Senior Counsel; Dave 
Rapallo, Minority Staff Director; Daniel Roberts, Minority 
Staff Assistant/Legislative Correspondent.
    Chairman Issa. The committee will come to order.
    The Oversight Committee exists to secure two fundamental 
principles: first, Americans have a right to know that the 
money Washington takes from them is well spent and, second, 
Americans deserve an efficient, effective Government that works 
for them. Our duty on the Oversight and Government Reform 
Committee is to protect these rights. Our solemn responsibility 
is to hold Government accountable to taxpayers, because 
taxpayers have a right to know what they get from their 
Government. It is our job to work tirelessly in partnership 
with citizen watchdogs to deliver the facts to the American 
people and bring genuine reform to the Federal bureaucracy.
    Today, as we view a continued rollout of the Affordable 
Care Act, we deal with the Administration's selling technique. 
The Administration sold the health law to the American people 
with a simple, clear promise: if you like your plan, you can 
keep your plan; if you like your doctor, you can keep your 
doctor.
    After millions of Americans received notices that their 
plans were being canceled, the President was forced to 
acknowledge just how misleading he had been. The President 
apologized for people who were misled by his claim and found 
themselves in difficult circumstances. The quote is: ``I am 
sorry that they are finding themselves in this situation based 
on assurances they got from me. We've got to work hard to make 
sure that they know we hear them and we are going to do 
everything we can to deal with folks who find themselves in 
tough positions as a consequence of this.''
    Now there is mounting evidence that the President's second 
promise is also untrue. Americans cannot keep the plan they 
like, they cannot keep the doctor they like, and it is 
increasingly clear that more needs to be done to keep the 
President's assurance that we will do for folks everything we 
can.
    Americans deserve to hear the truth. The Administration has 
been stringing them along with promises that every day are 
being broken. Many of these promises were predictable; many of 
these occurrences cannot be reversed. But to the extent that we 
can bring the American people the truth of what is happening 
and reverse, in any case we can, the lowering of access to 
care, we must do it.
    Initially, in Minnesota, for example, the Mayo Clinic was 
only going to be open to people virtually within walking 
distance. Now it is open, because of the backlash, to at least 
people in Minnesota. But as a Californian, the ability to get 
reimbursed, if I am a California exchange, for the Mayo Clinic 
does not exist; and this is true throughout the Country.
    Just last month, thousands of doctors were terminated from 
Medicare Advantage plan networks, including 2250 in Connecticut 
alone. Thousands of seniors are facing the loss of physicians 
they relied and trust on.
    In Florida there are areas of Southwest Florida in which no 
oncologist exists for patients who currently have life-
threatening cancer.
    Many Americans who are shopping for plans on the Obamacare 
or Affordable Care exchanges have found that they offer 
extremely limited provider networks that exclude their 
preferred physicians, physicians who they have built 
relationships with. Many parents are finding out that their 
child's pediatrician is no longer covered by their insurance 
plan.
    We now know that exchange plans exclude our Nation's best 
hospitals, hospitals like Seattle's Children and Sloan-
Kettering, MD Anderson Cancer Center, and the like. 
Unfortunately, millions of Americans are likely to find out 
early next year that their new health insurance plan doesn't 
cover the doctors who they most value and trust. Such limited 
plans demand that we ask the question: What quality of care 
will Obamacare actually provide?
    The access shock has prompted many Americans to ask: Didn't 
the President promise me that I could keep my doctor, period?
    On November 19th, the White House press secretary explained 
that the President meant by that ``you can keep your doctor'' 
was that, if you want coverage from your doctor, you can look 
and see if there's a plan in which your doctor participates. 
Clearly, in the case of Federal and State exchanges, it is 
unlikely that the best, and perhaps most expensive, physicians 
will ever be available.
    Just this past Sunday a key architect of the law explained 
if you like your doctor, you can pay more for that doctor. 
Before the Affordable Care Act was passed, you had that right, 
and you had the right to pick a plan that suited you and paid 
for that doctor.
    In essence, the public is now being told, if you like your 
doctor, then you can try to find a plan that carries them, and 
then you can pay more for that plan. But you are already paying 
more for plans that include items you don't want, items you 
didn't need and likely will not need This is so unacceptable to 
the American people that there is no question, both through 
public polls and, if you will, even by Democrats no longer 
touting the main benefit of the Affordable Care Act being the 
improvement of affordability of healthcare, there is no doubt 
at all that if you could pass this bill again, you couldn't 
pass it in this Congress. Even if you had not read it and you 
knew what was going to happen, you would not vote for it.
    When our Government, including the Congress, passed this 
law, we have a solemn duty to honestly inform the American 
people of what is going to happen. In this case, clearly the 
American people were misled. This duty is no more solemn when 
it affects Americans' relationships with their physicians. That 
is a sacred trust; it is the most important thing in the life 
or death situation to many Americans, and it is a trust that 
has been broken.
    Today we will hear testimony from experts at think tanks 
and institutions. They will be on our second panel. We have 
concluded that the first panel should include three doctors who 
have actual life experience practicing with patients and 
realizing what can or cannot be done, what should or should not 
be done, and direct experience of what is happening under the 
Affordable Care Act not just to their practices, which are 
businesses, but to their patients, who are human beings in need 
of their care. Today the testimony from these physicians will 
describe in the most candid and personal terms exactly how the 
Affordable Care Act, or Obamacare, has affected these patients 
in their practices.
    I am sure these doctors will agree that there were problems 
in the healthcare system that needed to be reformed. The fact 
is America had an imperfect system developed with a number of 
public and private forms of money, tremendous Federal taxes, 
insurance companies that were often difficult to work with, and 
the like. But a broken system that is repaired by crashing it 
into a wall is not, in fact, a fixed system.
    With that, I would recognize the gentleman from Maryland 
for his opening statement.
    Mr. Cummings. Thank you very much, Mr. Chairman, and thank 
you for calling this hearing. This week I had the tremendous 
honor and privilege of traveling to South Africa as part of our 
Nation's delegation to honor the life of the late President 
Nelson Mandela. It was an inspirational trip, a life-altering 
trip because I had the opportunity to reflect on the amazing 
changes that one individual, working with determination over a 
lifetime, can bring to millions of others.
    There will always be forces aligned against progress, 
against equality, and against basic human dignity. But Nelson 
Mandela's life reminds us that our mission on Earth is to 
transcend these destructive forces and always pursue the 
betterment of our fellow man.
    As I traveled back yesterday on the 20-hour flight home, I 
began thinking about today's hearing, and I was amazed again at 
the significance of what our Nation accomplished with the 
Affordable Care Act. Before we passed this landmark law, 
millions of our own citizens could not obtain health insurance 
because they had preexisting conditions, and we allowed 
insurance companies to discriminate against them. They charged 
exorbitant premiums that were prohibitively expensive, they 
attached riders that excluded care for these illnesses, and in 
many cases they did not access the health insurance altogether. 
Think about this: Before we passed the Affordable Care Act, 
there were about 50 million people in the United States without 
health insurance. Fifty million. That is almost exactly the 
population of the entire country of South Africa. Before the 
Affordable Care Act, we had an entire Nation within a nation of 
people without coverage; no insurance for doctors' visits, 
cancer treatments, prescription drugs, or hospital care. That 
was a shameful and immoral legacy for a Nation as prosperous as 
ours.
    Three years ago, after decades of inaction, Congress and 
the President passed the Affordable Care Act. We finally banned 
insurance companies from discriminating against people with 
preexisting conditions. We prohibited insurance companies from 
charging higher prices for women than for men. We eliminated 
junk plans that collected premiums, but then did not pay 
hospital bills when the people got sick. The result today is 
that tens of millions of people now have something they did not 
have before we passed this law: the opportunity and the ability 
to afford and obtain quality health insurance that will 
safeguard their financial security and recognize their dignity 
as human beings.
    Congress understood, when we passed the Affordable Care 
Act, that these changes would tend to increase premiums for a 
subset of people who already had insurance under the old 
discriminatory rules. So we put in place several measures to 
lower prices and control costs, including subsidies to help 
people buy insurance, a requirement that insurance companies 
spend at least 80 percent of premiums on healthcare services or 
offer rebates to consumers, and reviews of proposals by 
insurance companies to raise their rates by more than 10 
percent in a year.
    The good news is that the actual premium rates have now 
been submitted by insurance companies, and they have come in 
much lower than expected. In September, the Department of 
Health and Human Services issued a report explaining that 
actual premium rates now being offered under the Affordable 
Care Act are 16 percent lower than projected. Based on this 
actual premium data, the Center for American Progress issued a 
report in October showing that these lower premiums will save 
the Federal Government $190 billion over the next 10 years, 
meaning 700,000 additional people will be able to obtain 
coverage.
    More broadly, the Centers for Medicare and Medicaid 
Services issued a report finding that national health spending 
has slowed to only 3.9 percent in the last three years, which 
is the lowest rate since the Government began keeping these 
statistics in 1960.
    I understand that we will consider two studies today that 
assert that premiums are increasing for the majority of people 
in the exchanges. Both reports have significant, very 
significant flaws. First, the Heritage report completely 
disregards the subsidies provided by the Affordable Care Act. 
Completely. As a result, it inaccurately inflates the actual 
cost of coverage for consumers across the Country. Second, 
although the Manhattan Institute study is better because it 
includes subsidies, it still compares ``apples to avocados,'' 
as one commenter explained. It compares five plans under the 
Affordable Care Act with the five cheapest plans offered before 
the law passed. The obvious problem is that the old cheap plans 
offered vastly inferior coverage. To me, the most significant 
problem with comparing premiums before and after the Affordable 
Care Act is that it disregards the 50 million people who could 
not get insurance. If someone could not afford a policy that 
covered a preexisting condition, the price of that 
prohibitively expensive plan is not considered.
    Let me close by offering a final thought. One of the things 
that Nelson Mandela will always be remembered for is his push 
for reconciliation. I respect the viewpoints of my colleagues 
on this committee, as well as those of our witnesses, and I 
understand that the Affordable Care Act is not perfect. I have 
said that many times. In that spirit, I hope that we can work 
together in a bipartisan way to improve the Affordable Care 
Act, rather than continuing to fight over its very existence.
    One of the things that the late President Mandela said, and 
I have thought about this a lot because it is so true, he said 
it always seems impossible until it is done. It always seems 
impossible until it is done. We can no longer disregard the 
experiences of 50 million members of our population. We can no 
longer ignore the pain, the frustration, and the fundamental 
inequality of this Nation within a nation.
    And with that, Mr. Chairman, I yield back.
    Chairman Issa. I thank the gentleman.
    Members may have seven days to submit opening statements 
and other extraneous material for the record.
    We now welcome our first panel of witnesses. Dr. Patricia 
McLaughlin, M.D., is an ophthalmologist in a private practice 
in New York City. Dr. Eric Novack, M.D., is an orthopaedic 
surgeon with the OrthoArizona practice in Phoenix, Arizona.
    And I would like to recognize the gentleman from Georgia, 
Mr. Woodall, to introduce his constituent, Dr. English.
    Mr. Woodall. Thank you, Mr. Chairman. I appreciate that 
courtesy. We do have the great pleasure having Dr. Jeffrey 
English with us today. He has been a tremendous resource to the 
Georgia delegation, not just to me and Mr. Collins on the 
committee, but to the entire delegation. I want to tell you 
just a little bit about his background.
    He earned his bachelor of arts in psychology at Boston 
College in 1991 and then graduated from Dartmouth Medical 
School in 1995; served relatively close by here as chief 
resident in neurology at the University of Maryland in 1999; 
and to the great pleasure of all Georgians has chosen to call 
Norcross home, where he is now the Director of Clinical 
Research at the Multiple Sclerosis Center in Atlanta and 
President of the Georgia Chapter of Docs for Patient Care.
    It is with great pleasure that I welcome you today, Dr. 
English, and thank you so much for what you do for us not just 
on the committee, but for us back home.
    Thank you, Mr. Chairman.
    Chairman Issa. Thank you.
    Pursuant to the committee rules, I would ask all three of 
our witnesses to rise to take the oath. And please raise your 
right hands.
    Do you solemnly swear or affirm the testimony you are about 
to give will be the truth, the whole truth, and nothing but the 
truth?
    [Witnesses respond in the affirmative.]
    Chairman Issa. Please be seated.
    Let the record reflect that all witnesses answered in the 
affirmative.
    Dr. English, do you have time in your practice to watch C-
SPAN?
    Dr. English. [Nonverbal response.]
    Chairman Issa. Well, then for all of you, I will give you a 
brief. First of all, with unanimous consent, all of your 
opening statements in their entirety will be placed in the 
record. In addition, any pertinent or even extraneous material 
you would like to submit now or for the next seven days will be 
included in the record. That leaves you free to use the entire 
five minutes on the clocks in front of you to say anything you 
would like to say, but I would ask that, as that runs down, you 
try to wrap up.
    Dr. English.

                       WITNESS STATEMENTS

               STATEMENT OF JEFFREY ENGLISH, M.D.

    Dr. English. Mr. Chairman and members of the committee, I 
want to thank you for inviting me to talk about how the 
Affordable Care Act is going to affect my patients.
    Practicing physicians who see real patients like myself, 
members on the panel, and the Group of Docs for Patient Care, 
who have the read the law and understand the law have already 
predicted some of these outcomes that you mentioned earlier. 
None of what you are seeing and are about to see is unforeseen. 
The Affordable Care Act's problem is not a computer site. It 
would be common sense to me that a program that is designed in 
Washington, D.C. by people who don't take care of patients, 
that is supposed to affect people from Maine to Oregon in a 
sort of a top-down fashion, with patients being so variable, is 
going to have a lot of unintended consequences, as you 
mentioned before. Unfortunately, those unintended consequences 
are the patients that we are going to talk about, and they are 
also your constituents and our fellow Americans.
    I am a private practice doctor, but half of what I do is in 
a salaried position at the MS Center of Atlanta, which is a 
nonprofit for the treatment of patients with MS. What I am 
going to talk about is not isolated to MS, certainly.
    MS is a disease of the brain and spinal cord, and can be 
very disabling; affects about half a million Americans. Most of 
the patients are female and it affects them at a young age, 
twenties and forties. In the 1990s we had no medications; now 
we have ten. They are highly variable; patients' response is 
highly variable and they can have life-threatening side 
effects. So the MS patients require twice the number of staff 
and twice the amount of time to take care of. So these people 
can present as young teachers, working mothers who all of a 
sudden can't walk, a typical presentation.
    MS doctors must be able to identify risk factors and start 
to move very quickly to therapy. It takes a lot of experience 
to know how to do that, which is why we have about 5,000 
patients that come from 28 States and 118 of our 159 counties 
in Georgia, and they look at us as their primary care providers 
because they see us so often.
    We are now set up with a healthcare plan where we are 
looking at things like metrics that different physicians will 
be weighed against, and I think my colleagues will probably 
touch on this too. The metrics, again, are set up by people, 
mostly in Washington, D.C., who don't take care of patients. If 
you comply with these metrics, there are bonuses; if you don't, 
there are penalties. And section 302 and 307 of the healthcare 
law actually states some of those penalties include removing 
physicians from Government-approved insurance.
    So I want to give you a couple of stories, and hopefully I 
can finish them in five minutes.
    Number one was a report by CMS, or Centers of Medicare-
Medicaid Services, February of 2012, and it said that I was an 
over-utilizer of MRIs, compared to my peers. MRIs are what we 
use to look at brain injury. They are a routine protocol for 
MS. Not to do so can lead to disability, so we obviously don't 
want to not do the MRIs. So I called CMS and I said, first of 
all, who are my peers, were they other MS doctors? They said 
no. My other peers also included orthopaedic surgeons. And I 
also said are you aware that I am an MS doctor and that these 
are routine protocols, and I got nos to that as well. They did 
tell me on the report, though, that this information would be 
on the Medicare website in the future, and people would look 
and they would see that I did not meet their standards. Again, 
that will be on their website.
    I heard earlier in the opening testimonies about United 
Healthcare. Many of you have read United Healthcare dropped 
quite a few providers, and according to The Wall Street Journal 
article, it mentions that this was in part due to managing its 
network using Medicare's new five star rating system that ties 
bonus payments that meet certain measures on cost and quality.
    Well, you are looking at now a downgraded physician. I am 
not off United Healthcare, but I am downgraded because of, 
again, in compared to my peers, which are fellow neurologists, 
general neurologists, they looked at cost and quality. And I 
want you to know that my quality was literally off the chart. 
There was a bell-shaped curve. We were over here, thanks to my 
wonderful staff. However, because of cost, I was also too high, 
so that was what downgraded me. And the two areas of cost were, 
guess what, MRI, which we talked about, and the other was drug 
cost. MS drugs are expensive and I have absolutely no control 
over that. And, again, my peers are neurologists who send me 
their most complicated patients that require these therapies.
    So I actually reached out to CMS a few years ago with a 
question, and I want to ask United Healthcare, but besides a 
December 2nd deadline to appeal, after three weeks of calling 
we still, now four weeks out, have not gotten through to United 
Healthcare to appeal after the deadline. So what I want to 
know, as a provider, am I supposed to not take care of MS 
patients, or do I just take care of them, but I don't do what 
is required, and limit my MRIs and my medications in order to 
meet metrics. And I think, again, this is just an example. I 
think physicians will be stuck with, the way the law is written 
now, that we will be penalized for taking care of these more 
complicated patients.
    I will close by saying that I have submitted testimony on 
the State exchanges. They are going to have as equal a 
difficult time as far as access to medications and to providers 
who know how to care for certain types of patients like I do 
myself.
    With that, I will close and again I thank you for this 
opportunity.
    [Prepared statement of Dr. English follows:]

    [GRAPHIC] [TIFF OMITTED] 

    Chairman Issa. Thank you, Dr. English.
    Dr. McLaughlin.

             STATEMENT OF PATRICIA MCLAUGHLIN, M.D.

    Dr. McLaughlin. Good morning, Mr. Chairman and members of 
the committee. I want to thank you for the invitation to be 
here, and I welcome that opportunity. I have submitted 
testimony which I hope you will all take the time to read; it 
is packed with details about the nuances of how these plans 
were designed and architecture with perhaps improper thoughts 
of the privates in the battlefield, and that being the patient 
and the doctor.
    You are all generals, and we respect the hard work that you 
have done to get this law passed. And as Mr. Cummings said, 
even in my own family I can personally attest the fear that 
came when my father passed away and my mother ,at the age of 
61, with a terrible medical history, lost her insurance because 
it was company-based with my father's company, and for four 
years she was essentially uninsured. So I have walked that road 
and I understand where you are coming from, and the President, 
in wanting to do something for the citizens of this Nation who 
had such fears as well.
    However, in taking care of that, unintentionally there were 
horrific events that are only starting to come to light, which 
is the part that concerns me so much. In my State society in 
ophthalmology, I serve as the third-party liaison, and I look 
at all things that insurances do as a patterned behavior and I 
report on them, and then we take appropriate action, as 
necessary; and most times, with good negotiations, we can 
sometimes make great strides. So I am an optimist at heart and 
I believe that everything can be fixed.
    My former training in college and my graduate work was an 
aerospace engineer, and I had hoped to become an astronaut, 
but, because of my mother's health, my life took a vast change. 
And I must tell you a little divergent comment. The pay-for-
performance structure that we have now in Medicare for bonus 
pay, to most physician colleagues, I think we can honestly say 
should be scrapped. We are trained to give our best to our 
patients. We are paid, supposedly, to give our best to 
patients. We shouldn't be doing metrics that have no bearing on 
the field that we do. In my field of ophthalmology, some of the 
pay-for-performance measures could include something as 
ridiculous as being a body mass index. What does that have to 
do with the health of the eye or what the eye says about other 
conditions in the body? Nothing.
    So you are spending Medicare money for ridiculous measures, 
taking our time in clinical practice to document this for 
someone who is a statistician who wants to run numbers. This is 
not what the doctor-patient relationship is about, and that is 
the only thing that this is about.
    My comments have no bearing on politics or what brought us 
to this point. We are now at T minus 20 days and counting. The 
doctors and the patients are going to be having extreme 
difficulties in accessing care.
    And yes, Mr. Cummings, I agree with you it is nice to carry 
a plastic insurance card to say you are insured. It is quite 
another thing to access the care.
    Whoever allowed the insurance companies to devise the 
current plans and how they are structured on the Affordable 
Care Act and, I might say, affecting small businesses, as well, 
outside or off the Affordable Care Act, leaves a lot to be 
desired. And I am glad that I was put in the middle of this, 
because for everything bad something good comes of it, and that 
is why I am here today. As a small business, I insured my 
family and my two employees, and I had wonderful insurance. I 
was pleased with it. It was a small business plan. And I might 
tell you a little fact now that you will find surprising. In 
2008, just as you said, those premiums raised ridiculous 
amounts every year. One year it was 26 percent for this great 
insurance plan. I was in sticker shock. It got to the point, in 
2008 dollars, that each individual in my small business plan, 
to have a fully comprehensive plan, would have cost $859. These 
are 2008 dollars. I did the math and I said I can't possibly 
afford this, so I contacted my insurance broker, I said what 
are my options, and he mentioned the consumer-driven health 
plans. Not very familiar with it, a little bit leery about a 
new concept, I explored it. It took me two years to sign on, 
however.
    What that did in those 2008 dollars, without the Affordable 
Care Act legislation, the insurance company took my premium of 
$859 and dropped it down to $300 for the same plan. So why? It 
did that because we had to assume a $2,000 first-pay deductible 
expense. That is where the risk got put. The insurance company 
lowered the premium by increasing the deductible. We didn't 
have a deductible before for in-network coverage. We had a very 
modest deductible of $500 to go out of network. And I was 
blessed, yes, with an out-of-network plan. I continued this 
plan for all those years and I was pleased.
    I was not pleased when I received a letter dated September 
21st that my plan was going to be canceled, that it was not in 
compliance, it said, with the ACA. I am no one to judge that; I 
have not read that 2,000-page document. I am assuming the 
insurance company is telling me the truth. They said that plan 
would be replaced by something comparable, and I trusted them 
for that. I have been with this company for years. I was a 
participating provider with them for years. Just like patients 
have trust in their doctors, patients have trust, sometimes, in 
their insurance company too, and I was one of them.
    The new plan rolled out. It took away my out-of-network 
benefits, which I might say I might be able to live with 
because, under the high deductible plan, the in-network 
deductible was $2,000 for an individual, but the out-of-pocket 
was $3500. I was less likely, I must say, even in my position, 
and certainly my staff, to go to an out-of-network physician 
because those first dollar amounts would be ours to bear and, 
being a responsible individual, you should take care of your 
bills.
    The new plan does not give out-of-network benefits; not 
just to me, but to all small businesses. The Affordable Care 
Act insurances do not allow for individuals out-of-network 
benefits.
    What I also noted with my new plan that was developed was a 
very crafted letter that implied that even though I was going 
to have an in-network plan, presumably of the same level as my 
current day plan, but only in-network, it would now be called 
an EPO. The EPO plan was not going to have the same network of 
physicians that my current plan did. Both EPO and PPOs had the 
same network. The HMO physicians were a smaller, different 
network. So some doctors, by their contract, had the ability to 
be in one or the other network, but by some contracts they had 
to be in all products.
    So what happened now was there was this term about I needed 
to be careful, as the administrator, and I needed to inform my 
employees that they needed to check to be sure that all of 
their doctors that they currently saw in-network--now, mind 
you, the same insurance company makes this a bit difficult, 
because you would assume if your doctor was in-network before, 
why wouldn't your doctor be in-network afterwards? But that was 
where the catch was.
    The new network was given a fancy name, it was called 
Pathway, with variations; Pathway X, Pathway X Enhanced, or 
just simply Pathway. I didn't understand that. I am a 
participating physician. I never heard Pathway before. I just 
knew that I took care of the EPO and PPO levels, I took care of 
the HMOs and the point of services. But I didn't understand 
Pathway. I went to their website and I looked this up, and what 
I saw was that actually these pathways were very restricted. So 
we have now an inability to refer patients. As an 
ophthalmologist, I will need a neurologist, but if that 
neurologist is not in that network, how am I going to give the 
patient with optic neuritis and sudden loss of their sight the 
ability to see a fine physician that I have sitting on my 
right?
    We have to fix this, and we have to fix this now. We have 
no time to play with this. Patients lives are at stake. Acute 
care situations need a specific doctor to refer the patient to; 
it is not enough to send them to an emergency room. And, by the 
way, many hospitals are not in these networks either.
    I thank you so much for your time and I hope I can count on 
you to fix this. Thank you, sirs.
    [Prepared statement of Dr. McLaughlin follows:]

    [GRAPHIC] [TIFF OMITTED] 
    
    Chairman Issa. Thank you, doctor.
    Dr. Novack.

               STATEMENT OF ERIC N. NOVACK, M.D.

    Dr. Novack. Mr. Chairman, members of the committee, thank 
you for having me back again.
    When President Obama made the case in 2009 that the U.S. 
needed to lower cost and improve access to healthcare, I agreed 
with him. On June 23rd, 2009, I told the House Subcommittee on 
Health that ``The system within which you are allowed to 
provide care is as important to the delivery as the people 
providing it. So if we are not willing to put the same level of 
attention to detail into designing the system, it is doomed to 
fail.''
    During that same hearing, Congressman Dingell announced 
that he ``would never presume to tell somebody how to take out 
an appendix or to replace a knee,'' but he does know a little 
bit about drafting law; he's been doing it for 50 years.
    Since then, the healthcare law has failed to deliver on 
nearly every promise, including if you like your doctor, you 
can keep her, and if you like your healthcare, you can keep it.
    The problems and failings certainly extend to Medicaid.
    In February 2013, the Obama Administration made clear their 
position about access to care for Medicaid patients in a court 
filing in the 9th Circuit: ``There is no general mandate under 
Medicaid to reimburse providers for all or substantially all of 
their costs.''
    As Children's Defense Fund President Marian Wright-Edelman 
said at that same hearing in June 2009, talking about a child 
on Medicaid who died, ``His mother couldn't get the dentist to 
take him because of low Medicaid reimbursement rates.''
    In addition, Obamacare architect Jonathan Gruber's research 
and Austin Frakt's research suggests that between 50 to 80 
percent of all new Medicaid enrollees will actually lose 
private insurance as it is crowded out by Medicaid.
    And in Arizona, according to a 2013 Milliman report, most 
hospitals receive 70 percent of Medicare rates from Medicaid, 
which is unsustainable.
    While some will benefit from the expansion, the losers will 
far outnumber the winners. To respond to Congressman Dingell, 
he may not be saying how the surgery gets done, but he is 
certainly impacting who will get it and when.
    But the access problems do not end with Medicaid. As I 
wrote in August 2010, the healthcare exchanges are really just 
a variation of Arizona's 100 percent Medicaid managed care 
system, which, the last time it was expanded, has actually cost 
over four times what was predicted by the supporters.
    The policies available through the exchanges, even with 
subsidies, are, for many, far more expensive than Democrats and 
the President promised, and many have higher deductibles, 
copays, and coinsurance, and very narrow provider networks.
    OrthoArizona, the group of over 70 musculoskeletal 
providers I am in, does not have a single exchange contract by 
choice. One reason is the required 90-day grace period for 
policies. This means we can provide two months of care, 
thinking the patient has coverage, and then we are on the hook 
for payment, and the insurers have no responsibility. And 
OrthoArizona is not alone. At least one major Phoenix area 
hospital system does not yet have a single exchange contract, 
in large part because the rates being offered are at or near 
Medicaid rates.
    I recently spoke with a retired professor from an esteemed 
New York medical school. She feels Obamacare is morally right. 
But she notes that none of her personal doctors take Medicare, 
let alone Medicaid. Unwilling to make a moral stand and not go 
to those doctors, the professor is blaming the doctors and 
seeks to have Government force them and hospitals accept 
whatever payment the Government decides, even if they go out of 
business doing so. And I strongly suspect we will be hearing 
some variation of this very soon from the Administration.
    Those who do not wish to defend the failures of the law are 
quick to say, well, what is your solution? I know this hearing 
is not focused on alternatives, but I want to quickly mention 
three areas that should contribute to the many larger proposals 
that do exist.
    This year, Arizona passed a first in the Nation price 
transparency law. I would add, with significant bipartisan 
support. The law extends already ``only in the Nation' State 
constitutional rights to spend your own resources for legal 
healthcare services, but it also ends direct pay price 
discrimination based upon insurance status. This law goes into 
effect on January 1st.
    OrthoArizona, since its inception in 1994, has focused on 
quality, utilization, and cost. We have shown repeatedly with 
payers that local, same specialty physician accountability is a 
reproducible and effective way to lower healthcare costs while 
maintaining high-quality orthopaedic care.
    Intelligent InSites, a software company with whom I work, 
is a company that provides a platform that takes automatically 
collected data and provide analytics on that data combined with 
other sources of information. Getting better, more accurate, 
unbiased information in the hands of everyone from transporters 
in the hospital to doctors to healthcare system CEOs to you, 
the policymakers in the Country, has never been more needed.
    Ultimately, we must move to policies that ensure patients 
and families maintain control of their healthcare decisions, 
and that includes access to quality physicians.

    [Prepared statement of Dr. Novack follows:]

    [GRAPHIC] [TIFF OMITTED] 

    Chairman Issa. Thank you. I thank all three of you. I will 
recognize myself for a first round of questions.
    Dr. English, you said very well in five minutes a position. 
I just want to make sure I ask a question that makes it clear 
to all of us. Under the Affordable Care Act, what was often 
called rationed care is occurring simply because you are being 
told that if you take an expensive practice, you could be 
locked out, while a doctor who sends off, casts off the kinds 
of people you deal with, in other words, a doctor, a 
neurologist who says, look, anyone gets MS, I am going to dump 
them onto Dr. English because Dr. English costs more, and I am 
going to keep my costs down by not having those patients; he or 
she wins, you lose under this rating system. Is that pretty 
much a wrap-up of what you are dealing with?
    Dr. English. Correct. That is my interpretation.
    Chairman Issa. But you can fix that. You simply provide 
marginal care and do less MRIs and so on, and then you will be 
okay, is that right?
    Dr. English. Or I stop working for the MS Center of Atlanta 
and just do general neurology, correct.
    Chairman Issa. So you cannot take these difficult patients. 
And the same with an oncologist who says I am going to go into 
a practice where I only deal with people up until the time they 
have a serious cancer event, but after that I am going to dump 
that person. So the really sick, under the current system, 
unless we change it, find themselves undesirable either to get 
full care, which costs more, or, quite frankly, to get to the 
doctor at all. That is what you are dealing with unless we make 
these changes.
    Dr. English. Yes.
    Chairman Issa. Dr. Novack, transparency is a good thing, 
and certainly the person who walks in and writes a check or 
hands out cash for the service should not be disadvantaged. 
What happens, though, if--and I support that. I really, from 
the bottom of my heart, find it hard to believe that your cash 
customer pays more, as they do in almost every State and every 
hospital in America, and they don't even know they are paying 
more because there is no transparency. But what would happen to 
the hospital system if everybody walked in and paid the 
Medicaid reimbursement, if that is the lowest rate?
    Dr. Novack. Mr. Chairman, in my conversations with a 
variety of hospital system C suite folks over the last few 
months, for the most part they feel that they need to be able 
to be profitable at Medicare rates, which, talking to, again, 
major hospital systems, meaning they need to actually cut their 
operating costs by 30 percent. So I can speak to Arizona, where 
the average hospital Medicaid reimbursement is 70 percent of 
Medicare. So, for example, for a total knee replacement, the 
average commercial payment is $24,000. Medicare pays 14; 
Medicaid pays 8. So were that to be extended further, there is 
simply no way that basically any of the hospitals, certainly in 
the Phoenix area, and I guess the bulk of the ones around the 
Country, would stay open.
    I would add, by the way, that that isn't that unique a 
statement, because if you look at the Medicare actuary report 
that came out, there is an expectation that up to 25 percent of 
the hospitals won't be able to survive this decade, anyway.
    Chairman Issa. So one of the things that we have to do is 
figure out how to stop cost-shifting. In other words, anyone, 
including the Federal Government, mandating a rate less than 
what it takes for an entity to stay in business, unless we are 
willing to work with that entity to make sure they can in fact 
live with that rate.
    Dr. Novack. That is correct. It is important to know, on 
the issue of transparency, as a very brief aside, remember that 
over 100 million Americans get their insurance through a self-
funded payer. So in the same example of transparency, what we 
found out was that, again, in Arizona, using hospital 
association data, that the commercial payment was $24,000. In 
Arizona, if you pay cash for a total knee replacement, it was 
$19,000. So as one of the executives of a privately held large 
company in the State said to me, in exchange for doing 
everything right for our employees and their spouses, we are 
paying $5,000 extra, or 20 percent more, for that knee 
replacement.
    So when we look at what the healthcare price transparency 
law has done in Arizona, is in effect it creates a mechanism 
where not only can we protect the uninsured, but ultimately we 
are going to protect the folks who are insured by hopefully 
lowering the difference between what they are going to pay.
    Chairman Issa. One quick question. And I am going to 
respect the five minute clock very exactly today. The fact is 
that you are all seeing something else, I believe, and I would 
just like a yes or no if you have observed it. Federal 
reimbursement for a particular event at a clinic or a doctor's 
hospital is almost always less than in a hospital, right?
    Dr. Novack. Correct.
    Chairman Issa. So one of the interesting things is if a 
doctor's hospital is more efficient than a hospital, a doctor's 
office is more efficient than a hospital, we don't say we are 
going to try to get people to the most efficient rate by paying 
a fair rate to the doctor; instead, we simply pay less to the 
doctor, more to the hospital, and it is causing hospitals to 
buy up doctors' practices, which means we are paying more. Is 
that correct in all of your experience?
    Dr. Novack. Yes.
    Chairman Issa. Thank you.
    The gentleman from Maryland, Mr. Cummings.
    Mr. Cummings. Thank you very much, all of you, for your 
testimony. I appreciate your passion and what you do, and I 
want you to be effective and efficient in what you do. It is so 
important.
    Dr. English, you talked about the work that you do with 
multiple sclerosis patients. I am very familiar with that whole 
area. Johns Hopkins is smack dab in the middle of my district, 
so we spend a lot of time dealing with that issue. You also 
discussed the costs associated with it as being about $50,000 
per year, is that right?
    Dr. English. [Nonverbal response.]
    Mr. Cummings. That is a hefty price tag. Dr. English, MS 
is, of course, a troubled disease and I sincerely appreciate 
the work that you do to treat those patients afflicted with it. 
And I know you have concerns about the Affordable Care Act, but 
I have serious concerns about what happens to the 20-year-old 
woman or the 40-year-old woman who is diagnosed with MS but 
does not have insurance. So do you agree with the Affordable 
Care Act's prohibition on discriminating against people with 
preexisting conditions? Do you agree with that? I can't hear 
you, I am sorry.
    Dr. English. Yes. Again, as we opened up, everyone agrees, 
I think, with the majority of your opening statement about the 
need to fix the healthcare system and preexisting conditions, 
so sure.
    Mr. Cummings. Do you agree that if an uninsured person with 
MS were seeking healthcare coverage in the individual market 
prior to the ACA, that person would have been very unlikely to 
have gotten insurance? Would you agree?
    Dr. English. No. In my experience, at least in my State, 
the majority of my patients had very good access to care. Those 
who were uninsured, there were methods of getting them care. 
Again, as Congressman Issa mentioned, I am cheap. The cost of 
seeing me is cheap. The medications are expensive, and those 
are usually subsidized.
    Mr. Cummings. So prior to the ACA, insurance companies were 
allowed to discriminate against patients with preexisting 
conditions and exclude them from coverage, and that is a fact. 
But do you think that people with MS would have been able to 
get health insurance, or would it have been so cost-prohibitive 
that they wouldn't have been able to afford it?
    Dr. English. Well, again, I would agree with your original 
statement that we need to handle preexisting conditions. What I 
am seeing here is that patients are getting, again, as Dr. 
McLaughlin said, a card that gives them access to nothing. So I 
want to solve the problem that you exactly stated. I am on 
board with you 100 percent, especially since at the time it was 
the University of Maryland that was the MS center. Now Hopkins 
has taken over, you are right. But at the University of 
Maryland, again, I was----
    Mr. Cummings. That is right, you graduated from Maryland?
    Dr. English. From Maryland.
    Mr. Cummings. Oh, wonderful.
    Dr. English. I have two children born in your district. My 
wife got an MBA at Loyola.
    Mr. Cummings. Fantastic. I am a Maryland graduate too.
    Dr. English. Good.
    Mr. Cummings. Go ahead.
    Dr. English. So, yes, so we needed to solve that problem. I 
don't think this, in my opinion, my experience, and what you 
have heard here, this didn't solve that problem, and we are 
going to see these unintended consequences in the very near 
future and you are going to hear it from your constituents.
    Mr. Cummings. Thank you.
    Dr. McLaughlin, I just couldn't help but think about the 
things that you said about your mother not having insurance for 
a short period of time. A member of my immediate family had a, 
they found some precancerous cells with regard to the breast 
and could not get insurance, could not get it for four or five 
years; and this was a young woman. Couldn't get it. As I 
listened to you, I can see that you all seem to understand the 
problem here. On the one hand, we want to make sure that 
treatment that is provided is the appropriate treatment and it 
does not--because we hear all these complaints about, and I 
know you have heard them, doctors giving too many tests and all 
this kind of thing, and at the same time we want to get the 
results so that people can stay well or get well, if they are 
sick, because if they have to keep coming back it is only going 
to cost the system even more.
    The last thing you said, and this is written in the DNA of 
every cell of my brain. You said I want you to fix it. That is 
what you said, didn't you?
    Dr. McLaughlin. Yes, sir.
    Mr. Cummings. And I want to fix it. What suggestions do you 
have, based upon the things that you talked about today, that 
you would suggest to us about fixing it?
    Dr. McLaughlin. Well, I am glad you asked. Thank you so 
much. You see, the real problem with this, too, besides these 
networks being set up that are so restrictive, I also got a 
letter dismissing me as a participating provider from the 
insurance that would cover patients on the ACA. No one here 
intended that to happen, I am sure, but that is what is 
happening to us as physicians. Or we are being put on these 
panels without knowledge that we are because of contracts we 
signed 10 years ago that had all products clauses. And you 
might assume, as someone who owns a business, that if you were 
paid X number of dollars by the insurance company as a 
participating provider currently with them, wouldn't you be 
offered the same fee just simply because you were taking care 
of the new Government law? Well, that is not the case. They are 
coming in with fees that are sometimes 50 percent of Medicare 
and, as businesses, we can't survive.
    So back to your question, the other problem here is these 
deductibles, sir, is their subsidy, but that is for people who 
qualify for it. And maybe this is not universal across the 
Nation, but in a large city like New York City, a studio 
apartment is $2,000 a month. How is a person earning $50,000, 
which by most standards across this Country is not a terribly 
small amount of money, but someone earning $50,000 in New York 
City, paying $2,000 rent for a hole in the wall, cannot afford 
a $3,000 deductible for a plan that is being advertised as 
affordable because they take the bronze plan. The bronze plan 
in New York State, for something like Emblem, has a 50 percent 
coinsurance after that patient reaches that $3,000 deductible.
    What we have found, when we went back to that 2008 level, 
is that just simply having these high deductible plans slowed 
down healthcare utilization because patients were afraid that 
they would have to pay that first deductible amount. Other 
patients saw good physicians, went to the hospitals, and then 
are in collections. We can't have a whole Nation of patients in 
collection and we can't have a whole Nation of physicians' 
offices and hospitals fighting the system to get paid. And this 
isn't fair to the patients.
    So when we talk or there is rumor about a single payer 
system, I think, in my heart, the quickest answer to help us in 
the next 20 days is eliminate these networks. Let everybody who 
signed up stay in those plans, and those insurance companies 
must be made also to be transparent about what they will pay, 
which, by the way, up until this point they haven't. I have 
colleagues that have no idea that they are even on these panels 
and they have no idea what they are going to be paid. So let 
the insurance companies, so not to hurt their business 
operations, because we all want them to stay in business too 
for the rest of us, let them pay that same dollar amount as the 
access reference point, and then allow a negotiated fee between 
the patient and any doctor they want for a value for that 
service. Who is hurt by that? You will then establish a 
competition between physicians to keep prices controlled, 
unless you want to have one of those often spoken about 
concierge practices that charge enrollment fees of $24,000 for 
a certain one percent of this Nation. But everyone else will 
keep their prices in check with this negotiated amount. The 
doctors will be able to remain in private practice, keeping 
them out of the facilities that are going to cost everyone more 
money, and the patients will have the ability to see someone 
for a modest fee, if that is available, or they can negotiate 
some other fee. That is the only fix right now. But get rid of, 
please, those networks and allow the doctors to stay in 
business at the same time.
    Mr. Cummings. Thank you, Mr. Chairman.
    Chairman Issa. Thank you.
    I now ask unanimous consent that the article today in The 
Wall Street Journal, or actually yesterday in The Wall Street 
Journal, entitled Juking the Obamacare Stats, be placed in the 
record. Without objection, so ordered.
    Chairman Issa. I now recognize the gentleman from Florida, 
Mr. Mica.
    Mr. Mica. Thank you, Mr. Chairman. Perfect lead-in, putting 
that into the record.
    The title of the hearing is Obamacare Impact on Premiums 
and Provider Networks. Let's first talk generally about the 
impact on premiums and the people who have been affected so far 
that we know about. So far, the chairman just put this in, The 
Wall Street Journal said yesterday that between 4 million and 
5.5 million people have had their plans liquidated. Isn't it 
your observation that most of these people are now going to 
face a higher premium, Dr. English? Actually, a higher premium 
and lower deductibility. I mean higher deductibility and higher 
premiums, both. Would that be your guesstimate?
    Dr. English. Well, I think there is so much variability, I 
think, as we have talked about. We want people to have----
    Mr. Mica. But these people who had existing plans now have 
been notified that they are not getting them, with the new 
mandates in that. For example, I have been forced onto 
Obamacare. My deductibles are doubled or tripled, and my 
premiums are up, and I think that is what 4 million to 5.5 
million have seen. What do you think, doctor?
    Dr. English. I would answer that. I am reading what you are 
reading. I just can't give you personal experience with my 
patients.
    Mr. Mica. Okay.
    Dr. English. Some of them even don't know yet; they don't 
know what they are having.
    Mr. Mica. Well, again, with more mandates, the cost, the 
premiums are more. So they have shafted as many as 5.5 million 
in their premiums.
    Dr. Novack, any comment here?
    Dr. Novack. No. Clearly, we are seeing that it is highly 
likely that the number of net losers are going to substantially 
outweigh the number of----
    Mr. Mica. And they have signed up a whopping 364,682.
    Dr. Novack. And we don't know if those are--since the 
Country is starting out with a 5.5 million negative number, so 
we don't know who those people are. Are the 300,000 people or 
so just the people who previously had insurance but lost it? So 
we don't know who those numbers are, let alone whether or not 
they paid for it.
    Mr. Mica. Let's jump to the impact. Again, the title is 
Impact on Provider Networks. Here is another article from The 
Wall Street Journal about what the chairman talked about in his 
opening statement. In my State, which has many, many senior 
citizens residing in Southwest Florida, their primary 
oncologist provider was the Moffitt Hospital. That has been 
dropped. Thousands of seniors now do not have access to this 
critical care. Is that the kind of impact you are seeing? 
Again, this is on our seniors. This doesn't involve Obamacare 
coverage, this is an existing Medicare Advantage, of which 28 
percent, I guess, of all the Medicare people are on. This is an 
indirect result of Obamacare and what is going on in the 
marketplace.
    Is that correct, Dr. English?
    Dr. English. Yes. I think Congressman Issa mentioned, 
again, the drafter of the law who was on the talk shows talked 
about paying more to see doctors on those plans. The State 
exchanges are set up, there are different exchanges in the 
State, so your providers, if they are in a different area, you 
can't even move out of that exchange to see those people.
    Mr. Mica. What we are seeing is absolute turmoil in the 
marketplace. Seniors, they are the most vulnerable in our 
society and probably need the most medical coverage. Instead of 
getting coverage, they are searching for a doctor to serve 
them, as doctors have been thrown out in the cold.
    Dr. McLaughlin?
    Dr. McLaughlin. Well, absolutely, sir. I can tell you, in 
New York State, we are such a large State and, really, the 
behavior of the insurance companies has been quite different 
upstate New York as opposed to downstate New York. In the 
downstate area, 2100 physicians were dismissed from Oxford 
United managed medical----
    Mr. Mica. So it is not just Florida.
    Dr. McLaughlin. Absolutely no.
    Mr. Mica. We are seeing it across the Nation.
    Dr. McLaughlin. And there is a reason for that and there is 
a link to the ACA, because the CMS budget to these managed care 
companies was decreased from 17 percent to I believe the figure 
is about 8 percent to manage the Medicare beneficiaries. Now, 
with all due respect to the business operations of an insurance 
company, when they have a cut like that in their payments from 
the Government to manage these patients, as a business, they 
have to do something to cut their costs. Morally and ethically, 
none of us in here are happy with that, but I can understand 
where that came about.
    Mr. Mica. Doctor, you had mentioned the panels that are 
being set up and I hear from seniors these rumors that certain 
ages, certain types of care is going to be cut off. Do you 
envision that happening? I heard rumor 73 you don't get cancer 
treatment or there is a possibility of not getting transplants 
and things like that. What do you see----
    Chairman Issa. The gentleman's time has expired. The 
gentlelady may answer, doctor.
    Dr. McLaughlin. May I answer?
    Chairman Issa. Of course.
    Dr. McLaughlin. Okay. You know, a lot of that could be 
hearsay at this point. We heard rumors about death panels and 
things like that, but clearly rationing care is something that 
has to be part of this to make it work. It is not the 
appropriate answer, however. So I am not quite sure what the 
facts are about at what age some procedures will be limited, 
but I would not dare think that that may not come.
    Mr. Mica. Thank you.
    Chairman Issa. If I could ask unanimous consent just to 
follow up for 30 seconds on this, because when the word death 
panel is used, Dr. Boustany and others who are serving in 
Congress have a real problem with it.
    Dr. McLaughlin, you do agree, I believe all of you, that 
medically sensible decisions about whether to use extreme 
healthcare options or not, in other words, decisions that are 
not always to do the most expensive and thorough do change with 
age, and that medical doctors need to make those decisions. So 
the term death panel hopefully does not mean that doctors don't 
make a decision that extraordinary measures sometimes are not 
appropriate for the elderly. And I want to ask that because I 
think both Republicans and Democrats found that word to divide 
us, rather than unite us, on your making decisions about what 
is best. So just a yes or no, if you can.
    Dr. McLaughlin. The simple answer is most of us who are 
physicians will have a talk with the family and advise them 
what we feel is medically appropriate at the time and will do 
everything possible to sustain life where there is life and to 
allow the family to make a just decision. We hope most people 
will do advance beneficiary notices so that the individual has 
that choice and takes that burden away from the family. And if 
there is anything we can do as a society, we should be pushing 
individuals to make that decision. Thank you.
    Chairman Issa. I appreciate that. I didn't want that to 
divide this panel, because I think we are united on the need to 
fix healthcare.
    The gentlelady from Illinois, Ms. Duckworth.
    Ms. Duckworth. Thank you, Mr. Chairman. Thank you for that 
comment. As someone who was accused of being involved in death 
panels at the VA, where they certainly use outcomes-based to 
deem what is appropriate for veterans, that is a very sensitive 
statement, so thank you very much for bringing that up, Mr. 
Chairman.
    Dr. English, I just wanted to follow up with you a little 
bit. You know, the goal of giving Americans access to 
affordable, quality, life-saving healthcare is critical. It is 
not only the moral thing to do, to make sure that getting sick 
in America doesn't lead families to bankruptcies, but, as far 
as I am concerned, it is common sense for our Country's 
economic competitiveness and our Government's fiscal health. I 
personally think that the Affordable Care Act made big steps in 
that right direction, but, as you have mentioned, there have 
been some real problems with it that need to be fixed. You 
spoke a little bit about the issues with CMS, for example, and 
how they rated your use of MRIs and incorrectly compared your 
use to others. I, myself, understand how different types of 
therapies will differ and associated diagnostic equipment that 
you need to do to treat that.
    Are you saying in your testimony that the CMS decisions on 
how you are evaluated with your use to this is specifically to 
the Affordable Care Act, or are you saying this is just part of 
their trying to improve the Medicare-Medicaid system?
    Dr. English. I believe that outcomes measures are a major 
part of the Affordable Care Act, and they are using models like 
that. Some of those things were predated with the stimulus 
package, some of that started ahead of the Affordable Care Act, 
but that is big portion when we look at the Medicare cuts for 
the future. How will we evaluate outcomes and physicians and 
bonuses versus penalties, that is part of the Affordable Care 
Act. So it is a combination.
    Ms. Duckworth. Do you support outcomes based on decision-
making in medicine in terms of aggregate treatment and outcomes 
of those treatments for your patients, this particular 
procedure works better than others? I know you come from a very 
cutting-edge institution that is, according to your web page, 
very progressive and aggressive in treatment which, if I had 
MS, that is what I would want, but do you support looking at 
outcomes?
    Dr. English. I do. I think when they come from as far away 
from where the actual patient care is occurring, the more 
mistakes are made, and I think the ACA really approaches this 
coming from D.C., which was the wrong way. I really wish 
specialty societies were encouraged to come up with metrics, 
given a few years to say what is appropriate care in MS, what 
is appropriate care in knee surgery, etcetera. That would have 
been a better way, in my opinion.
    Ms. Duckworth. So what I am hearing is not so much that 
looking at outcomes is a bad thing, but that the way CMS is 
going about it, using accountants to look at it versus relying 
on the healthcare practitioners to be the ones who inform that 
process of developing what those guidelines are, so that if 
they are going to evaluate the outcomes, if they are going to 
use outcomes, base evaluation of physicians who deal with MS, 
they should probably have some MS physicians who would inform 
that process of developing those guidelines so that your use of 
MRI would be perfectly in keeping with other physicians who 
treat MS in an institution like in your setting, right?
    Dr. English. Yes. As I stated, I think the Affordable Care 
Act, again, is going to have all of these unintended 
consequences because it is built from the top down, not from 
the ground up. So whether you like the law or not, I want you 
to understand these things, these unintended consequences, are 
going to happen and they are not unforeseen.
    Ms. Duckworth. Well, I happen to agree with you that we 
need to fix these unintended consequences, and I would love to 
be able to continue to focus on that. I don't know that 
repealing the law or unfunding it or defunding it is the way to 
go, but I do agree with you that there are many problems that 
need to be fixed. But there are good things with it. I have a 
preexisting condition. I would assume that someone with MS 
would be considered to have a preexisting condition if they 
were to enter the marketplace or try to find their health 
insurance now. Have you had experience with MS patients on 
reaching lifetime caps from insurance companies for their 
treatment?
    Dr. English. Well, first of all, I would say everybody in 
this room has a preexisting condition, it is just that some of 
us don't know it yet.
    Ms. Duckworth. Good point.
    Dr. English. So you need to have an insurance that actually 
will follow you once that happens. If everybody owned their own 
insurance, then once they got sick there is no such thing as 
preexisting conditions.
    So in my practice the answer is no, I have never, to date, 
13 years in Atlanta at our center, not been able to get the 
care to my patients through one way or another. Even with gaps 
there have been ways to do that.
    Ms. Duckworth. Let me fix that. I am talking about caps 
from insurance companies. I think your institution does a 
fantastic job of raising alternate funds as a charity, to 
provide charity dollars in order to cover patients who have 
lost the coverage from their own insurance companies. That is 
very different. I am glad that you can get the care to the 
patient. But the fact of the matter is you are using other 
techniques. And I would think it would be better if the patient 
had insurance that stayed with them and would cover so that 
they did not have to rely on charity.
    I am out of time. Thank you.
    Chairman Issa. I thank you all.
    We now go to the gentleman from Michigan for his questions.
    Mr. Walberg. Thank you, Mr. Chairman, and thanks to the 
panelists for being here. Thanks for the work you do, as well.
    Dr. Novack, let me go back to some questioning beforehand, 
and specifically what are your views on the Independent Payment 
Advisory Board, or IPAD?
    Dr. Novack. Sure. Thank you for that question. Obviously, 
the IPAD, which is supposed to be in existence, but no one has 
been nominated yet, to my knowledge, they say that it is not 
going to be involved and it doesn't have the power to determine 
what care can or cannot be given, but as I believe not only are 
the people on the panel with me saying, but I think in the 
comments of the members implies, that what the IPAD can do is 
determine effectively how much you get paid for it. And if the 
payment for something drops to a point where you cannot stay in 
business or keep your doors open if you continue to provide it, 
less of it is going to be available.
    So I think it is a bit of semantics and I think some of the 
words can cause division, but the ultimate reality and the 
ultimate goal of the Independent Payment Advisory Board, if 
Medicare expenditures go up faster than inflation, or 1 percent 
above inflation, is to reduce those costs, and they are going 
to go where the money is. So they are going to go to the 
expensive patients with MS and say we are just going to pay a 
lot less because we think that means that centers like Dr. 
English's will just not make services available, and that is 
how they are going to lower the cost.
    Mr. Walberg. So it takes away decisions from the patient 
and the healthcare provider.
    Dr. Novack. Correct.
    Mr. Walberg. To a great degree.
    Dr. Novack. Correct.
    Mr. Walberg. I would assume that that is, from what you 
say, a negative to the healthcare system.
    Dr. Novack. Well, I think that ultimately the question is 
how do we get the best healthcare to the mom who brings in 
their child to me after they fall at the park.
    Mr. Walberg. The best healthcare, what we deserve.
    Dr. Novack. And the ultimate answer is trying to get 
patients and families involved on multiple levels to help try 
to make the best decision for them, because certainly in my 
world, taking care of a number of fractures and acute injuries, 
I don't have the luxury of longstanding experiences with 
patients and families, so you need to be able to get data so 
that families can make the best decisions.
    Mr. Walberg. Do you have any evidence, doctor, that 
competition and choice is a better way to increase value and 
reduce cost than Government bureaucracies and their expertise?
    Dr. Novack. Sure. Obviously, you have examples in certain 
parts of medicine where that does exist, but I think we can 
look, for example, in California more recently with what 
WellPoint has done with reference pricing for joint 
replacements, and by changing the structure, they have lowered 
the cost of joint replacements by 20 percent in, I think, less 
than two years. So the idea of creating transparency and really 
giving the opportunity to create new creative ways where you 
bundle your services together, you can actually provide high-
quality care at a lower cost that ultimately results in better 
patient satisfaction.
    Mr. Walberg. Okay. Thank you.
    Dr. English, just to make sure it is clear where you stand, 
will Obamacare limit your patients' treatments?
    Dr. English. Yes.
    Mr. Walberg. In your testimony you mentioned 10 medications 
for MS patients. A Washington Post article from two days ago 
said one-way insurance plans under Obamacare are keeping costs 
low by not covering widely used MS drugs and requiring doctors 
to prescribe drugs in a certain order, which would compel 
patients to take drugs more toxic to them, potentially. Have 
you found that to be the case?
    Dr. English. This is our major concern, because I can't 
impress upon you enough how variable patients are and the drugs 
that they need, and without the ability to move quickly to one 
and switch to another. If I can't do that anymore, that is what 
will get me out of medicine, not the reimbursement stuff.
    Mr. Walberg. What does that do to your patients?
    Dr. English. It is my teacher who is paralyzed, who I know 
I can do something for, but I can't, and I have to watch her 
stay paralyzed. That is my concern.
    Mr. Walberg. And puts them at risk, at the very least----
    Dr. English. Correct.
    Mr. Walberg.--to take drugs that don't impact them 
positively, let alone produce the change that is necessary.
    Dr. English. Correct.
    Mr. Walberg. You stated Obamacare punishes you because you 
care for the most vulnerable patients. How does it do that?
    Dr. English. Well, let's look at that. I think Congressman 
Issa had mentioned, too, or it might have been Congressman 
Cummings, about if our center closed down and I was looking for 
a job at a hospital, and 5,000 expensive patients were coming 
that was going to bankrupt my hospital, which ones do you think 
would sign up to take me on? I want to work, like University of 
Maryland, the trauma center, I learned there. That was 
incredible, taking care of the sickest of the sickest. But I 
loved doing that. And I don't see how, under these payment 
models, that any hospital system is incentivized by taking care 
of the sickest patients; they would be disincentivized based on 
incomes.
    Mr. Walberg. So what we are looking at is a two-tier, those 
that can afford it for specialized treatment, have the money to 
do that, and then all of the rest of us.
    Dr. English. Correct.
    Chairman Issa. I thank the gentleman.
    We now go to the gentlelady from New York, Mrs. Maloney.
    Mrs. Maloney. Thank you, Mr. Chairman and ranking member 
for calling this hearing, and I thank all of the panelists for 
their testimony and participation, particularly Dr. McLaughlin, 
who is from the great State of New York, which I have the 
privilege of representing a portion of it.
    I do believe that you have raised some important concerns, 
but I truly do believe that the Affordable Care Act really is 
important legislation; and it is by no means perfect, but it 
really addresses some of the massive deficiencies in our 
Nation's healthcare system, such as covering preexisting 
conditions and providing coverage to over 30 million Americans 
that did not previously have coverage. And while I do want to 
get to your concerns and understand them in a deeper way, I 
would like to take a moment to highlight some of the successes 
of the marketplace in my home State of New York.
    Earlier this week, the New York State of Health reported 
that over 314,000 New Yorkers had completed their applications 
for insurance and over 100,000 New Yorkers have enrolled for 
coverage starting on January 1st, 2014. And I understand that 
70,000 selected a private insurance plan and one report stated 
that New York has the second highest raw enrollment numbers of 
any State. So there are some successes, but I do want to 
acknowledge that there is always room for improvement. And any 
massive new change in something as complicated as healthcare is 
going to have to face many improvements and we need to be 
willing to work together on both sides of the aisle to correct 
deficiencies and challenges that we see during this 
implementation process.
    But, Dr. McLaughlin, I would like to understand the 
concerns that you raised today, and I want to make sure that I 
understand completely your situation. You stated that you 
received notice last month from an insurance company stating 
that you would not be extended participating status on the new 
insurance plans in the Pathway network. Is that correct?
    Dr. McLaughlin. Yes, councilwoman, that is correct.
    Mrs. Maloney. And what about other insurers, did you get 
similar letters from other insurers?
    Dr. McLaughlin. Well, the way this works is the insurance 
companies can only approach those physicians that happen to be 
already networked with them, under contract to them. So, for 
instance, I am not in the Emblem system, so they cannot 
approach me or do anything to me involuntarily. And that is 
important to understand.
    Mrs. Maloney. But can you approach them, another insurance 
company? Would you be willing to participate in any plan on the 
exchange? Can you approach another plan?
    Dr. McLaughlin. I am assuming that that door may be open; 
however, what is clearly evident by the plans that I am already 
under contract to, BlueCross for the main one, they made a 
decision, for whatever reason, that they had enough 
participating physicians to form this Pathway network, which I 
might add, by just looking at the ophthalmologists serving 
Manhattan in that list, came to less than 150 names, of which 
most of them were in solo practices with no affiliation to 
large group contracting forces. So these physicians happen to 
be under contract to that company for the lowest fee 
reimbursement for the same service that another physician who 
is part of a faculty practice or a large group practice would 
get. And as insane as that sounds for doing the same work, 
physicians are paid differently in the current system depending 
on how large a group you belong to and what negotiating power 
comes with those numbers.
    Mrs. Maloney. Well, have you appealed the decision? I know 
that they are trying to save money. In fact, the New York State 
testified or released a report saying that the people that had 
enrolled, 100,000, were seeing premium rates that are as much 
as 53 percent lower than the rates in effect in 2013 for 
comparable coverage. So that is great news for them, but they 
are looking for services that are more affordable. But you can 
appeal these decisions, as you know, and, as you know, 
particularly in New York State, that is being run by the State, 
and State insurance is regulated by the State, and you can 
appeal to the New York State Insurance Commissioner, and I 
would be happy to work with you in setting up such meetings if 
you would be so interested. But have you appealed the decision?
    Dr. McLaughlin. There was not an opportunity mentioned in 
that letter for appeal, it was a unilateral decision. There was 
no notice in there that I even had a right to appeal. I must 
say also that I had an amended contract to my United Healthcare 
participating status, and that also said that because I was not 
in an Oxford Liberty current network, I would not be put onto 
the Affordable Care Act insurances. So that was an automatic 
opt-out. Not an automatic opt-out; I wouldn't be in it. And for 
those doctors who were in the Oxford Liberty current plan, once 
they see their fee schedule, they could then opt-out.
    Mrs. Maloney. And you can also get a navigator to help you 
or broker to determine what plan would be best and to help you 
with your appeal, but I would be delighted to help you with an 
appeal if you are so interested.
    Chairman Issa. I thank the gentlelady.
    We now go to the gentleman from Oklahoma, the head of our 
Energy and Healthcare Subcommittee, Mr. Lankford.
    Mr. Lankford. Thank you, Mr. Chairman.
    Thank you all for what you do and the way you are taking 
care of patients. You are going through a lot of paperwork and 
a lot of process right now that I can imagine the incredible 
amount of frustration that every day you are getting a new 
regulation, a new rule, or a new something that is coming out 
at you while you are trying to just take care of people and 
patients, what you love to do. So I want you to know from us we 
appreciate what you are doing and how you are trying to focus 
on taking care of people.
    The problems are very, very real you all are experiencing 
on the ground. We hear about them in our offices all the time. 
The numbers are out. For the first two months of enrollment in 
the Affordable Care Act in my State, in Oklahoma, they are now 
up to just over 1,600 people have been able to sign up in my 
entire State. To give you a point of reference, 1400 companies 
got a letter two months ago that their insurance was canceled 
because they were in a small business group just in Oklahoma 
City. So just in one town in my district 1400 companies 
received a letter all in the same day that they had all been 
canceled because their association is no longer legal and they 
are out looking. And now we have had 1600 people total in the 
entire State have been able to sign up.
    One of those was a small car dealership in Oklahoma City 
with 14 employees. They now are having to select a different 
insurance policy, a different company, and as the owner of the 
car lots told me, we can either select a plan that is much more 
expensive than what we had last year, but keep our doctors, or 
pay the same as what we had last year, but we all have to 
switch doctors. But we can't do both. We can't both keep our 
plan and keep our doctors or keep the price and keep our 
doctors; we have to choose on it. And it has been a very 
difficult process for them as a small business, as it is facing 
a lot of small businesses across our area.
    Dr. McLaughlin, you mentioned that even with your own 
practice. That is becoming a big issue. It is one of those many 
things that is out there.
    So let me just ask a couple questions about processing. By 
one count, this law creates about 159 new boards or agencies. 
We asked the Congressional Research Service to try to determine 
how many boards or agencies are created by this. They said it 
is not knowable at this point exactly how many.
    Dr. English, you mentioned multiple times the difficulty of 
decisions being made in Washington, D.C. and getting passed on 
to you, and I have direct family members that have MS, and I am 
very familiar with the process and the drugs and what is going 
on. So I am trying to process through 159 different agencies 
that are all setting these different rules and you get 
instructions about how to take care of your patients. What does 
that do for you day-to-day?
    Dr. English. Well, let me give you an example. I have, for 
the first time in my career, had patients who are healthy 
previously not walking, etcetera, on a medication doing great 
who are crying in my office. People are really afraid, as you 
are seeing as well. They don't know whether their medication is 
going to be covered. I am filling out forms. Patients who are 
stable on medications, but they are not on the list anymore of 
the restricted provider list.
    Mr. Lankford. So we are talking about people that are 
currently under medication doing better, stabilized in the 
process, that instructions are coming down to them to say we 
may have to switch the regimen for treatment to a different 
drug or a different treatment regimen when they are currently 
stabilized right now.
    Dr. English. Correct.
    Mr. Lankford. That sounds like someone in Washington 
telling you how to take care of a patient that is doing well 
with their treatments, and saying we are going to experiment 
with a different way to do this with your patients.
    Dr. English. And in the Georgia State exchange we have no 
idea what medications are going to be available to those 
patients and then, again, we are less than a month away from 
patients coming to my office on those insurance plans.
    Mr. Lankford. And the current system, as it has been set 
up, is there a discouragement to take the more complicated 
patients. So the more complex the case is, the more that that 
is discouraged financially and in every other way from the 
Federal Government and from the system, is that correct?
    Dr. English. The current system in the ACA, the current 
system before----
    Mr. Lankford. The current system, ACA, that is coming at 
us.
    Dr. English. As we discussed in my testimony, there are 
many things that will be discouraging me to take care of the 
sickest patients, yes.
    Mr. Lankford. Dr. Novack, you mentioned before all the 
issues with Medicaid that are out there based on the 
reimbursement rates and the number of physicians that do that. 
Half of the people that have now signed up for insurance 
nationwide are not signing up for private insurance, they are 
in State Medicaid programs. While they have access to care on 
that, what are the issues that they are going to face in the 
days ahead?
    Dr. Novack. Well, I think the first issue, again, I think 
the crowd-out issue is something we really can't discount. 
Jonathan Gruber, who was really the architect of Romneycare and 
he was really an architect of the Affordable Care Act, his own 
research that he did originally in the 1990s and then repeated 
in 2007 showed half the people who ended up on the Government 
program lost private care. Again, the more recent study from 
Austin Frakt, I believe from one of the Boston area 
universities, showed that up to 80 percent of the people who 
will end up on expanded Medicaid will lose their private health 
insurance.
    When you look at the smaller networks, when you look at the 
lower payment rates that discourage people to accept it or 
create long waiting lists to get access to it, I think, again, 
there will be a few winners, but ultimately the number of 
losers is going to be a lot greater. And we see in orthopaedics 
in Arizona that access to certain kinds of durable medical 
equipment, access to getting physical therapy after an injury 
in terms of limits, access to certain medications, all of those 
are severely restricted under Medicaid relative to what was 
existing in the commercial market.
    Mr. Lankford. There is a tremendous difference between the 
hope of what this would be and the reality of what it actually 
is on the ground.
    Dr. Novack. Yes.
    Mr. Lankford. With that, I yield back.
    Chairman Issa. I thank the gentleman.
    We now go to the gentleman from Pennsylvania, Mr. 
Cartwright.
    Mr. Cartwright. Thank you, Mr. Chairman, and thank you for 
all the witnesses appearing today. I believe the Affordable 
Care Act is a landmark law. It is obviously, by no means, 
perfect, it needs a lot of work, but all of us need to roll up 
our sleeves and work together and make it better.
    I had planned to ask all of the witnesses questions about 
provider networks, including Dr. Feder, but, unfortunately, the 
Majority didn't inform us they decided to change the panel 
structure today. They didn't inform Dr. Feder, either. Dr. 
Feder was here and ready to testify at 9:30. I would say that 
the fact that she is here and waiting for the second panel, 
while we are not including her now, is disappointing.
    But, Dr. McLaughlin, I was interested in your testimony and 
your comments, and I would like to follow up on some of the 
things that Congresswoman Maloney covered with you. It is my 
understanding that--well, a large part of your testimony has 
surrounded the fact that you got dropped by Empire BlueCross 
and BlueShield, right?
    Dr. McLaughlin. As a participating provider in the new 
plans that they are developing for small businesses off the 
Affordable Care Act exchange, as well as those serving the ACA.
    Mr. Cartwright. All right. And not to put too fine a point 
on it, you are still waiting to hear about the larger 
employers, whether you will be included in that coverage.
    Dr. McLaughlin. No, I am completely in that.
    Mr. Cartwright. You are in that.
    Dr. McLaughlin. For now, yes.
    Mr. Cartwright. Okay. So we want to look into why these 
things happen. You got less than a full explanation from Empire 
BlueCross and BlueShield, am I correct in that?
    Dr. McLaughlin. Yes. And everyone who is on my associated 
hospital staff had the same letter. This is not an isolated 
letter, this is clear across the board.
    Mr. Cartwright. Right. So if I am not mistaken, you got the 
Empire BlueCross Blue Shield letter on October 29th of this 
year, am I correct in that?
    Dr. McLaughlin. Yes.
    Mr. Cartwright. Okay, so I want to talk about what efforts 
you have made in the couple of months since then to go over 
what the situation is and see what light you can help us shed 
on the situation. So I think you said you saw about 150 names 
of ophthalmologists who are included in the system, is that 
correct?
    Dr. McLaughlin. That is correct.
    Mr. Cartwright. Did you make an effort to compare different 
sets of facts, for example, compare your own credentials with 
those of the other ophthalmologists who made the list? I assume 
you are board certified, for example.
    Dr. McLaughlin. It is not based on that. We are all equal. 
What the basis clearly is is the original fee schedule of the 
networks that the doctors are in. And, as I said, if you are a 
complete solo practitioner, not part of a large group who 
negotiates a fee schedule with the insurance companies, you get 
what is called the standard rack rate from the insurance 
company, and those preferentially are those doctors that are on 
this network, they are the lowest paid of the physicians, and 
that is clearly what the decision is.
    Mr. Cartwright. I don't mean to belabor the point, but are 
you saying you haven't really engaged in a comparison of your 
own credentials with those of the 150?
    Dr. McLaughlin. There is nothing to compare. This is across 
the board. Everyone who is at my hospital was not offered the 
status. We are all of equal rankings, do the same work, the 
same exams. That is not what this is about.
    Mr. Cartwright. So you think it is more about pricing, it 
is about money.
    Dr. McLaughlin. It is clearly about money.
    Mr. Cartwright. All right. Well, let's take that, then. 
Have you compared the pricing? Have you compared how much it 
costs people to get treated by you and the other people who got 
dropped versus the people who got accepted into the system?
    Dr. McLaughlin. Well, first of all, I would have no way to 
compare that. There are quite a bit of regulations on us, also, 
as far as fee schedules. We have antitrust regulations and we 
are not allowed to collectively negotiate, so, in honesty, I 
would have no idea to know pure facts as to what someone is 
being paid compared to myself.
    Mr. Cartwright. Well, obviously somebody engaged in that 
comparison; that is why some people made the list and some 
people didn't.
    Dr. McLaughlin. That is right. That is maybe for you to 
find out.
    Mr. Cartwright. Thank you.
    Dr. McLaughlin. You are welcome.
    Mr. Cartwright. But another thing you mentioned was this 
idea, and I had heard it before, that if you want to protect 
yourself as a physician, you want to join groups, and the 
bigger the group you are in, the more protection you have as we 
enter the new age. You are a solo practitioner, am I correct in 
that?
    Dr. McLaughlin. That is correct.
    Mr. Cartwright. So intertwined with that thinking, you have 
the least protection of anybody entering the new age, and I 
want to ask you hadn't you heard this, hadn't you heard what I 
had heard, that you were going to protect yourself by joining 
medical groups?
    Chairman Issa. The gentleman's time has expired. The doctor 
may answer.
    Dr. McLaughlin. Well, let me just share this with you. I 
had been, for eight years, a full-time faculty member at a 
major hospital in New York and enjoyed my time there. But I 
also saw the benefit of being able to be a physician, to make 
choices for the patient care in a way that I see fit, and the 
best care that I see fit for the patient that works for me and 
my patients. I don't want to give up that freedom by joining a 
larger group that has a non-physician administrator telling me 
how fast I have to see a patient and what I can or cannot do 
for them. That is a choice that I have in this Country, thank 
God, and I want to keep it for my patients' sake.
    Chairman Issa. I thank you.
    We now go to somebody who knows about patients' care, first 
on the list, Dr. Gosar.
    Mr. Gosar. Thank you, chairman.
    Dr. Novack, can you discuss for me the confusion your 
patients are feeling about Obamacare, your services, and then 
also touch a little bit about urban and rural? You know, we are 
from Arizona, so there is definitely a dichotomy going on here.
    Dr. Novack. Sure. I think that if there is one term, 
regardless of your political party preference, that describes 
whether it is providers or patients or administrators or staff, 
it is confusion, because no one really knows. And I have 100 
patients a week coming through, the bulk of whom will actually 
ask that question, because they know I am involved in different 
policy issues, and my answer is we just don't know. They don't 
know what plans are going to be available. They don't know what 
services are going to be available. They don't know what 
medications are going to be covered. They don't know which 
hospitals they are going to be allowed to go to.
    So the issue here is basically abject confusion, and no one 
knows what is going to happen January 1st. And to say that that 
was an unforced error because of political realities, the great 
tragedy are really the tens of millions of Americans and 
hardworking American families that have been suffering 
emotionally because of the uncertainty that the law has 
created, because of work that was not done, the lack of 
transparency, the unwillingness to release regulations.
    I have patients who work for insurance companies, and I was 
hearing from them throughout the summer that they didn't even 
know the requirements that they were going to be forced to put 
into the software that they had to write. We are hearing that 
they are being required to be responsible for the data on these 
servers, but they are not allowed to get access to the servers 
to be able to test the integrity of the data that they are 
being held responsible for.
    So at every single level, unfortunately, the claims that 
were made to pass the law are not the reality, and the losers--
this is not about the three of us up here, it is not about the 
dentists, it is about the fact that we do need to do something 
about preexisting conditions, but that was a small part of the 
population. The same amount of people basically that folks have 
recently been saying that, oh, it is a small number, don't 
worry about them that are getting their policies canceled, it 
was really only 10 to 15 million people that had these chronic 
conditions, and we could have addressed that. Instead, we have 
totally uprooted essentially everybody.
    Real quickly about the Medicare Advantage issue. There is 
nothing tangential to the changes in Medicare Advantage as it 
regards the Affordable Care Act. Remember that the Affordable 
Care Act cuts between $130 and $150 billion out of Medicare 
Advantage this decade, and that is why you are seeing these 
cuts to Medicare Advantage networks.
    Mr. Gosar. So when you are talking about preexisting 
conditions, I am going to ask you and Dr. English, we just 
exchanged, as the ranking member talked about, a prejudice to 
preexisting conditions, we just traded one prejudice for 
another. Would you agree with that?
    Dr. Novack. Correct.
    Mr. Gosar. Dr. English, would you agree with that?
    Dr. English. Correct. You haven't, in my opinion, increased 
care, you shifted care, and that is quite obvious.
    Mr. Gosar. Well, I want to get to that and I really want to 
applaud you. I have family members and dear friends that have 
MS, so thank you very, very much. But there is prejudice now 
because we are talking about acute care versus chronic 
conditions, right, Dr. English?
    Dr. English. Correct.
    Mr. Gosar. So you are handicapped when we are talking about 
chronic care, are we not?
    Dr. English. Correct.
    Mr. Gosar. And so we are asking you to decrease time, 
reduce reimbursement, reduce the possibility of drugs, reduce 
your opportunity to individualize individual treatment 
modalities. But I have a question for you. Did you see any tort 
reform in this bill?
    Dr. English. No, sir.
    Mr. Gosar. Dr. Novack, did you see tort reform in this 
bill?
    Dr. Novack. No.
    Mr. Gosar. Dr. McLaughlin, how about you?
    Dr. McLaughlin. Absolutely no.
    Mr. Gosar. Have you ever heard of solving a problem without 
putting everything on the table, Dr. English?
    Dr. English. Say that again, please?
    Mr. Gosar. Have you ever heard of solving a problem, but 
not putting everything on the table?
    Dr. English. No.
    Mr. Gosar. It is foreign to me.
    Dr. Novack. And the law did actually approve the 
opportunity for some demonstration programs for medical 
liability reform, but in the law, the plain language of the law 
says you may not do any demonstration program that includes any 
limits on non-economic damages. So the constraints were fairly 
significant.
    Mr. Gosar. Dr. McLaughlin, I want to go back to this. 
Reducing time for physicians to see their patients, we are 
reducing the reimbursement rates, we are reducing the panels, 
all choreographing hurting the patient. Would you agree?
    Dr. McLaughlin. Absolutely.
    Mr. Gosar. You made the comment that you want to practice 
medicine your way. You want to individualize, take your time, 
how you see fit, individualize the treatments, right?
    Dr. McLaughlin. Yes, sir.
    Mr. Gosar. How do you feel most patients would like it, 
would they appreciate your thoughtfulness?
    Dr. McLaughlin. Absolutely, because over and over again I 
will have patients returning to me, perhaps even out of 
network, as they go to some of these larger group practices 
where physician extenders are employed to process patients 
literally through a quicker assembly line so that that facility 
can reap more benefits, cost-wise, out of the poorer 
reimbursements, but they may actually only have two to three 
minutes of face-to-face physician time in that. And most people 
are often told to bring a companion with them, because when you 
are the one that is seeking care, you are only observing half 
of the response from that physician, and you are losing the 
other half, which is why most of us actually face umpteen phone 
calls after the fact, because there is something they forgot to 
ask or something they didn't understand. So you can only 
imagine how that problem is magnified with only two minutes of 
face-to-face time with the doctor. Patients are generally 
nervous under those conditions.
    Chairman Issa. I thank the gentlelady.
    Dr. Novack, I just want to make sure the record is clear. 
When you were talking about what wasn't in the Act in tort 
reform, you were talking prohibition on MICRA, like they have 
had in California since the 1970s, limitations on things over 
and above full compensation for actual loss, is that correct?
    Dr. Novack. Correct. I think there is a little bit of money 
for demonstration projects in the States, but in the law it 
actually says those demonstration projects may not include any 
demonstrations that include any limits on non-economic damages.
    Chairman Issa. Thank you.
    The gentleman from Nevada, Mr. Horsford.
    Mr. Horsford. Thank you, Mr. Chairman. The title of this 
hearing is Obamacare's Impact on Premiums and Provider 
Networks, but the majority of the opening testimony has largely 
focused on inadequate reimbursement from Medicare and Medicaid 
rates, which private insurance companies use, in large part, to 
set their own rates. So weren't the issues related to 
reimbursement rates under Medicare and Medicaid issues for the 
provider community before Obamacare and the Affordable Care Act 
were even law? Yes or no?
    Dr. Novack. There is no question, but I think, and I will 
speak a little bit, is that if the title is about provider and 
provider networks, we need to look at this is not about us, 
right, it is about how do we get the maximum number of people 
the best personalized healthcare we possibly can. And the 
practical reality is our large group employs nearly 500 
people----
    Mr. Horsford. With all due respect, my question was are 
Medicare and Medicaid reimbursement issues issues that the 
provider community were dealing with prior to the Obamacare, 
Affordable Care Act ever becoming law, yes or no?
    Dr. Novack. Yes.
    Mr. Horsford. The rest of the panel?
    Dr. McLaughlin. Yes.
    Dr. English. Yes.
    Mr. Horsford. So isn't the real issue that you all, as the 
provider community, want this Congress to focus on, as many of 
the doctors in my district in Nevada have talked to me about, 
is the need to reform the reimbursement rates under Medicare, 
specifically the SGR? Isn't that the focus that would help to 
address a large part of this problem?
    Dr. Novack. I will speak for myself, and I would say, 
Congressman, I don't think so. This isn't about creating a new 
Washington system to have to figure out how to pay people to 
provide care. This is much more broadly about how do we 
establish policies to allow patients and families to remain in 
control of their healthcare and healthcare decisions. So----
    Mr. Horsford. So why did you guys bring up the 
reimbursement rates under Medicare and Medicaid as one of the 
reasons why there is this lack of adequacy of network providers 
within some of the plans?
    Dr. Novack. I would say it is one of the reasons, so it 
makes an impact.
    Mr. Horsford. So if the Congress could help address the 
reimbursement rates and reform SGR, would that help or hurt the 
process?
    Dr. Novack. I think it all depends upon how it is done. And 
again I would refer you back to the position of the Obama 
Administration, who said in a court filing this year that there 
is no general mandate under Medicaid to reimburse providers, 
including hospitals and that, for all or substantially all of 
their costs. So the position of the Administration seems to 
be----
    Mr. Horsford. But SGR is focused on Medicare.
    Dr. Novack. But I am just saying that the position is----
    Mr. Horsford. It is not the same thing. You are giving me a 
reference that is not my question. My question is on the SGR, 
which is largely the basis for how reimbursement rates to 
doctors are established by the private insurance companies.
    Dr. Novack. I think that things would be improved if there 
was not an annual uncertainty every year for us to say that on 
January 1st, 2014, we are getting a 25 percent cut, so we tell 
our patients that under those conditions we cannot continue to 
see you, so we have to decide if we are going to be willing to 
see Medicare patients until Congress chooses to fix the problem 
every year.
    Mr. Horsford. So if the Congress worked to fix the problem 
with the lack of reimbursement to cover the cost to the 
providers providing care under Medicare and Medicaid, that 
would help, not hurt, correct?
    Dr. Novack. I think it would--depending upon how it was 
done, it might help, but there is always the possibility that 
new policies could not be helpful.
    Mr. Horsford. Okay. Well, later today we will be voting on 
a budget deal that includes a rule on the SGR extension for 
another three months. Not reforming it, not increasing the 
reimbursement rates like doctors in my State of Nevada want us 
to do because they are not covering their costs, it is just 
extending it for another three months. So I would just hope 
that at some point in the Government reform part of this 
committee we would work to bring forward those bills. I have 
signed letters with my colleagues on the other side in favor of 
these reforms. I am prepared to work on legislation to bring 
these needed reforms forward.
    But instead we are having kind of these dog and pony kind 
of show hearings that don't get at any of the real reforms to 
make the law work better, or to address other issues that are 
unrelated to the law. Medicare and Medicaid reimbursement 
issues for doctors were a problem before Obamacare, before the 
Affordable Care Act was put into place, so to somehow suggest 
that it is because of the Obamacare that these issues are 
happening is to fail to recognize the history of the problems 
in the healthcare system to begin with.
    Chairman Issa. Would the gentleman yield?
    Mr. Horsford. No, Mr. Chairman, I just want to conclude 
my----
    Chairman Issa. The gentleman's time has expired.
    We now recognize the gentleman from Tennessee, Dr. 
DesJarlais.
    Mr. DesJarlais. Thank you, Mr. Chairman. I would be happy 
to yield a minute to you to finish your thought.
    Chairman Issa. Thank you.
    I was only going to say that I wasn't here in 1997, when 
they scored a big savings based on a theoretical reduction in 
the cost of doing business. You weren't here. It is something 
that I agree with the gentleman, we need to realize that simply 
paying doctors less, and then reneging on agreeing to pay them 
less when the real cost-savings didn't occur because we never 
legislated or did anything to help drive down the cost of 
delivery, is in fact a very good point, and I agree with the 
gentleman that that fundamental change, which was scored before 
you and I got here, is not about just paying doctors more, 
because we did say we are going to find ways to be more 
efficient in what drives their cost up. So I look forward to 
working with the gentleman on that. It won't come to our 
committee, but I would certainly be happy to work with the 
gentleman to try to drive down the cost of doctors delivering 
quality healthcare.
    And I thank the gentleman for yielding.
    Mr. DesJarlais. Certainly. Reclaiming my time. I will also 
add that we just had a Doctors Caucus meeting this morning. As 
you know, there are markups pending in Ways and Means and 
Energy and Commerce dealing with an SGR replacement. There is 
going to be a three-month patch, but we are working with the 15 
members of our GOP Doctors Caucus, as well as our dentists and 
our nurses, and we are going to try to find something that has 
a sensible approach to reimbursing physicians, unlike the SGR, 
which over the past 15 years has yielded nothing, I think, but 
a 1.9 percent increase; and I think most industries would have 
a hard time making that work with rising costs in other areas.
    I wanted to put up a video, if we could.
    [Video shown.]
    Mr. DesJarlais. Okay, I am sure this is probably something 
most everyone in this room has seen or heard, maybe everyone 
across America, and practicing primary care medicine for the 20 
years before coming to Congress, I know that a lot of my 
patients who had insurance probably believed the President. If 
you had an insurance plan that you liked and you had a doctor 
you liked, and you were given that clear assurance over and 
over again, right up through 2012, right before the election, I 
am sure a lot of your patients were secure that maybe this 
healthcare law wasn't going to impact them. Well, now they are 
finding out that that is simply not the case.
    So I would ask you--we can just go down the line--what are 
your patients finding and feeling when they, all of a sudden, 
realize they have been duped?
    Dr. English. Well, again, there is fear because they have 
an established relationship and patients will follow their 
doctors. What is wrong about the last part of that video is, as 
I said, if you are in a different part of Georgia and your 
exchange does not have me, but then you go into that exchange 
three hours away, now your primary doctor is three hours away 
too. So you can't just pay more to see us anymore; you are 
excluded if we are not on that list. And United Healthcare's 
website says I am non-preferred, so you can still see me, but 
you have to pay more because your doctor is being penalized 
because he takes care of sick people.
    Dr. McLaughlin. The patients are numb. I think that is 
about all I can say.
    Mr. DesJarlais. Okay.
    Dr. McLaughlin. And many of the patients who had a State 
subsidized plan in New York called Healthy New York received 
letters that that plan would end and they would have to go into 
the New York marketplace. I actually approached many of those 
patients that were in my practice; they never bothered to open 
the mail. They didn't even know that their plan terminated; I 
was the one that informed them. So these patients are numb, 
they are upset. And as you know as a primary care doctor, you 
don't work alone, you work with specialists. So Rahm Emmanuel 
had said that you can pay more for a plan that has your doctor. 
Well, it may have your doctor, one of them, but it may not have 
the four or five specialists that you see also. So there is a 
discontinuation of care no matter how you look at this.
    Mr. DesJarlais. Dr. Novack, I am going to finish because 
you bring up a great point. Supporters of the healthcare law 
claim that 30 million people will gain insurance. Can you 
explain the difference between having a health insurance card, 
particularly one for a Government program, and having access 
for care? And I will just preface that with I came to Tennessee 
in 1993, a year before TennCare was instituted, which was a 
model for what we are experiencing now, and it didn't work. So 
I think you know very well that somebody can come in with that 
card and they need maybe an orthopaedic surgeon, and if you are 
in a rural area, they may have to go 100 miles or more to try 
to find that doctor and you might have to hire extra staff just 
to stay on the line at night, after clinic hours, trying to 
find a referral or someone who can accept it.
    What are your experiences with that? Do you think it is a 
good idea to reform healthcare based on the expansion of 
Medicaid?
    Dr. Novack. I don't think the data suggests that is a 
particularly good idea, and I think it is the unfortunate 
reality. And to touch on what you said, I know Congressman 
Gosar, the last time I was here, made that point exactly in his 
opening remarks, that what we are seeing, unfortunately, is 
that a plan that was supposedly designed to help those who need 
the most, we are seeing in rural areas there are fewer and 
fewer doctors available, and we are seeing in inner cities the 
closure of clinics, the moving out of primary care doctors, the 
near complete absence of specialists in many cases. So, 
unfortunately, the groups that we really do want to do things 
to be able to help, unfortunately the law, while well intended, 
I just think we need to recognize is not doing what it said 
needed to be done. So this is beyond tinkering to make it 
better; this needs essentially a complete revamping and address 
the real problems.
    Chairman Issa. I thank the gentleman.
    We now go to the gentleman from Virginia, Mr. Connolly.
    Mr. Connolly. Thank you, Mr. Chairman, and thank you to our 
three panelists.
    One might be forgiven, looking at this panel and the 
theater of it. Frankly, if Democrats had had the chance to put 
together a panel of three doctors, I guess we could ask you to 
wear your white coat. And I guess we could find three doctors, 
I know we could, who would praise the plan. But the idea, and 
this doesn't in any way disparage the value of your opinion or 
your experience, but the idea that your experience is to be 
generalized as universal is false, and it is a false premise 
and it does a disservice, in my opinion, to this discussion.
    None of you are policy experts and none of you universally 
speak for your profession. You were asked at one point, by one 
of our colleagues, about how difficult it is to sign up. Well, 
if we are going through anecdotal experience, I can tell you 
that I and my entire staff must go on the exchange on 
Obamacare. All of us signed up, met the deadline. If you are 
under a certain age on my staff, the average premium cut ranges 
from 30 to 70 percent. They are happy as clams. The deductibles 
are comparable or better; the copays are comparable or better. 
I can tell you in my district of small businesses, who are 
crowing about the fact that when they went on the exchange they 
had better choices than they have currently. I talked to one 
the other day with four or five employees; he is going to save 
$6,000 to $7,000 a year.
    It isn't an honest intellectual pursuit to deliberately 
cherry-pick facts and to deliberately put together a panel of 
critics of a piece of legislation that is admittedly complex.
    You were asked about tort reform, as if tort reform was 
dispositive on the cost of healthcare. It is not. It is a 
factor, but, of course, what the questioner didn't say as a 
prelude to his question was, of course, on our side of the 
aisle we decided, a priori, to oppose it no matter what was in 
it. We didn't give it a chance. And the fact that an entire 
party decided to take a powder on a major piece of legislation 
precisely meant tort reform wouldn't be at the table in a 
meaningful way, at least as determined by them. Of course not.
    We had a prominent Republican Senator in the other body who 
said if we defeat healthcare--this was before we even knew what 
was going to be in it; it didn't matter--it will be Obama's 
Waterloo. That tells you everything you need to know. It wasn't 
about healthcare. It wasn't about the quality of healthcare. It 
wasn't about whether you are in a plan or you are properly 
reimbursed. It was about a political game to try to make him a 
one-term president, and it didn't work.
    I hope some day we have a substantive hearing where we 
actually, as Republicans and Democrats, try to find out what is 
working, what isn't, and make it better. That is the history of 
transformative legislation in this field. Unfortunately, it is 
not the history here. We spent 46 votes in this Congress to 
simply repeal it, defund it, or gut it; not based on 
substantive analysis, not based on experience, but based on a 
political predilection to oppose this bill and this President, 
even though there are elements in the bill that actually came 
from Republican think tanks, the individual mandate being one 
of them. Not a Democratic idea; a Republican idea.
    So I am glad you are here. Certainly have enjoyed listening 
to your testimony, but I have to put it in a different context. 
You will forgive me. And it is too bad that the panel couldn't 
have been more balanced and it is too bad Dr. Feder is kept 
waiting, when she was under the impression, as were we, that 
she could join this panel to provide a different perspective.
    I yield back.
    Chairman Issa. I now ask unanimous consent that the 
gentleman from Virginia, Mr. Connolly's website, which I will 
put up there, from 2010 be placed in the record, in which he 
says, for the past years my constituents have told me we want 
health insurance reform, but only if it meets certain tests, 
Connolly said. Will it bring down premiums for families and 
small businesses, will it reduce the deficit and will it 
protect choice of plan and doctor?
    Without objection, so ordered.
    Chairman Issa. We now go to the gentleman from----
    Mr. Connolly. Could I inquire of the chairman?
    Chairman Issa. Yes.
    Mr. Connolly. Is it going to be the practice of this 
chairman to start to actually individually put members' 
websites into the record? Because we would be glad to return 
the favor on this side of the aisle.
    Chairman Issa. I have no problem at all. I asked for it 
because it was germane to your anecdotal statement of objection 
to their anecdotal statements, so it just seemed appropriate. 
And good staffing, as you know, Gerry, somebody looked and 
said, heck, Gerry used to be for what these people are 
testifying we are not getting, that is all.
    Mr. Connolly. I stand by the website. Those were the three 
criteria I used, and that is why I voted for the bill and 
continue to support it, Mr. Chairman. So happy to have it. Just 
wanted to make sure----
    Chairman Issa. No, we put it in because it was a historic 
piece. And, candidly, the requested individual from your side 
of the aisle is on the next panel, along with all the other 
non-medical doctors, and that is the reason it was divided. 
Medical doctors who were giving their anecdotal examples of 
what they see as practitioners, current practitioners, and then 
the think tank crowd will be next. And hopefully you will not 
disparage the think tank crowd for not being doctors.
    Mr. Connolly. No, Mr. Chairman, absolutely not.
    Chairman Issa. Thank you.
    Mr. Connolly. There was no disparagement of doctors, there 
was just a cry of the heart that some Democratic doctors not be 
at the panel.
    Chairman Issa. If you had suggested one, we might have had 
him.
    Mr. Cummings.
    Mr. Cummings. Just for a second, Mr. Chairman. I would 
hope, Mr. Chairman, that we would not be engaged in putting 
members' campaign website stuff up or whatever.
    Chairman Issa. This is not a campaign. We would not----
    Mr. Cummings. Whatever.
    Chairman Issa. No, we would not put a campaign website.
    Mr. Cummings. What was that?
    Chairman Issa. This is in fact official property of the 
House of Representatives.
    Mr. Cummings. I just want to make sure. I am just so 
concerned that we stay focused on this and not be distracted by 
certain things. I thought it was a website campaign, and I 
think--but thank you very much.
    Chairman Issa. No, no, I appreciate it. But the reason we 
chose this was that it was said on the floor of the House, it 
is on a Government site, and it is pursuant to exactly why we 
chose this question, which is what is the impact to doctors. I 
know a couple weeks ago, when we were looking at failures of 
the website, something that we all are working on reforms to 
fix, we had a discussion about what about what about the 
fundamentals of the healthcare.
    Mr. Cummings, I will say something to you here today. You 
and I do not control, we were not the committee of jurisdiction 
for the Affordable Care Act, but the exact problems that these 
doctors are talking about are what we have to take a leadership 
role in fixing. Mr. Horsford has left, but a lot of it began in 
the 1990s, when we thought we could simply pay less from the 
Federal docket in Medicare and Medicaid reimbursement. These 
are problems that are longstanding. The reason I am having them 
here today is I agree with what you said to me in a sidebar, 
which is when are we going to start fixing some of the 
individual parts of it. The Affordable Care Act is not going 
away in totality, but these doctors, and I take Dr. English 
particularly, are telling us about a chronic problem, which is 
are doctors being incentivized not to take the tough patients. 
And in some cases, and Mr. Cartwright alluded to this, in some 
cases it is our Government reimbursement. In some cases it is 
how insurance companies are reacting.
    And I will pledge to you today I will treat how the 
Government acts and how insurance companies act the same in 
trying to get these doctors to be able to practice what they 
do. And we can have a discussion about how much reimbursement 
comes out of tax dollars, but hopefully today, both in the 
first and second panel, we are dealing with what is happening 
currently so that we can fashion some legislation that has to 
be bipartisan if we are going to fix it.
    Mr. Cummings. Well, thank you, Mr. Chairman. I just want to 
make sure we stay on track. I keep going back to what Dr. 
McLaughlin said. She said fix it, and it can be fixed. By the 
way, Mr. Chairman, I appreciate what you said to Congressman 
Horsford, because he did raise some very legitimate concerns 
and I think that we can work in a bipartisan way. We can help 
these doctors be effective and efficient in what they do and 
help the American society. So thank you very much.
    Chairman Issa. Thank you.
    The gentleman from Georgia.
    Mr. Woodall. Thank you, Mr. Chairman.
    I thank you all for being here. My colleague from Virginia 
characterized you as Obamacare critics. I would not 
characterize you that way. I don't know how you would 
characterize yourself. I would characterize you each as patient 
advocates. And if that leads you to be critical of the 
Obamacare legislation, then fair enough. But to the gentleman's 
point, I thought he was exactly right: find out what is working 
and what is not, and make it better. I wish that had been the 
counsel this Congress had applied before the passage of the 
President's healthcare bill, because each of you has made 
testimony about patients that you had, patients that were 
receiving care, patients that were given the individual 
attention that they need, who will no longer because of this 
new legislation. Those folks weren't having problems; we 
created those problems. And you all are in the caretaking 
business much more than I am.
    But the stories that you tell that touched me the most are 
the tales of the problems that we create, the uncertainty that 
you mentioned, Dr. Novack. There is no way to take those fears 
away. Those fears are real for those families today. If, six 
months from now, those fears turn out to be unrealized, we 
still won't be able to take away the pain and frustration those 
families have experienced today.
    I tell everyone at town hall meetings that I thought the 
President identified exactly the right challenges; that 
healthcare costs were rising too fast and that many Americans 
did not have reliable access to care. I thought he crafted 
exactly the wrong solution to do that. I think we can work 
together to solve those problems. The concern is that, 
certainly from your testimony and from the experience of my 
constituents, we have created a whole new batch of problems.
    I am going to ask you, Dr. English, you know my good friend 
Todd Williamson in Gwinnett County, Dr. Todd Williamson. He is 
a neurologist as well. He told me the other day--he is just a 
little bit older than you are--that here we are the largest 
county in the southeastern United States, one of the fastest 
growing. He has been in practice for more than 20 years. He has 
not seen a new neurologist come into Gwinnett County. I tried 
to look at the ages of folks in your practice. Are you the 
youngest in your practice or have you found some young 
neurologists coming in?
    Dr. English. I am not the youngest anymore. I wish I was.
    Mr. Woodall. Because that is one of those challenges. I 
look at the dollars that we have poured into the President's 
healthcare bill. Just today the headlines: Chicago Tribune, 
Only 7,000 Illinoisans Enroll in Obamacare Plans in the First 
Two Months; Weekly Standard, HHS Awards Another $58 Million to 
Obamacare Navigators. The list goes on and on. Bergen County 
Record in New Jersey, Many New Jerseyans Stuck In Healthcare 
Limbo as December 23rd Deadline Nears; AP, 398 Alaskans Pick 
Marketplace Plans, Despite Untold Millions Spent There; Oregon 
Signs Up Just 44 People for Obamacare, Despite Spending $300 
Million.
    What would have happened if we had spent those $300 million 
on community health centers? I happen to be a huge community 
health center advocate. I believe folks are entitled to a level 
of care and I believe we can provide that interesting sliding 
scales, ability to pay. We already had such a mechanism in 
place.
    My colleague from Virginia called this a pony show. When 
the question came to you, Dr. English, does Obamacare limit 
your patients' treatments and the answer came back yes, I don't 
know why that is not the end of the conversation. I don't know 
why there are not 435 members of Congress who say, you know 
what, we care about people and we care about people having 
access to care, and we want to improve the access to care for 
folks who don't have it; but if you have access to care today 
and we are doing things in this body that limit the medical 
professionals' ability to treat their patients, why can't we 
all decide that is wrong and that we should go back and take 
another crack at that?
    The Affordable Care Act is important legislation, I heard 
from one of my colleagues, because it deals with preexisting 
conditions and access to care. I want to ask you, since you 
have been characterized as Obamacare critics, is there one of 
you, is there even one of you who does not believe that we 
should deal with preexisting conditions and that we should 
improve access to care? I will start with you, Dr. English.
    Dr. English. Of course we have to do all those things.
    Mr. Woodall. Have to do those things. Have to do those 
things.
    Dr. McLaughlin?
    Dr. McLaughlin. Sir, physicians have always given charity 
care, love of their heart, to people who couldn't afford it. 
Always did.
    Mr. Woodall. Always did.
    Dr. McLaughlin. And always will continue to do so. But what 
this has created, sir, is a roadblock of unsurmountable 
proportions. The high deductibles that were imposed on these 
patients is nothing more than them not having insurance. Can we 
understand that?
    Mr. Woodall. Dr. Novack?
    Chairman Issa. The gentleman may answer, of course, doctor.
    Dr. Novack. I agree with you.
    Mr. Woodall. Mr. Chairman, I know my time has expired, but 
we have found that collection of ideas on which we can agree, 
and I agree with my colleagues on the other side of the aisle; 
we should begin working towards those goals and we should do 
that immediately. I yield back.
    Chairman Issa. I thank the gentleman.
    We now go to the gentleman from Massachusetts for five 
minutes.
    Mr. Tierney. Thank you.
    Thank you for being here today. I wanted to ask. I think it 
was Dr. McLaughlin who made a comment that the insurance 
companies did not renew a patient's policies and, as a result, 
that was an issue. I wanted to ask you whether or not, when you 
were having this discussion with your patients who had their 
policies not reissued by their insurance companies, whether or 
not you looked and saw if those old policies had, as part of 
their coverage, the following services and benefits: ambulatory 
patient services, emergency services, hospitalization, 
maternity and newborn care, mental health and substance abuse 
disorder services, including behavioral health treatment, 
prescription drugs, rehabilitative and habilitative services 
and devices, laboratory services, preventative and wellness 
services, and chronic disease management, pediatric services, 
including oral and vision care. Did your patients in each case 
have all of those benefits and services?
    Dr. McLaughlin. Sir, I can only speak of my small business 
plan because I----
    Mr. Tierney. Well, let me ask you. You gave me information 
about your patients and what you thought were their situation, 
so I am asking you, before you reached a conclusion or an 
opinion on that, did you look at their policies to see whether 
or not they actually covered all of those benefits and 
services.
    Dr. McLaughlin. The policies I referred to is Healthy New 
York, or State-run, and, yes, they had all those benefits.
    Mr. Tierney. All of those services were in those.
    Dr. McLaughlin. But the reason why the State canceled----
    Mr. Tierney. So you are going to tell me now that that 
policy had each and every one of those services in it?
    Dr. McLaughlin. Absolutely.
    Mr. Tierney. Okay. Did you look to see whether or not any 
of your patients that you are talking about had been advised by 
their insurance company that they could go to an exchange in 
New York and compare and contrast what they now were offered 
with whatever else might be on that exchange as an alternative?
    Dr. McLaughlin. They received notification of that, yes.
    Mr. Tierney. Okay. And do you know whether or not they have 
gone and checked that out?
    Dr. McLaughlin. I can't tell you what patients do.
    Mr. Tierney. And do you know whether or not your patients 
were eligible for a subsidy, in other words, if they were 
earning less than over 400 percent of poverty?
    Dr. McLaughlin. Again, obviously, as a physician, we don't 
know what a patient's earnings are, but I can tell you from the 
careers that I see----
    Mr. Tierney. Well, that wouldn't be fair because----
    Dr. McLaughlin. Well, it would be fair.
    Mr. Tierney. So did you ask them whether or not any of them 
qualified for a subsidy and, if so, how much?
    Dr. McLaughlin. Well, I can speak even of my own staff who 
were covered. Yes, they checked.
    Mr. Tierney. I want to know about these patients that you 
were referring to.
    Dr. McLaughlin. Yes.
    Mr. Tierney. You weren't checking about your staff; you 
told us about patients.
    Dr. McLaughlin. Some checked.
    Mr. Tierney. And some?
    Dr. McLaughlin. And some had a subsidy, some did not.
    Mr. Tierney. Okay. And do you know which of them or which, 
how many of each, and whether or not it covered all or some of 
what they thought was an increase in the policy?
    Dr. McLaughlin. The closer that an individual, these 
patients, get to the upper limit of what qualifies for that 
subsidy, they were told that they would only save about $5 a 
month on the premium. So a subsidy doesn't cover everything. It 
depends on how far away from the maximum that is covered.
    Mr. Tierney. That is the idea of a sliding scale and a 
subsidy, right?
    Dr. McLaughlin. Correct.
    Mr. Tierney. Okay. Did you also talk with your patients 
about the medical loss ratio part of the Affordable Care Act, 
that part that says that insurance companies have to now use up 
to 80 percent of their premiums for actual health services, as 
opposed to overhead and management, things of that nature?
    Dr. McLaughlin. With all due respect to the patient 
population, sir, they don't understand a medical loss ratio.
    Mr. Tierney. Do you?
    Dr. McLaughlin. I do.
    Mr. Tierney. Okay. So you are aware that in 2012 consumers 
saved $3.4 billion through lowered premiums based on those new 
standards?
    Dr. McLaughlin. My plan did not have that; I got no refund.
    Mr. Tierney. My question to you, though, was that if you 
are familiar with it, do you understand that in 2012 consumers 
saved $3.4 billion through lower premiums based on those new 
medical laws.
    Dr. McLaughlin. I understand that, yes.
    Mr. Tierney. And do you understand that, in addition, 
companies that did not meet those standards issued $500 million 
in rebates?
    Dr. McLaughlin. Yes, I do.
    Mr. Tierney. Okay. Do you know whether or not any of your 
patients were beneficiaries of those rebates?
    Dr. McLaughlin. Some of them were, yes.
    Mr. Tierney. Okay. I just want to close out. I am not going 
to use all of my time on this, but with respect to a comment 
that was made earlier from somebody on the panel here about the 
history of this bill, and this was not a committee of 
jurisdiction, I was on one of the committees of jurisdiction. 
My memory is that during the coercive debate of this particular 
bill, tremendous effort was made to try and have it be a 
bipartisan measure, and we reached out and asked for 
participation of both sides of the aisle and one side decided 
not to participate. Incredibly, even when certain provisions 
that people thought were generally good, bills that were drawn 
by Republicans on that part were asked to be introduced, 
Republicans refused to introduce them. And even when some 12 to 
15 of them were put in as amendments, those people who had 
drawn those original bills that were now the amendments voted 
against them. So I think it is some indication of the effort 
that has been made to try and have this be a joint effort all 
across the aisle, with everybody working on this, shows from 
the earliest parts of this whole exercise or whatever, a 
concerted effort, I think, with one part just to not even be 
involved in it and not participate in trying to make it the 
best project it could possibly be, and I think that is part of 
what we are seeing a continuation of here.
    Chairman Issa. Would the gentleman yield?
    Mr. Tierney. I am afraid I am out of time, according to 
your strict standards, Mr. Chairman.
    Chairman Issa. Okay. The gentleman's time has expired.
    The gentlelady, Dr. McLaughlin, you were cut off several 
times because of limited time, but is there anything that you 
did not get a chance to answer?
    Mr. Tierney. Mr. Chairman, is it your turn to question? Am 
I missing something here?
    Chairman Issa. It is the requirement----
    Mr. Tierney. You just asked for me to yield to you and I 
have no time to yield, so now you are just----
    Chairman Issa. No, no. I am not asking any questions. The 
prerogative of the chair under the rules is to make sure that 
there is a full and complete, clear answer, and to correct the 
record, if necessary.
    Mr. Tierney. That is not at all accurate.
    Chairman Issa. I am not correcting the record. This is a 
longstanding practice under both Republicans and Democrats. The 
gentleman had limited time. The gentleman, in his limited time, 
cut you off several times. If the doctor had anything that she 
felt was germane, I have always allowed witnesses to continue 
answering even after time has expired.
    Was there anything, doctor, that you felt you needed to 
fully answer there was not time for?
    Dr. McLaughlin. The purpose of this committee is to talk 
about the limited networks and whether premiums were indeed 
lowered or not, was it not?
    Chairman Issa. That is correct.
    Dr. McLaughlin. And as I said to Mr. Cummings, we have 20 
days to fix how we are going to provide care to patients with 
limited access, and there is no debating that. We talk about 
MS. I will talk about ophthmalogy for a second.
    Chairman Issa. I apologize. I would love for you to do 
that. I just wanted to give you time on something that he had 
asked, which included subsidies. He cut you off during your 
statement on occupations of your patients and so on. Please, I 
am only trying to make sure the record is full. If there is 
anything you wanted to say about your patients and so on, that 
was the line.
    Dr. McLaughlin. The cutoff----
    Mr. Tierney. Mr. Chairman, if it is an answer to my 
question----
    Chairman Issa. The gentleman is not in order.
    Mr. Tierney. The reason that the witness was asked to move 
to another subject was she was not being responsive to my 
question. Now, if you want to ask a new question in a different 
direction, get some time.
    Chairman Issa. The gentleman is not in order, please.
    Mr. Tierney. Well, neither is the chair, and I think we 
have an issue here as to whether you are going to be some sort 
of arbiter of what my questions were, and now you are going to 
shut the microphone off.
    Chairman Issa. Yes.
    Mr. Tierney. You are just a model of leadership, I tell 
you.
    Chairman Issa. Thank you.
    Please limit yourself to anything that you felt was asked 
that you were unable to answer. I certainly want you to be 
germane, that is why I did ask you to stay to what the 
gentleman asked.
    Dr. McLaughlin. Forty-five thousand dollars, I believe, is 
the income ceiling in New York to attain a subsidy. Forty-five 
thousand dollars in living in New York barely makes it. So most 
of the people who are going to be getting these insurance plans 
will not receive a subsidy, and they are going to have a 
difficult time paying these deductibles and paying their 
premiums. Thank you.
    Chairman Issa. Thank you.
    The gentleman from Georgia, Mr. Collins.
    Mr. Collins. Thank you, Mr. Chairman.
    Look, I just have a couple simple questions. I have a 
daughter who fits the special needs category. Dr. English, I 
appreciate you being here from our home State, as well as the 
rest here. I am just going to ask a very broad sort of question 
and give a personal experience. One, I have heard it said many 
times, and I think one of the things that is being said here is 
there are a lot of things out there to fix. Well, this is one 
of the fixable laws, this is just one that is broken and it was 
inherently flawed. And that is just a disagreement that both 
sides of the aisle is going to have, and we are going to deal 
with that. I don't believe it can, but there are things that 
can be done. But we have to now deal with reality. Reality is 
that, as in the case of my daughter, who has spina bifida, 
early in life, before six years old, she had 30 major 
surgeries, three of which went eight hours plus, ranging just a 
vast array of different things. Now she is fine, she is 21 
years old, and she actually rules the house if nothing else is 
said.
    But doctors in her life, especially early on, were very 
important, and they still are. And we are making the 
transition, as I had a chance this morning to speak with Dr. 
English about the transition from pediatric to adult; and that 
is hard for a father, so I will just leave that at that. But 
she is a young woman.
    The problem I have here, and I want you to address--I am 
going to stop here and just sort of open it up, and then if you 
don't have a lot to say, then, fine, we will be done and we 
will move forward. But the plans are hurting the very ones I 
believe they were intended to help, especially with the zones 
and especially with the areas of access, and especially on 
borders and especially those who need multidirectional or 
multi-physician care. Could you speak to that? Not the politics 
of this thing, but speak to what happens to a father who has a 
daughter named Jordan who may not be at 21, they may be at 6 or 
they may be at 5, and they are trying to get everything they 
can so that their daughter or son can move within the 
limitations of what you are now seeing. Can you speak to that 
for just a minute?
    Dr. English, would you start? And then anybody else who 
would like to pick up.
    Dr. English. I will start. The problem is, as you said, 
this is the group of patients that we really need to provide 
for. I know your area, you are about an hour from us without 
traffic, depending upon the time of day.
    Mr. Collins. Three and a half to four with traffic.
    Dr. English. So that is not a far place to go for somebody 
like that to see a pediatric surgeon. Boston if you are from 
Massachusetts, going to Boston is not a big deal for anybody in 
Massachusetts. But if you are out of the exchange district, 
then you don't have access and patients like your daughter will 
not have access; not to mention the Mayo Clinics of the world 
and Walter Reed and all of those places where a subset of 
patients have to go. So my concern is that, again, you have 
that card, but because of where you live, that is even going to 
restrict your access to the provider that you need.
    Mr. Collins. And that actually increases cost because you 
don't have the collaborative effort that you could do in, say, 
a clinic setting or something else at times, and I think maybe 
you have that experience.
    Dr. McLaughlin?
    Dr. McLaughlin. You see, it is a team approach in many 
illnesses, and the whole team has to be with us, because this 
was allowed to be created now as all in-network coverage. 
Besides the high deductibles, all in-network coverage. That is 
not saying you can't go to see a specialist like Dr. English, 
but you would have to pay for it; and that won't go to 
satisfying your deductible or your out-of-pocket. So there are 
flaws in this. And I am not against the Affordable Care Act, 
but there are flaws in this that are increasing the costs to 
the patients, the very patients that you wanted to help, and 
this needs to be fixed.
    Mr. Collins. Dr. Novack?
    Dr. Novack. There will be some families who will see some 
improvement, but what we have changed with the law is really 
the set of who the winners and losers are. And again certainly 
to date, and there has been, frankly, not a shred of any 
actual, real-life evidence that the number of winners are going 
to even come close to approaching the number of losers.
    Mr. Collins. And I think that is the concern that we are 
seeing in my office. That is the concern that is coming on that 
was just a natural outflow of this, and there are things that 
have to be addressed. It is a passionate issue, not just for 
the folks on Capitol Hill. In fact, for the 535 of us on 
Capitol Hill, we are just reflections of, really, the people in 
our districts who are dealing with this every day. The hearing 
is entitled Obamacare's Impact on Premiums and Provider 
Networks. Frankly, I appreciate the chairman bringing this and 
the ranking member being here, and the differences on both 
sides, but I would have to just say that Obamacare's impact on 
premium provider networks is a generic term for Obamacare's 
impact on the lives of people and families. And if we ever 
disconnect our discussions of insurance and healthcare and all 
this from the very people who need it, then we have made a 
mistake, and that is why this hearing is important, because it 
actually is dealing with those who actually need the help and 
the doctors that they need for day-to-day living.
    I appreciate you being here.
    Mr. Chairman, I yield back.
    Chairman Issa. I thank you, sir.
    We now go to the gentleman from Illinois, Mr Davis.
    Mr. Davis. Thank you very much, Mr. Chairman. I am pleased 
to report that I just came from a markup in Ways and Means, 
where, on a vote of 39 to 0, we voted to do a fix for three 
months of the SGR and kind of looking after the needs and 
concerns of doctors.
    I also want to take a moment to just associate myself with 
the comments of my friend from Georgia, Mr. Woodall, who just 
spoke glowingly about community health centers and the 
accessibility, as well as impact, that they have had. I happen 
to have worked for two of them in civilian life and also had 
the good fortune to be president of our national trade 
association at one time, and I certainly think that they are a 
tribute to what can happen in the development of ambulatory 
care. So I just want to thank him for that comment.
    As we begin, I want to make sure that we don't lose sight 
of the fact that many of these policies that we have talked 
about did not include basic services, such as hospital care and 
prescription drugs. They were what many people call junk 
policies that provided very bare bones coverage that would have 
resulted in catastrophic medical debt if policyholders became 
seriously ill. Back in September, a young woman named Aqualine 
Lori requested to testify at a hearing before this committee, 
and although she ultimately did not testify, Ranking Member 
Cummings read part of her statement into the record.
    Like millions of other Americans, Ms. Lori had a 
preexisting condition, a rare blood disorder. In 2005 she 
needed emergency gallbladder surgery and suffered complications 
due to her condition. Although she had insurance at the time, 
her insurance company dropped her, refunded her premiums, and 
left her with a $50,000 hospital bill. Although she spent years 
trying to appeal this decision, she was not successful. 
Eventually, the hospital she was treated at decided to forgive 
the bill.
    My question to each of you, all of you are in the business 
of providing healthcare. You clearly have all interacted with 
insurance companies and know about insurance. Was this type of 
policy recision common prior to the enactment of the reforms in 
the Affordable Care Act? And what were your experiences in each 
of your practices? And we could begin with you, Dr. Novack.
    Dr. Novack. Sure. In my 13 years of practice and then 5 
years of training before that up in the Seattle area, I have 
not seen it, and I have taken well over 1,000 days of on-call 
at multiple hospitals and seen over 50,000 patients. Most 
States actually have laws already that preexisted the ACA that 
prevented inappropriate recisions, so that is a different issue 
that I think is being conflated a little bit incorrectly. So 
laws against canceling people's policy because you get sick 
have been against the law in most States for a long time. That 
is a different problem than this idea of people's insurance not 
being renewed.
    Now, the idea that people who had preexisting conditions 
not being able to find affordable insurance, there is not 
likely a person in this room, there is not a person I have ever 
come across in my 25 years of taking care of patients that 
doesn't feel like we need to do something or make policy 
changes to address that. The conclusion, however, is that the 
policies that were put forth through the Affordable Care Act 
are actually making these problems worse, and not better.
    Mr. Davis. Dr. McLaughlin?
    Dr. McLaughlin. It was illegal to cancel the policy because 
of increased utilization of it for a serious medical illness. 
This wholesale nonrenewal of policies is shocking. It has been 
reported that the insurance companies felt that small 
businesses were a losing proposition to them economically, and 
this probably became a great opportunity to just rewrite those 
policies, which is why we are where we are today with so many 
small business policies being not renewed.
    Hospitals, again, have always taken care of acute care 
conditions when somebody is uninsured, but we have to fix the 
problem that we are facing now, as much as it laudable to see 
the people who have preexisting conditions can have insurance. 
Thank you
    Mr. Davis. Dr. English?
    Dr. English. Due to time, I don't really have much more to 
say than Dr. Novack. Obviously, we agree that there are changes 
that needed to occur, and now we are just pointing out that, 
unfortunately, this plan is having huge amounts of unintended 
consequences.
    Mr. Davis. Mr. Chairman, with your indulgence, could I just 
simply ask the panel if they would agree that many of these 
policies were in fact junk policies that we have been talking 
about?
    Dr. Novack. I don't think that there is any evidence to 
date that the 5.5 million people who have had their policies 
cancelled, I haven't seen exact numbers, what percentage those 
are ``junk policies.'' A lot of them were ones because they 
didn't actually contain some of the new mandates in the law.
    Dr. McLaughlin. No one in my practice had a junk policy.
    Dr. English. I have nothing else to add.
    Mr. Davis. Thank you very much.
    Mr. Gosar. [Presiding.] I thank the gentleman from 
Illinois.
    I would now like to recognize the gentleman from Michigan, 
Mr. Bentivolio.
    Mr. Bentivolio. Thank you, Mr. Chairman. Mr. Chairman, we 
now know that you can't keep your insurance, even if you liked 
it. You can't keep your doctor, even if you have been seeing 
him for the last 30 or 40 years. You can't keep your hospital. 
Premiums are increasing and we have higher deductibles. 
Obamacare raided $700 billion from Medicare, including $300 
billion from Medicare Advantage alone, to pay for the ACA. 
2,250 physicians were terminated from Medicare in Connecticut 
alone. Most of the orthopaedic surgeons in Dayton, Ohio 
dropped. In Florida, 250 physicians from one medical center 
dropped.
    In January, Mr. Chairman, I am sure we will discover 
thousands, if not tens of thousands, of people, to their 
dismay, that they thought they signed up for the ACA, but 
because of a glitch in Healthcare.gov did not. Mr. Chairman, 
the website itself is in question. A website that asks the most 
personal, intimate questions does not have the proper security 
protocols to ensure the personal medical data of our citizens 
that are safe and secure.
    Obamacare created a panel of 15 unelected bureaucrats, 
called the Independent Payment Advisory Board, who have the 
power to control the types of treatment seniors receive through 
Medicare. And according to Dr. Jason Fullmer and Dr. David 
Gratso, this unelected body will have the unprecedented ability 
to singlehandedly change the allocation of healthcare resources 
should Medicare spending exceed medical inflation, which, for 
the record, it consistently does.
    Dr. Novack, what are your views on this IPAB, I believe it 
is called, the Independent Payment Advisory Board?
    Dr. Novack. Sure. As I mentioned earlier, I just think it 
is a serious area of concern. I don't think that for those of 
us, and actually for most families, that creating another new 
layer of bureaucracy that are making determinations about 
accessibility is a step in the right direction. I would add 
that I think that there is fairly significant bipartisan 
opposition to the Independent Payment Advisory Board because of 
the way it is structured and how their decisions effectively 
have the ability to bypass Congress.
    Mr. Bentivolio. Do you have evidence that competition and 
choice is a better way to increase value and reduce cost than 
Government bureaucracy and experts?
    Dr. Novack. I think there is a fair amount of evidence that 
if we increased transparency, provide more information to 
patients, that a lot of patients will make better decisions. 
That is also true on the physician side. And a lot of those 
solutions are a lot simpler and cost a lot less than the $2.5 
trillion to $3 trillion we are spending on the Affordable Care 
Act over the next 10 years.
    Mr. Bentivolio. Thank you. Do you think that many people 
signing up for coverage don't know that their doctor or their 
children's doctor will still be in their network and they will 
still be able to visit their family doctor?
    Dr. Novack. I think the evidence of this panel is not only 
do the patients not know, but we don't know either.
    Mr. Bentivolio. Mr. Chairman, we are consistently 
unearthing the lies, half truths, and distortions of this 
poorly conceived law.
    Dr. Novack, what do you anticipate will occur next year 
when people go to their doctor and find out they are no longer 
covered?
    Dr. Novack. Well, congressman, it gets back to this 
uncertainty issue, that already, on the provider side, we spend 
enormous amounts of time, as was mentioned, enormous number of 
phone calls trying to sort through some of these very 
complicated issues regarding health insurance. And, by the way, 
this is not just for people in the private market; it is not 
just for people on Medicaid; it is equally true for people with 
Medicare and the 130,000 pages of regulations that go along 
with Medicare.
    This is only going to grow. So at least for our practice, 
since we have no idea what the exchange will bring, and this 
90-day grace period issue is such an enormous issue for us that 
we don't feel that we can actually see patients under these 
exchange contracts that we were pushed into without choice 
until this body or other bodies actually figures out what the 
rules are going to be so we can continue to provide services 
and be able to pay our staff.
    Mr. Bentivolio. Thank you very much.
    Chairman Issa. [Presiding.] Would the gentleman yield?
    Mr. Bentivolio. Yes.
    Chairman Issa. Dr. Novack, I just want to make it clear. 
Under this 90-day plan, if you have, let's say, a $2 million 
practice, including the pay you pay all your people and so on, 
you could end up with, 90 days, one-quarter of that, $500,000 
of patients that aren't covered and don't pay. That is the kind 
of exposure you could have, is paying all your people, paying 
out $500,000, and getting back none of it. That is the 
uncertainty that was in the law, is that correct?
    Dr. Novack. Right. And the concern is almost all insurance, 
is my understanding, there is always a 30-day grace period, 
right? Because sometimes we forget to send a check in. Things 
happen. But under the law the exchange plans have a 90-day 
grace period. For the first 30 days the insurers are required 
to actually pay the bill. But when we go do an insurance 
authorization on day 31, it is going to look like the patient 
has insurance, but the insurance company is going to hold 
payment, and if that premium is not paid by day 90, the 
insurance company says, well, it is not our problem, go collect 
it from the patient. And generally speaking, in those settings, 
talking to hospital people as well, your collection rate is 
about one or two cents on the dollar for that money.
    Interestingly, we had a conversation with one of the newer 
insurers that is going to be on the exchange in Arizona and we 
said we would like some kind of protection against this exact 
problem. We didn't have an issue in terms of what the payment 
rate was going to be for services, we just said we need some 
kind of protection; and they were unwilling to provide us that 
protection, so we walked away from that contract.
    Chairman Issa. I want to thank all our witnesses today. I 
certainly think that we closed on a good note. The fact that 
there is something that I think all the people on this side of 
the dais can agree on is that we certainly need to make sure, 
just as if you were taking a Visa or Mastercard and you checked 
it and it was good, your expectation is that when you let the 
gas or the other product leave your store, that it would be 
honored, and not that 60 or 90 days later you would find out, 
retroactively, you weren't going to get paid. So as we look at 
the many problems presented here on this first panel, I think 
that is certainly a good example of one that we look forward to 
working together to try to fix and fix quickly.
    Again, doctors, I thank you for remaining in this industry, 
remaining in your practices, and offering us some ideas of 
where we need to keep from driving you and doctors like you 
out.
    And I recognize the gentleman from Maryland for a closing.
    Mr. Cummings. Thank you very much, Mr. Chairman.
    I want to thank all of you, too, for what you do every day. 
You have very, very important jobs. You bring a quality of life 
to life and in many instances save lives, saving sight. It is 
so important. I want you to be paid. I want you to be paid for 
what you do. At the same time, I also want people to have an 
attitude of staying well and, if they get sick, knowing that 
that insurance card that they have means something. And I heard 
what you said, Dr. McLaughlin, about the various situations 
that you found yourself in with your mom. So some kind of way 
we have to balance all of this.
    You know, Congressman Tierney was so accurate. A lot of 
these things probably could have been resolved when the bill 
was being put together, but there was a lot of give and take 
and a lot of things happened that I think we could have avoided 
a lot of what we have here now. There are problems, but you are 
right, we have to fix this, and it has to be a can-do attitude, 
and not one of just throwing up our hands. Because you know 
what? The people who suffer are the very people that you try to 
help everyday.
    So I thank you for what you do. I also thank you for 
bringing the passion that you bring to your professions. We 
understand. You are just trying to help people, to get them 
well and keep them well, and we really appreciate you. Thank 
you.
    Dr. McLaughlin. I thank you so much for this opportunity.
    Chairman Issa. Thank you all. And, again, you will have 
seven days, if you want to put additional statements or other 
material in the record.
    We will now take a short recess for the second panel.
    [Recess.]
    Chairman Issa. I want to thank all of you for your 
patience. We will now welcome our second panel of witnesses. 
Professor Judith Feder is a Professor of Public Policy at the 
McCourt School of Public Policy at Georgetown University and a 
Fellow with the Urban Institute. Mr. Edmund Haislmaier, welcome 
back, is a Senior Research Fellow for Health Policy Studies at 
the Heritage Foundation. And Dr. Avik Roy, M.D., is a Senior 
Fellow at the Manhattan Institute for Policy Research.
    As you saw on the first panel, pursuant to the rules of the 
Committee, would you please rise and raise your right hands to 
take the oath.
    Do you solemnly swear or affirm that the testimony you are 
about to give will be the truth, the whole truth and nothing 
but the truth?
    [Witnesses respond in the affirmative.]
    Chairman Issa. Please be seated. Let the record reflect all 
witnesses answered in the affirmative. Dr. Roy?

                STATEMENT OF AVIK S.A. ROY, M.D.

    Dr. Roy. Chairman Issa, Ranking Member Cummings and members 
of the Oversight Committee, thank you for inviting me to speak 
with you today about the Affordable Care Act.
    My name is Avik Roy, I am a Senior Fellow at the Manhattan 
Institute for Policy Research, in which capacity I conduct 
research on health care and entitlement reform.
    I am an advocate of market-based universal coverage. I 
believe that the wealthiest country in the world can and should 
strive to protect every American from financial ruin due to 
injury or illness. Furthermore, I believe that well-designed, 
subsidized insurance marketplaces are among the most attractive 
vehicles for achieving these goals. It is for these reasons 
that I am deeply concerned about the way the ACA's insurance 
exchanges have been designed and implemented. Most of all, I am 
concerned that the law will drive up the cost of health 
insurance, especially for people who shop for coverage on their 
own.
    As you know, the ACA makes substantial changes to the 
individual health insurance market. The law broadly bars from 
charging different rates to the sick and the healthy and 
requires insurers to raise rates on younger individuals in 
order to partially subsidize care for the old. It mandates that 
insurers cover a broad range of services that individuals might 
not otherwise choose to purchase. The law taxes premiums, 
pharmaceuticals and medical devices in a manner that has the 
net effect of increasing the cost of insurance.
    Earlier this fall, I and two colleagues from Manhattan 
Institute completed the most comprehensive study to date of 
individual market premiums in 2014 relative to 2013. We 
examined the five least expensive plans available in the 
individual market for every county in the United States, 
averaged their premiums and adjusted the result to take into 
account those who, due to pre-existing conditions, could not 
purchase insurance at those rates. We examined premiums for 27, 
40 and 64 year old men and women.
    We then compared those rates to the five cheapest plans on 
the ACA exchanges, apples to apples comparison. Our analysis 
found that the average State would see a 41 percent increase in 
underlying premiums prior to the impact of subsidies. Among the 
States seeing large increases are Nevada, 179 percent, New 
Mexico, 142 percent, North Carolina, 136 percent, Vermont, 117 
percent, and Georgia, 92 percent. Our analysis did find that 
eight States will see average premiums decrease under the law, 
including Massachusetts of negative 20 percent, Ohio, negative 
21 percent and New York, negative 40 percent.
    Of the six categories we studied, 27 year old men face the 
steepest increases with an average hike of 77 percent; 40 year 
old women received the mildest increase with an average of 18 
percent.
    We also studied the impact of the law's premium assistance 
payments on exchange premiums. Our analysis found that for 
individuals of average income, taxpayer funded, insurance 
subsidies primarily flow to those nearing retirement. This is 
because the elderly will stay pay more for insurance on average 
than younger individuals and because the subsidies are designed 
to fix a percentage of one's income devoted to paying health 
insurance premiums.
    Taking subsidies into account, 64 year old men will pay on 
average 19 percent less for insurance under the ACA system, 
whereas 27 year old men will pay 41 percent more.
    The Manhattan Institute analysis indicates that we are 
indeed likely to see a fair amount of adverse selection on the 
exchanges. People who consume an above average amount of health 
care services, such as sicker or older individuals, have a 
compelling economic incentive to enroll in the ACA 
marketplaces. Healthier and younger individuals, however, have 
less of an incentive, even when one takes into account the 
individual mandate.
    Our analysis did not directly examine the degree to which 
exchange-based plans have higher deductibles and narrower 
provider networks relative to plans available in 2013. There 
have been, however, many anecdotal reports of people paying 
higher premiums for plans with higher deductibles and narrower 
physician networks than the plans they previously enjoyed. In 
particular, prestigious academic medical centers that 
specialize in the most complex cases in the various diseases 
tend to provide costlier care than the typical American 
hospital. These facilities have been mostly excluded from the 
exchange-based provider networks.
    It is not inherently a bad thing for individuals to choose 
plans with higher deductibles and narrower networks, especially 
if those choices allow Americans to reduce their monthly 
premiums. In theory, by encouraging price competition among 
health care providers, exchanges could exert a downward 
pressure on overall health costs.
    The problems is that in the case of the ACA, many 
individuals are reporting higher premiums for less attractive 
health coverage in a way that will all in all increase national 
health spending. It would be one thing if the ACA was forcing 
Americans off their old plans, and offering them more 
attractive plans at a lower price. But millions of Americans 
are likely to see less attractive coverage at a higher price. 
If they do, then the Affordable Care Act will not live up to 
its name, and its goal of universal coverage will remain 
unfulfilled.
    Thank you.
    [Prepared statement of Dr. Roy follows:]

    [GRAPHIC] [TIFF OMITTED] 

    Chairman Issa. Thank you.
    Ms. Feder?

                STATEMENT OF JUDITH FEDER, Ph.D

    Ms. Feder. Chairman Issa, Ranking Member Cummings and 
members of the Committee, I welcome the opportunity to speak 
with you today about the Affordable Care Act. My views are my 
own, not those of Georgetown University or the Urban Institute, 
where I have spent much of my career. And over my career there 
and elsewhere, I, like you, have watched the millions of 
Americans without health insurance rise to 50 million people 
and go without care, even as Americans who have health 
insurance spend more and more to hold onto it. At long last, 
the Affordable Care Act enables us to assure Americans access 
to affordable health care. We have a simple choice: effectively 
implement the law or resign ourselves to the unacceptable 
status quo, a status quo that I believe is quite different, the 
evidence tells us, from the rosy picture that we were left with 
in the last panel, where everybody gets their care and their 
doctor and all is well.
    My own research has contributed to a substantial body of 
literature demonstrating that insurance matters. Americans 
without health insurance get less care, get it later in the 
course of the illness and are more likely to die than Americans 
without it. And to the extent they get care, that care is paid 
for by those of us who have health insurance and our insurance 
premiums and through our local, State and Federal taxes.
    Who are the uninsured? They are mostly workers, or in 
families of workers, who are not offered coverage through their 
jobs the way most of us are. Pre-ACA, they have few options to 
protect themselves. Coverage in the non-group or individual 
market with denials of coverage for pre-existing conditions and 
limited benefits and non-renewals simply does not work for 
people with they get sick. Far from living up to the promise 
that people who have this insurance can keep their doctor or 
their doctors paid for, Mr. Chairman, as I heard you argue, the 
limits on their annual payments as well as other limitations 
frequently leave them high and dry, and that is what the 
evidence tells us.
    And while Medicaid provides an invaluable safety net for 
people who are eligible, it is far from an empty cart or an 
empty promise, and research shows us it actually does get 
people access to care. Except in a few States with waivers from 
Federal law, Medicaid excludes coverage of adults who are not 
parents of dependent children, no matter how poor they are. So 
the very same low and modest earners who can't get coverage 
through their jobs can't get public protection.
    It is these giant holes in our health financing structure 
that the ACA aims to fill. As Avik said, the ACA requires 
insurance to end discrimination based on pre-existing 
conditions, gender and other factors to cover the range of 
services health professionals typically provide and to 
eliminate dollar caps on annual and lifetime benefits. And so 
that people don't wait until they get sick to enroll, the ACA 
accompanies these requirements on insurers with requirements on 
individuals, to purchase coverage or pay a penalty. And to make 
that requirement feasible and coverage affordable, the ACA 
provides tax credits and other protection to limit people's 
premiums and cost-sharing as a share of income.
    These policies together make it possible to transform what 
is an empty card in individual America today into what 
insurance is supposed to be: available, adequate and 
affordable. And the ACA addresses the holes in Medicaid by 
expanding its eligibility to people with incomes below 138 
percent of the poverty level, regardless of their family 
status. Until 2017, that expansion is fully financed by the 
Federal Government with Federal financing gradually dropping to 
90 percent for 2020 and subsequent years. States will 
ultimately pay 10 percent.
    Analysis shows that the expansion will make States 
financially better off by reducing the burden of uncompensated 
care, while contributing to the overall health of State 
economies. Indeed, research shows that because taxpayers in all 
States contribute to financing for the ACA, citizens in States 
that choose not to participate in Medicaid will actually pay 
for benefits in other States, without reaping any of the 
benefits for themselves, in addition to Federal funds.
    And while the ACA expanded coverage by improving the market 
outside employment, it is important to emphasize that the law 
leaves the employer-sponsored insurance that most of us depend 
on fundamentally as it is today. Despite claims to the 
contrary, the analyses by CBO, Rand and my colleagues at the 
Urban Institute show that employer-sponsored health insurance 
will remain the core of the American health insurance system. 
Essentially, we have left roughly 150 million people who rely 
on employer-sponsored insurance, their coverage is the same as 
it has been, not with some improvements, and not more 
effective. They were not the group that we were talking about 
this morning, and that is the coverage outside of employment.
    At the same time, I see my time going, we are seeing the 
slowest cost growth that we have seen in history, in part a 
function of the ACA's elimination of overpayments to Medicare 
and promotion of initiatives to support efficient, higher 
quality care. And that is affecting everyone.
    By filling the gaps in our current financing structure and 
slowing the growth in our health care costs, the ACA has 
enormous potential to address the flaws in our health care 
system that all of us decry. The biggest barrier I see to 
realizing the law's potential is the political resistance to 
its Implementation, with too many States unwilling to establish 
their own marketplaces or to expand Medicaid, despite the 
enormous advantage to their own citizens.
    Come January 1st, millions of Americans will for the first 
time have access to affordable insurance they can count on when 
they are sick, along with the benefits people are already 
reaping from the ACA.
    Chairman Issa. The gentlelady's entire statement will be 
placed into the record.
    [Prepared statement of Ms. Feder follows:]

    [GRAPHIC] [TIFF OMITTED] 

    Chairman Issa. We now go to the gentleman----
    Ms. Feder. May I finish the sentence? I thought you said 
earlier that everybody got to finish their sentences.
    Chairman Issa. You may finish the sentence, but not the 
entire script. You are one minute past, and you did say you 
were wrapping up. The gentlelady will finish the sentence.
    Ms. Feder. I will be glad to. Along with the benefits that 
we see people already reaping, we need to move forward to 
implement the real promise of the ACA. Standing in its way and 
standing for the unacceptable status quo is simply wrong.
    Chairman Issa. I thank the gentlelady. We now go to the 
next witness, Mr. Haislmaier.

               STATEMENT OF EDMUND F. HAISLMAIER

    Mr. Haislmaier. Thank you, Mr. Chairman, Ranking Member 
Cummings, for inviting me to testify today.
    I am focusing my testimony on the issue the committee asked 
me to talk about of limited provider networks in the exchange 
plans under the Patient Protection and Affordable Care Act. You 
have a copy of my written testimony. I will simply summarize a 
few of the points.
    Obviously, as you have heard in the panel before, provider 
contracting si nothing new. It is a two-way street. It is up to 
both the insurers and the providers to come to terms. If one of 
them doesn't like the terms, you don't have a contract. That 
shouldn't surprise anyone.
    Is there something significant or different about the 
contracting and the networks in plans in the health insurance 
exchanges under the Patient Protection and Affordable Care Act? 
There appears to be, based on the widespread news reports, and 
by that I mean from all sectors of the Country and involving 
all different types of providers. With that said, nobody has at 
this point any definitive, conclusive handle on the extent to 
which those provider networks are different from the ones that 
we see out there today. We just simply don't know, in part 
because some of those networks are still being built, or those 
contract negotiations are still ongoing.
    What we do know, though, is that in a number of cases, the 
insurers are offering network coverage that is significantly 
less than what they offer in plans outside of the exchanges. 
The thing I would direct the committee's attention to as a 
policy matter is that what I see driving at least some of this, 
because the assumption has been that well, the consumers would 
be price sensitive, and the insurers are trying to keep prices 
down so they exclude providers.
    But I think the design of a portion of the law actually 
drives this. I am specifically referring to the cost-sharing 
subsidies. Most of the attention has focused on premium 
subsidies. But the law has a second set of cost-sharing 
subsidies that pays the insurer to reduce the cost-sharing for 
lower income enrollees.
    The problem with that is that because the cost-sharing for 
a significant portion of their expected enrollees is nominal, 
the insurers have reason to expect that there will be higher 
utilization, and indeed, HHS confirms that, HHS is adjusting 
the cost-sharing subsidies to reflect their estimate of higher 
utilization.
    Essentially what is happening is the insurers will get 
paid, but the are no longer able to use a tool of cost-sharing 
to steer patients to be more prudent consumers. Thus they must 
rely on other tools, and that is, I think, one of the reasons 
we are seeing narrower networks in these plans.
    The other interesting thing that I found in research that I 
did which was published at the beginning of the month, and I 
think I am the only one who has done this so far, is I analyzed 
all of the insurers who are participating in the exchanges and 
looked at them and their businesses in the State today and sort 
of the insurers that are not as well, to see what kind of 
patterns emerge.
    One of the interesting patterns that has emerged from that 
is 20 percent of the carriers who have gone into the exchange, 
their principal business in the State where they went into the 
exchange is Medicaid managed care. And indeed, we do find 
evidence that these plans recognize a structure, meaning the 
patient faces very low premiums and only nominal cost-sharing 
for a generous benefit package that looks a lot like what they 
are dealing with in Medicaid managed care. Indeed, I quote one 
of the CEOs of those plans saying, yes, it looks essentially 
the same, that is why we went in.
    Given that, my expectation of how this plays out is that 
individuals at the lower end of the 100 to 400 percent of 
poverty that would be subsidized, 100 to 200 percent will 
probably gravitate towards the silver plan, particularly if you 
have been uninsured. The tradeoff of low premiums and low cost-
sharing for limited provider access is not necessarily 
something that you are going to be terribly upset about, 
especially if you are coming from not having insurance.
    However, somebody who is used to having insurance, who 
makes more money, who is maybe 300 to 400 percent of poverty, 
paying higher deductibles and co-pays for a limited provider 
network is not going to be attractive. So I expect those 
individuals would probably move to bronze plans or, certainly 
above 300 percent of poverty the subsidies are quite small, 
they might just look for coverage elsewhere.
    So I think that is going to be the dynamic that plays out. 
At this point it remains to be seen how many of these more 
limited networks we see in the coming days. But I expect that 
that will probably be fairly prevalent.
    My time is about to expire, Mr. Chairman, so I thank you 
again and would be happy to answer questions.
    [Prepared statement of Mr. Haislmaier follows:]

    [GRAPHIC] [TIFF OMITTED] 

    Chairman Issa. Thank you.

    I now ask unanimous consent that an article in Bloomberg in 
September of this year be placed into the record. It is 
entitled Recession, Not Health Law, May Be Responsible for Cost 
Curbs. Without objection, so ordered.
    Dr. Roy, you mentioned free market as a better way to get a 
working system. Earlier on the first panel, I asked all three 
doctors about the practice that the Federal Government, in its 
reimbursement, pays different rates for the identical treatment 
depending upon where you have it. Isn't that an example of an 
inherently flawed system in that if a hip replacement done in a 
clinic that specializes in it does therapeutically and equally 
good or better job with equal or better results, and does it 
for a more efficient way, whatever that term means, less 
overheard, generally, that by paying them less and by paying a 
hospital more, you are essentially driving up the cost of 
health care by subsidizing hospitals, even if they have higher 
overhead? Isn't that correct?
    Dr Roy. It is. And it is a distortion that Medicare 
introduced into the market and has been around, and has gotten 
worse over time as Congress tries to tweak that problem and 
make it better. Sometimes there are unintended consequences 
that make it worse as well.
    Chairman Issa. In my own State of California, we are seeing 
hospitals buying up clinics and physician practices at a high 
rate, paying them essentially as much as they, more than their 
practice is really worth, not because they are generous to the 
doctors, but because the anticipated revenue growth means that 
the same doctor doing the same job in the same facility, once 
they become part of a hospital, pays more. Therefore, the 
hospital is doing this in order to increase its revenue.
    Is that something that, in a small way, we should be 
attacking as part of our reform?
    Dr. Roy. We should. In fact, I believe MedPAC has 
recommended, modifying the reimbursement structures that Part B 
and Part A pay the same rate in that instance, so that this 
arbitrage can't continue. I would also mention that hospital 
consolidation broadly, provider consolidation broadly, 
something that the ACA actually accelerates, is a serious 
problem which is driving up market power for these providers 
and driving up prices in the commercial market.
    Chairman Issa. One last question, and I think for a couple 
of witnesses, in 1960, we spent 5 percent of GDP, a then 
smaller GDP, on health care. And we lived about 7 and a half 
years less long than we do today. Today we are spending roughly 
18 percent of GDP, that is not just almost five times, four 
times the amount, but actually with GDP growth in constant 
dollars, we spend about five times as much on health care as we 
spent then.
    I will start with you, Doctor. As a physician, is there a 
real justification, in spite of all the improvements, is there 
a real justification for spending five times as much in real 
dollars on health care, or have we essentially built 
inefficiencies into the system? And if so, does the Affordable 
Care Act attack any of those inefficiencies?
    Dr. Roy. The Affordable Care Act increases the amount that 
we are going to spend on health care, unfortunately. And I do 
agree that it would be nice to spend less. We don't need to 
spend as much. There is an enormous amount of inefficiencies in 
the way we deliver and pay for health care. These are 
longstanding problems which some things about the Affordable 
Care Act may address, we hope. But broadly speaking, it goes in 
the other direction.
    Chairman Issa. Mr. Haislmaier, just a couple of questions. 
First of all, you were at the table at Heritage during the 
Affordable Care Act markup, were you not?
    Mr. Haislmaier. I was at the Heritage Foundation, yes. I 
wasn't participating in the markup.
    Chairman Issa. I wasn't at the table either, despite what 
Mr. Tierney said. But when you watched that process, were there 
any ideas that came out of Heritage or other, if you will, 
conservative Republican groups that you saw being accepted as 
amendments from any source? Particularly I want to talk about 
medical malpractice reforms such as MICRA.
    Mr. Haislmaier. No, on medical malpractice, actually, we 
had somewhat of a different opinion than some of our friends in 
Congress who wanted a Federal solution. We thought it should 
remain at the States.
    Chairman Issa. But I am just saying, the Affordable Care 
Act barred it.
    Mr. Haislmaier. Yes, my observation is that frankly, the 
bipartisanship ended right about, and I could look up the exact 
date, it was July of 2009, it was the day they finished the 
Health Committee markup in the Senate. In that markup, the 
Republicans had made a number of substantive changes, all of 
which were voted down on a party line vote, and then proposed a 
lot of technical changes to which, in my opinion, was the 
worst-drafted of all the bills that were considered. And they 
accepted like a hundred of those and then announced they had a 
bipartisan bill. I think at that point is when the Republicans 
walked away.
    Because I had been working with members and there were 
things they were drafting to submit that at that point they 
just didn't submit them. It was clear that there was not going 
to be any meaningful input.
    So the interest in doing something bipartisan pretty much 
stopped about mid-July from what I can tell, because the 
demands for me to help people draft things just evaporated.
    Chairman Issa. Thank you. Mr. Cummings?
    Mr. Cummings. Dr. Feder, according to doctors, for America 
some States ``have much stronger requirements for general 
providers and also for essential community providers.'' Some of 
these stronger State requirements include the following. The 
reason I am going to this is because the people on the panel 
before basically blame the Affordable Care Act for the reason 
why they may not be on a provider network. But these are some 
State guidelines and requirements. A provider covered person 
ratios by specialty or primary care, geographic accessibility, 
waiting times for appointments with participating providers, 
hours of operation, volume of technological and specialty 
services available to serve the needs of covered people who 
require advanced or specialty care.
    Dr. Feder, so if there concerns within a State about the 
adequacy of provider networks, who can consumers go to and what 
actions can States take to address those concerns?
    Ms. Feder. Mr. Cummings, you are rightly raising that the 
Affordable Care Act actually establishes requirements or calls 
for requirements for network adequacy. As in many areas of the 
law, it leaves it to the State to enforce those requirements. I 
think we need attention to them, it is a legitimate 
requirement.
    It does fall to the insurance commissioner in the State, 
and States have different degrees of willingness and ability to 
address it, and we are not seeing an active enough effort in 
that regard, and we need to attend to it.
    Mr. Cummings. You have decades of experience in assessing, 
Dr. Feder, the health care system. We hoped to have you on our 
first panel, but here you are. Dr. Feder, one of the most 
critical features of the Affordable Care Act is the expansion 
of Medicaid eligibility to millions of low income adults. Prior 
to the ACA, Medicaid eligibility was restricted primarily to 
low income children, their parents, people with disabilities 
and seniors. In most States, adults without dependent children 
were not eligible.
    According to a study issued on October 23rd by Kaiser 
Family Foundation, only about 30 percent of poor, non-elderly 
adults had Medicaid coverage in 2012. Under the ACA, Medicaid 
eligibility can be expanded to cover all non-elderly adults 
with incomes below 138 percent of the Federal poverty level. 
The Federal Government would pay the States 100 percent of the 
costs for the first three years, and then phase down its match 
to about 90 percent by 2020. Is that right?
    Ms. Feder. It is correct, Mr. Cummings.
    Mr. Cummings. Now, despite this huge level of Federal 
assistance, as many as 25 States have decided not to be a part 
of the expansion, leaving millions, literally millions of their 
own citizens without health care, is that right?
    Ms. Feder. That is absolutely true.
    Mr. Cummings. Now, Dr. Feder, what is your opinion of 
States that refuse to expand their Medicaid programs?
    Ms. Feder. My opinion of the States, I am sad and 
disappointed for their citizens, both the citizens who need 
care and the citizens who are contributing to paying for care 
through their taxes and other States that do expand. Expansion, 
research shows from the Commonwealth Fund and the Urban 
Institute ran how much in the interest of States this expansion 
is. I believe it is only political opposition to this law that 
is depriving these citizens of access to care and the States of 
needed revenue.
    Mr. Cummings. So by not participating, are they leaving 
significant resources on the table that could be used for their 
citizens?
    Ms. Feder. They sure are.
    Mr. Cummings. And sadly, a lot of these people are getting 
sick and sicker, and sadly, some of them will die early?
    Ms. Feder. We know of that. Essentially the Institute of 
Medicine found that lack of insurance kills. So your statement 
is correct.
    Mr. Cummings. Why is the expansion of Medicaid an important 
component of the Affordable Care Act? Why is that so important?
    Ms. Feder. Well, we have a big hole, as you point out, in 
our safety net coverage, our floor of protection. That is that 
if you are not the parent of a dependent child or disabled or 
old, you really are not eligible for coverage in most States. 
That hole is a vestige of an old-fashioned welfare system that 
kind of assumed that these people would get coverage through 
their jobs. They don't get coverage through their jobs. They 
are left out of employer-sponsored coverage, and they are left 
out of the public safety net, and that is why they needed to 
expand it.
    Mr. Cummings. Now, the Commonwealth Fund issued a study 
this month showing that States that expand Medicaid will gain 
important benefits beyond covering poor people, such as 
reducing uncompensated claims. Tell me something. I remember 
reading something about Missouri, and a lot of the hospital 
administrators came and said to the government, you have to 
accept this because our hospitals are going to be in trouble if 
we don't provide for Medicaid expansion. Can you explain that 
to us?
    Ms. Feder. Sure. Hospitals, although they don't provide 
unlimited care, and people without insurance don't get all they 
need, hospitals get stuck dealing with people who don't have 
insurance coverage. And they have to provide emergency care, it 
doesn't mean everything, but they are stuck and they don't get 
paid.
    What this law created was the opportunity they get paid for 
patients who walk in the door and they are counting on it.
    Mr. Cummings. Just one last question, Mr. Chairman. The 
same study says by choosing not to expand Medicaid, some States 
will lose billions of dollars, and I talked to Senator Cruz 
about this the other day. Texas, for example, will forego an 
estimated $9.58 billion in Federal funding in 2022, taking into 
account Federal taxes paid by Texas residents. The net cost to 
taxpayers and States in 2022 will be more than $9.2 billion.
    Similarly, Florida's decision not to participate will cost 
its taxpayers more than $5 billion in 2022, and Georgia, I 
could go on. Dr. Feder, what will this mean with regard to sick 
people in those States? By the way, in Texas, one out of every 
four persons has no insurance.
    Ms. Feder. That is where most of our insurance is and it is 
going to stay there. Those people are left without access to 
care, and as you said, they are more likely to suffer and more 
likely to die as a result.
    Mr. Cummings. Thank you very much. Thank you, Mr. Chairman.
    Mr. Gosar. [Presiding] I thank the gentleman.
    Dr. Feder, are you a physician?
    Ms. Feder. No, sir.
    Mr. Gosar. Is Medicaid financially sustainable? Yes or no. 
It is an easy one.
    Ms. Feder. It is not, actually.
    Mr. Gosar. It is really easy.
    Ms. Feder. No, it is not, because it is about long-term 
care, largely, which is what----
    Mr. Gosar. No.
    Ms. Feder. Medicaid costs are growing very slowly. We have 
too many low-income people----
    Mr. Gosar. Based on reimbursement rates it is 
unsustainable. Would you agree with that?
    Ms. Feder. Not the--I thought you were talking about 
financially.
    Mr. Gosar. It is financially unsustainable. Dr. Roy, would 
you agree with that?
    Dr. Roy. It is unsustainable, I should just say, I am not a 
physician, although I did go to medical school.
    Mr. Gosar. Mr. Haislmaier, it Medicaid sustainable 
financially?
    Mr. Haislmaier. No, not in the present form.
    Mr. Gosar. Not in its present form. Even expanding, it is 
not either, is it?
    Ms. Haislmaier. No, it is not sustainable in its present 
form, and the expansion will simply add to that in a number of 
ways. It could be, if you reformed it along different lines, 
but that is a different subject for a different day.
    Mr. Gosar. Dr. Roy, you heard the comments and you saw Ms. 
Feder just talk about. What is your opinion in regard to, are 
we not just chasing our tail with the expansion of Medicaid?
    Dr. Roy. I recently published a book entitled How Medicaid 
Fails the Poor. It details in 48 pages how the reimbursement 
structure of the program, how it underpays physicians for care, 
has led to very poor access for those individuals. That is 
leading to poor health outcomes. So the most definitive study 
on the score was conducted in the State of Oregon, was 
published in the New England Journal of Medicine by a panel of 
esteemed health economists, which showed that Medicaid, 
compared to being uninsured, showed no Improvement in health 
outcome.
    Mr. Gosar. So because you actually get a card, does it mean 
something when you have a card if you don't have providers to 
see you?
    Dr. Roy. You heard the earlier panel this morning, just 
having a card that says you have health insurance is not the 
same thing as access to care. And that is a distinction that I 
fear that the Affordable Care Act has not understood well.
    Mr. Gosar. So when we are reimbursing physicians below 
market rates, they don't even make a profit, we just heard the 
gentleman basically make a comment that it is up to the States 
to enforce proper panels. So we are going to force physicians 
to take fees that they can't even pay their own bills?
    Dr. Roy. In Massachusetts, under the most recent health 
reform bill they passed in 2012, they considered a provision 
that would have required all licensed physicians in the State 
to accept all forms of payment. The physicians rebelled and 
that was not included in the law. But that is something that we 
may see more of over time, an effort to do that. And that would 
be problematic.
    Mr. Gosar. So let me ask the next question. You are very 
familiar with debt coming out of school. Are physicians coming 
out of school with less debt or more debt?
    Dr. Roy. More debt, unfortunately. The cost of medical 
school has skyrocketed, it has increased perhaps more than 
health inflation.
    Mr. Gosar. So reducing their fees is going to help them 
better pay that?
    Dr. Roy. It has discouraged a lot of new physicians from 
accepting Medicaid patients. And again today, all the studies 
and surveys show the percentage of physicians who are willing 
to accept new Medicaid patients is substantially lower than it 
is for private insurance in particular and Medicare, where that 
is also increasingly a problem. Over time, as States expand 
their Medicaid programs, they will face further fiscal 
pressures. The only real mechanism that States have to keep 
their budgets under control under Medicaid is to turn down the 
amount they pay physicians and hospitals to care for those 
patients.
    So this problem is only going to get worse over time, and 
Medicaid expansion will accelerate that.
    Mr. Gosar. We heard earlier in the panel, the earlier panel 
talking about patient dumping. So this is like Federal patient 
dumping onto States for that jurisdiction.
    Dr. Roy. In my experience, physicians who are already 
caring for patients are really reluctant to let that patient 
go, just out of a humanitarian interest. But they are very 
reluctant to take on new patients, to commit to new patients 
under that reimbursement structure.
    Mr. Gosar. Because it puts them in a harmful situation, 
does it not? Because they can't abandon the patient, because 
that is a litigation issue.
    Dr. Roy. There are very ethical problems here
    Mr. Gosar. So understanding rural and urban dictations, we 
are really skewing the benefits for rural. I am from rural 
Arizona. We are seeing huge catastrophic access issues. I mean, 
in the previous Administration, we tried to look at federally 
qualified health centers, which the gentlelady didn't bring up, 
because they are not allowed to turn away anybody. It is a 
sliding fee scale, if I am not mistaken, right?
    Dr. Roy. Yes.
    Mr. Gosar. They can't turn anybody away. So that was part 
of the safety net. Unfortunately, I practiced kitty-corner 
from, when I saw the patients they didn't want to see. Because 
they skewed the results. What they did is they Medicaid and 
Medicare patients and skewed them to a one percentage of the 
day and they took fee for service patients and insurance 
patients and they took them in at a regularly scheduled 
appointment. Very skewed results.
    Dr. Roy. One thing we should point out is that what the 
market price would bear would really be in a free market system 
for paying doctors and hospitals. We don't know, because we 
don't have a free market for health care, because Medicare in 
particular and also Medicaid have so distorted what the prices 
are for a lot of services. The evidence suggests that in 
general, the prices for these services in the United States are 
higher than they are in other countries.
    Mr. Gosar. And I am going to take the liberty, since I gave 
the gentleman a little extra time, that is one of the reasons 
why we don't have a lot of family care physicians, isn't that 
true, is that government has skewed that process and the 
reimbursement rate, so that everybody goes into the specialty, 
because that is how you can make a living.
    Dr. Roy. Which is what you will hear every physician say, 
they get paid for procedures, for writing prescriptions, they 
are not paid for their time. And that is what a lot of 
physicians like about so-called concierge or retainer 
practices, they are finally paid for their time and they can 
spend more time with their patients. Unfortunately, the 
evolution thereof may lead to a two-tiered system where you 
have the doctors treating Medicaid patients who don't spend a 
lot of time with those patients.
    Mr. Gosar. One last question. We hear of this downticking 
in expenditures for health care due to the ACA. I don't agree 
with that, I think they have a lot to do with the economy. 
Would you agree?
    Dr. Roy. Yes, in fact, I have written about this. In 
general, across the OECD countries and developed world there 
has been a massive slowdown in the growth of health 
expenditures, driven by the global economy. Also, there has 
been substantial evolution in the United States of an increase 
in the use of high deductible plans with health savings 
accounts in the employer market. That is also leading to a 
slowdown in spending.
    Mr. Gosar. I thank the gentleman.
    Mr. Cummings. Would the gentleman yield for just a second?
    Mr. Gosar. I would happily yield.
    Mr. Cummings. Why don't we want to give the President any 
credit? Any credit? I mean, I hear this over and over again, 
that the cost of insurance is going down, and you are trying to 
say that President Obama and his efforts with the Affordable 
Care Act have no effect?
    Dr. Roy. As you know, sir, the bulk of the Affordable Care 
Act has not been implemented yet. So it is very improbable that 
the Affordable Care Act is having a system-wide effect on 
health spending.
    Mr. Cummings. Ms. Feder?
    Ms. Feder. I think there are two challenges. I think we 
agree a lot on the power of the recession in bringing costs 
down. But what is missing from that picture is that Medicare, 
that in the Affordable Care Act, by making Medicare a more 
efficient, effective payer in terms of the reductions in 
overpayments, and there may be room to go, but that made a big 
difference to spending.
    And that the whole thrust of the Affordable Care Act on the 
cost containment side is to move to a more efficient delivery 
system in many of the ways that people on both sides of the 
aisle would like to see it move. That part has not had much 
effect yet I would agree. Although the Administration does 
point to the reductions in readmission rates to hospitals has 
already shown an influence of those policies.
    Mr. Gosar. Mr. Haislmaier, I would like to give you the 
opportunity.
    Mr. Haislmaier. This really gets to the core of the debate 
over health care. The chairman was talking about the percent of 
GDP. We all know that we as a country spend more per capita, 
percent of GDP than any other country in the world on health 
care. We also are all pretty much across the political spectrum 
not satisfied with the results.
    Mr. Gosar. Right.
    Mr. Haislmaier. It is uneven, too many uninsured, et 
cetera. So I do this in my general audience talks, I make the 
observation that what we have here is a value problem. The 
value is the relationship between what we are spending and what 
we are getting, I don't care whether you are buying a hamburger 
or you are buying health are. We are either paying too much for 
what we are getting or we are not getting enough for what we 
are paying.
    So the central challenge in health care is how do you 
improve value in the system. Ideally, what you would like to do 
is get more and pay less. I think we would all agree on that. I 
don't think there is any disagreement on that.
    The problem comes in on how are you going to do it. As my 
colleague just pointed out, there is a view point that she 
holds and is embodied in this legislation that we can do this 
by having better micromanagement of doctors and hospitals and 
insurers and all the rest.
    The other view, that I hold and my other colleague holds is 
that the way you do this is to have Government limit itself to 
what it is competent at doing, which is pretty much in this 
case taking money from A and giving it to B and stay out of 
trying to run the rest of it. If you want to give B a little 
more money than C, that is fine too. But just move it to a 
patient-centered system where people can pick and choose and 
seek value and be rewarded for providing value.
    I look at the system as do folks on the other side, and we 
all look and we say well, gee, look at Merrill or Geisinger or 
InterMountain Health or Cleveland Clinic, they all provide 
better results at a lower price. And I look at the system and I 
say, okay, if that is true, why aren't they eating everybody 
else's lunch? Why aren't other hospitals having to come to 
their standards or go out of business? Thanks to my office, I 
have a BlackBerry, but they aren't so good, they are getting 
their lunch eaten by Apple. Why isn't that happening in 
hospitals? Because we are propping them up with all these 
payments, et cetera.
    The other side looks at it and says, look, we can go into 
Merrill and study how they do it and then we are going to write 
a bunch of rules that tells everybody else how to do it, then 
we come out with the Affordable Care Act and the accountable 
care organizations. It is just a difference of how you go about 
doing it.
    Mr. Gosar. I hear you. Thank you.
    I now recognize the gentlelady from New Mexico, Ms. Lujan 
Grisham.
    Ms. Lujan Grisham. Thank you, Mr. Chairman, and I have to 
say I really appreciate the panels and this committee. I am not 
a doctor, although I have a J.D., and so Dr. Feder, thank you 
for your graduate work. I will tell you that I think I can be 
qualified as a health care expert for three reasons. I am a 
patient. Every single day, all the time, more than I want to 
be, try not to be, try to do everything right, doesn't matter.
    Two, I am a primary caregiver for a chronically sick mother 
who is incredibly complicated. I don't care what system you put 
her in, she is all by herself, she is navigating it, she is 
doing concierge, she is on Medicare, she is on Medicaid, she is 
on indigent care, she is on U and M care, she is on her own, 
she is married to a dentist, doesn't matter. It is exhausting, 
complicated, so complex I could spend the rest of my life 
explaining it to her. And she is a smart woman. Gave birth to 
me.
    But I can't do it. And I have done health care and policy 
making for 30 years.
    So here is, for me, what is telling. You say that there has 
been an economic downturn, not that that is what you said, but 
the economy itself has played a huge role in the reduction of 
health care costs. CBO says exactly the opposite. We can work 
every single day, and we can get experts from every single 
place to give us a different opinion. We have the most 
complicated, convoluted system in the world.
    And the Affordable Care Act at least tries to level that in 
many ways, but I am one of those policy makers that think we 
need to go do a lot more. And I spent 20 years before the 
Affordable Care Act and before States were figuring out how to 
do Medicaid waivers, and before we made changes to Medicare. I 
watched HMOs and provider networks shift and change every time 
there was a profit motive to do that. Every single time.
    I dealt with patients who were left out, left under, left 
cold no matter how much they were privately paying for their 
health care. It depends on who you are, where you live, what is 
going on. And what I mean by who you are, you are more likely 
to be chronically sick or not and are you living in an urban 
center or not.
    So we are going to have to do not one size fits all, we 
have to do many sizes all the time. And this is a great 
experience about many people get better care as a result of the 
Affordable Care Act and get access. In New Mexico, we are 
paying some of the lowest rates in the Country because of the 
Affordable Care Act. Our problem is going to be insurance 
regulatory oversight and we don't have enough insurance 
companies. I never thought I would say that in my entire life. 
But it happens to be true in this case, regardless of what my 
personal opinions are. It is true in this case.
    So what I am really interested in is using experts such as 
yourself and others to start thinking about ways, because we 
just cost shift in this Country. What we are even proposing to 
some degree is more cost shifting. Costs shift back to the 
States. Costs shift back to the individuals. Costs shift back 
to business. Costs shift back to veterans. What do we have, 
nine, ten, eleven independent systems of care that no other 
country has, and a not very robust public or community health 
system? Those are the real reasons that health care doesn't 
quite work in the way that we want it to.
    And we hope that all three of you stay dedicated to help us 
navigate those critical next steps. Because I don't think the 
Affordable Care Act is responsible for shifts and limited 
access. I think it may exacerbate that in some cases. I don't 
think coverage means access. And I that will improve it in some 
way. I hope that we are wise and brave enough here to really 
use experts such as yourselves. I never mean to do these 
diatribes, but there are no simple questions, and there are 
certainly no simple answers. There are not.
    Except that if we don't start leveling the playing field, 
and we don't start really focusing on consumers and we are not 
brave enough here to deal with the folks who still have 
significant problems before the Affordable Care Act, with the 
Affordable Care Act, through the Affordable Care Act, I pay 
more because of the Affordable Care Act. But that is because I 
am required to go to the D.C. exchange. Not because I am a 
consumer left to navigate through the Affordable Care Act rules 
in my own State.
    So it depends on the real details of those issues. So on 
the one hand, I can tell you that I am one of those folks who 
is complaining, and on the other hand, I can tell you that I am 
really glad that more people are helping me help you pay for my 
mother's chronic care procedures every single day. And I will 
tell you that she is more than happy to help pay for 
everybody's maternity care, so it all gets leveraged out. 
Because I was also county commissioner.
    Because it is not just Medicaid. Medicaid's gaps are paid 
for by local government, which is paid for by taxpayers. It is 
all paid for by all of us, every single day, all of the time.
    So I guess my question is, and Mr. Chairman, thank you so 
very much. Is there a way that this committee can continue to 
work hard to get as much valid information about really what we 
can do, starting today? Because my provider networks changed. 
Because every time you do a reform we open a window for 
somebody to legally do adverse selection and cherry-picking. 
And that is not dealt with at the Federal level at all. And if 
I was a for-profit insurance company, and it is legal, why 
would I create a network that has the sickest patients? Why 
would you do that? You cannot. So you don't.
    And that is not all the reasons that occurs, but make no 
mistake, in my opinion, there is no one here on any panel that 
can demonstrate that that is not part of the reason that this 
always happens. So thanks for being here, Dr. Feder and all the 
other doctors on the panel. I thank you for my diatribe. I feel 
great today, I can get my pens out of my finger and I am going 
to try not to be one of the expensive high-end users of health 
care no matter what I pay.
    Thank you, Mr. Chairman.
    Mr. Gosar. I thank the lady from New Mexico and I had hoped 
that she would sign onto my bill on repealing McCain-Ferguson 
after listening to you. One of the things that you have to look 
at is getting to the least common denominator. And I will talk 
to you about that in a second. Mr. Cummings?
    Mr. Cummings. Just briefly, Mr. Chairman, I will close. I 
want to go back very briefly to Dr. Roy, something you said. I 
am not asking questions, I am just giving a statement. On 
September 9th, 2013, CBO Director Doug Elmendorf issued a paper 
entitled The Slowdown in Health Care Spending. Drawing from 
multiple sources, the paper concluded that health care spending 
growth had slowed dramatically across the Country. The slowdown 
in health care cost growth has been sufficiently broad and 
persistent to persuade us to make significant downward 
revisions to our projections of Federal health care spending, 
he said.
    He goes on to say specifically, CBO found that relative to 
a 2010 baseline projection through 2020, Medicare spending is 
15 percent lower than projected, Medicaid spending is 16 
percent lower than projected. Now, this is the CBO. And private 
health insurance premiums, per enrollee, are 9 percent lower 
than projected. He goes on to say, the paper also made clear, 
by the way, that these reductions, and listen to this, are 
apparently not because of the financial turmoil and recession 
but because of other factors affecting, and this goes to what 
you said, Dr. Feder, the behavior of beneficiaries and 
providers.
    And with that, I say this. Witnesses on the prior panel 
said, we have to get it right, we have to fix it. Chairman Issa 
a few minutes ago talking to one of our colleagues, Mr. 
Horsford from Nevada, said that there are things we have to do 
try to fix certain parts of this. And we have to. We have to 
get this done and get it done in a way where there is a win-
win-win-win-win. I do believe that that is possible. And again, 
I say, coming from having traveled some 20 hours on a plane to 
go to Nelson Mandela's memorial, I have to tell you, I left 
there saying to myself, we are so fortunate in this Country, we 
are so fortunate to be where we are. We can accomplish 
anything. We just have to put our minds to it.
    And somebody once said, it is not that people don't know 
what to do. It is whether they have the will do it and do it. 
So again, I want to thank you all. Your testimony has been 
extremely helpful. And we are going to go forward.
    Mr. Gosar. I thank the gentleman. I would like to ask the 
gentleman a question. Do you believe the actuaries from the 
Centers for Medicare and Medicaid?
    Mr. Cummings. Give me the specific question.
    Mr. Gosar. Would you think that their oversight of spending 
would be more deliberative and more accurate than CBO?
    Mr. Cummings. I am not sure, but one thing I do know.
    Mr. Gosar. They deal with it every day, this is their due 
diligence, the actuarials deal with numbers.
    Mr. Cummings. Well, the fact is, again, I quote what I just 
quoted, I do again, the costs are coming down according to CBO. 
And the reason why I got a little upset a few minutes ago, Mr. 
Chairman, and I appreciate your question, but it seems like 
this President gets no credit for anything. Nothing. Zilch. And 
over and over again, when everything goes well, some say it 
must have been a mistake, it must have been a fraud. If it goes 
bad, it was his fault.
    The fact is that there is a lot that can come out of this. 
We just have to have the will to get it done. And we will get 
it done.
    Mr. Gosar. I just want to go back to my question. The 
actuaries at the Centers for Medicare and Medicaid Services, 
who do not answer to the White House, said yesterday in the 
Journal of Health Affairs that the costs eased because of the 
economy, not because of Obamacare. Would you agree with that, 
Dr. Roy?
    Dr. Roy. Yes, that is the overwhelming evidence. I would 
just add that I am an admirer of the President. If the 
Affordable Care Act is successful in achieving its stated 
goals, I will be absolutely thrilled. My concern is that it 
will not, and I think it is my obligation to alert the 
committee to the concerns that I have shown.
    Mr. Cummings. You asked me a question, I just want to 
answer it in fairness to you. Earlier this year, the Centers 
for, they also said this. The Centers for Medicaid and Medicare 
and Services issued a report finding that national health 
spending had slowed to only 3.9 percent in the years between 
2009 to 2011. This represents the lowest growth rate in health 
care spending since government began keeping these statistics 
in 1960.
    Mr. Gosar. Being a dentist, just so that I am fair about 
this, I can tell you about that spending. And dentistry didn't 
sell its soul to the Federal Government, for the most part. And 
there are problems don't get me wrong. But the problem is 
expendable money. We have seen it go down. There is nobody who 
is flush with money in their pockets to buy increased care or 
to do investing in health care. There is none.
    I believe personally empowering patients. That is what 
Nelson Mandela would have wanted. Because empowering patients, 
not to make them cripples, but to make them entrepreneurs and 
to hold onto their health care and demand that system to 
benefit them. Patient centered, patient friendly. Has to start. 
And that is not what was included before Obamacare or in 
Obamacare. It is a government-dictated centric relationship.
    I want to see the patient benefit and be empowered, not to 
be a cripple. So I want to thank the witnesses for coming 
forward. We appreciate it. With that, we will adjourn this 
meeting.
    [Whereupon, at 1:12 p.m, the committee was adjourned.]


                                APPENDIX

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               Material Submitted for the Hearing Record

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