[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]




                H.R. 1384, MEDICARE FOR ALL ACT OF 2019

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

                                HEARING

                               BEFORE THE

                           COMMITTEE ON RULES
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                               __________

                        TUESDAY, APRIL 30, 2019

                               __________

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                    Available via http://govinfo.gov
             Printed for the use of the Committee on Rules
             
             
                    U.S. GOVERNMENT PUBLISHING OFFICE
                
36-400                      WASHINGTON: 2019             
             
             
             
             
             
                           COMMITTEE ON RULES

               JAMES P. McGOVERN, Massachusetts, Chairman
               
ALCEE L. HASTINGS, Florida,          TOM COLE, Oklahoma,
  Vice Chair                           Ranking Republican
NORMA J. TORRES, California          ROB WOODALL, Georgia
ED PERLMUTTER, Colorado              MICHAEL C. BURGESS, Texas
JAMIE RASKIN, Maryland               DEBBIE LESKO, Arizona
MARY GAY SCANLON, Pennsylvania
JOSEPH D. MORELLE, New York
DONNA E. SHALALA, Florida
MARK DeSAULNIER, California

                       DON SISSON, Staff Director
                  KELLY DIXON, Minority Staff Director
                                 ------                                

             Subcommittee on Legislative and Budget Process

                  ALCEE L. HASTINGS, Florida, Chairman
                  
JOSEPH D. MORELLE, New York,         ROB WOODALL, Georgia,
  Vice Chair                           Ranking Republican
MARY GAY SCANLON, Pennsylvania       MICHAEL C. BURGESS, Texas
DONNA E. SHALALA, Florida
JAMES P. McGOVERN, Massachusetts

                                 ------                                

          Subcommittee on Rules and Organization of the House

                   NORMA J. TORRES, California, Chair
                   
ED PERLMUTTER, Colorado,             DEBBIE LESKO, Arizona,
   Vice Chair                           Ranking Republican
MARY GAY SCANLON, Pennsylvania       ROB WOODALL, Georgia
JOSEPH D. MORELLE, New York
JAMES P. McGOVERN, Massachusetts

                                 ------                                

                  Subcommittee on Expedited Procedures

                     JAMIE RASKIN, Maryland, Chair
                     
DONNA E. SHALALA, Florida,           MICHAEL C. BURGESS, Texas,
   Vice Chair                           Ranking Republican
NORMA J. TORRES, California          DEBBIE LESKO, Arizona
MARK DeSAULNIER, California
JAMES P. McGOVERN, Massachusetts




                            C O N T E N T S

                              ----------                              

                             April 30, 2019

Opening Statements:
                                                                   Page
    Hon. James P. McGovern, a Representative in Congress from the 
      State of Massachusetts and Chair of the Committee on Rules.     2
    Hon. Tom Cole, a Representative in Congress from the State of 
      Oklahoma and Ranking Member of the Committee on Rules......     4
Witness Testimony:
    Mr. Ady Barkan, Founder, Be A Hero Organization..............     7
        Prepared Statement.......................................    10
    Dr. Charles Blahous, J. Fish and Lillian F. Smith Chair and 
      Senior Research Strategist, Mercatus Center................    14
        Prepared Statement.......................................    17
    Dr. Dean Baker, Senior Economist, Center for Economic and 
      Policy Research............................................    24
        Prepared Statement.......................................    27
    Ms. Grace-Marie Turner, President, Galen Institute...........    39
        Prepared Statement.......................................    41
    Dr. Sara Collins, Vice President for Health Care Coverage and 
      Access, The Commonwealth Fund..............................    57
        Prepared Statement.......................................    59
    Dr. Doris Browne, Immediate Past-President, National Medical 
      Association................................................   103
        Prepared Statement.......................................   106
    Dr. Farzon Nahvi, Emergency Room Physician...................   109
        Prepared Statement.......................................   112
Questions and Additional Testimony:
    Hon. James P. McGovern, a Representative in Congress from the 
      State of Massachusetts and Chair of the Committee on Rules.   114
    Hon. Tom Cole, a Representative in Congress from the State of 
      Oklahoma and Ranking Member of the Committee on Rules......   119
    Hon. Ed Perlmutter, a Representative in Congress from the 
      State of Colorado..........................................   124
    Hon. Rob Woodall, a Representative in Congress from the State 
      of Georgia.................................................   128
    Hon. Jamie Raskin, a Representative in Congress from the 
      State of Maryland..........................................   135
    Hon. Michael C. Burgess, a Representative in Congress from 
      the State of Texas.........................................   141
    Hon. Mary Gay Scanlon, a Representative in Congress from the 
      State of Pennsylvania......................................   148
    Hon. Norma Torres, a Representative in Congress from the 
      State of California, Prepared Statement....................   154
    Hon. Debbie Lesko, a Representative in Congress from the 
      State of Arizona...........................................   155
    Hon. Joseph D. Morelle, a Representative in Congress from the 
      State of New York..........................................   161
    Hon. Donna E. Shalala, a Representative in Congress from the 
      State of Florida...........................................   170
    Hon. Mark DeSaulnier, a Representative in Congress from the 
      State of California........................................   179
Additional Material Submitted for the Record:
    Statement from National Nurses United dated April 30, 2019...   187
    Statement from Diane Archer, President, JustCareUSA.org dated 
      April 30, 2019.............................................   220
    Letter from Mayra E. Alvarez MHA, President, The Children's 
      Partnership dated April 29, 2019...........................   227
    Statement from the American Hospital Association dated April 
      30, 2019...................................................   230
    Statement from Eagan Kemp, Health Care Policy Advocate, 
      Public Citizen, dated April 30, 2019.......................   234
    Article by Erica Werner, Washington Post, entitled ``House 
      GOP plan would cut Medicare, Medicaid to balance budget'' 
      dated June 19, 2018........................................   244
    Article by Alex Cooke, CBC News, entitled `` 'This is the 
      face of the health-care crisis': Woman issues plea to N.S. 
      premier'' dated April 25, 2019.............................   246
    Letter from Nathan Rodke, Washington Community Action Network 
      dated April 29, 2019.......................................   253
    Letter from Mark Dudzic, National Coordinator, the Labor 
      Campaign for Single-Payer dated April 26, 2019.............   254
    Letter from Nancy J. Altman, President, and Alex Lawson, 
      Executive Director, Social Security Works dated April 29, 
      2019.......................................................   255
    Letter from Dr. John Aldis dated April 22, 2019..............   257
    Statement from Rebecca Wood dated April 30, 2019.............   258
    Letter from the Partnership for Employer Sponsored Coverage 
      dated April 30, 2019.......................................   261
    Opinion Editorial by Enrique Padron, the New York Post, 
      entitled ``Hey, Democrats: Here's the price I paid for your 
      socialist dream'' dated April 17, 2019.....................   264
    Paper from Dr. Giles Birchley, Centre for Ethics in Medicine, 
      Bristol Medical School: Population Health Sciences, 
      University of Bristol entitled ``Charlie Gard and the 
      weight of parental rights to seek experimental treatment'' 
      dated May 17, 2018.........................................   268
    Curriculum Vitae and Truth in Testimony Forms for Witnesses 
      Testifying Before the Committee............................   273



 
  ORIGINAL JURISDICTION HEARING ON H.R. 1384, MEDICARE FOR ALL ACT OF 
                                  2019

                              ----------                              


                        TUESDAY, APRIL 30, 2019

                          House of Representatives,
                                        Committee on Rules,
                                                    Washington, DC.
    The committee met, pursuant to call, at 10:05 a.m., in Room 
H-313, The Capitol, Hon. James P. McGovern [chairman of the 
committee] presiding.
    Present: Representatives McGovern, Perlmutter, Raskin, 
Scanlon, Morelle, Shalala, DeSaulnier, Cole, Woodall, Burgess, 
and Lesko.

                       OPENING STATEMENTS

    The Chairman. The Rules Committee will come to order. Good 
morning, everybody. And I want to welcome our witnesses to the 
Rules Committee. Thank you so much for being here. Before I 
give my opening statement, I would like to outline the time 
agreements that we reached between the majority and minority on 
this committee for the purposes of this hearing. In the Rules 
Committee, we have no rules, but we are going to have rules 
today, at least a little bit.
    So, you know, while the rules of our committee provide 
members with 5 minutes to ask questions of the witnesses, that 
rule has not been followed for as long as I can remember. I 
believe we have reached a fair agreement with our minority that 
respects the time of our expert witnesses and provides members 
of this committee with ample time to ask questions.
    Under the agreement, the chair and ranking member will 
provide an opening statement around 5 minutes. If other members 
of the committee have opening remarks, we ask that you submit 
those statements for the record. Each witness will then have 5 
minutes to provide an opening statement. If you go over a 
little bit, fine. But if you see that red light on, that means 
try to wind it up.
    After the committee receives testimony from our witnesses, 
each member of the committee will have about 15 minutes to ask 
questions of the witnesses. And if a member has a question for 
Mr. Barkan, please ask him your question at the beginning of 
your time and then proceed with your questions for the other 
witnesses to give Mr. Barkan some time to type his responses. 
Please be sure to leave some time at the end of your 
questioning for his responses.
    The chair and ranking member will have an additional 15 
minutes to provide comments throughout the hearing or to 
provide additional time to members during questioning. The 
minority's additional time must be used before the majority's 
last member begins his or her questioning. The chair and 
ranking member will have about 5 minutes to close, and the 
chair will close after the ranking member offers his very, I am 
sure, eloquent closing remarks.
    I want to thank Ranking Member Cole for his assistance in 
reaching this agreement, and I thank all of our members, both 
Democratic and Republican, for participation in this hearing. 
And before I begin, I just want to acknowledge some people here 
in the audience. You saw Speaker Pelosi was here a little bit 
earlier. We appreciate her coming by. And Congresswoman Katie 
Porter is here from California. We are grateful that she is 
here in the audience. In addition, we have Amirah Sequeira from 
National Nurses United, Jean Ross from National Nurses United, 
Nicole Jorwic from the Consortium of Citizens with 
Disabilities, Kristy Fogle with the Maryland Progressive 
Healthcare Coalition, Robert Kraig with People's Action, and 
Savanna Lyons with People's Action. Rebecca Wood and her 
daughter, Charlie, are here. Charlie was born prematurely, and 
before the age of 3, she had suffered through more therapies 
and injections than most experience in a lifetime. And as the 
expenses piled up, Rebecca and her family faced tough choices 
regarding Charlie's treatment, which highlight the need for 
adequate long-term care in this country.
    Jennifer Epps-Addison is sitting behind Ady from the Center 
for Popular Democracy; Nate Smith, Ady's lifelong friend and 
caretaker; Liz Jaff, president of Be a Hero, which is Ady's 
organization; and Elazar Barkan, Ady's father, is here. I am 
sure you are very proud of your son today, as we all are. 
Yochai Benkler, Ady's uncle, is here; and Ari Benkler, Ady's 
cousin. And the incredible Pramila Jayapal is here. When I get 
to my opening statement, I want to thank her again because it 
is her legislation that is why we are all here today.

STATEMENT OF THE HONORABLE JAMES P. MCGOVERN, A REPRESENTATIVE 
 IN CONGRESS FROM THE STATE OF MASSACHUSETTS AND CHAIR OF THE 
                       COMMITTEE ON RULES

    Let me begin with my opening statement. I believe this is a 
historic day. Today the Rules Committee is holding a hearing on 
the Medicare for All Act, and this marks the first time 
Congress has ever held a hearing on Medicare for All. And I 
want to thank again Congresswoman Pramila Jayapal and 
Congresswoman Debbie Dingell and their staffs, Senator Sanders 
and his staff as well, for leading this effort and for all 
their help with this hearing. But I particularly want to thank 
Congresswoman Jayapal for her commitment and her dedication to 
this issue, and we are all grateful to her.
    We have a talented witness panel with us today, and I have 
a sneaking suspicion that we will have a lively debate. And 
that is a good thing. After nearly a decade of Republicans 
talking only about how to rip healthcare away from people when 
they were in charge, this majority is here to discuss how to 
expand coverage and how to lower costs and improve outcomes in 
the process.
    I have long believed that healthcare is a right for all, 
not a privilege for the lucky few. That is why I voted for the 
Affordable Care Act, a law that gave 20 million more people 
access to health coverage. It banned insurance companies from 
discriminating against cancer patients and women and made sure 
that health plans actually covered essential benefits.
    The ACA changed lives. It saved lives. But we knew then 
that it was never going to be the last stop in healthcare 
reform, that we were always going to have to come back and 
build upon those core values. And that is what today is all 
about, because the work of reform isn't done. Twenty-nine 
million Americans are still without coverage. Forty-four 
million people have coverage that isn't there for them when 
they need it. And all of us deserve healthcare that we can 
afford without health insurance middlemen unnecessarily jacking 
up costs or deciding who gets care. Because it is still true 
today that for too many in America, you can go broke if you get 
cancer; you can lose your home if your kids get sick. That is 
not healthcare being delivered as a basic human right; that is 
healthcare that remains out of reach for too many.
    The Medicare for All Act would change that. The 29 million 
uninsured Americans in our country today would get healthcare. 
The 44 million underinsured people would have the peace of mind 
of finally knowing that their healthcare will be there for them 
when they need it. And all of us--workers, seniors, students--
all of us will be free from crushing out-of-pocket costs.
    Importantly, this bill would also guarantee for the first 
time that people living with disabilities have access to 
services they need to live with dignity. The Medicare for All 
Act is a serious proposal. That is why more than 100 Members of 
Congress are cosponsors. That includes me, and it includes some 
others on this panel. Not only does it deserve to be part of 
the discussion as we consider ways to expand and strengthen 
coverage, it deserves to move forward. I hope today is just the 
start.
    Congress should be a place where we tackle big things, 
where we are not afraid to have hearings and real debates. I 
know we won't pass this bill overnight, but we won't pass it 
unless we start the dialogue.
    This Democratic majority was built by Americans tired of 
political leaders who tried to sabotage their healthcare and 
who looked after the wealthy and well-connected at the expense 
of everyone else. The American people in the last election 
spoke loudly and clearly. They wanted a Congress that works to 
expand coverage. They are sick and tired of the problems that 
are fundamental in our system today.
    So, if my Republican friends want to use a lot of scary 
words like ``government takeover'' and ``socialism'' today, 
have at it. They tried that during the passage of Medicare. 
They tried that during the passage of Social Security. They 
tried that during the passage of the Affordable Care Act. And 
every time, the American people saw through it and supported 
those programs. This would be no different.
    And by now, we all know that the Republican plan for 
healthcare can be summed up in one word: repeal, no 
replacement. To the extent that they had a healthcare plan, I 
think it could probably be summarized as take two tax breaks 
and call me in the morning. They didn't hold a single hearing 
on the repeal plan last Congress, not one. Well, this majority 
is taking a different route. We have fantastic witnesses who 
will talk about this bill today. Some are for; some are 
somewhere in the middle; and some are against.
    But I want to focus on one witness. With us today is Ady 
Barkan. Ady is a father and a husband and, out of circumstance, 
a healthcare advocate. I think we all have a picture of Ady's 
beautiful family here today. And I am sure your son is 
incredibly proud of you being here at the first ever Medicare 
for All hearing. We are so honored that you are here.
    If you recognize Ady's name, it is because he has been 
fighting like hell for his life and for all of ours. Ady was 
diagnosed with ALS in the fall of 2016. Since then, he has 
battled insurance companies, drug companies, medical device 
companies. You name it, Ady has battled it just to get the care 
that he needs.
    And I say ``battle'' because that is exactly what he has 
had to do. Battle to get care, battle to get services, battle 
to get life-sustaining medical equipment. But no one should 
have to fight a healthcare company while they are fighting for 
their lives.
    I can't do Ady's story justice. I will let him tell it. But 
I will leave my colleagues with this: If you think healthcare 
in America is just fine today, if you think we only need to 
nibble at the edges of reform, look at Ady after what he has 
gone through and try to tell him that.
    Of course, Ady, you are welcome to stay here as long as you 
want and take any breaks that you want. We are just honored 
that you are here. You literally put your life on the line to 
travel here from California, and we are fortunate to be able to 
hear your story.
    Let me just close with this: You know, in Washington, we 
talk a lot about national security. That is everybody's 
favorite topic. And I believe we need to expand the definition 
of national security to include more than just the number of 
bombs we have. National security should also mean things like 
quality healthcare for every person in this country. You know, 
we expect the Federal Government to defend us against enemies 
abroad. I don't think it is too much to expect the Federal 
Government to protect us against illnesses here at home.
    We are going to have a spirited debate here. I am looking 
forward to it, but before I get started I want to first 
recognize our distinguished ranking member from Oklahoma, my 
good friend Mr. Cole.

   STATEMENT OF THE HONORABLE TOM COLE, A REPRESENTATIVE IN 
 CONGRESS FROM THE STATE OF OKLAHOMA AND RANKING MEMBER OF THE 
                       COMMITTEE ON RULES

    Mr. Cole. Thank you very much, Mr. Chairman. And I too want 
to thank you for holding the hearing.
    And I want to thank all of our witnesses for coming and 
participating. I had the opportunity to read all of your 
testimony. And, frankly, I found it very informative in all 
cases and quite moving, obviously, in a number.
    And it is interesting to me to note, Mr. Chairman, that 
while, as you pointed out, there is a variety of perspectives, 
as there should be, amongst our witnesses today, each and every 
one of them is interested in the best possible healthcare for 
the American people. And they may disagree over how they get 
there, but it is a noble and worthy goal that you all share 
and, frankly, you have all dedicated a lifetime in pursuit of. 
So I am very grateful for that, as I know every member of this 
panel is.
    Today's hearing, Mr. Chairman, is quite extraordinary. We 
are here today to consider H.R. 1384, the Medicare for All Act 
of 2019. Unlike our usual weekly hearings, today's hearing is 
an original jurisdiction legislative hearing, covering a bill 
over which the Rules Committee has some original jurisdiction. 
I say ``some'' because out of the 120 pages of bill text, the 
Rules Committee has jurisdiction over precisely one of those 
pages. That is it, just one page. Yet we are about to hold our 
first original jurisdiction legislative hearing in nearly 3 
years on this bill. That is what makes this hearing 
extraordinary.
    I also think it is worth noting that Speaker Pelosi's 
personal committee is the one to take the first swing at this 
ball when three other committees in the House can claim wider 
jurisdiction than Rules. Energy and Commerce, Ways and Means, 
and Education and Labor could, and should, all conduct multiple 
hearings on this legislation as well. And, frankly, I am sure 
ranking Republican members of those committees will be 
requesting their chairs to take up this legislation in the 
relevant committees. And I hope that happens.
    Of course, there is a reason it is coming to Rules first, 
and that is because this bill too is an extraordinary bill. 
What Democrats are proposing today would completely change 
America's healthcare system and not, in my view, for the 
better. Medicare for All would require all Americans to pay 
more in taxes, wait longer for care, and receive potentially 
worse care. Even worse, it would put our current Medicare 
recipients at risk.
    As Medicare is structured now, current Medicare recipients 
and Medicare Advantage plan holders are, by and large, 
satisfied with the healthcare they receive. In particular, 
Medicare Advantage plans are extremely popular. However, this 
radical bill puts Medicare itself at risk by enrolling millions 
of new recipients who have not paid into the program in the 
same way current recipients have. It would reduce the quality 
of services, enforce longer wait times, and ban Medicare 
Advantage entirely. For current Medicare recipients, Medicare 
for All really means Medicare for none.
    Indeed, this bill is a socialist proposal that threatens 
freedom of choice and would allow Washington to impose one-
size-fits-all plans on the American people. Private health 
insurance would be completely banned. Everyone, every man, 
woman, and child in America with private employer-based or 
union-based health insurance, would lose their plan. Even if 
you like your plan, you really can't keep it.
    More than 150 million people will lose health plans they 
like, plans that they bargained for, and, in many cases, plans 
that they have earned through years of hard work. Medicare for 
All throws it all out the window in favor of a one-size-fits-
all government-run health plan.
    We will hear from one of our witnesses, Ms. Grace-Marie 
Turner, on the impact this will have on employer-sponsored 
insurance and the method by which roughly half of Americans 
receive their healthcare.
    In the midst of all this, I think the majority needs to be 
honest about the phenomenal cost of this new program. We are 
going to hear from Dr. Charles Blahous, a former public trustee 
for Social Security and Medicare. He reviewed Medicare for All 
for the Mercatus Center and authored a very telling study on 
the topic. Dr. Blahous' work showed the previous more basic 
version of Medicare for All would cost at least $32 trillion 
over the next 10 years, and, frankly, the version in front of 
us would cost more than that.
    The majority has not told us how much this massive new 
program will cost, how they will raise the money to pay for it, 
or whose taxes will have to go up to pay for it. On the last 
concern, I can assure you that the answer is everyone. 
Everyone's taxes will have to more than double to pay for this 
program. The majority needs to be honest with us and with the 
American people about the cost.
    Beyond this, I would like to point out one of the most 
egregious provisions of the Democratic healthcare bill is that 
it relates to the Federal funding of abortion. As many know, 
the Federal funding of abortion has been limited for well over 
three decades by several legislative provisions: The Hyde 
amendment limits taxpayer public funding of abortion; the 
Weldon amendment prohibits States from discriminating against 
providers that do not support abortions; the Church amendments 
protects the conscience rights of health practitioners; and 
even ObamaCare maintained limited conscience protections.
    However, this bill contains none of them. It requires 
coverage of comprehensive reproductive care, quote/unquote, 
which includes elective abortions paid for with taxpayer 
dollars. Section 701 of the bill explicitly states that this 
bill must ignore these Federal laws dating back 33 years.
    Mr. Chairman, I would hope that you are encouraging your 
leadership to pursue hearings and markups within the committees 
that have primary jurisdiction over the majority of healthcare 
issues--Energy and Commerce and Ways and Means--so that we can 
ensure that longstanding life protections are included as you 
move Medicare for All to the floor for a vote.
    Mr. Chairman, I am looking forward to today's hearing, hope 
our witnesses can shed some light on these and other questions 
as we review this proposal that, if passed into law, would 
dramatically change the American healthcare system for 
absolutely everyone and, in my opinion, not for the better.
    Thank you, Mr. Chairman.
    The Chairman. Thank you very much, Mr. Cole, for your 
statement. And let me just assure you that I hope all of the 
committees of jurisdiction will do hearings on this bill 
because I think that would be, as I mentioned in my opening 
statement, a big contrast to the way my friends on the other 
side of the aisle conducted themselves when they tried to 
repeal the Affordable Care Act. There were no hearings. 
Hearings are a good thing. And as far as why Rules is 
beginning, I would like to think it is because it is an 
enlightened chairman.
    We are ready to begin. Our first witness is Ady Barkan. Ady 
is a lawyer and an organizer with the Center for Popular 
Democracy and the founder of the Be a Hero PAC. He helped 
design and draft policy proposals to enhance the quality of 
low-wage jobs in New York City, including the right to paid 
sick days, regulation of major retailers, and unionization of 
the car wash industry. He graduated from Yale Law School and 
Columbia College cum laude. And as I said in my opening 
statement, we are deeply honored to have you here, Mr. Barkan, 
and the floor is yours.

    STATEMENT OF ADY BARKAN, FOUNDER, BE A HERO ORGANIZATION

    Mr. Barkan. Chairman McGovern and members of the committee, 
thank you for inviting me to testify today. My name is Ady 
Barkan. I am 35 years old, and I live in Santa Barbara, 
California, with my brilliant wife Rachel and our beautiful 
toddler Carl. She is an English professor at the University of 
California-Santa Barbara, and I am an organizer at the Center 
for Popular Democracy and the Be a Hero project.
    I earned my bachelor's degree from Columbia University with 
a major in economics and my law degree from Yale Law School. 
For 20 years, since I was a freshman on my high school debate 
team, I have been giving speeches and presentations on topics 
like healthcare reform and the Federal budget, but never before 
have I given a speech without my natural voice. Never before 
have I had to rely on a synthetic voice to lay out my 
arguments, convey my most passionately held beliefs, tell the 
details of my personal story.
    Three years ago, Rachel and I felt like we had reached the 
mountaintop. We had fulfilling careers, a wonderful community 
of friends and family, and a smiling chubby infant boy. We 
could see decades of happiness stretching out before us. The 
sun was shining, and there was not a cloud in sight. And then, 
out of the clear blue sky, we were struck by lightning: ALS, a 
mysterious neurological disease with no cure and no good 
treatment, a life expectation of 3 to 4 years. Most of its 
victims are in their fifties and sixties. I was 32.
    Every month since my diagnosis, my motor neurons have died 
out, my muscles have disintegrated, and I have become 
increasingly paralyzed. I am speaking to you through this 
computer because my diaphragm and tongue are simply not up to 
the task.
    Although my story is tragic, it is not unique. Indeed, in 
many ways, it is not so rare. Jennifer Epps-Addison, the 
president of my organization, is sitting next to me. Like me, 
her husband was struck at a young age by a neurological 
disease, multiple sclerosis. Ten percent of Americans have a 
serious disability. Every family is eventually confronted with 
serious illness or accidents. On the day we are born and on the 
day we die and on so many days in between, all of us need 
medical care. And yet in this country, the wealthiest in the 
history of human civilization, we do not have an effective or 
fair or rational system for delivering that care. I will not 
belabor the point because you and your constituents are well 
aware of the problems: high costs, bad outcomes, mind-boggling 
bureaucracy, racial disparities, bankruptcies, geographic 
inequities, and obscene profiteering.
    The ugly truth is this: Healthcare is not treated as a 
human right in the United States of America. This fact is 
outrageous, and it is far past time that we change it. Say it 
loud for the people in the back: Healthcare is a human right. 
For my family, although we have comparatively good private 
health insurance, ALS now means paying out of pocket for almost 
24-hour home care. This costs us $9,000 every month. The 
alternative is for me to go on Medicare and move into a nursing 
home away from my wife and my son. So we are cobbling together 
the money from friends and family and supporters all over the 
country, but this is an absurd way to run a healthcare system. 
GoFundMe is a terrible substitute for smart congressional 
action.
    Like so many others, Rachel and I have had to fight with 
our insurer, which has issued outrageous denials instead of 
covering the benefits we pay for. We have so little time left 
together and yet our system forces us to waste it dealing with 
bills and bureaucracy.
    That is why I am here today urging you to build a more 
rational, fair, efficient, and effective system. I am here 
today to urge you to enact Medicare for All. There are three 
simple reasons why Medicare for All is the right solution, the 
only solution to what ails the American healthcare system. I 
will summarize them here, but I urge you to read the fantastic 
testimony submitted by the National Nurses United for more 
details.
    First, Medicare for All will deliver to everyone living in 
America the high-quality care that we deserve. The law will 
provide comprehensive care, including primary and hospital 
care, dental, vision, reproductive, and mental healthcare. We 
will all be allowed to see the doctors and specialists we want. 
And crucially, the program will provide for long-term services 
and supports that will allow people like me to stay in our 
homes and communities with the people we love. This will 
dramatically improve life for the tens of millions of people 
whose families include older or disabled people.
    Second, Medicare for All will save the American people 
enormous sums of money. Under the program, there will be no 
premiums, no deductibles, and no copays. That means that we 
will no longer need to choose between paying the rent and 
filling a prescription. It means we will no longer delay 
necessary care until it is tragically late and tragically 
expensive. It means that we won't have to worry every year when 
our employer announces the new rates. It means that we can 
finally start to eliminate the atrocious racial and economic 
disparities that destroy so many lives, that rob our 
communities of so much dignity, that strip us all of our common 
humanity.
    Any proposal that maintains financial barriers to care, any 
proposal that continues to charge patients exorbitant copays, 
deductibles, and premiums will necessarily leave people out. 
Any proposal that maintains the for-profit health insurance 
system will require that some people don't get the healthcare 
they need. Without the generous support of my family and 
friends, this would include me.
    Crucially, Medicare for All is the only way to make our 
healthcare system more efficient. Over the past 3 years, I have 
seen firsthand how the current system creates absurdly wasteful 
cost-shifting, delays, billing disputes, rationing, and worry. 
Administrative waste is costing us hundreds of billions of 
dollars every year.
    Medicare for All will streamline the entire system, letting 
doctors and nurses focus on delivering care instead of on 
paperwork. As a single-payer program, Medicare for All will be 
able to eliminate immoral price gouging by pharmaceutical and 
device companies. The fundamental truth is that too many 
corporations make too much money off of our illnesses, and they 
are spending zillions of dollars lobbying and campaigning and 
fighting to stop us from building something better.
    It is very important to emphasize the following point: 
These cost savings are only possible through a genuine Medicare 
for All system; other proposals to increase health insurance 
coverage, such as those that would make Medicare compete with 
private insurance, would not facilitate administrative and 
billing savings. There are many other major benefits to 
Medicare for All detailed in the written testimony submitted by 
the nurses and others.
    But my time to deliver this testimony is running out. And 
in a much more profound sense, my time to deliver this message 
to the American people is running out as well. So I want to end 
on this third and final note: Our time on this Earth is the 
most precious resource we have. A Medicare for All system will 
save all of us tremendous time. For doctors and nurses and 
providers, it will mean more time giving high-quality care, and 
for patients and our families, it will mean less time dealing 
with a broken healthcare system and more time doing the things 
we love together.
    Some people argue that, although Medicare for All is a 
great idea, we need to move slowly to get there, but I needed 
Medicare for All yesterday. Millions of people need it today. 
The time to pass this law is now. Winning this reform will not 
be easy. The monied interests will do everything in their power 
to stop us, and yet, despite these obstacles and despite the 
personal challenges that I face, I sit before you today a 
hopeful man, a hopeful husband, and a hopeful father. I am 
hopeful because right now there is a mass movement of people 
from all over this country rising up. Nurses, doctors, 
patients, caregivers, family members, we are all insisting that 
there is a better way to structure our society, a better way to 
care for one another, a better way to use our precious time 
together.
    And so my closing message is not for the members of this 
committee; it is for the American people. Join us in this 
struggle. Be a hero for your family, your communities, your 
country. Come give your passion and your energy and your 
precious time to this movement. It is a battle worth waging and 
a battle worth winning. For my son, Carl, for your children, 
and for our children's children, we have a once-in-a-generation 
opportunity to win what we really deserve. No more half 
measures, no more healthcare for some. We can win Medicare for 
All. This is our Congress. This is our democracy, and this is 
our future for the making.
    [The statement of Mr. Barkan follows:]
    
    
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    The Chairman. Thank you very much, Mr. Barkan.
    I appreciate it. I think this entire committee is grateful 
for your testimony, and we are honored to have you here.
    Let me yield to my colleague, Mr. Cole.
    Mr. Cole. I simply want to echo your remarks. It is a great 
privilege to have you here and at considerable sacrifice and 
risk to yourself, which is a testament to your courage. We are 
very happy and honored to have you in this debate, in this 
hearing today. Thank you.
    We will go next to Dr. Charles Blahous, who is the J. Fish 
and Lillian F. Smith Chair and Senior Research Strategist at 
the Mercatus Center at George Mason University as well as a 
visiting fellow at Stanford University's Hoover Institution, 
previously served as a public trustee for the Social Security 
and Medicare programs, and was deputy director of the National 
Economic Council under President George W. Bush.

  STATEMENT OF CHARLES BLAHOUS, J. FISH AND LILLIAN F. SMITH 
     CHAIR AND SENIOR RESEARCH STRATEGIST, MERCATUS CENTER

    Mr. Blahous. Thank you very much. Chairman McGovern, 
Ranking Member Cole, all the members of the committee, I 
greatly appreciate this opportunity to appear before you to 
discuss the estimated Federal budget costs of Medicare for All.
    Before I proceed to the estimates, just a few caveats. This 
is not an analysis of whether Medicare for All is good policy 
or bad policy. It is purely a cost projection. And as I discuss 
the factors that play into the estimates, it is purely by way 
of explaining how they affect the numbers.
    The second caveat is that my testimony is based on an 
analysis of the Medicare for All Act of 2017, introduced by 
Senator Sanders in the last Congress. Obviously, there are more 
recent bills introduced by Representative Jayapal and by 
Senator Sanders himself. These would be expected to cost 
somewhat more because they have added long-term care benefits, 
but I have had not had an opportunity to analyze these bills.
    Medicare for All would add somewhere between $32.6 trillion 
and $38.8 trillion in new Federal budget costs over the first 
10 years. The $32.6 trillion estimate is a lower bound 
estimate. It essentially assumes every cost containment 
provision in the bill saves as much as possible. If, instead, 
things play out more consistently with historical trends, the 
new Federal costs would be closer to $38.8 trillion. And I will 
say more about the specific assumptions later.
    Now, obviously, such enormous numbers are very difficult to 
grasp. We are talking about 11 to 13 percent of our GDP in 2022 
rising to 13 to 15 percent of GDP in 2031 being added to the 
Federal ledger. And we simply do not have historical experience 
with permanent government expansions of this size. So, to 
provide a sense of the magnitude, the study notes that doubling 
all currently projected Federal individual and corporate income 
taxes would be insufficient to finance even the lower bound 
estimate of $32.6 trillion.
    Now, to be clear, these would not be the total costs of 
Medicare for All. These would be the Federal Government's net 
new costs above and beyond currently projected Federal health 
obligations. Total Federal spending on Medicare for All over 
the first 10 years would be somewhere between $54.6 trillion 
and $60.7 trillion.
    Now, the vast majority of these costs would arise simply 
from the Federal Government's assuming responsibility for 
health spending that is now done by others, by State and local 
governments, by private insurance, and by individuals in their 
payments out of pocket. Other aspects of Medicare for All would 
add to that existing health spending. Still others are intended 
to bring costs down.
    The biggest factor increasing health spending under 
Medicare for All would be its expansion and increased 
generosity of health insurance coverage. Spending on behalf of 
the currently uninsured would rise, as one would expect and 
presumably intend. Additional benefits would be provided that 
Medicare currently doesn't, such as dental, vision, and hearing 
services.
    Perhaps most importantly, as has been noted here, Medicare 
for All would provide first dollar coverage of all Americans' 
health expenses, meaning no deductibles, no copays, no other 
cost-sharing. And this would considerably increase the demand 
for health services for the well-documented fact that the more 
of people's healthcare that is financed by their insurance, the 
more they tend to consume. So, under Medicare for All, the 
Federal Government would not only take on responsibility for 
funding currently projected health services but a significantly 
increased demand.
    Now, other provisions of Medicare for All are expected or 
hoped to reduce costs. The study assumes substantial 
administrative cost savings from eliminating private health 
insurance and it brackets a range of possible outcomes of 
efforts to negotiate lower drug prices.
    Now, the big variable here is payment rates for health 
providers. The bill indicates that providers will be paid at 
Medicare payment rates, and these are much lower than those 
that are paid by private insurance. For hospitals, the payment 
reductions would be more than 40 percent for treatments now 
covered by private insurance; and for doctors, the reductions 
from private insurance rates would start out around 30 percent, 
on average. They would grow even steeper over time, reaching 42 
percent within 10 years.
    Now, importantly, these reduced payment rates would be 
substantially below providers' reported costs of providing 
services. We do not know what would happen to the supply, 
timeliness, or quality of healthcare services if we were to 
impose sudden provider payment cuts of this magnitude while 
simultaneously increasing the demand for services. And because 
of this, several other studies performed prior to the bill's 
introduction assumed higher payment rates than Medicare's would 
be needed.
    Now, my study did not take sides on whether these provider 
payment cuts would be desirable. But purely from an analytical 
standpoint, you have to recognize that they are much larger and 
more sudden than lawmakers have historically been willing to 
implement. If historical patterns continued and such payment 
reductions did not occur, Medicare for All would further 
increase national health spending even above current 
projections.
    My written testimony provides comparisons showing that 
these estimates are generally similar to those of other experts 
when you adjust for the years being estimated as well as for 
alternative assumptions regarding the administrative costs, 
prescription drug costs, and provider payment rates.
    I hope this information is useful, and I thank the 
committee again for the opportunity to discuss these important 
aspects of Medicare for All.
    [The statement of Mr. Blahous follows:]
    
    
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    The Chairman. Thank you very, very much. I appreciate it.
    Dean Baker is a macroeconomist and cofounder of the Center 
for Economic and Policy Research, CEPR, in Washington, D.C. His 
areas of research include housing and macroeconomics, 
intellectual property, Social Security, Medicare, and European 
labor markets. He is the author of several books, and his piece 
`` `Medicare for All' is not a fantasy'' was recently published 
on CNN's website. He received his B.A. from Swarthmore College 
and his Ph.D. in economics from the University of Michigan.
    Mr. Baker, we are very honored to have you here.

STATEMENT OF DEAN BAKER, SENIOR ECONOMIST, CENTER FOR ECONOMIC 
                      AND POLICY RESEARCH

    Mr. Baker. Thank you, Chairman McGovern and Ranking Member 
Cole. I have to say it is a great honor to be next to Ady 
again. I knew Ady from prior days when we were in the Fed Up 
coalition to pressure the Fed to allow more full employment, 
and that was an amazing effort that Ady deserves enormous 
credit for in addition to his great subsequent work. And I 
appreciate being here.
    I want to make three main points and then say a little bit 
about the transition. First off, I want to say that Medicare 
for All is affordable, that the bulk of the payments should be 
coming from shifting employer premiums to government basically 
to taxes. So it is not additional money out of workers' 
pockets.
    Secondly, that the amount of additional revenue that will 
be needed depends hugely on the extent to which we can reduce 
input costs. And here what we have to keep in mind front and 
center is that we pay twice as much for everything as everyone 
else in the world, and that doesn't make sense. And the third 
point is that lower costs can be associated with better care, 
not just for the obvious reason that it will increase access 
but for other reasons, that we should expect better outcomes.
    On the first point, in terms of the overall affordability, 
taking a look at Dr. Blahous' numbers, my basic story is very 
comparable, that you are looking at incorporating somewhere on 
the order--I was looking at 2021 to 2030; I think those might 
be slightly different years--but incorporating the private 
payments under the government budget. It is about $33.4 
trillion, by my calculations, using CMS numbers.
    First off, though, we know that there will be a lot of 
administrative savings. There was an analysis done back in 2003 
by Stephanie Woolhandler and David Himmelstein that compared 
our administrative costs with Canadian administrative costs. 
Most obviously, you have the huge difference in what we 
actually pay upfront for insurance; but in addition to that, we 
have huge administrative costs in providers: hospitals, 
doctors' offices, nursing homes. They all have to have large 
numbers of staff to deal with different billing from different 
insurers. So, using their figures, I calculate that we would 
get that tab down to $25 trillion. Still considerable. That is 
shown in table 1 of my written testimony.
    The second point, second adjustment, we will see more 
utilization. I think that with the amount of utilization, we 
are somewhat shooting in the dark here because we don't know 
what happens when we, in essence, make more healthcare free or 
cheap for people, but the important point to keep in mind that 
70 percent of our healthcare costs come from roughly 10 percent 
of the population.
    The point about that is those 10 percent, they are either 
on Medicaid or they have hit their out-of-pocket limits. In 
other words, they are not already constrained. So we are 
looking at 30 percent of total costs. So how much more will 
that go up? We don't know. I assume 10 percent of the total 
bill in the calculations. We need more research on this.
    Also, there will be some out of pocket again. That will be 
debated, how much you have. I assume 1 percent of GDP. That 
leaves us, after we account for the $11.6 trillion in employer 
payments, we are left with $13.6 trillion, still a substantial 
bill over a decade.
    But then I go, okay, well what about input costs? And I 
won't go into these in great detail; it is in my written 
testimony. But if we look at our input costs, as I say, if we 
look through medical equipment, prescription drugs, physicians' 
payments, dentists' payments, we pay twice as much as everyone 
else in the world. Now, will we get down to others' levels? 
That is an open question, but there is no obvious reason we 
should be paying twice as much for our drugs, for our medical 
equipment as people in France and Germany. We don't pay our 
auto workers twice as much. We don't pay twice as much for 
cars. It is not clear why we should pay twice as much for 
healthcare.
    And let me just focus quickly on prescription drugs. CMS 
projects we will spend roughly $6.6 trillion on prescription 
drugs. Now, the assumption in the bill, and by most people who 
have analyzed it, we can get that down a lot. One of the points 
I like to make is we are not talking about making prescription 
drugs cheap. The problem is we make prescription drugs 
expensive. Drugs would be cheap if we didn't give government-
granted patent monopolies. I understand there is a rationale 
for that, but the point is we can fund the research in 
alternative ways, and they would be cheap.
    So, just to come quickly to the last points, we could 
expect better care. People shouldn't have to deal with the 
stress. Ady and his family shouldn't have to deal with the 
stress of paying for their bills. That has to be a negative in 
terms of care for someone, a cancer victim, someone else 
suffering from a serious disease that they have to deal with 
bills. Also, in the case of prescription drugs, our opioid 
problem, at least it is alleged, is in large part the result of 
our patent monopolies. Purdue Pharma would not have done as 
they are alleged to have, pushed their drug, insisting that it 
wasn't addictive, when they had evidence it was. We helped 
create that problem by granting patent monopolies.
    Lastly, some points on the transition; I would be cautious 
on how you do it. First off, fix Medicare. It is absurd that we 
don't have an out-of-pocket limit on traditional Medicare. We 
need that. Secondly, not incorporating the drug benefit. We 
don't have standalone drug plans in the private sector. Why do 
we have that with Medicare? It just raises costs. That is 
utterly pointless. And we overpay the Medicare Advantage plans. 
A recent analysis found we overpay them by roughly 13 percent, 
$20 billion a year. No reason for that.
    Secondly, in the transition, I would say allow a buy-in, 
have a competitive Medicare plan.
    The third point, reduce input prices. I can give you lots 
of ways in which we can get input prices down. In addition, as 
I said, to public funding of research for prescription drugs.
    And, lastly, as just a very, very simple first step, how 
about lowering the Medicare age of eligibility to 64? That is 
very affordable in the scheme of things. A lot of 64-year-olds 
are already on Medicare through disability, or they are on 
Medicaid. A great downpayment, in my view.
    So, long and short, I think it is affordable, but we have 
to be careful in how we get there. Thank you.
    [The statement of Mr. Baker follows:]
    
    
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    The Chairman. Thank you very much.
    Mr. Cole.
    Mr. Cole. Thank you very much, Mr. Chairman. Ms. Grace-
Marie Turner is president of the Galen Institute, a public 
policy research organization that she founded in 1995 to 
promote an informed debate over free-market ideas for health 
reform. She has been instrumental in developing and promoting 
ideas for reform to transfer power over healthcare decisions to 
doctors and patients.
    She speaks and writes extensively about incentives to 
promote a more competitive patient-centered marketplace in the 
health sector.

  STATEMENT OF GRACE-MARIE TURNER, PRESIDENT, GALEN INSTITUTE

    Ms. Turner. Thank you, Ranking Member Cole. Thank you, 
Chairman McGovern, members of the committee, for the 
opportunity to testify today.
    Let me begin by saying that I believe there are important 
shared goals for health reform. Everyone should be able to get 
health coverage to access the care they need. It should be 
affordable. People should be able to see the doctors they 
choose. We must guard the quality of care, and we must protect 
the most vulnerable with a strong safety net.
    Millions of Americans are frustrated with the current 
system. Health care costs too much, and many are simply priced 
out of the market. Those with insurance say premiums and 
deductibles are so high they might as well be uninsured. Those 
on public programs like Medicaid struggle to find physicians, 
especially specialists, who can afford to take the program's 
low payment rates. People are hurting, and they feel powerless, 
like cogs in the $3.6 trillion health sector with little power 
to impact choices or costs.
    But it is hard to see how consumers would be more empowered 
when dealing with a single government payer. In a country that 
values diversity, will one massive program with one list of 
benefits and one set of rules work for everyone?
    I was in the gallery the night that the House passed the 
Affordable Care Act in March of 2010 and heard Member after 
Member talk about the importance of passing the bill in order 
to finally achieve universal coverage and to lower cost. Nine 
years later, with millions still uninsured and costs doubling 
in the individual market, our Nation is still struggling to 
achieve those goals.
    In calling this hearing today, you acknowledge the growing 
interest in this bold proposal. But when people learn that 
Medicare for All would mean much higher taxes and losing the 
coverage they have now, support plummets. What happened 
recently in Colorado and Vermont when they tried and failed to 
create their own single-payer systems I think is important to 
study.
    I believe the growing presence of government in the health 
sector is a significant contributor to its dysfunction. 
Government officials, not consumers, increasingly determine 
what services can or must be covered, how much will be paid, 
and who is eligible to both deliver and receive these services. 
Third-party payment systems lead to significant disruptions, 
and insurers and others must respond to government rules and 
regulation, shoving consumers to the bottom of the healthcare 
totem pole.
    Rather than dramatically expand the role of government, I 
believe we need to look more carefully at these problems and 
target appropriate solutions that empower consumers and build 
on what works.
    Medicare for all's promise of unrestricted access to 
benefits is virtually unprecedented, and it is difficult to 
anticipate the impact of this new system. Representative 
Jayapal's bill implies a recognition of cost by imposing global 
budgets to contain spending. Paying doctors and hospitals at 
Medicare rates would force many to close or significantly cut 
back on services and would worsen the existing physician 
shortage.
    We do know from the experience of other countries that 
global budgets and centrally-determined benefit structures lead 
to rationing, waiting lines, and lower quality of care, as I 
describe in my testimony. Tragically, it is often the most 
vulnerable who are left behind when the demand for services 
outpaces resources.
    Many Americans would see it as severely disruptive to lose 
their current coverage when public programs as well as job-
based health insurance would be shut down under Medicare for 
All. 173 million Americans get health coverage through the 
workplace, a highly valued benefit.
    My colleague Doug Badger explains that the employment-based 
health system is really a central pillar in our health sector. 
It produces a nearly 3-to-1 ratio in value-to-tax expenditures. 
Employer plans also pay doctors and hospitals more than 
Medicare and Medicaid do and provide the margins that most 
providers need to maintain quality and even keep their doors 
open.
    Employers also have more flexibility to tailor insurance to 
the needs of their workforce, to advocate for them and to 
provide education and incentives about good health.
    I describe in my testimony targeted solutions already 
underway to give individuals and workers more, not fewer, 
choices and to provide States with more resources and 
flexibility to help their health insurance markets recover. I 
describe work by the Health Policy Consensus Group, which I 
facilitate, in developing a plan to reduce the cost of health 
insurance while protecting the poor and sick, including those 
with preexisting conditions.
    Finally, Americans want more, not fewer, choices in health 
coverage, yet Medicare for All would put them on a single 
government program. When government officials are making 
decisions about what services will be covered, as the 
legislation explicitly says, how much providers will be paid, 
how much citizens must pay in mandatory Federal taxes, then 
consumers will have even fewer choices than they do today. It 
will reduce access to new technologies, stifle innovation, and 
result in a near doubling of the tax burden.
    I would welcome the opportunity to work with you to achieve 
the goals of better access to more affordable coverage and 
better protection for the vulnerable. Thank you for the 
opportunity to testify.
    [The statement of Ms. Turner follows:]
    
    
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    The Chairman. Thank you very much.
    Dr. Sarah Collins is vice president for healthcare coverage 
and access of the Commonwealth Fund. As an economist, she 
directs the fund's program on insurance coverage and access. 
Dr. Collins has led several multiyear national surveys on 
health insurance and authored numerous reports, issue briefs, 
and journal articles on health insurance coverage, health 
reform, and the Affordable Care Act. Early in her career, she 
was an associate editor at U.S. News and World Report, a senior 
economist at Health Economics Research and a senior health 
policy analyst in the New York City Office of the Public 
Advocate.
    Dr. Collins holds an A.B. in economics from Washington 
University and a Ph.D. in economics from George Washington 
University. Thank you for being here.

   STATEMENT OF SARA COLLINS, VICE PRESIDENT FOR HEALTHCARE 
             COVERAGE AND ACCESS, COMMONWEALTH FUND

    Ms. Collins. Thank you, Mr. Chairman and members of the 
committee, for this invitation to testify on proposals to 
reform the U.S. health system. My comments are going to focus 
on gains in health insurance since the passage of the 
Affordable Care Act, the problems people continue to report 
affording insurance and healthcare, and the potential of recent 
congressional bills to address these problems.
    The ACA brought sweeping change to the health system in 
expanding comprehensive health insurance to millions of 
Americans and making it possible for anyone with health 
problems to get coverage by banning insurers from denying 
coverage or charging more because of preexisting conditions.
    The number of uninsured people has fallen by nearly half 
since the ACA became law. There has also been a decline in the 
share of people reporting problems paying medical bills or not 
getting needed care because of cost. The large body of research 
on the ACA shows that the law's overall impact on people's 
ability to afford insurance and get healthcare has been 
positive.
    However, three distinct yet interrelated problems remain: 
29.7 million people remain uninsured; 44 million people with 
insurance have plans that are leaving them underinsured; and 
healthcare costs are growing faster than median income in most 
States. The stalled gains in coverage stem from five primary 
factors: 17 States have not yet expanded Medicaid; people with 
incomes just over the eligibility threshold for marketplace 
subsidies and many in employer plans have high premium costs; 
congressional and executive actions on the individual market 
and Medicaid have reduced potential enrollment in both; 
undocumented immigrants are ineligible for subsidized coverage; 
and cost-sharing is climbing in individual market and employer 
plans.
    A major factor underlying trends in both uninsured and 
underinsured rates is growth in healthcare costs. Healthcare 
costs are the primary driver of premium and deductible growth 
in private insurance. There is growing evidence that a major 
cause of healthcare cost growth are prices paid to providers, 
especially hospitals. There is also evidence that these prices 
explain the wide healthcare spending gap between the U.S. and 
other wealthy countries. And there is also evidence that the 
greatest provider price growth is occurring in private 
insurance.
    Congressional Democrats have introduced several bills to 
address these problems. The bills all propose to expand the 
public dimensions of our private and public health system and 
may be grouped into three categories: bills that add more 
public plan features to private insurance, such as enhancing 
marketplace subsidies and reinsurance; bills that give people a 
choice of public plans alongside private plans, such as plans 
based on Medicare or Medicaid offered through the marketplaces; 
bills that make public plans the primary source of coverage, 
such as Medicare for All bills.
    These bills are an amalgam of provisions that individually 
or collectively have the potential to make the following 
changes in the health system: improve the affordability, 
benefits, and cost protection of insurance; slow cost growth in 
hospital and physician services, prescription drugs, and 
administration; reduce the number of uninsured and underinsured 
people.
    Some notable estimates of the effects of these bills' 
provisions include lifting the top income eligibility threshold 
for marketplace tax credits could insure nearly 2 million more 
people and lower silver plan premiums by nearly 3 percent at a 
net Federal cost of $10 billion. Allowing HHS to negotiate 
prescription drug prices under a Medicare for All approach 
could lower drug prices by 4 percent to 40 percent. A Medicare 
for All approach could lower administrative costs from a 
current 14 percent of spending in commercial plans to anywhere 
from 6 percent to 3.5 percent of all spending. The estimated 
effects of a Medicare for All approach on U.S. health 
expenditures range from a decline of 10 percent to an increase 
of 17 percent.
    What has captured the most attention in the debate about 
Medicare for All is the significant shift in how healthcare 
would be paid for. Most Medicare for All bills shift most 
financial responsibility to the Federal budget. This shift 
raises important questions about financing sources, in 
particular the incidence of taxation.
    But what is notable about the range of national health 
expenditure estimates under a Medicare for All approach is that 
the increase in expenditures is often less than the increase in 
demand for health care induced by providing comprehensive 
coverage to everyone. These spending estimates vary widely 
because of assumptions about the degree of change in provider 
prices, prescription drug costs, and administrative costs. But 
the mechanisms for slowing cost growth in these proposals could 
be considered, refined, and applied not only in single-payer 
approaches but in other health reform approaches as well.
    In the absence of congressional action on improving 
coverage, many States have stepped up and implemented policies 
such as reinsurance programs. But improving coverage for 
everyone will ultimately require Federal legislation. Expanding 
coverage, limiting families' costs, and slowing cost growth are 
achievable goals, and these bills provide mechanisms to move 
forward on each.
    I look forward to your questions. Thank you.
    [The statement of Ms. Collins follows:]
    
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    The Chairman. Thank you very much.
    Dr. Doris Browne is a retired colonel in the U.S. Army 
Medical Corps and the 118th president of the National Medical 
Association. Dr. Browne retired from the National Cancer 
Institute, where she managed the breast cancer chemo prevention 
portfolio. She was a Woodrow Wilson Public Policy Scholar in 
2007 where her research focused on breast cancer health 
disparities. Her focus is on achieving health equity.
    Dr. Browne now serves as the president and CEO of Browne 
and Associates, a small business specializing in improving 
health outcomes. Dr. Browne graduated with a B.S. from Tougaloo 
College, a historically black college in Mississippi; an M.P.H. 
from the University of California in Los Angeles; and an M.D. 
from Georgetown University. She is a medical oncologist by 
training. And we are thrilled to have you here.

 STATEMENT OF DORIS BROWNE, IMMEDIATE PAST-PRESIDENT, NATIONAL 
                      MEDICAL ASSOCIATION

    Dr. Browne. Thank you. Thank you, Chairman McGovern, 
Ranking Member Cole, and members of the committee. I thank you 
for the opportunity to appear before the committee to discuss 
universal health coverage for all Americans, particularly the 
vulnerable underserved population.
    I am here as the retired military medical officer and the 
immediate past president of the National Medical Association, 
which is the largest and oldest national organization 
representing the interests of more than 30,000 African-American 
physicians and the patients we serve.
    As the Nation's only healthcare organization still devoted 
to the needs of African-American physicians and their patients, 
we are disturbed by the vast health inequities of our 
vulnerable populations. With numerous and often insurmountable 
obstacles to receiving quality healthcare, people of color 
experience differences in access to care, the affordability of 
these services, implicit bias by some providers, and limited 
participation in clinical research, which has consequences 
around viable medical treatment. And the NMA has been 
responding to inequities in the healthcare system throughout 
our history. Most notably, we were the only organization to 
support the Medicare Act of 1965.
    Research reveals that African Americans, of course, are 
more likely than other racial and ethnic groups to experience 
health inequities, and in my written testimony, I address some 
of those concerns. But given the disproportionate impact on 
chronic diseases in communities of color, Congress must find 
ways to make healthcare coverage affordable, accessible, and of 
high quality for all.
    For the National Medical Association, healthcare is more 
than a provision of medical services. Healthcare is a 
multifocal, complex product which takes into account the 
critical determinants of health, including the socioeconomic 
conditions, housing, education, food and nutrition, 
environmental exposures, genetics and biological factors. And 
while the ACA was a step in the right direction and made 
substantial improvements in our healthcare system, it did not 
go far enough.
    And in order to stem the high prevalence morbidity and 
mortality of chronic diseases, we must first develop a 
comprehensive agenda around health equity. And health equity is 
a state in which everyone has the opportunity to attain their 
full health potential, and no one is disadvantaged. It is 
imperative that healthcare be provisioned to surpass one's 
social position or socially defined circumstances. Health 
equity and opportunity are inextricably linked. When health 
equity is achieved, there is no health disparities.
    Universal health coverage is a pathway to achieving that 
health equity. It has the potential to address poverty, 
inequality, and discrimination. It can also provide a more 
efficient and effective cost-saving healthcare system for 
everyone. Because health equity and opportunities are linked, 
the health equity as I have indicated, there will be no health 
disparities.
    The government has maintained a track record for providing 
comprehensive healthcare throughout the military's TRICARE 
program, the Department of Veterans Affairs, and other 
sponsored programs, as you know, with Medicare and Medicaid and 
others. These programs have diligently worked to confirm 
affordable access to high-quality healthcare benefits for 
millions of citizens covered by these programs.
    Under DOD's TRICARE, which is the second largest single-
payer health system in the country and second only to the VA 
program, both of these high-caliber systems adhere to high-
quality, evidence-based, accessible care for their 
beneficiaries. A patient should not have to decide between 
getting their full prescriptions filled and whether they should 
buy food. And, of course, that certainly is something that we 
have seen in the private sector, taking care of cancer 
patients, where they would decide maybe I should fill only a 
part of this prescription. Part care does not get you to 
remission in cancer.
    Every patient should have the opportunity to receive first-
class medical care rather than being considered second best 
because of a lack of insurance, provider's bias, and limitation 
of the Medicaid system. And we have seen this over and over 
where an individual may not get the approved drug for care in 
cancer but get the second best because their system did not 
have the drugs on the formulary.
    The best framework for universal health coverage is through 
collaboration and engagement of diverse multisector partners, 
including the communities in which they serve. Some of the 
existing healthcare programs already have the infrastructure 
and provider network to serve our communities. But improvement 
is needed to target the excessive costs, service accessibility, 
while minimizing the duplicative services that we see in many 
cases.
    I want to leave you with two points. First, we must adopt a 
system of universal coverage that minimize the administrative 
medical costs. It does not matter what label you use, whether 
it is Medicare for All, universal health coverage, single-
payer, whatever. The coverage must be one that would allow the 
patient the ability to choose the provider for their care. And 
care should be the same, no matter whether you receive it in 
Mississippi or California, whether you are in rural America or 
urban America. And it should not be restricted based upon 
language, age, gender, racial and ethnic areas.
    And, secondly, we must continue to address the physician 
shortage and funding of our safety net hospitals.
    Dr. Browne. Universal health coverage would allow for 
increased investment in educating more providers and allowing 
for additional residency slots. With consistent and predictable 
provider costs, we can end the two-tiered system of healthcare 
that has placed hospitals that serve low-income and minority 
communities at risk for closure.
    Universal coverage would ensure that our safety net 
hospitals are sufficiently funded and resourced. The NMA will 
continue its long history of advocacy and education. We believe 
that all individuals in every community in the United States 
have a right to equal, quality, high-quality healthcare that is 
accessible, affordable, comprehensive, and coordinated. We 
begin by providing the comprehensive coverage benefits that we 
have under Medicare for All.
    Thank you.
    [The statement of Ms. Browne follows:]
    
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    The Chairman. Thank you very, very much.
    And before I go to Dr. Nahvi, I just want to acknowledge 
Congresswoman Debbie Dingell from Michigan who has arrived 
here. She is a coauthor of the Medicare for All Act, along with 
Congresswoman Jayapal, and we appreciate her leadership and her 
being here.
    Last, but certainly not least, Dr. Farzon Nahvi is an 
emergency medicine physician and an assistant professor for 
emergency medicine in New York City. Dr. Nahvi completed his 
M.D. and residency at NYU School of Medicine and has been 
featured on NowThis discussing his patients' struggles with the 
current healthcare system, and he is on the board of directors 
of the New York Metro Chapter of Physicians for a National 
Health Program.
    And I would urge my colleagues to Google Dr. Nahvi. He has 
some really interesting and compelling videos that highlight 
some of the inadequacies of the current system. We are happy to 
have you here.

    STATEMENT OF DR. FARZON NAHVI, EMERGENCY ROOM PHYSICIAN

    Dr. Nahvi. Thank you, Chairman McGovern, thank you, Ranking 
Member Cole, for inviting me to be here today. My name is 
Farzon Nahvi. I am an emergency medicine doctor in New York 
City, and I support Medicare for All.
    As an ER doctor, I have the opportunity to help all sorts 
of people in all sorts of ways. I get to save investment 
bankers from heart attacks and strokes, and I get to help 
homeless veterans from hypothermia in the winter. And that is 
what I love about my job. The idea that I could help any person 
with any problem at any time is what attracted me to emergency 
medicine in the first place.
    But over the years, I have learned that it becomes 
impossible to care for someone when our medical system forces 
them to fear things like bankruptcy and foreclosure when they 
decide to seek medical care.
    Now, if you ask any ER doctor, any ER nurse, or even any ER 
janitor in this country, you are going to hear countless, 
countless stories of people who came into the hospital to seek 
medical care only to walk out in the middle of the treatment 
AMA. AMA stands for against medical advice. And people often 
walk out against medical advice often because they are 
concerned about the cost of their treatment.
    The reality for many people in this country is that seeking 
medical care means weighing one's health against one's wallet. 
Now, everyone in this room is very smart. Everyone in this room 
already knows all the statistics. You already know that 41 
percent of Americans have skipped a visit to the ER in the past 
12 months because of cost concerns.
    That is easy to gloss over, but we should let that sink in. 
That is 41 percent of Americans. Over two in five Americans 
have skipped a visit. They felt that they needed to go to the 
ER, but then they decided not to go seek medical care because 
they were concerned about the cost of that visit.
    You also already know that 45 percent of Americans live in 
fear that a health event could lead to bankruptcy. But I see 
these numbers every day on the ground level. I have to look 
these patients in the eye, and I want to put some faces on 
those numbers that you all already know so well.
    A few weeks ago, I took care of a patient who I was sure 
had appendicitis. I recommended a CAT scan. We discussed IV 
antibiotics and possibly a surgery. But a short while later, 
this patient flagged me down, she pulled me aside, she asked me 
to pull out her IV because she wanted to go home.
    Now, she wasn't stupid. She wasn't crazy. She didn't 
distrust doctors or anything. The patient just was concerned 
about the cost of her treatment. She did some research on her 
phone. She learned that in some rare cases appendicitis can be 
treated with antibiotics alone. She asked me if I could give 
her a prescription so that she could go home.
    Now, you don't need to be a doctor to know that this is 
far, far, far from the standard of care for appendicitis. All 
cases of appendicitis need a hospital admission, IV 
antibiotics, and probably a surgery. I told her that there were 
way too many things that could go wrong with her plan and I 
strongly advised against it.
    Now, she asked about me about the risks and I told her the 
truth. I told her about the possibility of an abscess 
formation, perforation of her bowels, sepsis from infection, 
and even death. This is not an exaggeration. This is just the 
truth of what happens when you don't treat appendicitis.
    She sat back. She asked me for some time. She thought about 
it for a long while, but eventually she flagged me back down. 
She decided to leave. In her own words, she said, thanks, Doc. 
I appreciate all you have done. I really do, but I just don't 
know if I am going to be able to afford this. I am going to go 
take my chances.
    Now, in my line of work, I often have to give people really 
bad news. I often tell loved ones that their family members 
have died. I have had to tell parents that their child has 
died, children that their parent has died. I have had to tell 
spouses that their husband or wife has died. But I can tell you 
with complete sincerity that watching someone sick walk out of 
the door with something that is completely treatable right here 
in the richest country in the world is just as awful a feeling 
as any of those conversations.
    About 1 year ago, I took care of a young lady who came in 
for an overdose on fish antibiotics. She had a fever. She 
couldn't afford an ER visit, so she decided to go to her local 
pet store to buy some fish antibiotics for her symptoms. She 
had had a job interview coming up, and she wanted to make sure 
she was better for that interview.
    Now, of course, fish antibiotics come as a packet of 
powder. You put them in a fish tank so the fish can eat it. 
There are obviously no instructions for human consumption. She 
ended up overdosing by an order of magnitude. She had side 
effects that affected her brain and her central nervous system. 
She fell down a staircase while she was on that job interview 
actually and she had to be admitted to the ICU, all of that 
because she felt like she couldn't afford a simple visit to the 
ER for a simple fever.
    Twenty-one years ago, when she was 10 years old, my 
fiancee, who is here right now, she lost her mother because her 
mother decided to delay medical care for her abdominal pain 
until only after her stomach cancer had already spread beyond 
any hope for treatment. A housekeeper raising two daughters, my 
fiancee's mother was worried about the cost of her care, and 
she paid for it with her life.
    I am here today because my patients and my fiancee deserve 
better than this. These stories and countless, countless, 
countless others are absolutely ridiculous to be taking place 
right here in the richest country in the world.
    I am not asking for much. All I want to do is practice 
medicine in a world where I no longer have to watch a patient 
walk out of the ER without medical care that could save their 
life because they are worried about going bankrupt. And I never 
want to see another patient who thinks their best option for 
medical care is to go to their local pet store. To simply treat 
someone for a problem as simple as appendicitis in 2019 or to 
have my human patients take human antibiotics from a human 
pharmacy are absolutely not radical ideas.
    From my perspective on the ground, the solution has to 
involve approaching medical care in just the same way we 
approach educating our children, maintaining our roads, or 
supporting our armed forces. All this means is treating 
healthcare like any other public good, creating a universal 
healthcare system like Medicare for All, so that when they are 
at their most vulnerable, my patients never have to make any 
consideration except simply to do what they need to do in order 
to get better.
    Once again, thank you Chairman McGovern, Ranking Member 
Cole, and the Rules Committee for inviting me to be here. I am 
looking forward to any questions.
    [The statement of Dr. Nahvi follows:]
    
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    The Chairman. Thank you all very much for testifying. 
Before I ask some questions, I have a few unanimous consent 
requests I want to add into the record.
    You know, our healthcare system is built with checkpoints 
that more often than not prohibit a person from being able to 
access healthcare, including preauthorization requirements, 
lifetime limits, network restrictions, cost, and the inherent 
discrimination built into the system.
    Without objection, I would like to submit a letter from the 
National Nurses United, an organization with 150,000 members. 
Their letter explains how gatekeeper obstacles would be 
eliminated with this bill.
    And I would like to thank Jean Ross, president of the 
National Nurses United, who is with us here today, for her 
leadership and her work in ensuring that every American has 
access to affordable healthcare in this country. Jean is here 
in Washington, D.C., with the nurses from 28 different States 
advocating for Medicare for All. We want to thank you.
    [The document is printed at page 187]
    Without objection, I would like to submit in the record a 
letter from Diane Archer, the founder and past president of the 
Medicare Rights Center, which is a national nonprofit consumer 
service organization. In her letter she brings to light the 
serious concerns with Medicare Advantage and how Medicare for 
All, an improved and expanded Medicare system, can fix these 
problems.
    And, you know, a child's access to healthcare is crucial. 
They are going through a time of rapid brain and body 
development, and it is important that their health coverage 
reflects their needs. Yet a recent survey by Georgetown Center 
for Children and Families found an increase in uninsured 
children for the first time in a decade.
    [The document is printed at page 220]
    Without objection, I would like to submit a letter from The 
Children's Partnership, a California-based nonprofit child 
advocacy organization working to ensure that every child has 
access to healthcare.
    This letter outlines the critical components of health 
coverage and care for children that should be addressed in any 
policy Congress considers, including Medicare for All. And I 
would like to thank Mayra Alvarez, president of the Children's 
Partnership.
    [The document is printed at page 227]
    Hearing no objection, those documents will be added to the 
record.
    The Chairman. Let me begin my question. Mr. Barkan, let me 
ask you a question and then I will come back to you in a minute 
for the answer. But you know a little bit about how health 
insurance companies deny claims. And you testified that your 
medical bills cost thousands and thousands and thousands of 
dollars a month. You also talked about the time commitment it 
takes to fight back against these denials.
    My question is, what are some of the services or medical 
devices that were denied by your insurance company? And how is 
your life impacted by not having those services? And I will go 
to the next question then come back to you, Ady, in a minute.
    Let me say to Drs. Baker, Blahous, and Collins, you are all 
economists. Tell me, are economists always right?
    Mr. Blahous. No.
    The Chairman. I mean, no, right? Yeah. I mean, you should 
try being a Member of Congress. We are always right, right.
    But seriously, though, let's look at the studies. You know, 
even looking at Dr. Blahous' study from the conservative 
Mercatus Center, it seems like the studies suggest that 
Medicare for All could cost a little more or a little less than 
we are currently paying now, right. Getting that right?
    Mr. Blahous. I think that is fair.
    The Chairman. All right. So worst-case scenario, we could 
spend about what we are spending now nationally on healthcare 
and guarantee that another 29 million people get healthcare 
coverage, we could end crushing out-of-pocket costs for 
everyone, and we could include new services for seniors and the 
disabled. I mean, that sounds like a pretty good deal to me.
    When we have all these warnings about the high cost, I 
mean, we are spending an awful lot on healthcare right now, and 
we are not getting the services and the effectiveness that we 
are all demanding. And so I just want to put that out there 
because I think that it is important for people to put all this 
in perspective. We are not talking about all new costs. We are 
talking about costs that were already built into the system.
    Dr. Baker.
    Mr. Baker. If I could just throw a quick point in on your 
point about comments not being right. You know, I think the 
Affordable Care Act hasn't gotten as much credit as it should 
for reducing costs. And, again, one could argue how much it 
deserves credit for the slowdown in cost growth, but if you go 
to 2008, the projections from the Center for Medicare and 
Medicaid Services for 2017 compared with what we actually 
spent, we spent 1.5 percentage points of GDP less on healthcare 
than what they had projected. So that comes to $300 billion 
that year.
    Same thing if you look at the CBO projections. We are 
spending half a percentage point of GDP less on Medicare than 
what they had projected in 2010 before the bill passed.
    Now, whether you want to say the Affordable Care Act was 
responsible for all that slowdown, that is a totally arguable 
point. But the point was we are actually doing pretty good in 
terms of slowing the course of healthcare cost growth with, 
even as we increased government involvement.
    The Chairman. Dr. Collins.
    Ms. Collins. I just wanted to--my testimony covers the 
range of estimates that are currently out here, including Dr. 
Blahous'. And what you do see is exactly what you said. Some 
estimates show a decline in national health expenditures, some 
show an increase in national health expenditures. It depends 
crucially on savings that we can potentially get from lower 
provider prices, from prescription drug costs, from 
administrative costs.
    But I think what one of the major contributions of the 
Medicare for All bills is putting the issue out there on how 
much we are paying providers right now. I think that is a 
really critical issue. It is why we do see some savings in some 
of the estimates that we have seen of the Medicare for All 
bills.
    It is a conversation that the country needs to have right 
now, and the differences and the changes in expenditures under 
these approaches put a fine point on that issue.
    The Chairman. Look, all of us here, as Members of Congress, 
we do casework too, right. And we get an inordinate amount of 
casework that is healthcare related, and it is always about 
fighting with insurance companies, right. It is always about 
crippling costs.
    The point I am trying to make is that I would like to think 
we all believe we can do better. I am simply saying, when 
people push the panic buttons on cost, I mean, we are spending 
an awful lot right now and we are not getting the result we 
want.
    And to me, Medicare for All offers a better way to go 
forward and it gives us more care. And by the way, for senior 
citizens, it gives them Medicare plus. Seniors get a lot more 
than they are getting right now.
    I don't know, Ady, are you ready to--all right.
    Mr. Barkan. First of all, my plan doesn't cover long-term 
care, and so we have to pay for 24-hour care, which is 
incredibly expenses (sic). In addition, my insurance company, 
Health Net, denied me a breathing-assist machine. Health Net 
ruled that the ventilator and medicine provided by my 
neurologist was not necessary and that I would have to pay full 
price. The company also denied me a brand-new FDA-approved 
medicine to treat ALS.
    The first time I had to complain publicly and generate an 
outcry for them to reverse their decision. The second time I 
had to organize a protest at their headquarters. But most 
people don't have the ability to do that, and nobody should 
have the obligation to do that. But this is a big part of how 
insurance companies make their money. They deny, delay, and 
wait for patients to give up.
    I believe that approximately one-quarter of claims are 
denied. As a result, people get sick, get sicker, and die. 
Fundamentally, the priority for health insurance companies is 
to make a profit, but that is not in the public interest. By 
getting the profit motive out of the healthcare industry, we 
can refocus on the real priority: delivering high-quality 
healthcare.
    The Chairman. Thank you.
    Dr. Nahvi.
    Dr. Nahvi. I just wanted to piggyback on that. I do think 
when health insurance companies deny claims, that it is not 
only unethical. I just want to share a couple of examples of 
when it is just financially stupid as well.
    I have a couple cases I will share real quick. In my 
hospital recently there was a 28-year-old female, she came in 
with a regular, run-of-the-mill urinary tract infection--super 
easy to treat with a course of outpatient antibiotics. No 
problem.
    She was denied that claim for the antibiotics. No good 
reason was given why but she was charged $300 over the counter 
in cash. She couldn't afford that. She ended up going to the 
other side of the pharmacy, ended up buying some cranberry 
juice because she thought that might be her best option to 
treat her UTI.
    She ended up coming into the hospital 2 days later, septic, 
with a fever, high heart rate, had to be admitted to the 
hospital and get IV antibiotics. We denied her $300, but now we 
are paying thousands of dollars for that.
    There is another example I had. I had a patient that came 
in, he was having a heart attack. His cardiologist came down, 
recognized him, and started yelling at him and said, why did 
you stop taking the antiplatelet medication that I told you you 
cannot stop taking?
    He said, 6 months ago, I was admitted to the hospital with 
complications from my diabetes medications. My endocrinologist 
told me I can't stop taking those. I had to make a decision. I 
couldn't afford both of them, so I stopped taking my 
antiplatelet medications. He ended up coming back in with a 
heart attack.
    Because we insufficiently covered these patients' 
prescription medications, we ended up paying more in the long 
run.
    Another example. There is a patient I had, she was 38 years 
old. She had a long history of depression. Her depression was 
controlled with some psych medications. She had been on these 
medications for many years. Out of nowhere, her medical 
insurance company started denying that medication. She stopped 
taking them. She couldn't get in to see her psychiatrist for 
another month or two. So she ended up coming in because she was 
feeling suicidal and had to be admitted to the hospital.
    All three of these cases these patients had bad medical 
outcomes, and that is horrible in and of itself. But it is 
just--financially it doesn't make any sense. We ended up paying 
more for these bad outcomes, and that needs to be a part of 
this discussion as well.
    And when we talk about all these estimates of cost, I 
imagine that the kind of cost savings we would see by making 
sure patients are covered and fully covered, we don't really 
see that in these numbers because there is no way to really 
account for what we are seeing on the ground level. This would 
save a lot of money.
    The Chairman. Dr. Browne.
    Dr. Browne. Yes. Well, certainly in the oncology area we 
see this, most particularly with people of color, because, one, 
they have a fear of going to the doctor to begin with, and so 
they will deny that that lump is there and think it is going to 
go away, in many cases will say I will pray it away. But when 
they finally come in after being denied several times, it is 
advanced disease and they require much more care that is much 
more costly, but the outcome is negative because they tend not 
to survive.
    The Chairman. Mr. Barkan, let me ask you a question and 
then I will come back to you. You indicated, again, you are 
paying all these thousands of dollars worth of medical bills. 
And that you have turned to a GoFundMe page online, the online 
fundraising website to help you cover the cost.
    If you didn't have GoFundMe, what other household costs or 
family bills might not get covered to cover your care? You 
know, you are a pretty popular guy. Even I have seen your 
Twitter feed and know all about your work. Relying on GoFundMe 
might be something that someone of your stature can do, but not 
everybody could do that.
    What if you don't have the Twitter following you have? How 
would you afford the care? And do you think there is anything 
sane about our GoFundMe healthcare system?
    While you think of that answer, let me go to Dr. Browne and 
Nahvi. Based on your testimonies, I am guessing that these 
stories of insurance companies denying care isn't surprising, 
right.
    Dr. Browne, you are a cancer specialist. Can you tell the 
committee how a prepaid system like the military compares to a 
post-paid system like the one for the civilian population, and 
how it differs when it comes to patients getting the care that 
they need and actually following the doctor's best medical 
advice?
    And, Dr. Nahvi, you testified about your patients who put 
costs before their healthcare out of necessity or fear, and you 
have told some really horrible stories here. Do you believe 
that you are free to practice the best medicine you can, that 
your patients are free to take your advice without fear, or do 
you think that there is something standing between you and your 
patients getting the care that they deserve?
    Dr. Browne. Yes. Well, in the prepaid system in the 
military as a military provider, whether it is cancer or 
general internal medicine, it is an equal access system, and we 
do not have to be concerned with can that patient afford an MRI 
or should I just order an X-ray.
    Again, I know that the best possible care is what I can 
provide for those patients, and so I order the MRI and get the 
best care for those individuals so they don't look at, do I 
have a copay? Is it some out of pocket? They go to that 
facility in the integrated system and they get the best care.
    If you are outside, you weigh that. Maybe I should see if a 
CAT scan will suffice and I can still see the dimensions of 
this mass and its distinguishing features to whether I should 
order surgery.
    If the patient cannot afford for even a CT scan, then I 
look at what are the other kinds of things that I can order to 
get that patient to the care that they need. And that is not 
the way I was trained to practice medicine. You go in to 
provide the best possible care for those patients. And it is 
not based upon costs, it is based upon need so that you can 
improve the health outcomes.
    The Chairman. Dr. Nahvi.
    Dr. Nahvi. I couldn't agree more. The answer to your 
question is, no, I don't think I am practicing the best 
medicine I can practice. I feel like I am practicing with one 
hand tied behind my back. I feel like every time I--not every 
time, but oftentimes when I recommend something to my patients, 
they sit down and they think, can I afford this? Should I do 
it? Before they decide whether to do it or not.
    And these are lose-lose conversations. I feel like if I try 
to tell someone to do something and they say, no, I don't know 
if I can afford that CAT scan and they walk out, their health 
suffers.
    But even if I convince them, I don't feel terribly good 
about myself. If I convince someone to get a CAT scan that they 
are not sure they could afford, we might be taking care of 
their health, but I walk away thinking, did I just kind of 
sentence this person to years of debt that they are not going 
to be able to pay off? So there is no winning a lot of these 
conversations, and I am not giving the best care.
    The Chairman. Thank you.
    Mr. Barkan.
    Mr. Barkan. If I couldn't use GoFundMe, I would probably 
start by asking my parents to start spending down their 
retirement savings. Then we would go hat-in-hand to friends. 
Nobody dealing with a serious illness should have to do either 
of these things. We should instead have a rational, fair, 
comprehensive social safety net that actually catches us when 
we fall.
    The Chairman. Thank you.
    Mr. Cole.
    Mr. Cole. Thank you very much, Mr. Chairman.
    And if I may, I am going to follow your lead here, and I 
want to submit a letter, without objection, from the American 
Hospital Association in opposition to the legislation.
    The Chairman. Without objection.
    [The document is printed at page 230]
    Mr. Cole. Thank you very much, Mr. Chairman.
    If I could, Ms. Turner, I will start with you. H.R. 1384 
explicitly makes it illegal for private health insurers to 
provide for service that the government would provide under 
this legislation. How many people would lose their current 
health insurance that they have if we did something like that?
    Ms. Turner. Nearly everyone would lose the current health 
coverage they have, including the 173 million Americans with 
job-based health insurance. In addition, those with ACA 
coverage, seniors and others on Medicare, those on Medicaid and 
the Children's Health Insurance Program all would be reassigned 
to the new Medicare for All program.
    Mr. Cole. So under this legislation, really, if you liked 
your plan, you liked what you had, you would have any option at 
all to keep it?
    Ms. Turner. Only if you are covered under the VA or the 
Indian Health Service, as I understand it.
    Mr. Cole. Well, believe me, a lot of people in the Indian 
Health Service might want to make this change. That is another 
issue.
    Ms. Turner. Oklahoma is----
    Mr. Cole. Yeah. That gets to what Congress does and doesn't 
do in that service.
    But anyway, let me ask you this in followup to that. How 
would this impact both employers who provide the coverage and 
employees who are satisfied with what they are actually 
receiving?
    Ms. Turner. I think this is a significant issue. Colorado 
considered a ballot initiative in 2016 to create a single-payer 
system for the State. There was serious pushback from people 
who had not understood at first that it meant that they would 
lose their private coverage, including employer coverage.
    The employer-based system is a central pillar in our health 
sector for a number of reasons. Employers are able to help 
their employees access care by offering them different health 
plan options. They listen to their employees, what benefits 
they need, and what matters to them. Employers are always 
trying to balance costs and benefits to get the best deal for 
their employees. Many also offer wellness programs. They know 
that a healthy workforce is beneficial. They invest a lot in 
their employees.
    But I think there are two other points that are really 
crucially important. One is that employer plans pay higher 
rates to hospitals, doctors, and other providers to make sure 
their employees have access to the care and the treatment they 
need.
    Medicare--and Medicaid--underpay for health care, but 
because employer plans pay more, those on public programs still 
are able to access care. So part of the value of the employer-
based health insurance system, covering 173 million people--
half of the population of the country, including retirees, 
workers, dependents, et cetera--is helping to support the 
current Medicare system.
    Also both employers and employees get a tax break: health 
insurance is part of the compensation package companies offer 
their employees and therefore is deductible, and for employees, 
the value of their health insurance is excluded from their 
income.
    My colleague, Doug Badger, says that the value of employer-
sponsored health insurance was about $991 billion, almost $1 
trillion, in 2016, and the tax break is worth about $350 
billion to support employer-based health insurance. So that tax 
break supports 3 to 1--and some estimates are even higher--
health insurance for half of the country.
    Our robust employer-sponsored insurance system, which has 
evolved over 70 years in this country, is unique to America. We 
started on this path through some permutations of history, but 
it is something that people enormously value and has become a 
central pillar in our health sector.
    Mr. Cole. Well, your answer actually anticipated a lot of 
my next question, but let me put it to you this way and get 
your response on this as well. If we, as this bill calls for, 
held the reimbursement rates for providers at Medicare and 
Medicaid levels, how would that impact the providers? What--
how--what do you think the response would be?
    Ms. Turner. I am not an economist. I am a policy person. 
But the former actuary for CMS anticipated, when Congress was 
considering and actually enacted cuts to Medicare providers, 
that if hospitals and physicians were to see 40 percent payment 
cuts, many of them simply could not keep their doors open. They 
do not have that kind of a margin. They would either 
dramatically curtail services or they would wind up closing 
their doors, and you would have many fewer physicians in 
practice.
    Mr. Cole. Well, fortunately, you are sitting right next to 
an economist, so I am going to ask Dr. Blahous for his response 
to the same question.
    Mr. Blahous. Well, I think the honest answer is that the 
effects are unpredictable. We do know the data. We know the 
data indicates that Medicare payment rates for hospitals over 
the time window, first 10 years of Medicare for All, Medicare 
payment rates are a little bit more than 40 percent below 
private insurance rates. For physicians, they are about 30 
percent below at the beginning of that 10-year period. But 
those relative reductions under the MACRA law become even 
steeper, so they would be about 42 percent by the end of 10 
years.
    And the honest answer is we have no idea how providers 
would respond to this. We do know, roughly, that under the 
legislation the demand for health services would increase by 
probably about 11 percent. Other studies have made similar 
estimates.
    And if we make simultaneous very dramatic reductions in 
payment rates to providers at the same time as this increase in 
demand, none of us can say for certain how they would respond. 
We do know from the Medicare Actuary's Office that Medicare 
payment rates--that the margins on treating Medicare patients 
are negative for about 80 percent of hospitals. And Medicare 
for All would extend that situation to the population as a 
whole. How providers would react to that, what sort of 
disruptions there might be in the timeliness or quality or 
supply of health services, we simply don't know.
    Mr. Cole. Let me ask you this, because we all know that not 
all hospitals, you know, are equally profitable or serve 
populations that are equally affluent. Certainly, in my 
district we have lost a number of rural hospitals in recent 
years that have both--they are treating a population that is 
older, quite often sicker, and enjoys less private coverage, so 
they rely very heavily on Medicare and Medicaid and they are 
having a tough go.
    Again, if we remove that, it suggests to me the impact 
wouldn't be equal all across the country. In other words, I 
think rural areas in particular would really take a pretty hard 
hit unless something was done to change the rates. Is that a 
fair----
    Mr. Blahous. I think that is fair. And I--just to add an 
additional perspective on this, from the vantage point of my 
study, my main reason for flagging this issue is primarily just 
to help with understanding of the numbers.
    We have a set of cost estimates that would arise if you 
assume that these very dramatic payment reductions were 
implemented right from the get-go, right in the very first 
year. But if you look at the historical patterns of 
congressional behavior, you do not see a willingness to impose 
sudden cuts for providers or anything close to that magnitude.
    And if you think those historical patterns of congressional 
behavior were to continue, the cost estimate for the 
legislation would be much, much higher. It would be more in the 
area of $38 trillion rather than $32.6 trillion.
    Mr. Cole. Let me ask you this, and I am going to address 
this to all of you, if I may. We will just start actually down 
here and go across. This is an enormously complex undertaking 
that we are talking about to change the entire healthcare 
system. I lived through one of these things as many of my 
colleagues did, the discussion, debate, and then the 
implementation of ObamaCare, the ACA.
    Is 2 years a sufficient period of time? Because that is 
what the legislation calls for, as I understand it. Within 2 
years, we would make this entire transition. Is that a 
realistic--even for those of you that want to go in this 
direction, I worry about the timeframe, so----
    Mr. Baker. Well, I would just say that you would have to be 
cautious. Two years in certainly very ambitious.
    I just want to add quickly, if you are referring to your 
hospitals as largely rural and they already have a large number 
of Medicare patients, if that is the case, they are less likely 
to be a danger because they are already getting reimbursed at 
Medicare rates.
    Mr. Cole. Well, they also get private payments as well.
    Mr. Baker. Understood, but it is a smaller share.
    Mr. Cole. But if every patient they treated was at Medicaid 
and Medicare levels, I promise you, most of them would close.
    Mr. Baker. Well, I can't comment on the specific providers 
in your district. That may well be true.
    Ms. Collins. I think the transition issue, you can 
certainly decide to extend it, make it a longer period of time. 
The ACA was a 4-year transition period, so that certainly is 
something that you could consider.
    I did want to address the cost shift argument in the 
Medicare payment area. The evidence really does not show that 
the reason that private provider prices are higher is because 
Medicare prices are so low. If that were the case, we would see 
consistently higher margins all the way across the country. 
Instead, we see a lot of variability across the country.
    So the way this works is that private providers are 
negotiating with commercial carriers' prices that work the best 
for them. In concentrated markets, they get higher prices, and 
insurers want them in their network, so they concede to those 
higher prices. They then take that negotiated rate to 
employers. Employers then have to pay higher premiums. They 
reduce their workers' wages. They increase deductibles. So 
those costs get shifted ultimately to people.
    So there is really not a lot of evidence that the cost 
shift argument is a reason for higher prices. It is really 
these non-transparent price negotiations that occur in the 
private market.
    Mr. Cole. Dr. Browne.
    Mr. Barkan. Representative, may I please----
    Mr. Cole. Oh, yes. Absolutely.
    Mr. Barkan [continuing]. Respond to the employer issue you 
asked earlier?
    We don't expect employers to provide their workers with 
education for their children or with fire insurance. There is 
no reason to tie healthcare to employment. It just exacerbates 
the negative impact of job loss, and, frankly, it is a huge 
burden on employers.
    Mr. Cole. Thank you.
    Dr. Browne.
    Dr. Browne. Yes. I just wanted to add, in terms of people 
of color, the Medicare and Medicaid reimbursement cost is not 
the same across the board, so our providers are already getting 
a lower rate. It is not likely that they are going to go out of 
business.
    And in terms of employers and the amount that is being 
paid, many of the smaller businesses go to part-time 
individuals so that they do not have to carry that cost. And 
so, again, I think for providers that we are concerned about, 
they are not going to walk out on taking care of their patients 
even though they are getting a lower rate.
    Mr. Cole. Dr. Nahvi.
    Dr. Nahvi. Sure. I assume you are asking the question from 
an implementation perspective. But from a physician 
perspective, we are ready for this not in 2 years but 2 years 
ago. I am ready to stop seeing my patients not get good care 
because they can't afford things.
    Mr. Cole. Thank you.
    Mr. Blahous. And I will answer the question, as I am 
answering every question, from the Federal cost perspective. 
When I did my study, I was dealing with a bill that had a 4-
year transition and was not able--did not feel myself able to 
score the effects during that 4-year transition period because 
very unpredictable factors like transition costs, voluntary 
buy-in rates, things like that.
    And so for simplicity's sake, I assumed that in that fourth 
year, everything just instantly sprang forth fully formed, that 
we instantly had administrative cost savings, we instantly had 
a level shift downward in prescription drug costs, that we 
instantly had the full implementation of these provider cuts.
    So you could look at that and you could say, well, those 
might be reasons why the lower-bound estimate, even assuming a 
4-year transition, would be an understatement. If you had a 2-
year transition, obviously that increases the likelihood that 
the lower-bound estimate is a gross understatement, because 
there is probably very, very little chance that we would be 
able to attain those instant administrative cost savings, those 
instant drug cost savings that I am assuming in the lower-bound 
estimate.
    Mr. Cole. Ms. Turner.
    Mr. Barkan. Representative, may I please weigh in on the 
transition issue?
    Mr. Cole. Let me let Ms. Turner. I have very limited time 
left, and then I will come right back to you, if I may.
    Ms. Turner. Mr. Cole, there is an excellent article in 
today's Washington Post about Vermont's experience that is both 
relevant and instructive. Reporter Amy Goldstein took an in-
depth look at Vermont's experience in trying to create a 
single-payer healthcare system for the state--Green Mountain 
Care. Leaders worked for 4 years and were unable to figure out, 
for the small State of Vermont, how to structure it, how 
providers would be paid, and how to collect enough taxes to pay 
for it.
    The initial cost projections took what Goldstein calls ``a 
36,000-foot view'' of what the costs were going to be. But when 
they got into the hardwiring of implementation, they found that 
the costs were going to be so high that it would be highly 
disruptive to the State's economy and so disruptive to the 
current structure of their healthcare delivery system that they 
had to pull the plug on it. She wrote that Vermont ultimately 
found it would be very difficult to dismantle one healthcare 
system and replace it with another.
    Mr. Cole. May I----
    The Chairman. Yeah, absolutely.
    Mr. Cole. Okay. Mr. Barkan, please.
    Mr. Barkan. Here is what I know for sure: I needed Medicare 
for All to be in effect yesterday. If the richest nation in the 
history of the world really decided to, we could guarantee 
healthcare as a right and we could probably do it more quickly 
than people think. But the problem is that right now, we are 
not even trying. Too many people in the halls of this building 
are fine to accept the status quo that leaves people like me 
behind.
    Mr. Cole. Thank you very much.
    Thank you, Mr. Chairman.
    The Chairman. Thank you very much.
    I want to yield myself a minute here to make a couple of 
points to amplify Ady's point. Employer-sponsored healthcare 
means the effects of job loss are amplified. It also puts a 
huge burden on employers. Imagine if we expected employers to 
provide for fire insurance, as was mentioned, police insurance, 
school funding for K-12, and the paperwork that is all part of 
that. It is insane.
    And just one other point here, because I think some of us 
are looking at this whole initiative from a different 
perspective. People aren't going to lose their healthcare with 
Medicare for All. I mean, you would actually get to keep your 
doctors and go to your hospitals that you currently have. The 
only difference is you wouldn't have to deal with insurance 
companies. And I don't know about you, but that is not my 
favorite thing to do when I get sick.
    I now yield to my good friend, Mr. Perlmutter.
    Mr. Perlmutter. I just want to thank this panel, everybody. 
The professionalism in your testimony is very much appreciated 
by this Congressman and I know the Rules Committee generally.
    Mr. Barkan, a couple questions for you. You know, you talk 
a lot about time. Another guy in a chair like you, Stephen 
Hawking, he wrote a number of essays on time, but time is 
really a key piece to all of this. And you talked about a 
number of things, you know, the effect of taking time and the 
waste of time on you personally. So I would like you to maybe 
expand on that a little bit.
    And then you also said we could save enormous sums of 
money. I would like you to expand on that. And then you said we 
could avoid immoral price gouging. I think those were your 
words. So I am just putting those three things that you talked 
about, I would ask you to expand.
    Now, to the economists, I would like to just talk a little 
bit more about the money that is in the system, in the 
healthcare system--it is the biggest part of our economy. In 
its own right, the healthcare system, 19, 20, 21 percent, 18 
percent, whatever it is, it is far bigger than anything else.
    So my first question, I guess, to you, Dr. Baker and Dr. 
Collins, is how does that percentage of our overall economy 
compare to the rest of the world, other countries, 
industrialized countries?
    And, I guess, to all of you, and, Dr. Blahous, you as well, 
the overall savings that we might expect from something like 
this--and, you know, there was an economist, Bob Pollin, and 
sort of his approach to these things, because it is a massive 
change. And why do we want to undergo a massive change if we 
are not going to save some money and have better outcomes for 
patients? And I will get to you doctors, you medical doctors in 
a second to talk about the outcomes.
    And then, Ms. Turner, just so you know, I am going to talk 
about Colorado, so I will tee that up for you.
    Mr. Baker. Okay. Well, we spend about 18 percent of our GDP 
on healthcare, and that is roughly twice the average from the 
OECD. You have a range. If you take a lower-cost system like 
the U.K., we could finance that whole system from what we spend 
now in the public sector. That is how much we are out of line 
with everyone else.
    And, you know, the point that I think is striking, on the 
one hand, we have huge administrative cost, but the other point 
that I was trying to emphasize in my both comments and my 
written testimony, we pay twice as much for all the inputs, so 
twice as much for the drugs, for the medical equipment, for our 
doctors, on down the list.
    And, again, that is not true of our cars. It is not true of 
our auto workers. So you are sort of hard pressed to say why do 
we have to pay twice as much for drugs as everyone else? We 
don't pay twice as much for our--you know, our cups here and 
our cars, but we do. And that, I think, speaks to the enormous 
potential savings.
    Again, I understand none of that is easy. You are the ones 
that have to fight with these people, because these excess 
payments--that is income for people. But if we just make the 
comparison, what does it look like, the U.S. compared to 
everyone else, we are paying twice as much on average.
    Mr. Perlmutter. Dr. Collins.
    Ms. Collins. I would just echo Dr. Baker's comments. And we 
have a--there is a chart in my testimony that shows all the 
detail on the countries that pay so much less than we do. And--
but I would also make the point, that we also don't get 
commensurate outcomes for the spending that we are making. So 
we actually have worse outcomes in a number of areas than other 
countries that are spending far less. So the quality issue is a 
huge issue internationally as well.
    Mr. Perlmutter. And, Dr. Blahous, and I appreciated your 
testimony when Mr. McGovern was asking you some questions 
about, you know, ultimately it is kind of a push, maybe it is a 
little bit of a loss, maybe a little bit of a gain. This Dr. 
Pollin, I guess, economist from University of Massachusetts, 
thinks that there is a big savings. Do you have any comments on 
that?
    Mr. Blahous. Well, sure, if I could try to unpack it a 
little bit.
    Mr. Perlmutter. Sure.
    Mr. Blahous. And I want to build off some of the things 
that Dr. Baker and Dr. Collins have said. I think it was well 
stated by Dr. Baker that most of the costs from the Federal 
perspective are a shift. They are a shift from costs now being 
borne by the private sector to the Federal Government. I would 
add to that that the Federal Government would also be assuming 
costs that are currently borne by State and local governments. 
So it is not just the private sector, but it is all of that.
    Mr. Perlmutter. Right.
    Mr. Blahous. It is primarily a shift. That is the biggest 
piece of the Federal cost.
    Now, there are other things that would increase the cost 
beyond that. And I thought Dr. Collins said something earlier 
that I thought was very useful, where she said basically the 
total national cost increase would be less than the utilization 
increase. So in other words, the biggest part of this cost 
increase is an increase in service demand and utilization.
    Now, maybe we can cut into some of that increase by savings 
on administrative costs, savings on drug prices, things like 
that. Now, we wouldn't be able to offset that cost completely 
with those measures, and that is where the cuts to provider 
payments come in. The question is, would we be able to cut 
provider payments enough to offset that additional cost?
    Mr. Perlmutter. Well, and I think Dr. Nahvi mentioned this, 
and it is in somebody else's papers, you know, that two out of 
five people don't take advantage of healthcare, their need for 
healthcare because of fear of expense, that they walk back out. 
And he gave some dramatic examples. So in effect, you know, 
there is a lot of demand that is not being met because people 
are afraid of the cost.
    So I was a bankruptcy lawyer for many, many years before I 
was elected to Congress, and obviously one of the biggest areas 
of bankruptcy is because of healthcare costs. So I do 
appreciate your comments, Dr. Nahvi, when you said, yeah, I may 
convince somebody to stay there, but now have I saddled them 
with some debt that could cause a bankruptcy or something else.
    So there are all sorts of issues here, but I think to Dr. 
Browne and Dr. Nahvi, and then I would like to get back to Mr. 
Pollin's kind of estimates, if we were to go to this Medicare 
for All or universal healthcare system, do you agree that there 
would be more demand on the system? And can we--could we, from 
a provider standpoint, manage that?
    Dr. Browne. Thank you. Yes. I think that there would not 
necessarily be a demand on the system. I think you would 
practice medicine in a more appropriate, better way. And the 
idea is that you are going to increase your educational 
components for your patients and practice prevention. And if 
you put prevention into practice, you are not going to have 
many of those hospitalization visits that will end up in the 
intensive care units, and so there is cost savings there.
    We have not practiced prevention, and we have been talking 
about it for years and years, and it is just going to the 
wayside. If we get people to come in and to do their 
immunizations and get those standard tests of screening, so 
screening and early detection, find the diseases at an earlier 
stage and, again, you can then provide that care at a more cost 
effective--and so the demand is not going to increase. We are 
practicing care in a more efficient, effective way.
    Mr. Perlmutter. Dr. Nahvi.
    Dr. Nahvi. Yeah. I would like to echo that. So I gave you a 
couple examples of people that came in, didn't get the care 
they needed, then ended up having more expensive care. There 
will be some people that will be using more care, but we are 
going to be more efficient as well with primary care and other 
ways to utilize our healthcare system.
    As an ER doctor, I see a lot of people come in with late-
stage disease because they didn't get to go to their primary 
care doctor when they needed to and then we end up paying more 
for that. The reason for that is we have laws, a Reagan-era law 
called EMTALA in 1986, it is the Emergency Medicine Treatment 
and Active Labor Act. It makes it such that anyone insured, 
uninsured, documented, undocumented, whoever they are, they 
could come to the ER when they need to come to the ER and we 
treat them. And if they can't foot the bill, the taxpayers foot 
the bill or the hospital does.
    I think if we expand coverage, we get these people 
utilizing care at the right places. They end up going to their 
primary care doctors to get their diabetes, high blood 
pressure, high cholesterol controlled so they don't end up 
having strokes and heart attacks and coming into the ER for 
those things.
    Mr. Perlmutter. Do you think a system like this would help 
you avoid some paperwork?
    Dr. Browne. Most certainly.
    Mr. Perlmutter. Okay. So you could be treating your 
patients?
    Dr. Browne. Yes.
    Mr. Perlmutter. Okay. Ms. Turner, and then I would like to 
go back to Mr. Barkan. So--and I appreciated your testimony 
because you really kind of laid it out as to, you know, 70 
years ago, it was you paid out of your pocket or you got 
charity care. And a lot of that charity care was underwritten 
by the churches, by charitable organizations.
    And then Kaiser came along and said people are getting 
hurt. We have got to do a war effort. And so Kaiser Steel and 
Kaiser Aluminum and all those guys, they created the employer--
they started the employer system. So we are in this massive 
system, and to change it is obviously a big undertaking. So I 
agree with all of that.
    With respect to Colorado, so I am from Colorado, and I 
support Ms. Jayapal's legislation and I support the--beefing up 
of the Affordable Care Act. And I support--there is an effort 
out there that says for anybody 50 and older, you can buy into 
the Medicare system. So I think all are improvements over where 
we are today.
    But my question to you on Vermont and on Colorado, just as 
a voter on that thing, I voted against the ballot initiative 
because I didn't think Colorado on its own could undertake a 
Medicare for All system, that it was national in scope, and 
that is why I went this way. But I am happy to have you comment 
on it a little bit more.
    Ms. Turner. You know much more about the political debate 
in Colorado than I do. In Vermont, they were assuming that much 
of the money that currently is flowing to the State through 
healthcare, whether it would be employer contributions, ACA 
funds, existing taxes, et cetera, all would go toward funding 
the new single-payer system. They also were assuming there 
would be additional Federal funds coming in through a Section 
1332 State Innovation waiver Vermont planned to request. And 
they still couldn't make it work.
    Regarding Colorado, I did several debates in the State 
about the ballot initiative in 2016, and the feedback that we 
continually got was from people who were very nervous about 
losing their current coverage and the taxes that would be 
required to support single payer. Proponents talked about all 
of the funds currently supporting employer-based health 
insurance going toward the new plan, but that just wasn't 
enough. Studies showed the new taxes required would have 
significantly disrupted the economy.
    Mr. Perlmutter. And I think you are right from a policy and 
a--kind of a political standpoint, it wasn't enough to overcome 
a number of the concerns and fears. But I think, you know, 
listening to the testimony of the economists and the doctors 
and just, you know, our own experience--you know, my wife had a 
difficult surgery, initially denied. I mean, I can't tell you 
the panic that hits a family when something like that happens.
    You know, so there are all sorts of issues. And I am just 
pleased that Mr. Cole and Mr. McGovern were able to work out 
the details so that we could actually have this hearing and get 
this ball rolling, because I think it is a very important 
conversation for this Nation to have.
    Mr. Barkan, do you--can you answer my questions? Are you 
ready for that?
    Mr. Barkan. Thanks very much for your questions. This 
healthcare system only works if you are a pharmaceutical or 
insurance industry executive who wants to maximize their own 
profit at the expense of people like me. It is simply 
unconscionable that I should have to pay $9,000 per month for 
lifesaving medical care at a time when the insurance industry 
is raking in record profit. That is wrong, and it needs to 
stop.
    Here is the thing. It is a huge stress to have to fight 
with insurance companies over what they will cover. It is a 
huge financial strain. But most of all, I have come to realize 
that our time on Earth is the most precious resource any of us 
have.
    I wish I didn't have to be here today. I think you are 
wonderful Congressmen, but, frankly, I would rather be back at 
home being with my wife and playing with my son instead of 
trying to wake the conscience of this Nation's lawmakers.
    Every day is precious for me. I don't have time on my side. 
Americans who are dealing with the everyday realities of their 
healthcare don't have time on their side. No one should have to 
fight to be treated with dignity again, and that is why I am 
here today.
    Mr. Perlmutter. Thank you. I yield back.
    The Chairman. Thank you very much.
    Mr. Woodall.
    Mr. Woodall. Thank you, Mr. Chairman. And thank you for the 
holding of the hearing and the way you have conducted it so 
far.
    We have a tough time. It may not be obvious to you though, 
Mr. Barkan, with your reference to awakening the conscience of 
Congress. It may be obvious to you that we don't always get a 
good, healthy conversation on issues of this.
    I credit the young woman to your right there. Ms. Jayapal 
is--I cannot support her legislation, but I absolutely support 
her. And there is a way to have a conversation--I know you are, 
Pramila. I don't worry.
    Ms. Jayapal. Open arms, buddy.
    Mr. Woodall. There is a way to have that hearing.
    In fact, The Washington Post, I don't know if you all saw 
the article on you all this hearing. The Washington Post did an 
article on this hearing and you all as the witnesses and made a 
point of saying--in fact, they quoted Ms. Shalala saying that 
we are not going to make ourselves look crazy this morning, was 
the quote they grabbed.
    The Washington Post observed that there are lots of ways to 
start this conversation and that the chairman and the 
leadership of the House went out of their way to pick a group 
of folks who were going to start it on a healthy, productive 
measure. And I hope you take your role in that with a great 
deal of pride, as I take the chairman's role in that with a 
great deal of pride.
    I want to start with the numbers. Mr. Blahous, I appreciate 
what you do, what you did as a trustee. I used to read your 
work regularly. I read it less now that you are in the think 
tank world. I read it more when you were in the government 
world.
    My understanding is that our payroll taxes, our Medicare 
and Social Security taxes are the largest tax that about 85 
percent of American families pay. And yet every time I read a 
report from you or read those reports, and they haven't got any 
better, is that there is not enough money coming in to do the 
things that we have promised to do.
    I can't believe that I read your testimony correctly, but I 
want to check it out with you. $32 trillion over 10 years as 
the best-case scenario, not for the total cost of Medicare for 
All but just the add-on to the current Medicare program that is 
already there. Am I reading that correctly?
    Mr. Blahous. Yes. That is a lower-bound estimate of the 
additional Federal obligations above and beyond current Federal 
health obligations.
    Mr. Woodall. I sit on the Budget Committee, and we are--you 
know, we are not able to pass a budget out of the Budget 
Committee because we couldn't even agree as a committee on how 
to sort out our current challenges, much less future 
challenges. But it is--it was going to be about a $4.5 trillion 
budget, a little under that.
    Best-case scenario, $3.2 trillion annualized over 10 years. 
Worst but more appropriate scenario is your nearly $40 trillion 
number. The worst-case scenario or an expected scenario?
    Mr. Blahous. I wouldn't say it is a worst-case scenario. I 
think, basically, the cost estimate over 10 years would be in 
the region of $40 trillion, if you didn't assume any particular 
targeted savings from Medicare for All.
    Of the different categories of potential savings from 
Medicare for All, I think the relatively most likely is 
probably administrative cost savings, which would bring the 
total down to about $38.8 trillion over 10 years. But depending 
on your assumptions for provider payment rates, drug costs, 
things like that, the additional Federal cost would be 
somewhere between $32.6 trillion and $38.8 trillion.
    Mr. Woodall. Help me with that math. Looking at your best-
case scenario, your lower bound, everything goes right. What 
are we talking about in a per-American cost, per-person cost?
    Mr. Blahous. Well, this is very crude, but it is about 
$10,000 per capita, per person in additional Federal cost.
    Mr. Woodall. $32 trillion, 320 million Americans? Okay.
    Mr. Blahous. So basically--exactly. I mean, $35 trillion, 
350 million Americans, it is about $10,000 per person.
    Mr. Woodall. Okay. That is real money.
    And I was listening to your testimony, Dr. Collins, as you 
were going through some of those numbers and talking about 
after the Affordable Care Act, things that had gotten better. 
And I want to stipulate that I agree with everything that you 
said about increased outcomes.
    What wasn't reflected there, though, is whether we got the 
best bang for our dollar. Of course, if I spend 1 trillion new 
dollars on healthcare subsidizing American families with their 
healthcare costs, when I run a poll that says are your 
healthcare costs easier to manage today than they were 
yesterday, folks are going to say yes.
    Mr. Woodall. I don't think that is the right question, 
though. I think the question is, we agreed to spend $1 
trillion. Are we spending that $1 trillion in the way that 
helps the most families do the most for themselves, reduce 
those stresses that we have talked about?
    Have you seen any data along those lines? Not did we do 
better, but did we do the best we could do, given the enormous 
resources we invested?
    Ms. Collins. We can actually do better. Seventeen States 
haven't expanded Medicaid. So that is one area where we haven't 
fully implemented the law. There have been some changes to the 
cost-sharing reduction subsidies in the marketplaces that have 
bumped up premiums on silver plans, which has hurt some people, 
but people's tax credits adjust. And actually, the Federal 
Government is paying a lot more because we are not paying these 
cost-sharing reduction subsidies.
    So, in terms of implementation, there are definitely areas 
where we could do better. We could extend the subsidies so that 
people just over that threshold for marketplace tax credits 
could afford their plans.
    But I also want to say too, before--didn't really----
    Mr. Woodall. Let me reclaim my time just for a second, 
because I understand that if we wanted to improve the 
Affordable Care Act in its current structure, there are lots of 
things that folks are doing. In fact, I suspect there are lots 
of men and women around this table who would rather do that 
than the Medicare for All plan. That wasn't the question I was 
asking, though.
    My question is, and it goes a little bit to what Dr. Nahvi 
said. He said 41 percent of folks reported they didn't go to 
the ER, even though they thought they needed to go to the ER. 
Every ER physician I talk to says, Rob, we are in a conscious 
effort to keep people out of the ER. People keep wanting to 
come to the ER. We don't want them to come to the ER. We want 
them to go to our urgent care center right next door, because 
when they come to see us, if they don't really need to see us, 
we are wasting valuable resources on them in our environment, 
because it is hyper expensive. We could have served more people 
in more ways if we could have redirected them.
    That is what I am thinking about, maximizing the dollar 
that we are spending. Let's agree we are going to spend more 
money, but let's demand the very best of that money.
    And I think about that in your case, Dr. Nahvi. How does 
the Medicare for All plan, as Ms. Jayapal has crafted, what 
incentive is there than to do what all ER physicians are 
telling me needs to be done? We got to keep folks out of the 
ER, get them into urgent care instead. What is the skin in the 
game that keeps me out of your office?
    Dr. Nahvi. There doesn't need to be skin in the game. 
People want to go to their primary care doctor. They don't want 
to see me, and, frankly, I don't want to see them. I agree with 
the doctors you talked to. When a patient comes to me and they 
want me to adjust their diabetes medication, because I am the 
only doctor they could see, because I am the only doctor they 
could access because I am in the ER--I feel totally comfortable 
intubating someone, doing chest compressions, treating a heart 
attack or a stroke or stabbing or gunshot--But I don't feel 
comfortable adjusting someone's diabetes or high blood pressure 
medication. That is a primary care doctor's job.
    Mr. Woodall. Your experience is that overutilization in the 
ER doesn't come from my misunderstanding as a consumer what my 
needs are; it comes from EMTALA requires you to see me and that 
is why I show up on your doorstep?
    Dr. Nahvi. Yeah. Patients often come in and they will come 
to the ER, they say, I took my blood pressure at a pharmacy. I 
went to the Rite Aid, and they had the machine there for free. 
It was through the roof, so I didn't know what to do, so I come 
to the ER.
    I don't want them there. I want them to go to their primary 
care doctor. It will be cheaper for them. It will be better for 
them. It will be cheaper for all of us. It will be better for 
me. That is a win-win. I don't need to incentivize them. They 
already want to go there; they just can't get in.
    Mr. Woodall. That is a win-win. I think about that, Ms. 
Turner, in some of your testimony, about your desire to do 
better. You have invested a lifetime in trying to move us in a 
better policy direction.
    I was visiting with a small town doc in Georgia. We did not 
expand Medicaid in Georgia. And he said, Rob, you hand out all 
the new Medicaid cards you want to if it will make you feel 
better, but I am the only doc in five counties who still sees 
Medicaid patients and I can't fit anybody else in my waiting 
room.
    So we are not going to achieve Dr. Nahvi's goal of 
providing more care. We will just achieve a policy goal of 
feeling better about what we are doing in rural Georgia as it 
sits today.
    What policy reason is there if I want to achieve Dr. 
Nahvi's goal of not seeing folks walk out the door because they 
can't pay for their care? I don't understand the policy reason 
to take away all of the DOD healthcare system that my men and 
women in uniform tell me that they love. I don't understand why 
we have to abolish every union healthcare system that my union 
members back home say, Rob, I have got the best healthcare on 
the planet. Why to achieve the goal of serving the underserved 
is the policy solution to take everything away from people who 
already feel well-served?
    Ms. Turner. I think that is really a crucial issue. We need 
to fix the current system rather than blowing it up--because 
there are a lot of existing programs in the employer community, 
in TRICARE, in Medicare--to provide coordinated care, to 
provide better access for people--more humane, more patient-
centered care.
    If Medicare fee-for-service is used as the model, all that 
is blown up. And can we create a new system for better 
coordinated care in 2 years? That would be extraordinarily 
difficult. I think we have to value what we have, build on 
that, and solve the problems that we have, not destroy what has 
worked in a system built over decades.
    Mr. Woodall. Well, even in the Medicare system, in my 
jurisdiction, I live in a suburban area, and so, we have lots 
of providers, but more than 40 percent of my seniors have opted 
for Medicare Advantage. They have said, I don't want the 
traditional Medicare system. I have a better option now that 
you have provided that option. I am going to choose that. And, 
of course, that goes away, too.
    We poison the well of productivity around here on a regular 
basis, and I want to thank each one of you in your testimony. 
No one went out of their way to poison the well. And, again, 
you were chosen for a reason, to get this conversation started. 
I think we can achieve Dr. Nahvi's goal of not having the 
underserved walk out on what ought to be an affordable 
procedure, though I think we can do it without what--Dr. 
Blahous is virtually doubling the Federal budget, a Federal 
budget that I am not paying for today, that I am borrowing from 
others.
    What I love about Ms. Jayapal is she doesn't hide from 
those numbers that you have laid out. She recognizes it is 
going to be a tremendous increase in tax burden for the 
country--you can't get to $40 trillion without that--and 
believes it is worth it. And that is the conversation that we 
have to have.
    I want to ask, and I will ask the good doctor who has more 
experience in the military system than most of us do. I don't 
hear frustrations from my servicemen and women about their 
quality of care. In fact, what I hear them say is, Rob, because 
I am deployed all over the planet I have to have something 
different than what would work in just metro Atlanta in 
general.
    Is it necessary to achieve the goal that you want for 
America and our healthcare system to abolish that system that 
we promised our men and women in uniform, or could we keep that 
system while trying to achieve some other goal?
    Dr. Browne. I think you can keep that system and build on 
it. Medicare for All, whatever label you put on it, can be that 
system. And that is what I am saying. The government is paying 
for your health services, my health services, Medicare, 
Medicaid, VA, DOD already. You can duplicate that and label it 
whatever you want, because you see the efficiencies there.
    And particularly when we talk about the goal that Dr. Nahvi 
is mentioning for the underserved, you have to have the 
educational component and address the social determinants of 
health. If you are in an area where there is a food desert and 
you can't get nutritious food, you can't exercise, you have to 
have a whole list of prescriptions when they come in to see you 
and they lay it out.
    If you can provide them with preventive care and education, 
they will become healthier and not need the bag of pills, not 
need to go to the emergency room, and also, they have an 
assigned primary care provider that is going to keep them out 
of the emergency room.
    Mr. Woodall. I am glad you raised that. It is troubling to 
me, again, particularly given the trillions upon trillions that 
we are talking about investing here, that we are only talking 
about treating people after something bad has happened. There 
is nothing in here that says, what we ought to do is make sure 
that you are eating better before this happens. Diabetes, as it 
contributes over a quarter of our healthcare cost, nothing in 
here that says we need to get to exercise ahead of time. It is 
all a response to crisis instead of intervening before the 
crisis. So that is what healthcare professionals see. I don't 
go to my----
    Mr. Barkan. Representative, may I----
    Mr. Woodall [continuing]. On a good day. I go on a bad day.
    Let me ask this, and it goes to what Mr. Barkan said. I 
think you said 10 percent of American families are grappling 
with someone who is disabled in their household, the healthcare 
costs there are related to that.
    I do think it is outrageous that GoFundMe is what folks 
would call a successful healthcare system. I don't call that a 
successful healthcare system. But what I don't want to do is 
refocus America's resources away from your family and towards 
my family, if I am not in the 10 percent that is facing crisis. 
I want to focus the resources on the families that need them 
most.
    Is it clear from your advocacy and your work that we have 
to change it for everybody, instead of doubling down on those 
families that we know--there is not a man or woman who is not 
touched by your testimony, and who doesn't want to do better 
for you, not just on this committee, but in this entire 
Congress. And I worry that we are losing an opportunity to 
agree on that by trying to take the conversation even broader.
    Mr. Barkan. Representative, may I please weigh in on the 
cost issue?
    Mr. Woodall. Please.
    Mr. Barkan. One thing I can't help but think about today, 
Congressman, is how we always seem to find the money for things 
like tax cuts for the wealthy, and for corporate tax cuts. We 
never ask where the money will come from when we declare war. 
We always seem to just find the money. We only ask how we will 
pay for it when it comes to our health.
    This is such a clear problem with such a straightforward 
solution. We can save taxpayers money, we can save money for 
families, and we can provide high-quality medical care for 
every American by doing what every industrialized nation on 
earth already has.
    Mr. Woodall. If you would indulge me just one moment, Mr. 
Chairman, I thank you.
    I have to disagree with you, Mr. Barkan. And I do worry 
that that kind of pithy one-liner makes it harder to get to 
where we need to go. It is not just healthcare that we have 
this conversation. I live in a district that is a majority/
minority district. Twenty-seven percent of my constituents are 
first-generation Americans.
    We have the best education system in the country in our 
district. So says the Broad Prize that awards us year after 
year. We pay for that, and it is hard to pay for it. Our taxes 
are very high, but we make a decision every day. Are we going 
to have the best education system, or the second best, or the 
bottom best?
    Public housing in this country, Dr. Nahvi referenced that 
earlier, talking about some of our rights. We have people who 
live in desperately dangerous communities today, desperately 
unhealthy communities today, and we are not coming up with the 
money for those things either, because money is in every 
conversation.
    And I want to agree with you 100 percent, I support a war 
tax. I think it is absolutely immoral that we have taken the 
war off of the front page of the paper, and unless you have a 
family member who is at risk there. I know the chairman 
supports that as well, having that conversation and putting 
skin in the game.
    I would share with you, most respectfully, I need you to 
believe that folks on every side of the aisle care as much 
about serving men and women in need as folks on any other side 
of the aisle. It is not a budget dollars and cents issue; it is 
paying for those things that we value. We value you and we want 
to pay that.
    Mr. Chairman, you have been overly indulgent, and I am 
grateful.
    The Chairman. But I want to make sure that Dr. Nahvi--he 
had his hand up, and I want to make sure he gets----
    Dr. Nahvi. Yes, I just wanted to pick up on one thing you 
did say. You said that you talked to the men and women in 
uniform, and they are usually satisfied with their care. I work 
at a private hospital, a public hospital, and I also work at 
the VA as well. And that has been my experience too.
    And I think you inadvertently just made a great case for 
Medicare for All. Our VA system is wonderful. We provide 
excellent care, and I never had a patient at the VA leave 
against medical advice because they were worried about the cost 
of their treatment.
    So I think that our men and women in uniform have great 
care. And it is a federally funded program where the doctors 
there are employees of the government, and we have a single 
formulary, and we take care of patients in a great medical way, 
and also, a financially responsible way. So I do think if it is 
good enough for our men and women in uniform, it is good enough 
for all Americans.
    Mr. Woodall. Just so we don't confuse the issue, of course, 
the VA system stays under the Medicare for All plan. I am 
talking about the DOD system. Very different conversations I 
have with veterans about the VA system and DOD families who are 
serving abroad. But I take your point.
    Thank you, Mr. Chairman. I yield back.
    The Chairman. Thank you. Before I get to Mr. Raskin, 
because I am the chairman and you are the ranking member, we 
have a little extra time.
    Mr. Cole. When did I get that extra time? I am thrilled.
    The Chairman. You do have that extra time. You just haven't 
used it, that is all. You can yield it back at the end if you 
want.
    But just a couple of points. Just to Mr. Barkan's point 
about, you know, when it comes to certain things, we don't 
question money and the cost. When it comes to healthcare, we 
do. That is just a fact, and I know it is an uncomfortable 
fact, but it is.
    I mean, we passed a tax cut bill, which I know you guys 
supported. We didn't. I didn't support it. But we didn't have a 
hearing on it in the committee of jurisdiction. And it came 
right to the Rules Committee, and it went to the floor. I mean, 
we could argue whether that was a good idea or bad idea. I 
think it was a bad idea. But it is just the issue of how we are 
going to pay for it never really came up.
    And you and I agreed that when we are engaged in wars 
halfway around the world, we ought to pay for it, not just put 
it on the credit card. And we just don't do that, right? I 
mean, we make believe that we don't have to. But when it comes 
to healthcare, we do.
    Mr. Woodall raised two important points. One was that 
Medicaid rates are lower than private insurers, but that is 
when they pay, right? But we know that private insurers don't 
always pay.
    And Dr. Collins, I would appreciate if you could explain 
this for us, and also, would Medicare for All pay the lowest 
rates?
    Ms. Collins. Actually, Medicaid rates would go up under the 
Medicare for All proposal.
    The Chairman. And insurance companies don't pay oftentimes. 
We do casework all the time in our districts where we have 
people who have issues, and when it comes to paying for the 
bill, the insurance companies say no. I mean, that is a reality 
in this country, right?
    Ms. Collins. That is exactly right. And surprise medical 
bills are a huge issue right now. Congress has taken up this 
issue. People are getting bills for services that they thought 
were covered. And that continues.
    And outside of the surprise billing issue, people have very 
high deductibles. People talked about how great employer-based 
coverage is. People in employer-based plans across the country, 
their premiums and deductibles comprise about 12 percent of 
median income on average. Employer-based coverage is also one 
of the largest sources of increase in the underinsured rates 
that we are seeing. So it is a problem.
    The Chairman. I have talked to a lot of hospitals. I have a 
lot of hospitals in my district. In Massachusetts, we have some 
really fine hospitals. But one of the things they complain to 
me about all the time is the fact that they invest so many man- 
and woman hours into filing claims with insurance companies to 
get paid for what they provided. And sometimes, they get to the 
point where it is not worth the time, and they just eat the 
cost. I throw that out there to make sure that people 
appreciate that fact.
    I am now happy to yield to Mr. Raskin from Maryland.
    Mr. Raskin. Mr. Chairman, thank you so much. Before I 
begin, I wanted to submit for the record a statement from Eagan 
Kemp, who is the healthcare policy advocate for Public Citizen, 
which makes the important point that even Americans who have 
insurance today are facing spiraling costs, and that a Medicare 
for All system will enable us to lower drug prices and restrain 
the extraordinary growth in drug prices we have been seeing.
    [The document is printed at page 234]
    Mr. Raskin. I also want to recognize the presence today of 
the president of National Nurses United, Jean Ross, who is the 
leader of an organization that has been heroically fighting for 
healthcare for all Americans for many decades. And I just 
wanted to recognize her.
    Mr. Chairman, thank you for calling this historic hearing, 
which is a breakthrough in the national dialogue about 
healthcare, and what we are going to do to deliver healthcare 
to all of our people. I think not since Senator Kennedy had a 
hearing several decades ago about healthcare have we had one 
that is this comprehensive, this detailed, and this serious. 
And I want to thank colleagues on both sides of the aisle for 
participating.
    I especially want to thank you, Mr. Barkan, for your very 
lucid and poignant and compelling testimony today. And I wanted 
to start by saying that 9 years ago, I sat where you sit, 
metaphorically speaking. I was suffering from reflux symptoms 
and went to the doctor, who recommended that I go in for an 
endoscopy. And they said, while we are at it, why don't we have 
a colonoscopy. We wouldn't normally do it this early. I think I 
was 47 at the time. But let's just go ahead and do it.
    And when I woke up, they said, well, we have good news and 
bad news. The endoscopy went fine, but we found something in 
the colonoscopy. And I had Stage III colon cancer and was off 
to the races. And I did it all. I did radiation. I did 
chemotherapy. I had surgery twice. And I can't imagine any of 
my fellow citizens going through such a trauma, something of 
such an enormous emotional, psychological, and family strain as 
that, and not know where they are going to get insurance.
    And I was a State Senator and I was covered by Maryland's 
health insurance plan. But most State legislators don't make 
very much money. I think we were getting paid $40,000, $45,000, 
but we had a great health insurance plan. And I was covered and 
I was able to deal with it. But it opened my eyes to the fact 
that this is a crisis in our country, that there are tens of 
millions of people who don't know what they would do in the 
event that they came down with a diagnosis like that.
    Like Mr. Barkan, I decided that I was going to try to go 
through this personal crisis by staying at work and by engaging 
with the things that I loved. And one of the things I was 
working on was I was leading the floor fight in Maryland for 
marriage equality. And we adopted marriage equality. We became 
the first State in the Union to do so without a judicial order 
compelling us to do so.
    Mr. Chairman, you know, all glory to Massachusetts in all 
cases, but Massachusetts did have that judicial order from the 
Supreme Judicial Court telling them they had to do. In 
Maryland, we didn't have that, but we passed it anyway.
    And, you know, as the floor leader, you have got the 
opportunity when it is all over to make a little speech. And I 
got up to thank my colleagues, because I had been wearing a 
chemo belt to the debates, and to session for several weeks. 
The guy who sat next to me, Jim Brochin, who is a great 
conservative Democratic State Senator from Baltimore County, 
said that I just wore the chemo belt to try to get sympathy and 
votes for marriage equality, which is probably right. But we 
ended up pulling him over and changing his mind about it, so it 
worked, I guess.
    But I got up and I said, you know, that I had learned 
something in this process about the difference between 
misfortune and injustice. Because if your life is going great, 
you have got not one, but two jobs that you love and a wife 
that you love--and my wife is here today--and kids that you 
love and constituents you love, and you go to the doctor and 
the doctor tells you, you got Stage III cancer and you got a 
50/50 chance of coming through it alive, that is a misfortune. 
It is a terrible misfortune, but it is just a misfortune, 
because it is built into the nature of our species, you know. 
Any of us could be assigned such a verdict on any particular 
day. Anybody could get such a diagnosis.
    But, but, if you experience such a misfortune, and you get 
such a diagnosis and you can't get healthcare, because you love 
the wrong person or you lost your job, or you are not working 
or you are too poor, that is not a misfortune; that is an 
injustice, because we can do something about that.
    And life is hard enough, Mr. Chairman, with all of the 
illness and accident and heartbreak, for government to be 
compounding the misfortunes of life with the injustice of 
denying people access to healthcare when they get sick. And in 
the richest country in the history of our species, at its 
richest moment, not to advance forward to adopt a Medicare for 
All system is to deny I think the common humanity of our fellow 
citizens.
    And I read an essay during that period by Susan Sontag, who 
said that everybody is born with two passports. And one 
passport is to the land of the healthy and living; and the 
other is to the passport of the sick and the dying. And we all 
hope that we are just going to use one of our passports in 
life, but in truth, all of us are going to use both of those 
passports. And to me, it is an elementary question of 
democratic solidarity and equality whether we are willing to 
acknowledge that all of us are going to use those passports, 
and we should make everybody's trip as easy as possible.
    So I am a cosponsor of this legislation. I am not going to 
hide that fact. I am not just a neutral objective questioner 
here. But I am fascinated about how we are going to get through 
this process and bring everybody aboard and come up with a 
system that makes sense to all Americans.
    Now, I want to ask a question that came up before--I think 
Mr. Barkan raised it--about how we ended up tying in our 
society healthcare to people's employment. I read something, 
and I don't know whether it is true, but I read something which 
suggested that goes back to World War II when there were wage 
and price controls and employers, in order to attract new 
talent, had to give them something better than higher wages and 
they offered them health insurance. And that began quite 
accidentally, quite arbitrarily, the connection of employment 
and healthcare. And I just wonder if anybody could illuminate 
that for me. Perhaps, Mr. Baker, you could.
    Mr. Baker. That is, in fact, the history. And, of course, 
it spread, you know, to a wider range of employers, so that the 
vast majority of people below Medicare age are getting their 
insurance through their employer. And, you know, this has come 
up previously.
    I could speak now as a former employer, because I was a 
codirector at Center for Economic and Policy Research for 17 
years. We hated having to deal with our healthcare insurance, 
you know, just for obvious reasons. We were busy. We were 
trying to do lots of other things.
    Mr. Raskin. And most small businesses hate it, because they 
are not in the healthcare business, right?
    Mr. Baker. That is exactly right. And on top of that----
    Mr. Raskin. They are running a movie theater or they are 
running a think tank or a farm.
    Mr. Baker. And, you know, we are trying to keep our workers 
happy, obviously, our employees happy, and they have different 
needs. And, you know, we are trying to find--frankly, I don't 
know and I don't want to know what is the best insurance plan 
for my individual workers, but we had to pick--talk about one 
size fits all. We had to pick one plan that was going to be 
better for some people, worse for others. We didn't want to be 
in the business, and I can't imagine any employer wants to be.
    Mr. Raskin. So a Medicare for All system will liberate 
small business in America from the obligation of trying to 
figure out what is the best healthcare plan for their workers 
and from paying for it. Is that right?
    Mr. Baker. That is right. And I should also point out we 
had an insurance broker, an additional cost. You know, we had 
someone who would go through the plans with us. You know, this 
is a total waste.
    Mr. Raskin. You describe in your testimony, Dr. Baker, how 
financing Medicare for All starts by looking at how we are 
spending money today and then making it more efficient. And in 
many ways, that description of how to finance it sounds 
remarkably similar to a study done by another witness here, Dr. 
Blahous from the Mercatus Center. And in a piece for the 
American Enterprise Institute, he wrote the following: Quote, 
``Medicare for All supporters are correct to observe that 
Americans already pay for the vast majority of health spending 
that would occur under Medicare for All and that most of the 
Medicare for All's costs are, therefore, not new to the 
national economy.''
    Do you agree on that point with----
    Mr. Baker. Absolutely. I mean, clearly, there would be some 
increase in utilization, and that is partially the point. But I 
think that is limited for two reasons: One, that the people who 
most heavily utilize care--and this is something we have to 
keep in mind--basically, 10 percent of people account for 70 
percent of the cost. Most of those people already are not 
limited by cost, strictly speaking, because they are either on 
Medicaid or they have hit their out-of-pocket maximum. So these 
are, you know, where we might expect big increase in cost.
    But the other point that has been made by several people 
here, you have a lot of people that incur high cost because 
they are not getting the care they should need at an earlier 
stage. So then they end up going to the emergency room with 
very expensive care, when they could have had very simple care 
if they had had access to a primary care physician.
    Mr. Raskin. The other industrialized countries on earth 
have arrived at national healthcare plans, the kind that has 
proven so elusive for us. I want to ask a couple questions 
about that and first, perhaps, Dr. Collins, we can start with 
you. What is the principal value they are seeking there? Is it 
justice for everybody, so that everybody gets healthcare; is it 
efficiency of the system; or is it the public health in 
general, to advance public health? What are the values they are 
seeking to vindicate?
    Ms. Collins. I would say certainly all three. I mean, I 
think that having universal coverage enables people, everybody 
to get healthcare that they need. It definitely promotes 
efficiently run healthcare systems. People have access to care 
that makes them productive.
    We have a big problem when we have 30 million people 
uninsured, so it reduces their overall productivity as well. So 
I would say it is all three of those things.
    Mr. Raskin. Okay. And, Dr. Browne, do you agree with that, 
that all of those values are achieved?
    Dr. Browne. Certainly. And I think you also have to look at 
if you have a healthier workforce, you are going to have cost 
savings in your employment business, because the time that you 
lose for sick days and getting off and taking care of family 
and all of that would not be achieved, because you are then 
fully working and staying healthy. So yes.
    Mr. Raskin. Thanks. Dr. Nahvi, I have got a question for 
you, because I have received an increasing number of visits 
from doctors and nurses and people in the healthcare system who 
say that the current system we have got is not working for 
patients, and it is interfering with their ability to deliver 
quality healthcare to people for a whole host of reasons, 
including the ridiculous amount of time that they have to spend 
on bureaucracy and fighting with insurance companies whose 
financial model is to not pay for people's healthcare.
    The question I want to ask you is this: I think it was Ms. 
Turner who said we shouldn't just blow the whole system up. Of 
course, some of my colleagues across the aisle voted 70 times 
to blow up the Affordable Care Act. They wanted to take that 
system down. But I want to ask you a tough question about the 
transition from the Affordable Care Act to one that covers 
everybody, and tries to lower cost in the system, squeezing out 
the money that we all pay for copays and deductibles and 
constantly escalating premiums.
    As I understand it, President Obama said, We want to reach 
across the aisle and we will go to the plan that was cooked up 
at the Heritage Foundation. Now, that fact has been buried, but 
this was the Heritage Foundation plan, the Affordable Care Act. 
And it was the model for what Governor Romney did in 
Massachusetts, right? And so the idea was let's take the 
Republican plan of the individual mandate, which they came to 
revile and denounce, and put that at the heart of the system. 
They considered it an expression of individual responsibility.
    Then what happened was it became politicized, and rather 
than that compromise working, they turned on it, they renamed 
it ObamaCare. They voted dozens of times to try to destroy it 
and not replace it, but destroy it and leave nothing there, 
despite the fact that tens of millions more people got 
healthcare because of the Affordable Care Act. It was a giant 
step forward. And yet, we know of what its limitations are.
    Now, is it going to be possible for us to move from the 
Affordable Care Act, with its limitations, to a Medicare for 
All system? Is that going to be too complicated for us to 
accomplish?
    Dr. Nahvi. I don't think it is too complicated. And I also 
would say that we actually need to do it. I think just 
expanding the Affordable Care Act wouldn't cut it.
    And I gave three examples earlier: Of the 28-year-old 
female that had the urinary tract infection that tried to drink 
cranberry juice to solve it; and the gentleman that stopped 
taking his antiplatelet medication; and the lady with the 
depression medications. All these people--I don't know if I 
made this clear--they all had private insurance, and it just 
wasn't cutting it for them. They ended up having these problems 
despite having private insurance.
    Mr. Raskin. Well, sometimes people think Medicare for All 
is just for the 30 million people who have no health insurance. 
That for me probably would be enough. But it is actually for 
the 45- or 50 million Americans who have a weak insurance plan, 
where the premiums are always going up, the deductibles are 
going up, the copays are going up, and it doesn't work for 
them. So what we are looking for is a system that is going to 
serve all Americans.
    Now, it has been suggested by our, you know, distinguished 
colleague that, well, we don't want to interfere with the plans 
that are working. The plans that are always cited in that 
question are single-payer plans, like the VA or the military. 
So they say, don't mess with the people who have single payer 
now, because they love it.
    And then the point of the political opposition is to try to 
scare everybody into thinking, well, if we have single payer 
for all Americans, if we patriotically bring everybody in, then 
it is going to interrupt the single-payer provision that we 
have got now, right?
    Is it the case that we cannot afford a system that works 
for all Americans without taking away healthcare for people who 
are getting it from the VA or getting it from the military and 
so on?
    Dr. Nahvi. I am not an economist, but as an ER doctor, one 
of the first things you learn is that when things are getting 
crazy, you need to stay cool, calm, collected. Oftentimes, when 
everyone around you is yelling about all sorts of things, 
usually the problem is not that hard to deal with and we can 
deal with it.
    So from a big-step-back perspective, I apply something that 
I call the ``look test'' to this. Just look at what is out 
there and what makes sense. So if someone is coming here and 
arguing that heavier-than-air flight is not possible, but I 
just point to an airplane, I say, but look, I see an airplane, 
so I hear what you are saying but that can't be true.
    So the corollary to that is when everyone starts yelling 
and screaming that doctors are going to get paid so much less 
and these systems can't function, the hospitals are going to 
have to close, I would just point to other countries that are 
doing similar things and I would say, I hear you, but it seems 
to be working just fine.
    Mr. Raskin. Do any of the economists want to weigh in on 
this point? In order to have a Medicare for All system, do we 
have----
    The Chairman. I am going to lend you 2 minutes of my time.
    Mr. Raskin. Oh, forgive me. Okay, I didn't realize I was 
over. Okay. Let me just--I thought it said 2.
    Mr. Barkan. Congressman, may I make a comment?
    Mr. Raskin. Mr. Chair, I will yield back. I will yield 
back.
    The Chairman. I get my 2 minutes back.
    Mr. Barkan. Congressman, may I make a comment?
    The Chairman. Sure.
    Mr. Barkan. Congressman Raskin, 10 years ago, just before 
you got sick, when I was in law school, you came to speak to a 
student group. I was so inspired and amazed by the vision you 
laid out, and I decided that you were the kind of lawyer and 
public servant I wanted to become. And your comments today once 
again inspire me and give me hope for the future. Thank you.
    Mr. Raskin. Thank you, Mr. Barkan.
    The Chairman. Thank you very much.
    Before I yield to Dr. Burgess, I want to ask unanimous 
consent to insert in the record an article that appeared in the 
Washington Post back in June of 2018 entitled ``House GOP plan 
would cut Medicare, Medicaid to balance budget.''
    [The document is printed at page 244]
    The Chairman. And I do that not to break the spirit of 
camaraderie here, but simply to point out that, you know, when 
you complain about the lack of adequate reimbursement of 
Medicaid and that providers don't want to oftentimes take 
Medicaid, and then you support a budget that cuts Medicaid, 
that it is a little bit kind of not consistent. I ask that be 
put in the record.
    I also want to acknowledge that during the hearing 
Congressman Adam Schiff came in, and now we have Congresswoman 
Ilhan Omar here. We are happy to have you.
    I am now happy to yield to Dr. Burgess.
    Dr. Burgess. Thank you, Mr. Chairman. I take it under 
advisement that you said you are happy to yield to me.
    So it is interesting. I used to be a student of medical 
irony. I am a physician as well. Worked in the ERs when I was 
putting myself through residency at Parkland Hospital. We 
didn't have CAT scans back in those days. So you got operated 
on for appendicitis. It was probably a lot cheaper and more 
direct.
    However, I used to be a student of medical irony. Now I 
have kind of branched out and policy irony is part of my realm 
as well. And it is just I find it ironic that we are here today 
criticizing employer-sponsored insurance, that it is so bad, 
and yet the Affordable Care Act that we debated in this room 
many, many years ago had an employer mandate built into the 
Affordable Care Act. Employer insurance is so good we want to 
require one to have it. So just a point of historical context. 
And it is not my goal to relitigate the Affordable Care Act and 
how we got here. There are good books written on it. I think 
one of our witnesses has written a book, one of your committee 
members has written a book. So I encourage you all to check out 
Amazon; I am sure they are still available.
    But I do have to say that, you know, as the Affordable Care 
Act, President Obama was elected. He was elected, he said, on a 
healthcare mandate. And I reached out to the transition team 
and I said, Look, I didn't give up a 25-year medical career to 
come up here and sit on the sidelines while you all do this. 
Talk to me. There may be some places where we can work 
together. And they thanked me very much for my participation. 
That is the last I ever heard of them.
    The same with then-Chairman Waxman, who was the new 
chairman of my committee, the Energy and Commerce Committee. 
And the same discussion with Chairman Waxman. I didn't quit my 
day job to come up here and watch somebody else do healthcare 
reform. Talk to me. There are perhaps places where we could 
work together. And, again, I never got a response.
    So, again, my purpose was not to relitigate the Affordable 
Care Act, but it has come up several times today. And yeah, 
there were some missed opportunities. And I say that having 
been part--and just for people who are watching at home, I 
don't want to say this committee is not normal, but normally, 
healthcare policy would come through one of the committees of 
jurisdiction, what are called authorizing committees.
    Mr. Cole is an appropriator, so he pays for everything we 
authorize very graciously. But one of the authorizing 
committees would have had this type of hearing, and probably 
done it over several iterations. But this hearing in the Rules 
Committee is somewhat unusual. I mean, I haven't been on the 
Rules Committee more than 8 years, but it is unusual in my 
experience. We had two primary hearings when Republicans were 
in the majority, but they were on things that were outside of 
the normal realm of the authorizing committee. So just, I want 
you to know it is a little unusual to have this hearing, but it 
also indicates----
    The Chairman. Would the gentleman yield?
    Dr. Burgess. No.
    The Chairman. There is a new sheriff in town, that is why 
we are doing the hearing.
    Dr. Burgess. What is that?
    The Chairman. There is a new sheriff in town, that is why 
we are doing the hearing.
    Dr. Burgess. Exactly the point. This issue is so important 
to the Speaker of the House. This is the Speaker's committee. 
This committee is not--this committee is nine to four. Mr. 
McGovern is never going to lose a vote in this committee. If he 
did, he would probably have to leave town. So this is the 
Speaker's committee.
    The ratio was set up by a Texan, Sam Rayburn, who 
everything up here is named after Mr. Rayburn. Got a room 
downstairs. Got a building over there. I have got a freeway at 
home named for Mr. Rayburn. Mr. Rayburn set up the ratio of the 
Rules Committee in 1961 to facilitate enacting the agenda of a 
young activist, President John F. Kennedy. And the ratio has 
stood ever since.
    But it is unusual to have this hearing in the Rules 
Committee. But I make that point because this is the Speaker's 
committee. The Speaker has elevated this. This is what the 
Speaker wants us to be talking about today, this week, this 
month, and so we shall.
    I do have a number of specific questions, and I apologize 
for getting--it is just hard, because I devoted my time and 
experience to one of the authorizing committees that deals with 
healthcare, NIH. Our committee, our committee, Energy and 
Commerce Committee, produced Cures for the 21st Century. I 
mean, we can argue about how we are going to pay for things, 
but if we ain't got the things to pay for, it is a crazy 
argument.
    And, Dr. Browne, thank you so much for being here. Thanks 
for your service to the National Medical Association. I will 
tell you when we were doing Cures, and it had gone through all 
of the machinations that we could go through in the committee 
and the House had passed it, the Senate dragged their feet, and 
then an election happened and they decided they better get busy 
and pass Cures, because things weren't getting any better for 
them after the 2016 election. So they did, they passed a 
version of Cures. We quickly got a conference committee 
together, worked out the differences.
    And Mr. Rush, Bobby Rush, on our Energy and Commerce 
Committee came up to me and said, Doc, we forgot sickle cell. 
And, well, we didn't really forget sickle cell. We were trying 
not to be disease specific. This was about funding for research 
in the broad perspective. But I got what he was saying, because 
several months before, we had had a hearing in the Energy and 
Commerce Committee in the summer of 2016. And we had a witness 
from the Sickle Cell Disease Association, and she made the 
statement that it had been 40 years since a new sickle cell 
treatment had been approved by the FDA, 40 years. That meant 
the stuff that I was using at Parkland Hospital in the 1970s, 
that was state of the art. I could probably go back to work 
tomorrow, because it hadn't changed. That was an astounding 
statement that day.
    So, obviously, we were at a point with the Cures bill that 
nothing could be changed. The Senate had agreed, the House had 
basically agreed, and we were going to go to the floor for a 
vote and the President was going to sign it. I think it was the 
last bill signed by President Obama. It is a great bill, and 
evidence of what the Energy and Commerce Committee is capable 
of doing if we take our time and do things correctly.
    I did make a commitment to Mr. Rush that I would work to 
get a new sickle cell authorization. It hadn't happened since 
2004. That was tacked onto one of the Bush tax cuts. So it 
wasn't a true sickle cell reauthorization. And the next month, 
when I was chairman of the Health Subcommittee, we passed a 
sickle cell authorization bill. And it took the Senate forever, 
as it always does, but in October, they passed their version. 
We approved their version over here on the House floor and the 
President signed it into law, the first major sickle cell 
authorization that had been passed in certainly over a decade, 
and with no new therapy.
    And then here is why this is important, because I normally 
don't watch 60 Minutes. I don't think I watched it the night it 
was broadcast, but someone said, you should go to YouTube and 
look at this 60 Minutes broadcast on sickle cell. And if I am 
not violating copyright laws, I encourage people to do that.
    It was a fantastic discussion of what someone is doing at 
the NIH with fixing the genetic defect that causes sickle cell. 
I mean, that is unheard of. It is a two-base error and it seems 
like something--it is just a spelling error, simply spell check 
should have caught that, but it didn't. And this doctor has 
worked out a system where they are actually able to put that 
corrected DNA into a patient's cells. And I got to tell you, I 
am an Episcopalian, so I don't emote, but when I saw that 
picture of the blood film on 60 Minutes, that young woman who 
they were treating, and these were all normal red blood cells, 
I mean, I broke down and cried. That is incredible that that 
child could have that blood film picture.
    And, Doctor, you know from your time in the emergency room, 
a sickle cell patient, I mean, they go into crisis and it is 
tough. There is not a lot you can do. And people worry about 
prescribing opiates now. We should be judicious, but at the 
same time, these are people who need pain relief. And the old 
treatments of hydration and Thorazine, I suspect, is still one 
of the things that you do. But this is a great step forward.
    And, again, I bring that because the authorizing committee 
did that. Another bill that we did, I hated the sustainable 
growth rate formula. When you talk about Medicare for All, my 
God, there was one point where the Congress said, You know 
what, we are just going to cut your medical reimbursement for 
doctors, not for hospitals and not for insurance companies, not 
for Pharma, just for doctors, 20-some percent every year. Oh my 
God.
    And it never goes away. It was written in a way that even 
if Congress came back in and added some money, which we would 
do every year in December called the doc fix, if we did that, 
it still added onto what the eventual cost that the 
Congressional Budget Office would score as if you are going to 
repeal this, this is what it is going to cost due to the 
vagaries of something called the updated adjustment factor. And 
I am not an economist, I don't understand what that is, but it 
was bad, I know that.
    Thirteen years it took me to repeal the sustainable growth 
rate formula, and I did. And I did it in a bipartisan fashion. 
We had a 51-to-0 vote in the Energy and Commerce Committee. We 
had 393 votes on the floor of the House. We had 92 votes on the 
floor of the Senate. So that was a great example of bipartisan 
cooperation to correct a major problem that we had with 
delivery of our healthcare.
    But you can't stop there. And this is one of the things I 
learned. That when you finish a big bill like that and hand it 
off to the agency, with all due respect for anyone who might 
have worked at the agency at one time in their life, when you 
hand stuff to the agency, things can happen to it, and you have 
got to keep your eye on it. As members of the authorizing 
committee, we have had multiple oversight hearings on the 
implementation of what is called the Medicare Access and CHIP 
Reauthorization Act.
    So this was a major Medicare improvement that was agreed to 
in a bipartisan fashion, but, I mean, there is not a day, not a 
week that goes by that someone does not call my office with 
some concern about something that they are going to either not 
be able to do, or be required to do because of something the 
agency said--rulemaking that the agency makes.
    So I encourage people when they read this bill, this 
Medicare for All bill--and it is a real bill and is a real 
consideration. This is the Speaker's committee. We are 
considering this bill in the Speaker's committee. I worry about 
it, because of the number of times it says in that bill the 
Secretary shall, the Secretary shall. We are talking about the 
Secretary of Health and Human Services.
    With all due respect to anyone who might have been the 
Secretary of Health and Human Services at one time, that is 
kind of a difficult way for health policy to evolve, because 
then it goes out of the realm of the people's House to the 
agency. And what was the statement that Mr. Raskin made? A 
ridiculous amount of time spent on bureaucracy.
    If you think that is going away, if the fine folks over at 
the Hubert H. Humphrey Building are in charge of everything, if 
you think that ridiculous amount of time spent on bureaucracy 
is going away, it ain't. It will still be there in some form or 
fashion and it quite possibly could be worse.
    So I appreciate your indulgence. I just had a lot I wanted 
to get off my chest.
    Ms. Turner, let me ask you, because this comes up all the 
time in the issue of administrative cost in HHS and CMS. I 
mean, administrative cost, that is a little bit of--it is a 
little misleading, because if I want to go up and start an 
insurance company--I would never do it, but if I did, and I was 
going to take care of a lot of people, I would have to go 
borrow a lot of money. There would be a cost of capital that I 
would incur. CMS does not have to account for the cost of 
capital, do they?
    Ms. Turner. No, Dr. Burgess, it does not. Actually, Merrill 
Matthews with the Institute for Policy Innovation did a study 
with an economic consulting firm some time ago, looking at the 
comparisons of Medicare administrative cost with private 
insurance. And he said most of these comparisons are really 
apples to oranges. And when you include everything, including 
not only the cost of capital, but the Federal Government's 
ability to collect premiums and resources and the difference in 
the population of Medicare versus those that are younger, then 
it comes out pretty even.
    But I think the key point is that somebody is going to have 
to determine what benefits are allowed or not, who is going to 
be an authorized provider, how those providers are going to get 
paid, how the paperwork is going to get collected. Those jobs 
still must be done.
    Dr. Burgess. And we turn all that over to the Secretary 
with this Medicare for All bill.
    Ms. Turner. There is no question that somebody is still 
going to have to do the administrative paperwork. All of the 
medical goods and services that the taxpayers will be paying 
for as part of the new Medicare for All program will have to be 
documented and payments will have to be processed, et cetera. 
That is not going to go away.
    Dr. Burgess. Let me just take what time I have remaining 
and I need to enter into the record, ask unanimous consent to 
enter into the record. We are limited, only have two witnesses 
on the Republican side, so we are not able to have a patient. I 
wanted to bring this article that was printed this morning in 
CBC.ca. A mother in Nova Scotia living with cancer is 
challenging Premier Stephen McNeil to meet with her after a 
years-long battle with the province's healthcare system. In an 
emotional video, she said she went undiagnosed for 2 years 
because she couldn't access a family doctor. By the time she 
was diagnosed, her cancer had progressed to Stage III. This is 
the face of healthcare in Nova Scotia. ``I cannot receive help 
for trauma that I experienced because of the failed system 
until sometime in July.'' That is for the mental health that 
she thinks she requires.
    Doctors for Nova Scotia replied. Tim Holland, president of 
Doctors for Nova Scotia, says this is the first time he has 
heard this kind of story. He said this experience has all the 
elements of the problems that Nova Scotians are facing with 
their healthcare system, lack of a family physician, lack of 
access to emergency care, and knowing full well that those 
emergency departments aren't equipped to be diagnosing cancer, 
are stretched thin themselves. And I would like to insert that 
for the record.
    The Chairman. Without objection.
    [The document is printed at page 246]
    Ms. Turner. Dr. Burgess, could I just say that I think we 
must not ignore what we see happening in other countries. In 
Canada, if you can't access a primary care physician, you can't 
get a referral to an oncologist. The Fraser Institute, a 
Canadian think tank, actually spends a great deal of time 
tracking average wait times. The average wait time is about 5 
months for specialty care.
    In the U.K., we see ambulances driving around London for 
hours, waiting for the emergency room to have space to let a 
patient in. When they get in, patients are often warehoused in 
hallways. I cite an example in my testimony of people dying in 
a hospital emergency room hallway waiting to get care.
    So we have to look at the experiences of other countries. 
That is how they ration care. They ration through waiting lines 
and the lack of access to surgeries, diagnostics, and new 
medicines. In the United States, we have access to almost more 
than 95 percent of all new medicines. In France, patients in 
the government system can access only half of these new 
medicines. So that sickle cell treatment you discussed earlier 
may be available theoretically, but are you going to get it if 
the government has to pay for it?
    Dr. Burgess. I need to yield back. I know I have more time 
later on.
    The Chairman. I will use my time. Dr. Nahvi had a comment.
    Dr. Nahvi. I just did want to bring something up. And first 
of all, I do want to say, Dr. Burgess, I am always impressed at 
the way medicine was practiced back then, and I always am 
thankful for the luxuries that our generation has in dealing 
with this. So I did want to say that.
    But I did want to comment on something you said about kind 
of going through the normal protocols and taking our time and 
making sure we do it right. I do think that is critically 
important. If we are going to do something of this scale, we 
have to make sure we do it right.
    But on the flip side, part of the reason I am here, because 
my patients are suffering and they are dying. So I want to 
advocate. We just need, I think, a little bit more of a sense 
of urgency. We have to go through the right channels, we have 
to do things right, and we have to take our time, but we have 
to do this with a sense of urgency that people are dying as we 
are waiting and as we are doing this, and we need to have that 
fire to keep moving, whatever the solution is. And I do think 
that is critically important.
    At the end of the day, a lot of people here have mentioned 
that this is the United States. We are the richest country in 
the world. But we are also the boldest, most entrepreneurial 
country in the world. If we decide we want to do something, we 
can do it. And I am a little bit worried that there is a lot of 
finding problems with the solution rather than finding 
solutions to the problem, as my dad would say. And I think we 
need to invest more to try to start with the starting position 
that we can get this done and we need to get this done because 
people are dying and people are suffering, and then go through 
all the right channels, as you said, and do it the correct way.
    The Chairman. Dr. Collins, I will yield to you, but I also 
would like some clarification here. We have heard that kids, 
seniors, workers, everybody would lose their coverage under 
Medicare for All. I mean, is that right? Will all of us be left 
without healthcare under Medicare for All, and how would that 
coverage be better than today?
    Ms. Collins. I mean, the way the bills are structured, 
everybody would move from the current coverage they have, for 
the most part, and into a new system of plans with more 
comprehensive benefits in many cases. So it is not true that 
people would lose their insurance coverage.
    The Chairman. Did you have a comment?
    Ms. Collins. I did want to just address the wait times in 
other countries and the rationing of care. I mean, clearly, we 
are rationing care. Insurers are rationing care right now. We 
are rationing care by leaving so many people uninsured. So it 
is all a matter of how you use that term.
    But also in other countries, we actually have wait times 
that are very consistent. In our surveys of international 
systems, we find that wait times for specialists are about the 
same as they are in the United States. In countries that have 
had wait time issues, like the U.K., they have addressed those. 
So it doesn't mean that a single-payer system there (in another 
country) is going to be the single-payer system here (that we 
develop). There are ways to address wait times, and certainly 
other countries have done that.
    The Chairman. I want to add something about the Rules 
Committee, since it was brought up that it is unusual that we 
are having a hearing in the Rules Committee. It is not so 
unusual. Actually, this is the oldest committee in the 
Congress, and we do big things. I am proud of the fact that we 
moved the Affordable Care Act forward and we insured 20 million 
people who didn't have health insurance.
    And I think it shouldn't be unusual that we do hearings. 
When we did the Affordable Care Act, the House held 79 
bipartisan hearings and markups, and we had over 239 
amendments. 121 amendments were accepted. I mean, this was an 
enormous undertaking. Is it perfect? No.
    And we contrast that to the way my Republican friends 
handled the repeal bill. It basically bypassed the hearing 
process entirely. We just came right here to Rules and then 
right to the floor. So there is a contrast here. I don't think 
hearings should be viewed as unusual or undesirable. This is an 
opportunity for everybody to be able to say what is on their 
mind, pro and con, and that is not a bad thing. And, Dr. Nahvi, 
please go ahead.
    Dr. Nahvi. Yeah. I just wanted to say one thing about 
rationing. You mentioned that we are already rationing with the 
uninsured, but we are also already rationing with the insured. 
When 41 percent of Americans felt like they needed to go to the 
ER in the past 12 months, but then didn't, and considering only 
12 percent of Americans are unemployed, that is still about a 
third of Americans that have insurance that feel they need to 
go to the ER but don't. That is rationing by any other name. 
That is self-imposed rationing, and that is part of the crisis.
    The Chairman. And, Dr. Browne, quickly.
    Mr. Barkan. Chairman, may I make a comment?
    The Chairman. Absolutely.
    Mr. Barkan. Anecdotes aside, we know that single-payer 
systems in other countries have better outcomes than we do.
    The Chairman. Dr. Browne.
    Dr. Browne. I want to thank Dr. Burgess for the support of 
the sickle cell bill and how that has come about. And yes, we 
have one new drug that was just recently approved for the 
disease.
    And speaking to Mr. Raskin's comment, I want to say that 
even though I have a niece who, unfortunately, died from colon 
cancer, she was at the age of 48 so she could not get the 
screening test, because her insurance did not cover it. She 
waited too late, and she had advanced stage disease and died.
    So, again, having Medicare for All or universal health 
coverage, would allow those individuals to get the kind of 
screening test that does not follow those guidelines, because 
at any age, if you are having symptoms, you need to be treated.
    The Chairman. Thank you. I appreciate that.
    Ms. Scanlon.
    Ms. Scanlon. Thank you, Chairman McGovern, for the 
opportunity to participate in this hearing, to help us explore 
how we continue to try to make good on a commitment to 
accessible and affordable universal healthcare. I am grateful 
for the expertise and effort that my colleagues, especially 
Congresswoman Jayapal and my fellow freshwoman colleague, 
Congresswoman Shalala, have put into introducing and analyzing 
this legislation.
    I have no question that healthcare is a human right and 
that no family should have to go bankrupt or worry about 
putting food on the table due to medical costs or have to 
create a GoFundMe page. I understand that we have to find a way 
to address what my colleague, Mr. Raskin, called the injustice 
of being unable to afford medical care when hit with a 
misfortune of medical trauma.
    You know, I have already supported measures that would try 
to lower prescription drug costs, allow Americans over 50 to 
buy into a public option, but I am trying to parse the best way 
forward from here to protect the Affordable Care Act and move 
to whatever our next step is.
    There are constituents in my district who believe that 
Medicare for All is the best path forward, and there are others 
who are concerned about how it is going to work. And those 
concerns are multifaceted. They are rooted in fear of rising 
costs, changes to their existing employer or union-based 
insurance, and for many, the impact on their jobs.
    So it is my hope that I can get some information from this 
panel to help get answers to these important questions that I 
can take back to my district as we have this critical 
conversation about what a just transition to Medicare for All 
would look like, and how we achieve that elusive universal 
coverage.
    So, Dr. Collins and Baker, when we are talking about best 
ways to get to universal coverage, including Medicare for All, 
one of the things we talk about a lot is the financial burdens 
of the current health system on individuals. So whatever we do, 
how do we address the cost of rising premiums, prescription 
drugs, copays, deductibles?
    Can you talk about the impact a Medicare for All system 
would have on those premiums, copays, and deductibles for 
individuals? Dr. Baker first.
    Mr. Baker. Well, of course, if you did go the full ride of 
Medicare for All, basically those all go away. I mean, this 
is--basically, what we are doing is taking money that we are 
paying out of our pocket, our employers paying for us, that 
will go in taxes. I mean, it is a tax increase, if people think 
that is bad, whatever. But, I mean, it is money that we are 
paying now and instead it will be paid by the government for 
these services.
    So it is--you know, it relieves that problem. There is no 
doubt about it. I mean, the question is, you know, how to do 
that in a way that is least disruptive, how to do that in a way 
that is as efficient as possible. But there is no doubt about 
it, it takes away those costs that are now borne by 
individuals.
    Ms. Scanlon. Can I follow up on that? Is there any analysis 
of how an individual's tax burden would compare to their 
savings?
    Mr. Baker. Well, a lot will depend on how you actually 
structure the tax. My friend Bob Pollin, I think it was 
referenced earlier, at the University of Massachusetts, did an 
analysis and they have a payment plan. It is, I think, a 
reasonable one, but, I mean, it really would depend on how you 
decide to pay it.
    And also, again, you know, I had emphasized this point 
earlier, getting cost down. Now, we do know we get 
administrative cost down and we could argue how much, but I 
think there is no doubt about it, we are getting rid of an 
insurance industry. We also get rid of the administrative 
expenses that hospitals, doctors' offices, other providers 
have. That is a clear savings.
    The other question is what about the other inputs. How much 
will we save on drugs? I mean, I argue we should save a lot on 
drugs because I think we pay--I mean, basically, I think it is 
absurd. Drugs are cheap. We make them expensive. That seems 
stupid to me. Same with medical equipment. And I think our 
doctors' pay should be more in line with doctors elsewhere in 
the world. But those are all things that are up for debate, how 
much do you depress those costs.
    But, again, you know, point of reference, we look at other 
countries, they pay about half as much per person on average. 
There is some range there. There is no reason we should be 
paying so much more than other countries.
    So can we get as low as the average, can we--will it take 
us 5 years, 10 years? Those are all--you know, that is very, 
very much up for grabs. But it should mean that a typical 
person will pay much less in taxes than what they are paying 
now for their healthcare.
    Ms. Scanlon. Ms. Collins. Dr. Collins.
    Ms. Collins. Yeah, I would just say--add to that that, you 
know, there are--in my testimony, there are about 10 other 
bills that provide sort of smaller steps towards universal--
ultimately towards universal coverage. And there have been lots 
of different reform approaches that have been modeled by the 
Urban Institute and RAND; approaches that the Commonwealth Fund 
has funded modeling for.
    So there are lots of ways to improve people's cost sharing 
to lower premiums. Even in employer-based plans, there are lots 
of policies for moving this more slowly. Obviously there are 
tradeoffs. The Affordable Care Act, the lesson of the 
Affordable Care Act has been that we haven't seen any 
congressional legislation to improve the Affordable Care Act 
since it was passed. So there are definitely tradeoffs.
    But I would also say for people with employer-based 
coverage, there are lots of hidden costs in employer-based 
coverage. People make wage concessions so that they can have 
employer coverage. People, contribute a lot in premiums even 
with the wage concessions, and they are seeing increasingly 
higher deductibles.
    So a movement towards Medicare for All obviously would 
replace those costs because it would do away with the employer-
based system, and taxes would rise in order to finance that. 
But for many people, depending on how you would structure the 
taxes, many people would probably see a net cost of health 
insurance go down depending on their income. So the incidence 
of taxation would matter quite a bit.
    But I think the controversy in Vermont really did come down 
to legislators not being able to explain this change of 
financing from premiums to taxes to their constituents.
    Mr. Baker. If I could also just add quickly on Vermont. You 
know, I think every one of us agree that at least the goal, I 
mean, of Medicare for All is putting downward pressure on input 
prices like drugs, like medical equipment, which certainly the 
U.S. as a consumer can clearly do. Vermont with 600,000, 
700,000 people probably doesn't have the same sort of 
bargaining power.
    Ms. Scanlon. In speaking with experts in my home State of 
Pennsylvania, they have talked about long-term care as being 
one of the big drivers in cost and an issue that we really need 
to struggle with, particularly with all of the aging boomers 
coming into the system. How does Medicare for All deal with 
that?
    Mr. Baker. Well, the plan, you know, the Jayapal plan does 
cover long-term care, and that is a major problem in the 
current system, both because it is not covered in general, but 
also, you do have this coverage under Medicaid which creates 
this absurdity where you have many people that could get by 
fine with home healthcare that is not covered, but they could 
have nursing home care that is covered.
    It is obviously a less desirable situation for that person 
and their family, if they could get by with having some minimal 
amount of home healthcare to then--rather than going into a 
nursing facility, but on top of that, of course, it is much 
more expensive.
    So it is--you know, what we want to do is provide people 
with the care they need, not have them getting care that they 
may not need, but that is affordable because of the way we have 
structured the payment system.
    Ms. Scanlon. You had something?
    Ms. Collins. And I think too there has been talk about 
people losing their Medicare. But actually, under the bills, 
the Medicare for All bills, Medicare benefits would actually 
improve substantially, including with the addition of long-term 
care and home health services.
    Ms. Scanlon. So that would be another area where there 
could be substantial savings as a result of transitioning to 
this system?
    Mr. Baker. Absolutely. I mean, you get all sort--you know, 
we have had references to this earlier. You have all sorts of 
perversions in our current system because some things are 
covered, I mean, most importantly emergency room, so people 
can't see a primary care physician, run to the emergency room. 
So that is not good healthcare, and it is an incredible waste 
of resources. The people in the emergency room should be 
dealing with emergency situations, not someone who can't see a 
primary care physician.
    Ms. Scanlon. In terms of a just transition for those whose 
livelihoods are dependent upon the current system, can you 
speak at all to how that would occur?
    Mr. Baker. It really depends on how you write in--what you 
write into the law. So can you have something where you have 
special employment benefits for people in the insurance 
industry? It would be the most obvious people who would lose 
out. I mean, I think that is a reasonable thing that has come 
up with climate change as well. So what are we going to do for 
people in the fossil fuel industry if we move aggressively to 
promote solar and wind energy.
    So I think that is a reasonable thing for Members of 
Congress to look at. I mean, it is not in here in part. You 
know, I know the Jayapal bill has, you know, support for that, 
but, I mean, again, how you structure that, you know, it really 
depends on what Congress were to decide.
    And obviously, it is a consideration that we don't want to 
see workers lose their jobs and suddenly be unemployed. Is the 
situation worse than in other industries, because, you know, 
better or worse, workers are always losing their job. I don't 
mean to be cryptic about that. I take that very, very 
seriously, but I am just saying we have to think carefully how 
does that fit in with our other benefits.
    Ms. Scanlon. Can you also----
    Mr. Barkan. Representative----
    Ms. Scanlon. Yes.
    Mr. Barkan [continuing]. May I please weigh in on the cost 
issue?
    Ms. Scanlon. Please.
    Mr. Barkan. It is very important to emphasize the following 
point: These cost savings are only possible through a genuine 
Medicare for All system. Other proposals to increase health 
insurance coverage, such as those that would make Medicare 
compete with private insurance, would not facilitate 
administrative and billing savings.
    Ms. Scanlon. Okay. I actually was just going to speak to 
that subject and whether--what you saw is the pluses and 
minuses of the proposals that we move to a public option that 
would force the private insurance companies to compete.
    Mr. Baker. Yeah. I actually am sympathetic to that as an 
interim measure. I mean, I would like to see us get to Medicare 
for All, but I laid out, you know, what would you do in a 
transition. And I said part of the story first is, you know, we 
have kind of glaring inadequacies of the current Medicare 
program. Most obviously, there is no out-of-pocket cap, which 
is something--I am embarrassed to say how long I was in 
Washington doing policy work before I realized that, because it 
is kind of like why is there not an out-of-pocket cap?
    Also, the fact that prescription drugs are--we have a 
separate drug benefit, that makes no sense. You don't have 
separate drug benefits in the private sector. Why did we think 
that made sense in Medicare?
    So having those together--and also, of course, 
Representative Woodall made reference to the fact that many 
people get Medicare Advantage. Well, part of the story is we 
are subsidizing that. So we pay about 15 percent--I think it is 
13 percent more for a person on Medicare Advantage than we 
would pay for the person with the same healthcare condition in 
the traditional plan. Those are serious problems with the 
traditional plan.
    But in terms of the savings, if you envision a situation 
where we actually fix the Medicare program, so we probably have 
instead of two-thirds of people on traditional Medicare, 
probably 80 or 90 percent. I mean, I am guessing here, but, you 
know, clearly a higher percentage. And then on top of that we 
let people buy into it, I think we are talking about a massive, 
you know, program at that point.
    And I think there would be administrative savings for the 
simple reason that what I suspect is you would have a lot of 
providers that say we don't want non-Medicare people. You know, 
we--you know, this is a huge blind spot. They might ask ``why 
do we want to deal with United Health and other insurers when 
it requires so much additional administrative staff?''
    But the point is, you know, why do we want to play with 
them when we have this huge block, we know what they are doing, 
it is standardized, we don't have to play games. So I think 
there would be large administrative savings, which is not to 
say I don't want to see us go all the way towards Medicare for 
All, but I am just saying there would be savings with the 
intermediate step.
    Ms. Scanlon. Dr. Collins.
    Ms. Collins. I think there are some very critical design 
issues too in the Medicare for All in where you set the 
provider rate. The bills propose at Medicare rates, but clearly 
some of the analyses that have been done have looked at rates 
that are somewhat higher.
    But that is also a key design issue for a public plan. And 
going with a public plan option based on Medicare, maybe 
rolling it out in certain parts of the country where there are 
very few insurance companies gives--would give us an 
opportunity to see how that would work, where you would set the 
price, and what might work the best. So that would be an 
advantage of starting with a public plan based on Medicare or 
Medicaid.
    Ms. Scanlon. And that also relates back to the chairman's 
concern that if we keep slashing Medicare and Medicaid funding, 
then it becomes more difficult to get people on the provider 
side to buy in.
    Ms. Collins. That is right, yep.
    Ms. Scanlon. Okay. Thank you. I yield back.
    The Chairman. Thank you very much.
    Mrs. Lesko.
    Mrs. Lesko. Thank you, Mr. Chairman.
    I think it is important to note that all of us, no matter 
what side of the aisle we are on, want to improve healthcare.
    The Chairman. Would the gentlelady yield just one second?
    Mrs. Lesko. Yeah.
    The Chairman. If it is okay, I think what I am being told 
is that everybody needs a little bit of a break. If it is okay 
with you, can we take a break for votes and then come back?
    Mrs. Lesko. Sure.
    The Chairman. Unless you can't come back, then we will go 
right to you.
    Mrs. Lesko. Can I come back?
    I can come back.
    The Chairman. Okay. So we are going to take a little bit of 
a break.
    Right. So we are going to take a little bit of a break, you 
know, and when votes are over with, we will come back. And we 
have a few more people to ask questions and then closing 
remarks and then we will bring this to a conclusion.
    So I thank the witnesses for their patience, but I think 
you are entitled to a break now. Thank you.
    [Recess.]
    The Chairman. The Rules Committee will come back to order.
    And before I yield to Mrs. Lesko, I just want to ask 
unanimous consent to insert into the record a statement from 
Congresswoman Norma Torres, who is on this committee, who 
wanted to be here today, but she was on a fact-finding mission 
to South America and she has encountered some unforeseen 
problems leaving the country so she can't be here. But I am 
hoping that means that----
    Mr. Cole. We had nothing to do with that.
    The Chairman. Right. I ask unanimous consent to put this 
in. But Mrs. Torres, I know, is a strong advocate for universal 
healthcare.
    [The information follows:]
    
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    The Chairman. So at this point, where we left off, I will 
yield again to Mrs. Lesko.
    Mrs. Lesko. Well, thank you, Mr. Chair. And I hope Rep. 
Torres comes back soon. That is--hopefully, she is not being 
held against her will or something.
    Okay. You know, I just wanted to say we have had a long 
discussion here, and I think members on both sides of the 
aisle--I mean, I can speak for myself and my friends on the 
Republican side--we want to solve the healthcare problem. We do 
believe that there is problems in the healthcare right now and 
that improvements can be made. But I think we should do this in 
a bipartisan fashion, because I think really big issues like 
this actually need to be done in a bipartisan fashion.
    So when I was in the State legislature in the State senate, 
I actually worked on legislation to address surprise medical 
bills, which had been brought up before. And I got everybody 
together in a room and we kind of hashed it out. It was 
controversial, but we got it done. So I think that if we did 
work in a bipartisan fashion, we actually could get things 
done, even though we disagree on certain issues. I do really 
believe it can be worked out.
    However, this bill is not bipartisan. This is a very 
partisan bill. And I am sure that you know that most, if not 
all, Republicans in the House are probably going to vote 
against it, if it gets up for a vote. And certainly, the Senate 
is not going to hear it. So, you know, I don't know why we are 
doing this, but, you know, we are, so here we are.
    So as we have discussed in this several hours here, several 
reputable studies have been--have put that the extra price tag 
to the government of a one-size-fits-all healthcare system is 
north of $30 trillion, with a T, over 10 years. And as has been 
said before, some States have already tried to implement 
government-controlled healthcare, but the price tag is too 
high.
    In Vermont, as was stated, they said no because it said 
that the payroll taxes were going to increase by 11.5 percent 
and income taxes by 9 percent. And that was enough for even the 
Bernie Sanders constituents to say no thank you to this 
government-controlled healthcare.
    Given this history and that the Federal Government is 
already running massive debt deficits and the Medicare program 
is already reaching insolvency, I think that it is unclear that 
this new bill is going to solve any of our problems, and it is 
questionable how it is even going to be paid for.
    I would like to spend some time now talking about one of 
the most successful innovations in Medicare since its 
inception, the Medicare Advantage plan programs. This bill 
would take that all away, as we have talked about before. All 
Medicare Advantage plans would be gone. And so Medicare 
Advantage enrollment has almost tripled from about 7 million 
people in 1999 to over 20.4 million people that want Medicare 
Advantage in 2018.
    The 2019 annual report of the Medicare trustees released 
last week indicates that 37 percent of Medicare beneficiaries 
are currently in a Medicare Advantage plan and that this 
percentage is expected to rise to 40 percent over the next 10 
years.
    Also, according to the Kaiser Family Foundation, 88 percent 
of Medicare Advantage enrollees have plans which include 
prescription drug coverage, and about half of these 
beneficiaries pay no premium at all, which is the case of my 
mother. My mother is on a Medicare Advantage plan. She loves 
it. She doesn't pay anything extra for drugs. And I can tell 
you that if we took this away from her, she would not be happy. 
And if we forced her into another plan, she would be confused, 
because it is difficult, as you all know, to navigate this 
whole healthcare system.
    So, I guess, I wanted to point out, I got some numbers of 
how many people in--are members here that are here present 
today have their constituents that are on Medicare Advantage 
and that would lose it under this bill.
    So the first one, the one that has the most people under 
Medicare Advantage is actually Representative Morelle. You have 
98,360 of your constituents or 66.4 percent of all the Medicare 
population has Medicare Advantage in your district. And, Ms. 
Shalala, you have 81,043 of your constituents that have 
Medicare Advantage, which makes up 60.3 percent of all the 
people on Medicare. I come in third at 75,887 of my 
constituents are currently on Medicare Advantage, which is 44 
percent of all of the people on Medicare in my district. And I 
can go on and on. But my point is, Medicare for All would take 
away all of this from everyone.
    And so my question is to Ms. Turner. What do you think 
about that? Do you think seniors are going to be happy that 
their Medicare Advantage plans are taken away?
    Ms. Turner. Medicare Advantage allows seniors to 
voluntarily, as you said, enroll in private plans that provide 
better coordinated care, integrated care so that they can have 
one plan that provides access to physician coverage, to 
hospital care, prescription drugs, vision, and dental. And MA 
plans often provide additional benefits.
    So, yes, I think seniors have gravitated to these plans 
because they give them more resources to deal with an ever-more 
complex healthcare system, and they highly value this coverage. 
And now, about 20 million seniors overall are on Medicare 
Advantage, and as you say, the number grows all the time.
    Mrs. Lesko. Thank you.
    And my next question really has to do with how the 
bureaucracy would work under this program. So I would like to 
take a few minutes to walk through what I understand the 
process a hospital would need to go through to fix a leaking 
roof under this bill.
    So let's start off with a simple example and what happens 
under the current system. The roof is leaking. The hospital 
administrator or maintenance division calls somebody out to 
inspect it. Maybe they get a couple of bids, decide on a 
contractor, and the leak gets fixed. Pretty simple.
    But what happens, as I have been told, under this Medicare 
for All bill, well, first, since the hospital has a provider 
agreement, it needs to get funds from the government's capital 
expenditure budget to fix its roof. To get those funds, they 
have to submit an application to the regional director. Once 
they submit the application, they have to wait, wait until the 
regional administrator decides to review the application. How 
long will that take? What happens to the roof in the meantime?
    But that is not the end of the process. After it goes 
through the regional director, the Secretary of Health and 
Human Services has to review the application and decide whether 
to approve the application and how much money should be 
provided.
    Now, I am sure that the Secretary of the Health and Human 
Services has many more important things to do than go through 
applications for funding of a leaking roof. So how long does 
that take? Who knows. This bill doesn't set any limits on 
either of these two review processes.
    So a hospital could be sitting for months in line waiting 
for their application to be reviewed. We all know how painful 
it can be going to DMV, department of motor vehicles, sitting 
in that line, waiting for your number to be called. Imagine 
having to go to a Federal Department of Motor Vehicle for every 
little thing you need. Need a new X-ray machine? New 
application and wait. Need to buy the software upgrade for your 
electric (sic) health records system? New application and wait.
    And every single Medicare for All provider across the 
country is going to be forced through this one system. Everyone 
will be doing a lot of waiting. We need less bureaucracy in the 
system, not more. So that is a problem I see.
    Also, Ms. Turner, you have spoken about wait times in your 
testimony in other countries who have government-run 
healthcare. Is there anything in this bill to protect the 
American people from astronomical wait times?
    Ms. Turner. There is not. And I do believe the promises 
being made about Medicare for All evoke memories of earlier 
promises--that health insurance premiums would go down by 
$2,500 a year for a typical family, that everybody could keep 
their doctor, everybody could keep their plan . . .
    It is easy to say these things, but much, much harder to 
deliver. When you wind up with a system that is promising free 
access to the system without any checks, it is impossible to 
imagine the current infrastructure being able to meet the 
demands for care without having ever-lengthening queues.
    And that is, of course, what we see in other countries and 
why the Fraser Institute keeps track of how long those waiting 
times are, and why in the U.K., people can be waiting for a 
year for surgery. In Canada, the province may run out of money 
before the end of the year. And if you had a surgery canceled 
in late November, sorry, the hospital is not doing any more 
surgeries this year. Get back in line.
    Mrs. Lesko. Yeah. And so speaking of wait times, you know, 
it wasn't that long ago that Phoenix VA Medical Center was in 
the news, in the spotlight because of really long wait times 
for our veterans at the hospital. And some of the claims were 
that veterans died while they were waiting.
    And so one of the solutions that has been worked on and was 
supported by our late Senator John McCain was that there be 
more freedom of choice for the veterans outside of the 
government-run healthcare plan so that they could go see a 
private doctor if there--the wait lines--the wait time was too 
long.
    Now, to me, Ms. Turner, does this seem like the opposite 
approach, like we are going to more government-run healthcare 
instead of allowing patient choice?
    Ms. Turner. This plan is extraordinarily comprehensive in 
bringing everybody and virtually all current systems--public 
and private--under the Federal Government's control. Even in 
the U.K., people can buy private insurance. In Canada, patients 
who can afford it come to the U.S. for care. The Mayo Clinic 
has thousands of patients coming to the United States from 
Canada. So the fact that people would have a difficult time 
finding a private option in this country under Medicare for 
All, I think, would concern many Americans.
    Mrs. Lesko. Well, thank you. It certainly concerns me.
    Dr.----
    Mr. Barkan. Congresswoman, may I make a comment about 
Medicare Advantage?
    Mrs. Lesko. Can I ask Dr. Blahous a question first, and 
then if I still have time, certainly.
    Dr. Blahous, will this bill provide free healthcare for 
illegal immigrants?
    Mr. Blahous. Well, the bill I analyzed indicates that it 
would be--the benefits would be provided for every resident of 
the United States, and it is left to the Secretary of HHS to 
basically promulgate regulations that define who a resident is. 
There is nothing in the legislation that excludes the 
undocumented immigrants from receiving benefits, so my working 
assumption was that they would be eligible for benefits, yes.
    Mrs. Lesko. Thank you.
    And as members, as we have--you already know, I come from a 
district where the number one--the number one concern is border 
security and illegal immigration. I know we all come from 
different districts, and so I can tell you that my constituents 
and I would guess the majority of citizens in the United States 
would not feel happy that they are going to be forced to pay 
for illegals that aren't citizens free healthcare.
    And so with that, I am done with my questions. And, sir, 
you had a comment.
    Mr. Barkan. Medicare for All would deliver all of the 
benefits that are currently provided for with Medicare 
Advantage. Seniors wouldn't lose the choice of paying for 
Medicare Advantage. They would receive better coverage for no 
cost.
    Mrs. Lesko. Thank you. And thank you for your comment. But 
I can tell you, firsthand experience, my mother is on Medicare 
Advantage. It took quite some time to figure out which program 
was the correct one for her, and now she likes the doctors that 
she has, she is happy with that, she doesn't like changes.
    And my understanding is that this bill would take away that 
program and require everyone, everyone, no matter what they are 
on, if they are on Medicare Advantage or not, they would all 
have to take this government-run program, and I just find that 
unacceptable. It is not based on choice. It is government-run 
mandated healthcare.
    Thank you. And I yield back my time.
    The Chairman. I know Dr. Nahvi was trying to be recognized. 
You still have 44 seconds, so why don't we yield to him.
    Dr. Nahvi. I will be real quick. So I guess one thing that 
is worth pointing out is that regarding undocumented 
immigrants, we are already providing care for them for free in 
the most expensive way possible. They are coming to the ER 
because of that 1986 law signed by Ronald Reagan, and they are 
getting care and no one can stop them, and it is the most 
expensive place to get it.
    Medicare for All would provide such that these patients who 
are already getting care would just get that care in a more 
fiscally responsible way at the primary care doctor's office.
    Mrs. Lesko. Thank you, Mr. Chair.
    And, sir, I thank you for your testimony. But most people 
in the United States are not going to voluntarily want to be 
paying for illegal immigrants' free healthcare. And so there is 
a difference between people coming here illegally and showing 
up in the ER.
    And, by the way, we have a huge crisis at the border. And I 
hope--I am going to introduce several pieces of legislation, 
and I hope that Republicans and Democrats will get on board and 
realize we have a crisis at the border and we have to mitigate 
it.
    But I can tell you, I go to a lot of different meetings in 
my district and, quite frankly, throughout the State, and there 
is not going to be anybody happy about paying their taxes for 
free healthcare for illegal immigrants.
    Dr. Nahvi. But it is not about ideology. We are already 
doing that. The only difference would be we would save money in 
doing the same thing that we are doing now.
    Mrs. Lesko. Well, we can debate this. Obviously, we 
disagree, but I can tell you, I have heard loud and clear from 
people consistently they do not want their taxes going to pay 
for free healthcare for illegal immigrants.
    Thank you.
    The Chairman. Thank you.
    I have a couple of unanimous consent requests. First, 
without objection, I would like to insert into the record a 
letter from the Washington Community Action Network, Washington 
State's largest grassroots community organization with 44,000 
members.
    [The document is printed at page 253]
    I would like to insert a letter from the Labor Campaign for 
single-payer healthcare with 15 national unions at eight State 
labor federations and a large number of local and regional 
organizations.
    [The document is printed at page 254]
    I would like to insert a letter from the Social Security 
Works, an organization which seeks to protect and improve the 
economic security of disadvantaged and at-risk populations; a 
letter from Dr. John Aldis, a doctor in West Virginia. And they 
all support Congresswoman Jayapal's Medicare for All 
legislation.
    [The document is printed at page 255]
    The Chairman. Also, Rebecca Wood's daughter, Charlie, who--
this is Charlie right there--was born prematurely. I mentioned 
this at the beginning of my testimony. She had suffered through 
more infections, surgeries, physical therapists, and injections 
than most of us deal with in our lifetime. Her medical costs 
added up quickly, and much of that was paid for out of pocket. 
The financial devastation that forced her family to make tough 
choices regarding Charlie's treatment highlights the need for 
adequate long-term care in this country.
    Without objection, I would like to insert into the record 
this story submitted by Rebecca Wood where she thanks 
Representative Jayapal for her work. In the story she says, and 
I quote: Long-term supports and services included in this bill 
are crucial to families like mine. The bill would provide 
mandatory coverage of community-based services that people with 
disabilities need and want. Additionally, it ensures that 
services are equal across geographic areas, a problem that I 
have personally had to contend with. I want that in the record 
as well.
    [The document is printed at page 258]
    The Chairman. And, Dr. Blahous, I want to thank you. This 
is a personal thing for me, but when talking about the issue of 
immigrants, you referred to this group of people as 
undocumented immigrants. I much prefer that than having people 
refer to them as illegals. It is just a personal thing with me.
    I don't think anybody in this world is illegal, but I will 
just say to Mrs. Lesko who asked why are we doing this hearing, 
I mean, we are doing this hearing because many of us, not just 
Democrats but Republicans as well, are concerned about the fact 
that we have 29 million people who do not have insurance, over 
40 million people who are underinsured, who are afraid to get 
sick because they are afraid they are going to go bankrupt, and 
we need to do better. The system that we have in place is 
deeply flawed and it is hugely expensive, and we all think we 
can do better.
    I think Medicare for All is the way to go. Others have 
different opinions. But that is why we are here. And, you know, 
I would love to come up with a bipartisan solution here, but I 
will remind my colleague that--because I have been in the 
minority for 8 years. And every time there was a bill to repeal 
the Affordable Care Act, I don't recall ever being consulted or 
ever being asked to be part of any kind of discussion on how we 
should move forward.
    And before I yield, I know Mr. Barkan had an additional 
comment he wanted to make.
    Mr. Barkan. Congresswoman Lesko, you said you are not sure 
why we are doing this hearing, given that the Republican-
controlled Senate won't pass Medicare for All. First of all, if 
you don't remember, I want to remind you that we last ran into 
each other in Arizona during your election.
    Mrs. Lesko. I do.
    Mr. Barkan. At that time, when I asked you about Paul 
Ryan's plans to cut Social Security, you had no idea what I was 
talking about.
    Mrs. Lesko. That is not accurate.
    Mr. Barkan. Well, it seems you have chosen to not get your 
facts straight today either. Why are we having this hearing? To 
keep people alive.
    The Chairman. Thank you.
    Mrs. Lesko. Thank you. Mr. Chairman, if I could respond.
    The Chairman. I yield.
    Mrs. Lesko. Thank you.
    You know, the reason that I said that statement is because 
we are going through the Rules Committee, first of all. It is 
not--this bill is not being heard in a regular committee.
    The Chairman. Well, we are a committee.
    Mrs. Lesko. And also, I would like--this is a big issue, 
and I do believe we need to have high-quality healthcare at a 
reasonable cost for patients. And I concede that we can 
definitely improve on our healthcare system.
    But something this big, what--my point was something this 
big and this major, I think both parties need to work on 
together. And we are not going to agree on everything. I 
already know this. I did pension reform in my State. I did 
surprise medical bill. I did contentious things, but we worked 
through it.
    And I know that, you know, Representative Cole has said 
that in the past here he has worked on big issues in bipartisan 
fashion, and that is what I think we should do. Now, this--I 
mean, you must concede that you don't think that this is going 
to pass because you didn't ask for input from Republicans.
    And even though we are in the minority here, the Senate is 
still Republican and you still have a Republican President. And 
so that was my comment, why I said that, because we--I would 
hope that we would work on something that is actually going to 
pass, and that is what I would like to do.
    Thank you.
    The Chairman. Thank you.
    And, again, we are the Rules Committee. We are the oldest 
committee in the Congress, and we are one of the committees to 
which this bill was referred. And I hope all the other 
committees do hearings. Unlike when my colleagues were in 
charge where there were no hearings on any of these issues, we 
are doing hearings.
    And in terms of input, everybody is offering suggestions 
and we have witnesses who have all kinds of opinions, and we 
are having this discussion. This is what you are supposed to 
do. This is a deliberative process, right.
    And I think this has been good. I think this discussion has 
been good. I don't agree with what most of my colleagues on the 
other side of the aisle have said. I think it has been a good 
discussion, and I think it needs to continue beyond this 
committee, and we are going to do that.
    Having said that, I now yield to Mr. Morelle.
    Mr. Morelle. Thank you, Mr. Chairman.
    First of all, thanks for organizing this hearing today. I 
think we have an extraordinary panel of people testifying. I 
think this is the appropriate place to begin the conversation 
around healthcare. And I would congratulate Congresswoman 
Jayapal for introducing an ambitious piece of legislation that 
has brought us together.
    This is an important conversation about a critical issue 
facing Americans--America's patients and what we must do to 
ensure that we have quality, affordable healthcare for all of 
our citizens.
    Tomorrow, May 1, I would--should be celebrating my daughter 
Lauren's 33rd birthday, but unfortunately, Lauren passed away 
nearly 2 years ago of triple-negative breast cancer.
    Doctor, thank you for all your good work on breast cancer.
    And while it is a personal tragedy for my family and 
myself, we are hardly unique. I don't think there is a member 
in this room, I don't think there is a member in this body that 
hasn't been personally touched by tragedy as it relates to 
healthcare. And we have certainly--there is no one who has not 
heard from countless citizens about the many ways in which 
their lives are touched by illness or by the difficulties in 
our healthcare system.
    After making what I consider significant progress, we are 
backsliding now because of purposeful action taken by the White 
House. At the end of 2018, the percentage of U.S. adults 
without health insurance reached a 4-year high. More than 1 
million people across the Nation have lost coverage since 2016, 
and almost 14 percent of Americans are without health insurance 
today. Those are numbers we haven't seen since the enactment of 
the Affordable Care Act.
    And this is in part because of the actions of the 
President, cut funding for the ACA, push Americans into junk 
short-term health plans, which we don't even allow in the State 
of New York where I am privileged to represent, deny essential 
services, shorten enrollment periods for families to sign up 
for coverage, create burden after burden to seek Medicaid 
coverage, and repeated attacks on women's healthcare and 
essentially family--and essential family planning services.
    The fact is, Donald Trump does not have a plan to address 
healthcare, unless you consider dismantling the Affordable Care 
Act, stripping away protections for people with preexisting 
conditions, leaving millions of hardworking Americans without 
health coverage, a plan, to say nothing of the nearly 70 
million uninsured or underinsured people in this country.
    Unlike the President, the members of this House believe it 
is critical we address the healthcare crisis head on, whether 
it is this plan or others. We can begin taking steps toward 
meaningful healthcare reform that lowers costs, improves and 
strengthens the quality of care, improve patient experience, 
the so-called triple aim of healthcare, and ensures every 
person in our Nation has coverage they can depend on.
    And I think the American public has been clear. They want 
essential health benefits, protections from annual and lifetime 
caps without discrimination based on preexisting conditions.
    And I would say that the President and many of his 
colleagues on the other side of the aisle, including Senator 
McConnell, who has indicated that the Senate, despite the talk 
about bipartisanship here, isn't prepared to even address 
healthcare until after the 2020 elections, which I consider 
reprehensible at the very least.
    I think instead we welcome the opportunity to look to the 
future and begin the work of making our healthcare system, 
which has serious shortcomings and concerns, more affordable, 
more equitable, and simpler for people in my community and 
across this country. So I think this hearing is entirely 
appropriate.
    Having said that, I--there are a number of concerns. I have 
a number of questions regarding the financing of this system, 
healthcare cost trend lines, cost containment measures, some of 
which have been talked about, provider reimbursement.
    So I would like to start perhaps, and I would ask anyone to 
feel free to respond, but I note that, Dr. Collins, you have 
talked a little bit about this, but Dr. Baker as well, the--
currently, as I look at it, we spend, according to CMS, $3.5 
trillion a year in healthcare all in, that is all payers, 
private insurance, public insurers, and my back of the 
envelope, which is not very good.
    But even if you assume the 3.5 percent increase in the CPI 
and healthcare, which is pretty low, but let's just for 
argument's sake, we would be at about 4 and 3-quarter trillion 
dollars in 2026 over the next 10 years, about $41 trillion 
healthcare spent. Most of that, as I think you know, goes to 
healthcare spends in hospitals and physicians.
    So what I am struggling to understand is--and right now, 
Medicare payroll is about, I think, $289 million out of what is 
right now a $3.5 trillion spent. So as I think about it, and I 
was trying to figure out how this works, we saw it today in The 
New York Times, the number of corporations in the United States 
are now paying zero taxes, some getting rebates, how we will 
struggle to make this work unless there is a pretty dramatic 
increase in payroll tax.
    And I recognize--I apologize for the long question--but I 
recognize that people are paying premiums now. Those premiums 
presumably would go to pay, now instead of premiums, taxes, 
which will pay for the spend. So there is clearly a movement of 
those. But there are disparities as well. Some businesses pay 
for health insurance right now, coverage for their employees; 
others do not.
    So this is not as though it is going to be a smooth 
transition. But if you could talk about how the financing would 
work, in some detail, and if you have thoughts about income 
taxes, payroll taxes, other forms of taxes or premiums to meet 
that spend.
    Mr. Baker. I will take a stab at that. First off, you know, 
there--you know, we have talked about this. There clearly are 
large administrative savings. You know, most immediately we 
know that the private health insurance industry spends about 20 
percent, in fact, probably about 25 percent of what it pays out 
in benefits in administrative cost. Whereas our private--
whereas the Medicare system, traditional Medicare system, it is 
less than 2 percent. If we use Canada as a reference point, it 
is less than 3 percent. You know, so that allows for very, very 
large savings. In addition----
    Mr. Morelle. Yeah. May I----
    Mr. Baker. Go ahead.
    Mr. Morelle. I apologize. But let me just--as I looked at 
it, the private insurance, this will help perhaps guide your 
answer, private insurance is about a third of the Medicaid--or 
of healthcare expense.
    Mr. Baker. Healthcare.
    Mr. Morelle. So about $1.2 trillion right now. And I--if 
you estimate 18 percent savings, which is I think what others 
have talked about, translates to about $214 billion. So I will 
give you that. So--but I want to talk about the tax. So let's 
take that out of the mix, but you still have a--even if you----
    Mr. Baker. Right.
    Mr. Morelle. Even if you could realize all $200 billion, 
you would still be at a $3.3 trillion spend. So let's--I will 
give you that----
    Mr. Baker. Okay. But there is also--and I am not trying to 
avoid your question. There is also administrative costs that 
are incurred by hospitals, by doctors' offices, other 
providers, which would largely go away. They don't go to zero, 
but, again, comparing the U.S. to Canada, and there is research 
on this, our providers pay much more. So that would be 
additional savings.
    I also--you know, and I talked about this in both my 
written testimony and my oral comments, we do have to reduce 
payments to providers. There is no--you know, we pay twice as 
much for our drugs, for our medical equipment, for our doctors. 
You know, how much do you get those down, you know, you could 
argue on that. But I do think we have to get those closer in 
line to the rest of the world.
    Now, how do you get the rest of the money? To my view, I 
think a payroll tax has to be a very big part of the picture, 
because basically, healthcare premiums that are paid by 
employers are very similar to a payroll tax now. And as you 
point out, many employers don't pay that. Well, I think that is 
a problem, you know.
    So, you know, just as we have had other mandates on 
employers and, in fact, we do have mandates on employers in the 
Affordable Care Act, then, you know, I think you would in 
effect have to do that with--you know, in effect, a payroll tax 
would be equivalent to a mandate. So I think that would be the 
biggest chunk.
    I would also look--and, again, obviously this could be done 
a thousand different ways towards, other forms of progressive 
taxation where you would disproportionately have high-end 
earners, whether it be income tax. You know, there is Senator 
Warren running for President who is proposing a wealth tax. I 
think there is problems with that. I don't think you want me to 
get into that. But I think we can get more taxes from high-
income people who have been the big winners in the economy over 
the last four decades. So----
    Mr. Morelle. Okay. I appreciate that.
    Anybody have anything that they would like to add relative 
to the--how we pay for this?
    Ms. Collins. I will just jump in real quick and just make 
the point I made earlier about the significant cost growth that 
is occurring from provider prices and private insurance. So 
that is a key growth push in the healthcare system right now.
    Mr. Morelle. Yeah. And you answered that earlier, and I 
wanted to just understand a little better what you said. As I 
sort of think about it, and this is borne by the experience of 
talking to hospitals, physicians, other providers in my 
district and around New York, is that essentially the public 
payers, Medicare, Medicaid, CHIPs, and other programs, are too 
low for providers, and essentially the commercial world of the 
private insurance, whether it is self-insurance or the 
commercials, essentially subsidize payments to allow providers 
to be successful.
    Did you--but you said something earlier that I thought was 
at odds with that or--and I didn't really understand that.
    Ms. Collins. Right. So that--so I will just--yes. So the 
literature on the cost shift, which is a cost shift from lower 
payments in Medicare program and Medicaid program, are made up 
by higher prices in the----
    Mr. Morelle. Correct.
    Ms. Collins [continuing]. In private insurance. The 
literature really does not show that.
    A study that was done in Colorado on this issue found that 
the higher margins that providers were getting--the higher 
prices providers were getting in Colorado were going towards 
more administrative costs, higher margins, buildings, other 
things like that. There wasn't evidence that there was a cost 
shift. The prices were not going to fund their lower rates on 
Medicare.
    Mr. Morelle. So would your argument be--I am sorry.
    Ms. Collins. And there is an enormous amount of literature 
showing that too.
    Mr. Morelle. So would your argument be that we could pay at 
Medicaid or Medicare rates and not substantially affect the 
quality of providers or that we would not impact their ability 
to provide service?
    Ms. Collins. You know, I think that they--so the--so a key 
thing about the healthcare market that is so different from 
every other market is that prices drive costs in this market. 
Costs in other markets drive prices, so prices are a fair 
reflection of the cost of production. In healthcare, and 
particularly in private insurance, we choose the prices we want 
to pay. We choose the cost level we want to be at.
    So the--we know there is huge amount of evidence right now 
that the major growth in healthcare costs is occurring in what 
we pay providers and private insurance. If we want to get 
control of our healthcare costs, we have to start focusing on 
that issue. And this----
    Mr. Morelle. So----
    Ms. Collins. What these bills have done----
    Mr. Morelle. Yes.
    Ms. Collins [continuing]. Is bring this issue up.
    Mr. Morelle. The--so that--and I--some of you have looked 
at other health systems around the world. You know, in 
Rochester, it would not be unusual to pay a neurologist, a 
neurosurgeon 3 quarters of a million dollars or more, and we 
are not one of the higher costs compared to some other metro 
areas. What would be a comparison to what a surgeon of that 
kind would get compensated for in another place? Canada? Great 
Britain? Anyone know?
    Mr. Baker. Odds are it would be closer to $200,000, 
$250,000. They would be getting compensated considerably lower. 
Now, you know, I have had arguments with doctors about their 
compensation because they all think they get too little, but, 
you know, they don't pay for their education, for the most 
part, in other countries. I mean, to my view, that is not 
closely offsetting, but, you know--but they don't--that is a 
point to keep in mind.
    Mr. Morelle. Yeah. I want to talk just a little about----
    Mr. Barkan. May I comment, Congressman?
    Mr. Morelle. Yes, sir.
    Mr. Barkan. I want to say you are asking good questions. It 
is important to ensure we have a clear way to pay for such an 
ambitious policy proposal, but we are the richest country in 
the history of the world. We pay for far more expensive things 
like wars of choice. We can afford to do this. We just need to 
decide to make it happen. It is a political challenge, not an 
economic one.
    Mr. Morelle. Well, I appreciate that very much. And I agree 
with you that this is ultimately about what people are willing 
to do, but there are challenges to doing this and there will be 
disruptions in the marketplace. But we would--if we didn't go 
into it with a clear-headed view of what this will mean, then I 
think we are doing a disservice to have this conversation 
without talking about that.
    I do want to talk--and I apologize, I only have just a 
couple minutes left. As it relates to cost containment, 
utilization issues, I was involved in a practice transformation 
grant that we got from the Affordable Care Act I chaired back 
in Rochester called the Rochester Health Innovation 
Collaborative, where we embedded essentially case managers that 
were nurse practitioners that worked on social determinants of 
care, really tried to drive down the cost curve for--
particularly for older, chronically injured or chronically ill 
individuals.
    We had some success. I am not really sure where I see the 
pressure to do that in this system. This is--from my mind, 
unless you have a different view, this is essentially a fee for 
service. Not sure how utilization declines or how you get 
better coordinated care, because I don't see incentives to do 
that, but perhaps in the last moment or so folks could comment, 
anyone on the panel.
    Dr. Browne. Yes. Thank you so much for the question. I 
think if you are looking at the plan and the comprehensiveness 
of the services that you are going to provide, it behooves the 
plan to have those coordinators that are part of it that is 
going to go out, and whether it is community health workers in 
cancer, of course, we call them navigators, that is going to 
make the patients understand how to utilize the system in a 
more appropriate way.
    So you are talking about a patient-provider partnership and 
you are going to bring about better care. You are looking at 
whether you are providing them nutrition and food services, 
exercise programs----
    Mr. Morelle. Well, and I--and I don't mean to cut you off. 
I think that those are all great, and I agree with you. The 
goal here ought to be try to reduce the healthcare spend or at 
least bend the cost curve down, and you can do that with some 
of those things.
    I am just not sure that I see in a fee-for-service system 
that this essentially moves to where the incentives are to do 
that. I am not sure who provides that kind of coordination, 
because I don't see an incentive in this. I just see fee for 
service. I am really afraid of that because I think it blows 
out potentially the long-term healthcare trend lines in terms 
of cost.
    Dr. Browne. Well, I am looking at it sort of in a prepaid 
way so you have incentives built in the program. If you are 
basing it on the kinds of system that we have in TRICARE or you 
are looking at--and, again, that is a large integrated health 
system, or even some of the services that is provided under the 
VA, so you focus more on the preventive aspect of it.
    You want to keep--and TRICARE and all services want to keep 
our patients out of emergency rooms, and so you build in 
emergency care facilities, you then expand your hours, you get 
those people to practice prevention. And, again, that is not 
utilizing the costs that is there, and then they can get an 
incentive for keeping people well and healthy.
    Mr. Morelle. Well, and I completely agree, if there is a 
system that allows us to do that, and I am not sure this 
entirely sets up the incentives----
    Mr. Barkan. Global billing is exact--global billing is 
exactly how we bend the curve. No more fee for service.
    Mr. Morelle. Well, I agree. I am just not sure that this 
proposal contains that, but--and if it does, what do you do in 
a metro region when you exceed your--I apologize, Mr. Chairman. 
I know I am--exceeded my time. But I appreciate your thoughts 
on it.
    The Chairman. Did you want to finish your thoughts?
    Ms. Collins. Yes. I am just going to say one more thing. 
Medicare has been a leader in innovative payment practices for 
providers in accountable care organizations. I mean, there is 
no reason why those kinds of innovations could be brought into 
a bill like this.
    Mr. Morelle. But haven't those largely been done by some of 
the private insurers that create the programs around Medicare 
because you use private insurance right now to do it? I would 
love to talk to you maybe offline.
    Mr. Chairman, I apologize for taking up time.
    The Chairman. All right. And I would yield to Mr. Cole 
because he has some unused time.
    Mr. Cole. Thank you very much. I appreciate that, Mr. 
Chairman.
    I only have a couple minutes here, so I am going to kind of 
move you along pretty rapidly. Forgive me for that.
    Committees of primary healthcare jurisdiction right now are 
literally moving legislation that would make fixes to the ACA. 
And some of that legislation literally could be here in the 
next few weeks in front of this committee.
    So my question is this, and if you can, give me a yes or 
no, I would appreciate it. And I will start with you, Ms. 
Turner, is do you support abandoning the--these committee 
efforts to reform the ACA in favor of Medicare for All?
    Ms. Turner. You know, the Trump administration is trying to 
do a lot of things to give people more choices who have been 
shut out of the market. Some of them are options such as short-
term limited duration plans----
    Mr. Cole. I have got to ask for a yes or no or I am not 
going to be able to get all the way through the panel.
    Ms. Turner. So should they--should the----
    Mr. Cole. Should they abandon those efforts and focus on 
Medicare for All, or should we keep moving with the efforts to 
fix the ACA?
    Ms. Turner. I think we should try to do what we can to fix 
the ACA, both through administrative and legislative authority.
    Mr. Blahous. I agree.
    Dr. Nahvi. I think that is a false choice. I think we could 
do both.
    Mr. Cole. It is really not a false choice. There is only so 
much time up here, and there is only so much bandwidth to 
actually move something that become law. We can have--we have 
debated a lot of legislation this year that is not going to 
become law. We have a chance, I think, to make some fixes that 
we probably all agree on in a bipartisan sense. So should they 
continue to prioritize working on that?
    Dr. Nahvi. If you need more bandwidth, I am happy to help. 
I know a lot of citizens that would sign up for this.
    Mr. Cole. I appreciate that, but I don't think that is 
quite within your power legislatively.
    Dr. Browne. Universal health coverage is one way to fix it.
    Ms. Collins. I think that there are a lot of good ideas on 
the table and many bills that would move the system towards 
universal coverage, and even small little fixes could help 
millions of people.
    Mr. Cole. Mr. Barkan.
    Mr. Barkan. Both, please. Thanks very much.
    Mr. Cole. Okay.
    Mr. Baker. Yeah, if you could do fixes that would move the 
situation forward, do them, but I just don't see this coming at 
the expense of a comprehensive solution.
    Mr. Cole. Well, I am out of time. Could I ask one quick 
question?
    The Chairman. Absolutely.
    Mr. Cole. Okay. You are very kind, Mr. Chairman.
    Mr. Blahous, let me ask you this, is Medicare going broke 
now?
    Mr. Blahous. The Medicare Hospital Insurance Trust Fund is 
projected to be insolvent in 2026. That is actually less than 
half of Medicare. The other half of Medicare, by definition, 
cannot go insolvent because it is statutorily constructed so 
that you always give it enough money, but it also has financial 
strains going forward. So both sides of Medicare are in 
trouble.
    Mr. Cole. Let's fix what we have got first before we launch 
into a new system. I mean, I think there is a lot of risk 
involved in this when we have a system that millions of 
Americans depend on that is going broke right now under the 
current financing mechanism we have.
    Thank you, Mr. Chairman.
    Mr. Baker. Before the Affordable Care Act it was projected 
to go broke in 2019, this year.
    Mr. Cole. It suggests to me that we should be working on 
that, not Medicare for All.
    The Chairman. I yield another 2 minutes for Mr. Woodall.
    Mr. Woodall. If you are offering, Mr. Chairman, I accept. 
Thank you. And if I could ask unanimous consent, Mr. Chairman, 
I have got a letter from the Partnership for Employer-Sponsored 
Coverage that I would like to have entered into the record.
    The Chairman. Without objection.
    [The document is printed at page 261]
    Mr. Woodall. As you would imagine, they support employer-
sponsored coverage.
    And, Dr. Collins, I just wanted to clarify. I think in 
response to a question the chairman asked you about plans going 
away, your response was it is not true that anyone would lose 
their insurance coverage. I think we so often conflate 
insurance coverage and healthcare access.
    I think what is actually true is everyone would lose their 
insurance coverage because health insurance would no longer 
exist in America. Healthcare would exist in America. Am I 
misunderstanding the dynamic?
    Ms. Collins. Well, this is a single-payer insurance plan so 
people would have access to a set of benefits, and that would 
give them access to healthcare. I guess maybe I am not 
understanding your question.
    Mr. Woodall. Well, let me go to one of our actuaries. The 
reason the trust fund is going to be insolvent isn't that we 
are planning to stop providing care to people. It is that we 
have prefunded it through payroll taxes. There is no insurance 
out there. We just have a pot of money, and we are using that 
pot of money to pay for every claim that comes through the 
door. We are no longer insuring against risk; we are 
indemnifying folks with first dollar coverage.
    Mr. Blahous. You are talking about under Medicare for All?
    Mr. Woodall. Under Medicare today.
    Mr. Blahous. Right. I mean, you are basically providing 
first dollar provision of the entirety of people's healthcare. 
So, right, in a sense you are not insuring them against the 
risk of a large future health expense or an unforeseen event. 
You are basically providing payment for every service, routine 
and large.
    Mr. Woodall. And I wasn't trying to wordsmith. I am just 
saying there is a different set of challenges to fix the 
insurance system than to fix ``I am sick and I can't get access 
to care'' system. I have not heard Mr. Nahvi care two hoots 
about solving problems for insurers. He wants to solve problems 
for patients, a different challenge.
    Tell me, from a financing perspective--I appreciated Mr. 
Morelle's questions. We serve on the Budget Committee together. 
We are not paying for the promises we make today. We are not 
paying for the wars we are in. We are not paying for the 
healthcare promises we make. I have got $3 trillion in revenue, 
$4.5 trillion in expenditures. I am happy to spend my 
children's money, but apparently it is not important enough to 
me. I do think it should be important enough to us. This is an 
issue that is important to all of us.
    What is the order of magnitude that your numbers suggest we 
would have to increase our individual citizen contribution to 
pay for Medicare for All?
    Mr. Blahous. Well, again, on the national level, we are 
talking somewhere between $32 trillion, $38 trillion in 
additional funds provided to the Federal Government. On a per-
capita basis, that is about $10,000 per head.
    Now, to your other point, we have a very substantial 
financing shortfall in our current Medicare system, and we have 
not figured out how we are going to finance that yet. That is a 
much more manageable problem than trying to finance what is 
called Medicare for All. It is actually sort of a national 
single-payer system that differs from Medicare in many ways. 
But that is several orders of magnitude more difficult than 
financing current Medicare, which we have not yet figured out 
how we are going to do.
    Mr. Woodall. And that shortfall is not a Republican or 
Democratic shortfall. That is just an American shortfall. When 
you are talking about your numbers, these aren't Republican or 
Democratic numbers. There are conservative groups who are 
computing those scores and liberal groups computing the same 
order of magnitude?
    Mr. Blahous. The estimates are remarkably consistent, 
regardless of who makes them. I provided a table with my 
written testimony that shows if you adjust for the years being 
estimated and particular assumptions for administrative costs 
or drug costs or provider payments, you can basically get a lot 
of these different estimates to line up. And they are pretty 
much all in the same ballpark.
    Mr. Woodall. I am afraid I am out of time. I would welcome 
my chairman's indulgence, but in the----
    The Chairman. But we let you go on for 2 minutes.
    Mr. Woodall. I thought I had abused it already.
    The Chairman. Before I yield to Ms. Shalala, let me just 
say one thing, two things. First of all, Dr. Baker is going to 
have to leave at 3:10, so I don't know if there is anybody who 
has an urgent question for Dr. Baker. He is going to have to 
leave. He has got a hard stop. Thank you.
    Let me just say one other thing. You know, the question, 
should we fix the Affordable Care Act, or should we do Medicare 
for All or single comprehensive; I believe we can do great 
things here if we want to, right? We can walk and we can chew 
gum at the same time. When we have an ACA fix ready to go that 
will help more people, we should pass it. But that doesn't mean 
you can't do more. We ought to be able to go on both tracks. I 
refuse to believe that we are incapable of doing great things. 
Look at our history, at what we have done. Medicare is a great 
thing, right? Social Security is a great thing. We don't have 
to be picking and choosing. We can be doing both.
    And to my colleague, Mr. Woodall, I think I know what he is 
trying to do. He is trying to get a sound bite out here to say 
that people are going to lose their health insurance, you know, 
to add to the----
    Mr. Woodall. Mr. Chairman, I don't believe you are 
suggesting that my goal here is to get a sound bite on an issue 
as important as this one. I mean, I hope that is not your goal.
    The Chairman. I hope I am wrong. I am simply saying that I 
think what is motivating us here is the fact that the system we 
have right now is deeply flawed and that we have 29 million 
Americans without insurance, over 40 million Americans 
underinsured. People are afraid to get sick. They are afraid to 
take their doctor's advice. There is something terribly wrong, 
and we need to fix it.
    I know this is politically a hazardous topic to go down the 
road on, but we have to do it. I believe that this is a 
political condition, what we are faced with right now, because 
we can fix this. We have the resources to fix it. We have 
everything we need to fix it. It is whether we have the 
political will to fix it. And we will see whether we do or not. 
I hope we do, and that is why I think we can do small fixes, 
and we can do a larger piece here. Let me yield to Ms. Shalala.
    Ms. Shalala. Thank you, Mr. Chairman.
    I actually think this has been a very smart hearing with 
very smart people and very good questions. So I want to thank 
all of my colleagues. The truth is if any of us had a chance to 
sit down and establish a healthcare system from scratch, none 
of us would have designed the system that we have.
    It is a system in which we have cobbled together over the 
last half century or so a number of programs to fill gaps. Some 
people may call them incremental, but I don't consider Medicare 
and Medicaid or the Children's Health Insurance Plan or the 
passage of Medicare part D in the mid-2000s or the passage of 
the Affordable Care Act small steps.
    We Americans are not afraid of giant steps. And certainly, 
Congress has demonstrated over and over again that they have 
the backbone to take on big problems, put their arms around it 
and try to find a solution. In fact, that Affordable Care Act 
actually extended the Medicare, the HI fund by 8 years once we 
established it because it offset a lot of costs that would have 
otherwise been there.
    I want to see more changes in the healthcare system. I want 
to get to the place where Ady's family does not have to pay 
$9,000 a month to allow him to live at home with his wife and 
child and where patients are not walking out of Dr. Nahvi's 
emergency room with treatable conditions. We need that kind of 
healthcare system.
    I am for universal care. We have spent a lifetime filling 
in the blanks where the private sector couldn't fill in the 
blanks. Government has stepped up for the working, for working 
folks, for the poor, for senior citizens time and time again. 
But now what we have got is a system in which we thought the 
employer-based system was going to be the core of healthcare 
forever in this country. We adopted it after World War II. The 
unions bought into it. But it is deteriorating.
    And anyone that has talked to employers or has looked at 
the statistics sees a deterioration of the employer-based 
system. I know that. I have been an employer. I have sat on 
corporate boards. CEOs are struggling with trying to predict 
their healthcare costs for the future. And what have they done? 
Most of us have shifted more cost to our employees, increased 
the deductibles. In fact, high deductibles have become the norm 
here in this country as we have tried to contain healthcare 
costs with very crude instruments.
    Throughout all of that, Medicare in many places in many 
ways has been a star, because it has been better at reforming 
costs, at trying different kinds of reforms, but more 
importantly, from my point of view, at containing cost. But I 
am perfectly willing to debate the cost issue and how we are 
going to pay for it.
    But we are here because the employee system is 
deteriorating in front of our eyes, as our companies have 
changed and as we have moved to a gig economy, as we have 
gotten smaller and smaller companies, as they have lost their 
leverage, and because we want better outcomes, because we pay 
twice as much as anyone else in the world for our healthcare.
    I am far more interested in focusing on outcomes and how we 
get to outcomes and how we get an integrated health system. But 
I am for universal care. I think Medicare for All is one way of 
getting there. And looking at the VA and its integrated care 
system, at TRICARE, at the military healthcare system, we got 
lots of experience.
    And I am not afraid of transferring our system if that is 
what we decide to do because we have got platforms. We have got 
lots of experience in taking large-scale problems and 
integrating them, and we have got lots of platforms. Medicare 
happens to be one of the platforms that we could do it. I could 
build the system. I don't think I could do it in 2 years, but 
certainly our experience in the public system of taking 
advantage of platforms and extending it to more and more people 
is certainly possible.
    Dr. Collins, I would really like to start with you, though. 
I have some questions. Private insurers have been less 
effective at controlling costs than Medicare itself. In fact, 
private sector costs have gone up faster. You have talked about 
that a little bit, but you haven't explained the reasons for 
it. Is it because they are a smaller part of the market than 
Medicare is? Could you talk us through the reasons why the 
private sector--before we laud the private sector, let's talk a 
little about the deterioration as well as the failure of the 
private sector to be able to control costs themselves.
    Ms. Collins. Great question. One of the main reasons that 
we are seeing the price increases that we are seeing across the 
country in private insurance is the fact that prices are set 
through private negotiations between providers, hospitals, and 
insurers. And so providers, particularly in concentrated 
markets, have a lot of leverage to increase prices.
    Ms. Shalala. This is the complaints that hospitals have 
that they don't have enough docs to negotiate with, right? They 
don't have options?
    Ms. Collins. Right. So insurers want a hospital in their 
networks because it makes their networks more valuable. So then 
that cost then gets shifted to the employers. So the employers 
have a higher premium than they might otherwise have, and they 
share those costs. They try to lower those costs, those premium 
costs, by increasing deductibles for employees.
    Employees are already making wage concessions, but they are 
having to have benefits with higher deductibles that actually 
give them less coverage. That is really kind of a simple way of 
looking at how prices are determined and how that kind of 
filters through the system and hurts employees, particularly 
employees at the midrange of the income distribution.
    Ms. Shalala. Dr. Blahous, do you have anything to add to 
that, in terms of why the private sector has more trouble 
negotiating cost containment?
    Mr. Blahous. I really don't. I will be brutally honest, 
perhaps not that informative, but when I was doing the research 
for my paper, I found this area bewildering. I think Dr. 
Collins has a clearer view of the literature than I do. But 
obviously, I became informed in the course of the research of 
the paper about the discrepancies in payment rates between what 
Medicare pays and what the private sector pays, and I ran into 
a lot of conflicting explanations as to what was going on and 
why it was going on and what would be the consequences of 
making various changes.
    I ultimately concluded that it would be a fool's errand on 
my part to venture too far into there and try to explain what 
was going on. So, instead, I simply just flagged the issue. I 
noted where the payment rates are for private insurance 
relative to reported hospital costs, where Medicare's are. I 
flagged the issue, identified it, and noted some of the 
conflicting interpretations out there, but I fell well short of 
being able to explain it.
    Ms. Shalala. Do you, any of you, do you know very much 
about--I sat on the corporate boards, and one of the things 
that was apparent to me, particularly on healthcare boards, is 
that they are following the Medicare decisions on payment, that 
it is not the private sector setting up their own group to 
decide how much to pay; they are actually watching Medicare 
very carefully, and in many ways, Medicare is driving that 
cost. Is that your experience as well?
    Ms. Collins. I will just jump in really quickly, but I 
think it goes to Congressman Morelle's question about Medicare 
and how it could lead in innovation in payment, bundled 
payment, all kinds of different ways of lowering healthcare 
costs. So it has been a leader. The Medicaid program has been a 
leader in lowering healthcare costs. There is not a lot of fat 
in the Medicaid program or the Medicare program. In fact, what 
is really driving cost in both those programs is enrollment 
rather than prices in the private--in the commercial market.
    Ms. Shalala. Do you know a way in which, without an 
integrated system, we can get better outcomes? Is there any 
experience in this country in getting better outcomes without 
an integrated system? It seems to me that the VA has better 
outcomes. TRICARE has struggled with outcomes, but have done a 
pretty good job, as has the military healthcare system.
    Dr. Browne. But both of those are sort of integrated 
systems. So I don't think there is one that is not an 
integrated system. And I do want to add the comment, in terms 
of the Medicare costs, particularly for Mr. Cole, when you 
set--and I will just use the drive-by mastectomies that they 
had for a while, where patients had to stay in the hospital for 
a short time, get this procedure and go, so that you could 
lower the cost for those hospitals. The outcomes have been very 
different. They send patients home when they have congestive 
heart failure and some of those issues, and then the plans are 
penalized because, within a certain time period, those patients 
are coming back to the hospital. It is really not a cost 
savings under that program.
    You have to, again, practice better healthcare if you are 
going to lower those costs, and that is an integrated system.
    Ms. Shalala. There is no question that Medicare Advantage 
has provided some integration, depending on the plan. And 
certainly in Florida, in my district, over 60 percent are in 
Medicare Advantage plans. They feel like it. But we are paying 
more for it. We are walking and we are paying at least 13 
percent more for Medicare Advantage to get some integration, 
but it is still pretty fragmented when it comes to referrals 
for specialists.
    And that is, it seems to me, where the system breaks down 
because Medicare Advantage, often the HMOs come together, but 
they are mostly providing primary care and then contracting for 
the specialty care and contracting with as low cost as they 
possibly can for the specialty care.
    But I haven't seen the outcomes research on Medicare 
Advantage. Have any of you seen that outcomes research on 
Medicare Advantage? As far as I know, the research has not--
even though we are paying more and people may be happier 
because they are going to one place, I would argue that 
Medicare Advantage is as close to Medicare as we are going to 
see--Medicare for All as we are going to see, but we don't know 
very much about the outcomes yet. And I assume that that is 
your experience as well.
    And. Finally, let me give Mr. Barkan a chance to talk a 
little, again, about this fragmented healthcare system. How 
many interactions have you had to have with your private health 
insurance system in a month? Can you give us a feel for that?
    Mr. Barkan. Maybe 5 or 10.
    Ms. Shalala. You must be the best friend of your insurance 
company. These are all appeals, I assume, for them to cover 
more quickly?
    Mr. Barkan. I cost too much.
    Ms. Shalala. Mr. Barkan, of all of the people I have met on 
this Earth, you are the last person I would use that for. Thank 
you.
    Mr. Barkan. Congresswoman, I want to say how important your 
voice is in this debate. As Chairman McGovern said, this is a 
question of political will. Many Democrats are going to follow 
your lead on this, so I just want to plead with you to summon 
all the courage you can and help lead our country to a more 
rational, just, and humane system.
    Ms. Shalala. Mr. Barkan, I will try. I will try.
    Thank you very much. I yield back my time.
    The Chairman. Thank you very much.
    I yield back to Mr. Cole.
    Mrs. Lesko. Thank you, Mr. Chairman. One second, please.
    You know, Mr. Chairman, as I was thinking about this, I 
thought of the different, like fire, police, teacher unions and 
associations that negotiate their health plans, and sometimes 
it takes them years to get what they want. And they often trade 
better health plans in lieu of higher wages or salaries and 
other things.
    And so, Ms. Turner, would this bill take away the current 
healthcare plans negotiated by let's say the teachers' unions?
    Ms. Turner. Yes, it would. And I think one of the concerns 
that would be raised is the compensation that workers have 
forgone in order to get those benefits. Many believe that could 
be very, very disruptive, and it is something that would be of 
particular concern because union members make considerable 
sacrifices in their take-home pay in order to get their 
generous health benefits.
    Mrs. Lesko. Thank you, Ms. Turner.
    And, members, I am just actually a little surprised that 
some of my colleagues would--you know, understanding that these 
different unions--fire, police, teachers--negotiate a lot, and 
I know they do because they came to me when I was in the State 
legislature, and take away that and replace it with a one-size-
fits-all government-run plan.
    Thank you, and I yield back.
    The Chairman. I acknowledge Congressman Chuy Garcia from 
Illinois who is here, and we want to thank him for coming by.
    I yield to Dr. Burgess.
    Dr. Burgess. Thank you, Mr. Chairman. Let's talk just a 
little bit about global budgeting and what it means. So, if you 
have a budget and you have more expenditures than your budget, 
what happens?
    Mr. Blahous. Well, then you are going to have to cut 
something. You are going to have to--you have to cut the excess 
or restrict what you are paying.
    Dr. Burgess. So can you envision a system where that would 
perhaps result in the rationing of care?
    Mr. Blahous. Well, yes. And if I might elaborate a little 
bit----
    Dr. Burgess. Please.
    Mr. Blahous. There has been some discussion here about the 
effects of Medicare for All upon the demand for services. The 
economic literature is actually very, very clear and unanimous 
on this point. People do use or demand more health services 
when their insurance covers more.
    There was a very famous Rand insurance study several 
decades ago that demonstrated that when there is no cost-
sharing, people utilize more services. There was a more recent 
study by Cabral and Mahoney about what happens when Medicare 
beneficiaries carry Medigap insurance that has first dollar 
coverage. Costs of the benefits that they claim goes up by 
about 22 percent.
    So these are very real, very well-documented effects. So we 
would expect to see a very significant increase above and 
beyond currently projected health services under Medicare for 
All. So I am sorry, but just to quickly wrap up, when at the 
same time we are going to have various constraints upon supply 
because of the provider payment reductions. We don't know how 
those things will be balanced. The Urban Institute found there 
would be some insufficiency of supply to meet demand. I didn't 
have the ability to model that, but clearly something would 
have to give.
    Dr. Burgess. Something would have to give. I agree. And I 
am going to assume that the supplemental, Medicare 
supplementals have to go away under this bill that we are 
discussing today, I mean, because they would be duplicative 
and, by law, they would be unavailable to people, though it is 
not clear what the punishment would be for violating the law. I 
get that.
    So, Ms. Turner, let me just ask you, on the innovation 
side, new products, new drugs, new treatments, new devices come 
to market. I got to tell you, I mean, I deal a lot with people 
who are affected by coverage determinations by CMS. So what 
happens to a patient? Do they have to just wait until the next 
budget cycle if there is one of these new CAR-T therapies or 
new sickle cell therapy? They just have to wait until the next 
budget?
    Ms. Turner. That is certainly what we see in Europe. We see 
that access to the most innovative and oftentimes the most 
effective medicines absolutely are restricted. As I said 
earlier, we have access to about 96 percent of new medicines 
over the last 11 years in the United States. In France, they 
only have access to about half as many new drugs. In Singapore, 
only 18 percent.
    So other systems do provide chemotherapy, for example, but 
it is less likely to be with the newest and best chemotherapy 
drugs. And then innovation is crippled. We see in Europe that 
their formerly robust pharmaceutical, medical development, 
medical device industries have shrunk because of highly-
restrictive payment policies in Europe.
    The U.S. now is the medicine chest for the world. Most new 
drugs come from the United States because we continue to pay 
for them. We pay for research for the planet, and people object 
to that. But those new medicines are available because of the 
incentives that the companies have to continue to produce those 
new medicines. And without that, I think we would find that we 
have older drugs and leaky hospitals.
    Dr. Burgess. Right. And, of course, Cures for the 21st 
Century, an Energy and Commerce product, really moved the 
needle on that and Congress should be proud of that work.
    So, Ms. Turner, if current medical care and hospital 
provider rates are mandatory rates set for all health services, 
that is going to have an impact on patient access, correct?
    Ms. Turner. Actually, the CMS actuary said that under cuts 
similar to those propose in Medicare for All, many hospitals 
would be forced to cut back dramatically on services, on 
operations, and some would have to close. Many physicians' 
offices would be operating in the red. So yes, and this is not 
us issuing this warning. This is the CMS actuary looking at the 
potential impact. Many medical facilities simply wouldn't be 
able to keep their doors open under the dramatic payment cuts 
required under Medicare for All.
    Dr. Burgess. True story, personal experience. If you are 
losing money on every patient, you can't make it up in volume. 
I learned that in the 1980s.
    So, Dr. Blahous, you have made some assumptions regarding 
provider cuts. Is that correct?
    Mr. Blahous. Yes. Well, I have examined what was in the 
text of the bill, yes.
    Dr. Burgess. So someone asked a question about provider 
rates in other countries. Here is an op-ed from The New York 
Post, and I am going to ask unanimous consent to put it in the 
record.
    The Chairman. Without objection.
    [The document is printed at page 264]
    Dr. Burgess. Enrique Padron. In Cuba, doctors make the 
equivalent of 25 cents an hour, teachers 21 cents an hour, and 
pharmacists 8 cents an hour just for your reading pleasure.
    So, Ms. Turner, in the first quarter of last year alone, 
Britain's National Health Service canceled 25,000 surgeries. Is 
this a problem for a one-size-fits-all system?
    Ms. Turner. It is a problem when you have a strict global 
budget, forcing hospitals to make decisions about canceling or 
delaying surgeries, and people are seriously impacted. And once 
again, patients in other countries with government-run systems 
have access to fewer of the new treatments. If you are in a 
private system, you do have access to more of the new 
treatments, better surgeons. If you are in a public system, you 
may not even know it, but you will have fewer options.
    Dr. Burgess. And, I mean, I do have to bring up the issue--
and we talked about this offline a little bit--of patient 
autonomy. I have got a paper, Mr. Chairman, I would like to ask 
unanimous consent to put in the record----
    The Chairman. Without objection.
    [The document is printed at page 268]
    Dr. Burgess [continuing]. From the Journal of Bioethical 
Inquiry ``When Doctors and Parents Don't Agree: The story of 
Charlie Gard,'' the very sad story from the National Health 
Service, where the determination was made by the hospital not 
to acquiesce to the parents' request to bring that child to the 
United States, where they thought they had a treatment for his 
mitochondrial disorder. And I would ask that be made part of 
the record.
    So the 25,000 surgeries, is that isolated in government-run 
systems, or does that seem to be pervasive in government-run 
systems?
    Ms. Turner. Well, there is no one government-run system, 
obviously. And some do better than others in being able to 
reduce wait times.
    Dr. Burgess. That is a great point. I am going to interrupt 
you there.
    Ms. Turner. Yes.
    Dr. Burgess. With no thought for my personal safety, I 
attended the Commonwealth Fund's healthcare weekend. Thank you, 
Commonwealth Fund, for putting that on. I was the only 
Republican there. The director of the National Health Service 
was there. And he did point out to me that there is no single 
European health service. There is England. There is France. 
There is Germany. Canada, I believe, is structured 
provincially. The provinces run.
    So this thing that we are building and with no cost-benefit 
analysis, with no double-blind controlled randomized study, no 
toxicity study, this thing that we are building, no one has 
ever seen a system that is this big. Our Medicaid system 
currently is larger than the National Health Service. I believe 
that is correct. But this Medicare for All bill that we have 
under consideration in the Speaker's committee, the Speaker's 
desire to have this bill heard today, that is going to be 
gargantuan. Is that a fair statement?
    Ms. Turner. It is a fair statement. And I do think you have 
to worry about centralized decisions over access to care. In 
the U.K., just recently, a commission that helps determine what 
benefits will be available decided that cataract surgery was 
not a high priority, and so cataract surgeries have been 
significantly curtailed.
    If you have cataracts and you can't see, cataract surgery 
is not optional. But when you have centralized government 
bureaucracies deciding what services are available, that's what 
happens. I just don't think that is something that Americans 
are going to tolerate.
    Dr. Burgess. So, as a practical matter--and I don't 
understand from my reading of the bill, and I have read through 
it a couple times, and it is a frightening bill to read for me, 
but if you can't get your cataract surgery and there is an 
ophthalmologist down the street says, you know, I am doing 
these in my kitchen, what is to prevent that from happening? 
And what is to prevent a cottage industry of healthcare that 
then develops a black market of healthcare, if you will?
    Ms. Turner. Or offshore floating hospitals or Indian 
reservations could wind up being enclaves where you could 
actually be able to get private care.
    Dr. Burgess. And the cataracts are an interesting case 
study because during the Bush administration, the variable lens 
that could be replaced during cataract surgery and do away with 
bifocals, Medicare said, ``Hey, wait a minute, we don't pay for 
refractive services, so you only get a one-size lens,'' so 
Medicare patients were then--it was a pretty uncomfortable 
position for the Bush administration. We are going to deny the 
best treatment available to Medicare patients. And so they had 
to actually make a--and I remember when Dr. McClellan did it. 
And I was jubilant. I thought, oh, man, here is a balanced 
billing example that we can use. Patients were allowed to bring 
their own money to the transaction to get the state-of-the-art 
lens so they could read their Sunday paper without their 
readers. I mean, was I thought going to herald a new era of 
insight in the Medicare system, but I was wrong. But I did 
repeal the SGR. Thank you very much.
    Thank you, Mr. Chairman. I yield back.
    The Chairman. Okay. I want to--just some other people had 
wanted to say, so I will use the remaining time.
    Let me just say one thing, a couple things before I yield 
to Dr. Nahvi and I think--who else wanted to? Dr. Collins. Dr. 
Browne.
    I know, Dr. Burgess, you said you read the bill many times, 
and then you referred to the global budget. But the bill says, 
the reading that I read, that there will be a quarterly review 
of the global budget so we can choose to make sure that there 
are enough funds if there is any problem. So, I mean, that is 
actually written into the bill.
    And, you know, I know, I mean, people like to speak in 
alarmist terms. And we talked about the Affordable Care Act. We 
talked, my friends will tell you, about death panels. Well, 
that wasn't true. It wasn't true then; it is not true now.
    Dr. Burgess. Well, Mr. Chairman, if we don't have a budget 
for this year, where are we going to get this budget?
    The Chairman. Thank you. And then you also raised the issue 
of the U.K. and Canada and said that they can't get the latest, 
greatest services. I am not saying that we should be like the 
U.K. or Canada. I would like to think we can do even better.
    But let me ask Dr. Collins just on this point. I mean, does 
that mean that the U.K. and Canada have worse outcomes than we 
do?
    Ms. Collins. That is a really good point, and I was 
actually going to raise that. I mean, why is it then, such a 
gloomy picture was painted of the U.K., where, in fact, their 
outcomes and those in other industrialized countries with 
universal health systems are actually better than ours with 
less money spent.
    I also think, Congressman Burgess, that at the conference, 
the director of the National Health Service did say that they 
were covering CAR-T service, CAR-T therapy. They made a 
determination that it was highly effective as a curative 
therapy, and so they made a decision to cover it. So there is a 
different metric that is applied I think than we often do.
    Dr. Burgess. I did relate to him that at MD Anderson 
Hospital in Houston, they have actually come up with a therapy 
that is as effective but much less expensive and can be 
administered as an outpatient without having to spend time in 
the ICU. I will be happy to provide a paper for you.
    The Chairman. Dr. Nahvi.
    Dr. Nahvi. Dr. Burgess, I did just want to respectfully 
point out that if we are going to be talking about a 
hypothetical future where there might be rationing, we need to 
make sure we don't forget that we have rationing right here 
today. And it is not for the most expensive and the newest 
drugs or not only for the most expensive and newest drugs, but 
patients that can't get antibiotics or antiplatelet 
medications. We have that rationing right here today.
    And in regards to we would be the first country doing 
something like this, that is kind of what America is good at, 
to do things that no one else has done before.
    The Chairman. Dr. Browne.
    Dr. Browne. Thank you.
    And, Mr. Burgess, just wanting to add to the point that we 
are really not talking about one size fits all, because we are 
talking about a universal coverage, but we have moved into 
precision medicine, where we are trying to give the therapy 
that is specific for those individuals. And when we take in the 
social determinants that are very important for those 
individuals, we know the kind of care. And so it is equity that 
we are talking about, not equality.
    The Chairman. And I note Mrs. Lesko left, but someone just 
showed me a report that appeared in The Hill magazine, because 
she was curious about whether other committees would be doing 
hearings. And it says in that report that the Ways and Means 
Committee will do a hearing on this very bill. So she doesn't 
have to worry that we will be the only one.
    I now yield to Mr. DeSaulnier.
    Mr. DeSaulnier. Thank you, Mr. Chairman. You are almost 
done if you are down this end of the podium--the panel, I 
should say, you are almost done.
    But I want to thank you all for your patience, your ability 
to articulate your thoughts and your professional experience. 
And I obviously want to thank Mr. Barkan for your tenacity and 
your being here and your good demeanor in spite of difficult 
personal lots. So thank you all for being here.
    I am a little bit flummoxed, not unlike the hearing 
yesterday, with all due respect to my colleagues. The United 
States is number one in cost as a percentage GDP and as a cost 
per capita, almost twice other developed countries per capita 
for cost of healthcare. But our outcomes are the opposite of 
what you would expect, 28th in life and mortality, I think 
close to 30th in infant mortality.
    So, for me, it just strikes me, not unlike the conversation 
yesterday about the energy economy and the environment, is that 
we are arguing about status quo versus a world that is already 
changing and how are we going to adjust to that. I am a co-
author of the bill. I appreciate the author. And I think this 
is a discussion we have to have.
    As a former small business person, I remember owning 
restaurants. And, fortunately, where I live in the bay area, 
Kaiser in the East Bay is very dominant. It started in the East 
Bay. So the closed system in Kaiser is over half the population 
of the two counties where I live. That is about 3 and a half 
million people. And they have been able in that closed system 
to provide a pretty good quality of care versus cost.
    But when I started in the restaurant business 30 years ago, 
I could pay easily for Kaiser and pay a portion and, then after 
someone worked for me for 6 months, in full. But then towards 
the end, I had employees coming to me in tears, one manager in 
particular, where she couldn't pay the copay. So I came out of 
pocket as an employer, which goes to the statistics which Ms. 
Shalala talked about a little bit, is about the number of 
employees--employers I should say paying 100 percent or any 
portion. And I don't know what the numbers are for small 
businesses, but I think--I would imagine it is pretty 
staggering with small businesses and the cost of staying in 
business, just not being able to pay at all.
    My memory from reading is in 2000 or 2001, almost 30 
percent of employers paid 100 percent of their healthcare cost. 
Four years later, it had dropped by 10 percent. It has kept 
going down. So this model to me clearly doesn't work. So it is 
a question of what we are going to do about it.
    Like Mr. Raskin, I am a survivor of cancer. Four years ago, 
I was diagnosed with stage IV chronic lymphocytic leukemia. I 
took a pill 35 minutes ago that keeps me alive that costs $400. 
Senator Durbin said to me recently, because he knows of my 
health challenge, he says, ``How is your health?'' I said, 
``Fine, Dick, I have a pill in my pocket that I take every day 
that keeps me alive.'' And he goes, ``How much does it cost?'' 
And I said, ``$400.'' He said, ``That is outrageous.'' I said, 
``Not to me; it keeps me alive.'' My oncologist said, ``15 
years ago, Mark, somebody would come in with the same 
diagnosis, and we would sprinkle some water on your forehead 
and say good luck.'' Now the life expectancy is 85 percent if 
you can get through the first 5 years, and I am almost there.
    And a lot of this, as I have become familiar with it and 
gone out to NIH, actually was developed with taxpayer dollars. 
A doctor who worked for the Army for years and is now at Ohio 
State, Dr. Moynihan was nice enough, was the key person. And 
most of his research was taxpayer funded, much of the 
deployment. I went over to NIH and met with these young people 
making $60,000, $65,000 a year that went to Hopkins and 
Stanford and Harvard, and they are working at NIH because that 
is what they want to do.
    So one of the things to me is apples and oranges, counting 
this right. And I am sorry that one of the panelists had to 
leave because this was directed at him, but I want to direct it 
at Dr. Nahvi, because I will lead into this, is, what are the 
real costs to the average consumer and then accurately. So, if 
we know those numbers about individual costs and outcomes in 
the GDP, see, it is a huge disadvantage to us, because if we 
weren't at 18 percent and if we were like the Japanese at 12 
percent, with better outcomes, all that money could be going to 
more productive uses. Not that healthcare and keeping people 
alive, coming from me, isn't important, but we could be 
prioritizing.
    So the reason why I have been able to afford this, there 
was an interesting story in The Wall Street Journal that I 
would ask everyone to read about people who are wealthy with my 
condition and having a challenge paying for what they are 
paying for on private care health insurance.
    I was lucky enough to get elected to be a county 
supervisor. I chose to take my healthcare through what was the 
first county public option of the United States when the Contra 
Costa Health Plan was approved, the HMO. And they paid--I am 
here alive today because of that. If not, if I had stayed a 
restaurant owner, I would have made a lot more money, but now 
when I look back in hindsight, if I was paying for Kaiser, Blue 
Cross Blue Shield, I wouldn't have nearly the service versus 
what the out-of-pocket cost would be.
    So, Dr. Nahvi, I have an example from my experience as an 
elected official. In California, we delegate public health and 
delivery of services to the urban counties. Contra Costa, where 
I governed, was our biggest challenge, whether it is Los 
Angeles or all the urban counties, is the cost of the clinics 
and hospitals who do most of the indigent care. So one of the 
things we did when we rebuilt our county hospital--I was the 
swing vote--in L.A. at the time, their general fund 
contributions, with five hospitals and with an increasing 
indigent care population, was up to 23, 24 percent. Ours was 
going in the same direction. So we have tried in California to 
help the counties and say: You have got to cap your costs, be 
more efficient.
    My point is, when we get down to 10 percent, that extra 15 
percent we spent on libraries, the sheriff's department, 
economic development. So that is sort of the color of money. In 
your experience as a point-of-sale person, in different 
emergency rooms, you see people coming in the door, but their 
costs are all absorbed differently, but the consequences for 
who pays and subsidizes those costs are also different.
    Could you speak to that on a personal level? And then I 
would ask Ms. Collins to also talk to that.
    Dr. Nahvi. Sure. I think that if you go to different 
hospitals, people will be paying differently. And the 
interesting thing about New York is that we have a lot of 
hospitals that are right next door to each other that accept 
different types of insurance and different types of payments.
    So there are two hospitals that I work at that are right 
next door to each other. If someone comes in and they have 
insurance, they will be taken care of, and if they don't, they 
often get referred next door to the public hospital, where they 
wind up receiving care and then that hospital does not get 
reimbursed for it. And then that contributes to the challenges 
of that hospital not having enough money, and it creates the 
cycle.
    I think one of the good things about Medicare for All is 
that, in those hospitals that primarily serve the indigent 
population, they will be able to make more money because they 
will be reimbursed higher than Medicaid payments, and no one 
effectively will be uninsured. Every patient will be a paying 
patient.
    Mr. DeSaulnier. Before we leave you, just another, some of 
the behavioral health costs. In Los Angeles, we see where they 
have been pushed out of the hospital. I know in my county, we 
always looked at--I was on Joint Conference Committee. We would 
look at indigent care in the psych ward. And we were 
stabilizing them and pushing them out, but they would go into 
the emergency room first. I think the statistic on people who 
commit suicide, 60 percent of them go to see a primary care 
physician within 60 days.
    So that is another aspect I don't think we are talking 
about is we understand the neuroscience and the amazing 
research we are having on helping on behavioral health, but 
then the acuity of people who are going through the current 
system for medical conditions and then accruing greater 
liabilities, both real and financial on that side. And you saw 
that, I assume, in your experience.
    Dr. Nahvi. Yes, I do. And the people that end up in the ER 
that can't be reimbursed, we end up all paying for that. I am 
not sure if that answers your question.
    Mr. DeSaulnier. Yes, it does.
    Ms. Collins.
    Ms. Collins. Yeah. I just think on the benefits, the way we 
are designing benefits and the way employers are being forced 
to grapple with their higher costs are giving patients 
incentives or people incentives that goes against their own 
health interests.
    So people are making decisions, based on their deductibles, 
about whether or not to fill a prescription, whether or not to 
skip doses of the prescriptions, because they are afraid of the 
cost. And it just really does run counter to how we would like 
people to think about their healthcare and getting better.
    Mr. DeSaulnier. I don't know if others have had this 
experience, but I know the Rotary Clubs in my area take me out 
to their clinics where they have pro bono physicians and others 
who come. And especially in the disadvantaged communities, most 
of them who come to those Rotary clinics once a month, they 
won't go to the county hospital. They won't go because they are 
afraid of the cost. And some of it I am sure is part of white 
smock disease. Dr. Burgess would remember that. I have that. My 
blood pressure is usually off. I don't know why I don't trust 
doctors, Doctor, but I do now, because they have kept me alive. 
But the Rotary care stuff is really fascinating, because people 
will go to the Rotary clinics. And it is the same doctor, but 
the environment is different.
    Just I guess I am really appreciative. I didn't fully 
anticipate this hearing. I think it was good and constructive 
and largely positive. I hope that we go on from here. And I 
think the genesis of this in the bill. I remember it was 
Madison--not that this is going to happen--who said: Just 
because a Member of Congress doesn't think their bill will 
happen immediately shouldn't inhibit them from introducing it. 
And I think this has, at the very least, restarted an important 
conversation in this country.
    So, with that, Mr. Barkan, do you have anything to add to 
whatever is left of my 15 minutes, or is Mr. McGovern going to 
take it all?
    The Chairman. No, no, no. You have your time.
    Mr. DeSaulnier. As long as it is not Ed.
    Mr. Barkan. Thank you so much to members of this committee 
for having me. This has not been an easy trip to make, and it 
is a big risk for me, but I came here today because this is one 
of the most pressing crises facing our society. Every day I 
feel the weight of the moment. Every moment feels urgent, and I 
feel acutely my time running out.
    I hope that sense of urgency is pressed on everyone here as 
we think about how to build a more fair and just society for 
all. We are at a crossroads as a Nation. We can either become a 
society where care is rationed to those only with immense means 
to pay the most exorbitant, exploitative healthcare bills 
imaginable, or we can transform our society, alleviate families 
of the enormous financial burdens that come with a for-profit 
healthcare system, and live with more dignity and joy.
    I sit before you today hopeful because I believe we will 
make the right choice. I believe the number of people demanding 
justice across the country will only grow, and I believe that 
we will win. Thank you again for having me.
    Mr. DeSaulnier. It is all our pleasure. Thank you for being 
here.
    The Chairman. Everybody has asked their questions. At this 
point, I will yield to Mr. Cole for his closing remarks, and 
then I will make closing remarks, and then we will let you all 
go home.
    Mr. Cole. I want to begin, Mr. Chairman, by thanking you. I 
want to thank you for the manner in which you have conducted 
the hearing. You have been exceptionally generous with the time 
and kept us focused and very civil. So you can be very proud of 
your performance here, and we are all very proud of you.
    And I want to thank all of our witnesses as well. Each of 
you have brought insight, knowledge, professionalism. You have 
all contributed to helping us grapple with what is, you know, a 
challenge at a societal level. And obviously, we heard a great 
deal today about the majority's highest priority in Congress, 
which is, in my view, putting everyone in a one-size-fits-all 
government-run health plan that will double everybody's taxes, 
eliminate choice, and put Medicare at risk.
    It will take plans away from 173 million Americans and give 
them something they may or may not want and something they may 
or may not be willing to pay for. As we heard from Dr. Blahous, 
Medicare for All would cost a staggering amount, more than $32 
trillion over 10 years. Worth thinking about that.
    The current Federal budget annually is about $4.5 trillion. 
This would make it immediately $7.7 trillion. The legislation 
has not proposed any way to pay for that. But Dr. Blahous told 
us that even if you doubled everybody's taxes and doubled the 
corporate tax rate, it still wouldn't cover these costs. And as 
my friend Mr. Woodall pointed out, we are not paying for all 
the healthcare we are getting now. We are putting an awful lot 
of it on the national credit card.
    Dr. Baker offered up several ways to pay for this in his 
testimony. But many of those involve what euphemistically are 
called input costs or what everybody in the healthcare industry 
would call more than a 40 percent cut in their compensation. I 
can't imagine that an entire industry would accept that level 
of reduction.
    And I would also note that such cuts would put everybody's 
healthcare at risk. Indeed, Ms. Turner testified that many 
hospitals would simply close if they had to take 40-percent pay 
cuts, as envisioned in this bill. If such cuts become law, the 
Medicare for All truly would become nothing more than a program 
that provided minimal care in exchange for astronomically high 
taxes and much longer wait times.
    Most disturbingly to me, I think today's hearing made clear 
that Medicare for All would put the current Medicare system at 
risk. If we force doctors and hospitals to take lower payments, 
we run the risk of pushing them out of the industry entirely, 
thus making it impossible for current Medicare beneficiaries 
who have paid into this program for a lifetime to receive 
healthcare.
    In my home district, rural hospitals rely on higher 
reimbursement rates from private insurance to offset the lower 
reimbursement rates from Medicare patients. If these hospitals 
were to only be reimbursed at Medicare rates, most of them, 
quite frankly, would close.
    If nothing else, today's hearing shows that the committees 
of jurisdiction need to consider this bill as well. And I am 
proud that you have both called on that, Mr. Chairman, and 
announced that at least one of those are going to take it up. I 
particularly hope my friend Mr. Burgess gets another crack at 
this in the Energy and Commerce Committee and the Ways and 
Means Committee and the Education and Labor Committee as well. 
All of them, frankly, have significantly more jurisdiction in 
this area than we have here. And to be uncharacteristically 
humble for our committee and ourselves, they probably have more 
expertise than we have here because they have both the staff 
and--I will let you argue that with Mr. Neal and his 
counterparts and Mr. Pallone, because, frankly, they do. I 
mean, they just focus on these things.
    And guess what, I probably know more on Indian health than 
some of these things because I focus more on it. We don't have 
hearings up here. This is an unusual moment for us and a good 
one. I am not complaining about that, but I am glad you are 
going to have the opportunity for these issues to be discussed 
in front of the committees of jurisdiction.
    Though I think the Democratic Medicare for All proposal is 
an extreme one, I would remind the majority that Republicans 
are, as Mrs. Lesko said, committed to working together to 
improve the system we currently have and to build on and 
improve what works and ensure that every American gets the 
quality of care that they deserve. And while it is always 
fashionable to want to do a once-and-for-all total 
comprehensive bill, we went through that with the ACA. And with 
all due respect to my friends, I heard phrases like ``you can 
keep the doctor''--``if you like the doctor, you have you can 
keep him.'' ``If you like the plan you have, you can keep it.'' 
And, you know, finally, ``your insurance payments are going to 
decline by $2,500.'' None of those things happened.
    So count me as skeptical that a new one-size-fits-all 
system will achieve the objectives that its advocates have laid 
out with such optimism and such hope. And, you know, again, it 
is worth discussing for sure.
    I would hope in the meantime, though, we do what everybody 
here agreed we ought to do in addition to looking at this, 
which I have no objection to, that we actually focus on smaller 
steps that we know can become law, that we know can actually 
happen. I look forward to working with my good friends on the 
other side of the aisle, certainly with you, Mr. Chairman, to 
make sure that we can do something that matters in the weeks 
and months ahead that makes a big difference.
    And so, with that, Mr. Chairman, again, thank you for the 
hearing, thank you for the manner in which it has been 
conducted.
    I yield back my time.
    The Chairman. Thank you. And let me also thank our ranking 
member, Mr. Cole, for his participation in this hearing and for 
his courtesies and for his questions, quite frankly. I want to 
thank all my Republican colleagues as well. I don't agree with 
you on a lot of what you said, but I appreciate that this 
hearing, which is on a serious topic and was treated in a very 
serious manner.
    And I was recounting to some of you that some members of 
the press and some colleagues who have been watching this on C-
SPAN are kind of surprised that this has been such a civilized 
and in-depth hearing, and some of those people are on the 
committees of jurisdiction. I will tell Mr. Neal, who is the 
chair of the Ways and Means Committee, the second oldest 
committee in the Congress--we are the oldest--that he should 
follow our example.
    I want to thank the staff on the majority and the minority 
side as well for all their work in this. I want to thank 
Congresswoman Jayapal's staff and Congresswoman Dingell's staff 
and Senator Sanders' staff and others who have been very 
helpful in working with us on what this hearing should look 
like.
    I want to thank the panelists. You have been here since 10 
o'clock this morning, nonstop with a short break. And I think 
everybody here was excellent. We may have some differences of 
opinion, but I think everybody did an excellent job. So I want 
to thank, again, all of our witnesses for their time today.
    As this hearing comes to a close, let's remember why we are 
all here. We are here because 29 million Americans are still 
without health coverage; 44 million people are underinsured; 
and many more are paying ridiculous out-of-pocket costs for 
healthcare that just isn't there when they need it the most.
    You know, there is no healthcare system like what we have 
in America, and I don't mean that necessarily positively. 
People are forced to go without care. Those with coverage have 
to wonder whether their insurance provider will play games with 
their coverage when they need it most. And all of us up here 
know exactly what I am talking about because that is the kind 
of casework we do each and every day.
    What we have shown today, I believe, is that Medicare for 
All is possible, that we can build on the principles of the 
Affordable Care Act to make even bolder reforms, reforms that 
would give doctors like Dr. Browne and Dr. Nahvi the ability to 
treat patients and give them the best care every time without 
letting cost dictate medical decisions. That we can treat 
patients like Ady Barkan with the dignity that they deserve 
without forcing them to battle with insurance companies. If you 
walk away with nothing else today, know that we have the 
ability to do that.
    Medicare for All is possible. It is reasonable. It can move 
forward, and I think it should, and I am proud to support this 
bill and to work with Congresswomen Jayapal and Dingell and 
many others who have been championing it. And by the way, that 
includes not just its supporters here in Congress but many 
advocates, the doctors, the nurses, the patient advocates, 
consumers and more all across the country who have worked 
tirelessly to make this historic day a reality. It has been a 
long time coming, and it is the result of all the letters and 
the calls and the emails and advocating that has been going on 
for a very, very long, long time.
    I believe in people power. I got to be honest with you. I 
don't think we would be talking about any of this if our 
constituents weren't raising their voices. I am proud to stand 
with you, alongside of you, for Medicare for All. And this is 
just the first phase of the conversation, and I look forward to 
continuing this dialogue with all of you.
    Again, I want to say to Ady, I love this picture. And I 
look at your wife, Rachel, and your son, Carl, and I can't help 
but think how proud they all are of you. And I have been 
watching your dad, who is sitting behind you, and I could see 
how proud he is of your courage and your commitment to being 
here. This is a big deal, and your presence here is making a 
huge difference. I just want you to know that. We can do great 
things. We really can. But it means we have to stand up to the 
naysayers who tell us: No, you got to think small.
    You know, we need to think bigger than tweets, right? We 
need to think about how we impact the lives of millions of 
people in this country, who are struggling every day, wondering 
whether or not they are going to go bankrupt because they are 
sick or their kids are sick. It just shouldn't be. As everybody 
has said on all sides, we can do better and we have to do 
better. So I again want to thank everybody for being here 
today. This is the first step. It is a big step, but we are on 
our way.
    Thank you, and the Rules Committee is adjourned.
    [Whereupon, at 3:55 p.m., the committee was adjourned.]
    
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