Transcripts For CSPAN2 Capital News Today 20130425

it is a claims playing up -- claims paying a price that they're trying to move away from basilian modestly. the only way this kind of insurance plan ever really works is if you have patient cost sharing at the point of service. if you have a system ready into with employee elements their vacation bible and those insurer is paying any plan that is filed by any provider and is critical areas that i saturday, lyses and legitimate, the only we will make sure we provide managers with flexibility needed way to have any check on use of services is the beneficiary to adapt to emerging situations. population pays a portion of the costa point of service. >> you have the flexibility to the extra people on the ground so they think twice, is this a if necessary? legitimate thing that i need >> we make sure we have a tailored approach so those go phase. the patient has some uninterrupted to the american responsibility. therefore their is a little bit people. of a check. does not just use everything. >> at the folks at the that's think about this before we do so. in medicare come however, north-central river provide patient cost sharing is quite large. important data the national weather service houston forecasting river levels have river basin modeling, hydrologic there's an inpatient tractable, coinsurance rates, limits on the number of days is in the could you tell me how the hospital. the position co-payments and process works and how the data deductibles which is all wisely is gathered through hydrologic rendered useless because of wraparound insurance. remote-sensing? for the vast majority of we are not just worried about beneficiaries to participate in medicare fee-for-service they what cannot which is different, have other medigap supplemental but all the way down the rivers insurance, about 25%, or they into minnesota. have an employer wraparound plan , 40%, or they have medicate >> will be happy to follow up him roughly about 20%. when you put it all together, his locker discussion if you find that helpful in your essentially, and there are a couple of others, about nine out office. they're a combination of input data services to forecast from of ten ft.-for-service beneficiaries pay zero or near snowpack surveys run measurement zero at the point of service for their health care cost. made from noaa aircraft. so you have a fee-for-service the united states agency has the insurance system with the beneficiary population not primary responsibility for the sensitive by and large to the point of service. it is very, very predictable networks that provide critical will happen, which is this huge information. this data are relayed, most volume increase in medicare and has been for a very long time. commonly through geostationary the cbo did a study looking a overhead satellites. physician services between 1997 and 2005. it showed that overall there was so the scottish data via satellite relay links and make an actual real cut in the per measurements on the ground and service payments from medicare airborne measurements in field campaigns, all of which informed to a position community. the physics in the models for 5%. pretty remarkable. the ecological prediction and they pay their physicians less in real terms in 2005 than it the actual status of the environment the lettuce that did in 1997. decision inaccuracy to an overall physician service cost went out 35%. immediate forecast such as the ones who give to your constituents now. >> is it true in matters how the reason was volume and intensity of use when up by 40% quickly the ice and snow amount? we're afraid we have snow in during that a year time frame. three remarkable, actually. northern minnesota of all suddenly have an 80-degree day you dig into the data and say essentially what it implies is and never see anything like this that beneficiary communities because it doesn't happen that way, especially with were using and need 40 percent temperatures at night. more services for their care of a years later. >> attending a snowball through the spring season matter that is a very unlikely occurrence. critically. so there is lots of volume in yes, ma'am. >> i appreciate your work and medicare program. that you want to develop a third point would be that when personnel with hard budget times you look at medicare and its that i hope to change if we can get a deal going. influence, you can see the thank you for what you down. inverse by looking at when there is large penetration from the admiral papp coming off the medicare advantage program, hook. essentially the hmo program. opposite questions about several studies have done, and a dredging and if we need your help with their, were really in recent one done by michael trouble. that's at eight. czerny and others indicates that thank you earn much. when you have large medicare advantage penetration in the medicare market place it turns >> thank you very much. out that feed-for-service cost then they go to my questions and then of folks have additional, will go into that. actually goes down, not just admiral papp, let me ask you. medicare advantage. and that is because medicare i know in the capital investment advantage at least in the hmo plan you have for the part of medicare advantage does icebreakers about $2 million to have some incentives to change the practice of care by the continue planning. a little nervous to be frank with you. physician community. there have been several studies i know i've had to battle to get that show that that is spilling dollars into the system to set the process. over and influencing how can you tell me in your word fee-for-service positions where you see that program going actually -- or how the same as you know, even then alaska, physicians take care of their fee-for-service in the fishery population which is of a window what will be necessary to manage into medicare fee-for-service role in how it influences the delivery of health care. and alleviate potential risk as finally, the far turn over the we know less than two years ago chris, the one indication that the work you did was help between 1950 and 1990 there is a receiving incredible fuel, which is critical for survival through the winter. very, very large increase in the tell me how you see that plan. supply of medical care in the united states all to the good i'm concerned as you can imagine basically, basically as comic that give me thought that 600 percent increase in real what she think of the long-term. terms in the per-capita use of >> i still really good where medical care in the united iraq and the senator. states. on the vast majority of that three years ago i laid out for being very good. things they need to do to but, if you the into it and provide a speaking capability for the country. examine where all that came from the first is to get the a new pay for it and who insisted that very large buildup operating funds back in the coast guard budget. of the medical delivery system, medicare, fee-for-surface was at second was to get a hea least one of the top reasons. icebreakers service. we selected the polar star because polar star at the least the second being open-ended tax subsidization of employer paid health insurance. hurt they needed to be done and so i don't think we're ever i'm very proud to report polar going to get at the problem of star is ready for operations. delivery of medical care in the they expect to send polar star united states without seriously in addressing medicare to the arctic this summer so we can retain proficiency. fee-for-surface. thank you. >> thank you. it's been a long time since crews have broken ice, sunni defendant to get experience this >> thank you. summer. it is my goal in february 2013 and thank you for inviting me. i am here, i guess guy in relationship to my adviser at the national science status to the bipartisan policy center. foundation. and my remarks are oriented in that context. >> is renovation so forthcoming to remember what that was? first, last thursday the bipartisan policy center did release a report entitled a bipartisan prescription for >> how long will you be able to pages centered care in the at this point see the lifespan of that quakes system might cost containment. >> way of operating funds for polar star, so that will help it really was the outgrowth of us. our plan is to keep polar star an intense 9-month effort sustained for at least 10 years working with senators and the until we get a new polar icebreaker. suki pelee running because she was the only icebreaker we had come and get polar star former director of the omb and reactivated and start the cbo who is also a fellow here process for a new icebreaker come which i thought would eat brookings to work to see if they the most difficult thing to do. can do a combined effort that the president put the money and to start the process of the 13 will focus on both health care and budget pressures to produce budget. it causes concern simply because a policy that was very focused on how we improve care and the budget was enacted halfway through the year. quality in our health care delivery system. we didn't have it, so, so that's a good steward we said we can although leaders felt very strongly that our work had to be extend some of that money into the fy 14 spending along with grounded on improving the value the 2 million to keep this process going. that our return on investment in this country was indefensible right now we're doing a thoughtful, deliberate process and most important, we are not to make sure we reach out to the department of defense and the national science foundation, serving well the patients to enter our health care system. noaa and other agencies because this is a united states we've released a 4-pronged set of integrated policies. icebreaker company to make sure we take into account they included a reform of requirements that are going to medicare, tax exclusion policy, be important to the significant prevention and wellness, state investment. >> let me follow it. based reforms dealing with i see no month and half ago we had a hearing that i cannot take medicaid, work force to my medical liability challenges. suffice to say, will not go through all of that and i have regarding the amount of traffic moving through their and they been asked to focus on the medicare reforms. did a great job with a lot of anyone who has an older father, mother or as experience, as i do extra credit points. not only do they do it on the ground, but in front of a committee they do a good job at , a health care system for presenting the risk that is themselves and their children well knows the frustration of growing and this can regards to navigating to our health care system. the amount of traffic moving it is complicated, error prone, through their and not knowing a lot about it in the case of and uncoordinated. foreign vessels and some of the work that needs to be done of that there can be no doubt. there. do you share that same level -- physicians and other health care professionals responding to the obviously on the ground in the district it's always elevated flawed incentives predominately because you are there watching in our fee-for-service systems it. do you share the same concern are penalized for spending more we've got to start up in our time with patients and get eyes to what's going on there in the amount of traffic unclear of rewarded for ordering unnecessary and sometimes dangerous tests and procedures. none of these frustrations cargo or structure associates. translate into better care, and >> absolutely, mr. chairman. as such, our leaders directed us to develop policies that were it's almost a funny situation. patient focused and health care practitioner in powering. he generally puts up a chart of the world and shows all the federal and private-sector savings would be a desirable of points the navy is responsible for except for the bering growth, but it was not to be the driver of our work. strait. he has now started putting a symbol on the bering strait. by the way, i should just say that if you want to take on the while drilling poses challenges, health care reform issue in this my biggest concern right now is country, if you focus on any the increase of traffic through the bering strait. other approach then i can russia is from intent on opening absolutely guarantee you that the north sea route is a major you will not be pursuing sound route for commerce. policies are politically viable the seen a fourfold increase approach is. going through this bering strait so rather than embracing a and the potential for disaster, series of 1-up policy proposals that may be justifiable on the pollution disaster really more case-by-case basis, we likely friendships collating or constructed a vision that would have a meaningful impact on how being caught in a storm and we deliver care. becoming disabled. we were focused, by the way, in that thing i worry about the that context and not embrace a most. policy that is merely shifting the good thing is because of the costs to other purchasers. coast guard and we were able to recognizing -- fully recognizing that conservatives have major operate international united states maritime ocean. concerns with traditional medicare and progressives have the north said it for coast major concerns with premium support policies, we tried and guard former quick traffic schemes for the bering strait believe me succeeded in finding an approach that takes some of that will work to improve the most valuable components security in the year cicadas the above. route becomes vital to the entire world. we accept that the current fee-for a service program is flawed for obvious reasons that >> very good, sir. it drives up volume of those >> let me end with end with him correlation to quality and value or in moc senator rubio has we also accepted that most additional spirit as you know, i americans are very concerned met a proponent of making sure at some point we have some about shifting insurance risk access, maybe it deepwater port and possibly cost beneficiaries in the context of most because i say it's a large area traditional premium support proposals. and some of the regions of coastal areas. a policy envisions strengthening we've had inquiries from the and modernizing the traditional medicare programs by creating bering straits corporation and trying to resolve issues they incentives. are. it seems that district 17 is very interesting transfer mainland they are, but i thought appears someone in d.c. designed said improve care and quality. chester -- our approach embraces i don't know how much you know about the issue, but i want to put it on your radar screen. a number of policies that many would you give a commitment to health care experts have advocated as a way to transition away from the trend is -- bering straits community are traditional fee-for-service folks and negotiate this program. we support bundling or forms a resolution to this issue? obviously, to the long-term significant but short-term down issue of the deepwater port, but payment to help transition to a the needs of the coast guard more coordinated system. will need and projecting out 10, similarly, we do embrace an 15, 20 years from now. income related premium that we >> s. commissary. two things that i might. believe does improve upon the first of all woing thfirst federal agents the to administration's income related focus that was just unveiled in have an arctic strategy. the president's budget. we make certain that the subsidy defense secretary napolitano's desk right now and it's only the coast guard take point on this for all beneficiaries never declines below 20% in the to start a strategy to build administration is actually into a national strategy. working below 10%. they deepwater port is a part of that. we recognize it's difficult to review all where the action is within those contexts we also going to be. embrace an improved low income the specific issue i'm aware of subsidy programs and to parses a the broader structure of prescription drugs. divested ourselves of all in this population we have a lot property we have throughout of older by low-income medicare alaska and other places. beneficiaries or underutilizing we will commit to meeting with those constituent. low-cost generic drugs relative to the rest of the population. clearly mutual things we need to talk about because we don't thought our long-range plan on we designed a cost sharing mechanism that eliminates cost the terrestrial site are even. sharing for the use of generic or other low-cost products and >> and on that one issue and if cap the federal reimbursement anything we can do to help make rate to providers of those drugs sure will be happy to participate. they clearly understand there is to ensure that we give an obligation to the coast guard significant uptick in the use of to make sure when i say those products. the consequences that we get long-term, euromonitor region. over $40 billion in savings many, many years to come. every ten years. okay. secondly, we strengthen and improve the medicare benefits by let me turn to senator rubio. bringing into the 21st century >> i wanted to ask about the this address, something that we budget proposal that funds 3500 just heard about relative to the days at sea to surveys. need to modernize the benefit. we do finally extend new cash this proposal represents an increase of almost 1400 days coverage benefits for seniors. about the fiscal year 2012 we all know in this room that we don't have catastrophic coverage levees. what are you doing to make sure in the traditional medicare the time is distributed fairly program, and we do so in a in this sense it is according to budget neutral level by combining it electable the need among the different regions? what are we doing to balance the state's to ensure all the areas get data attention they think is catastrophic cap is capped at appropriate. >> in the last year we look for $5,300. a little bit over $5,300. that is budget neutral. one unique exercise to underpin that is not so new. the answer and have a senate process we rely on for that. we have an elimination of they are rigorous reassessment revalidation of are at sea physician services applying to observing requirements. that deductible. in other words, the physician services the delectable does not it's really an exercise to make sure we broke down to the level apply. of the parameters we need to have to mess left. observe specifically asked the in order to fulfill our missions so as we go forward and look at [laughter] ship allocations that might so, third and probably most significantly, we really alter augment, we can trace from a the incentives in the medicare program. specific observation to whatever i hope we have more time to talk about this. ways to make it available and provide the best balanced we a seller at the movement approach to fulfilling those toward the accountable care organizations. needs. recall that her fleet composition plan. we called the performance by addressing the shortcomings. one of the shortcomings, of they should spend buttoned up in the last few weeks and i look course, medicare beneficiaries forward to discussing that with don't even know there and it. you in the months ahead. that will be one underpinning. secondly, a planning process operated by ahead of the noaa there is a two sided risk. core and his officers and staff the policy is designed to of complete and direct accelerate into these networks participation of mission and and reform will we do with the science managers entities in that form retrieves the program. how do we do this? available ship capabilities to welcome on that side of it we have competitive bid, for programs straight up with the region by region and priority by fee-for-service program on the priority. >> i don't mean to inject to you medicare network side of it in order to facilitate medicare in another controversial issue, beneficiaries moving to what was being talked about we do fries but we're here anyway. it has to do with a lot of discussion in the context of immigration reform about order payment rates for all fee-for-service providers. security and areas where there is the border sector and a little more difficult because there is risk associated, but we seem not. in south florida, the cottage you will be paid, but the industry that emerged not so payment will be frozen, so you long ago going into cuba in have financial incentives to go and deliver those programs. bringing people and pass both begin talks about the implications of that. and from time to time its not rare to hear the story of a raft washing up or what have you so no time left. heard a dangerous mission and we should discourage it. any trends in those patterns hopefully we can open up for we've seen? more importantly what our questions. capabilities are if in fact -- some tobacco. migration patterns by as a all of these incentives will improve care and focus on result of instability in haiti quality. the aggregation of this is or the dominican republic one example of cuba and other $300 billion in net medicare places. what are the risks of the future savings, inclusive of the low income protections that i medication spike at the southern mentioned to you as well as the border is secure and becomes a less viable entry point or is reforming the scr physician there some sort of the people in the caribbean sacked or that payment forms. so that is net $300 billion in a could lead through there. significant contribution. what are they giving budget constraints put in place? significantly enhanced and improved health care delivery system that works in the >> i think we have adequate capacity right now, senator. beneficiaries. i would like to talk to more about that, but my time is up. but the coast guard does this have a deterrent value. thank you. one of the reasons i was out >> well, thank you so much. i suspect you will have a few there for the haitian mass more bites of the sample before this session is over. migration for the cuban mass migration that occurred at the same time. it's a terrible business to have to do that we need to persuade people to stay in their lands said they don't try to take the dangerous voyage to reach the i happen to notice this sitting united states. we do direct repatriation right here, preserving medicare for future generations, medicare now in our numbers are trending approaches to reform. fairly stable we haven't seen a spike in a long time. preserving medicare does not parties because they are still mean keeping it and changed. recovering and haven't had the in fact, to preserve medicare wherewithal. change is inevitable. part of the economy that tends it would be better if it were to attract people as well and we something we want to do. haven't seen that, but we monitor numbers carefully. i think the critical element here is to perform the program in the straits of florida, the thing that troubles me the most is this mugler's who do this for in a way that changes the profit, who are taking creative incentives that face both consumers or patients and health rows either through the bahamas thursday haitians run over to care providers. puerto rico, says a constant battle is the smugglers get more daring, but they are smaller the i think a good question is numbers in a land border because of the turned value. >> this mugler industry, said on the the increase or decrease? where can consumers effectively it's an expensive undertaking. my understanding is they charge exercise their judgment, ideally thousands of dollars, but is if an informed judgment, better that's something we seen an increase in coming decrease? informed than we now have. where is the best place for is that due to economic factors, consumer action to fall. enforcement, both? the other question i have is it and i would say that in spite of sounds to me like a fast vote the availability of my favorite medical adviser, the internet, through the middle of the caribbean is not necessarily something we would necessarily probably my doctor has -- my stop. >> flow of migrants is similar doctor has an advantage. to the flow of drugs. people are very creative and we seen an increase in people doing it for profit. ideally my doctor would tell me it is expensive, but expensive that is not a good idea. for poor unfortunate people did or to transfer them and is a where consumers can make a decision effectively is really dangerous business. as the southwest border with regard to this health plan. constraints and gets more that, again, if you have good secure, there's a tendency to information it is possible we squeeze something and i will find other direction to go in. i'm concerned about the southwest border, where there's have to change the incentives. an increase of drug smuggling going on the border, trying to he needs an incentive to not get into california. the scene and some migrants only give me give medical going up to. advice, but also have some awareness and concern about the the texas and mexico and other overall cost of my care. in other words, he is really natural ways to look for. going to be hair and my health plan is going to be there making >> thank you very much. a lot of decisions that i am before i go to senator colin. going to have direct control over but that would influence not only my care, but the cost i think you've answered this is to me and everybody else. that is true in the private health sector, trim medicare as that a lender opening and i was well. so medicare is critical to the questioned or received about $100 million if i remember the seniors today and will be supplemental command the. critical for the well-being a can you give me how you're using lot more people in the coming years. the question for me is whether, that end is that become valuable in the sense of keeping things in fact, we can go in the on track? direction was mentioned very, just give me a central cricket not have a couple more. very briefly at the end. >> the $111 million appropriated by the congress and let me we can do that in a more effective way to move in a express my thanks to both ctioth better chambers for that appropriation competition involves health was focused not on preventing a plans in the medicare program. and how far can we move in that gap in the satellite constellation, but should there direction. of course, do partial measures be one on identifying actions work? what are you that partial measures such as the proposal taken to mitigate the made by that the pc really will degradation forecast accuracy and reliability. we commissioned a study to reach far and wide into academia and not be affected. .. the private sector called for technically viable ideas. they brought forward a set of recommendations that boil down to six problems. one is a couple of sources of data not currently used because of technical problems with the data source or computing capacity limitations, look at using those. some data recurrently purchased. aircraft it is one great example. with a certain segment of the data. other coverage pattern speak about god to be sure you understand what purchases are of greatest value to sustain the forecast. improvements that we take the data and boils down to being sure you're using a well and effective competition above so that players, not just some of getting a handle on the errors necessarily in any line of data. them. we now have the medicare summer should pay attention to advantage program is competition that only involves and is not and consider using, leveraging models in the european center to directly involve the medicare program. the probably plans for quite a the outputs of models. few years now. underpinning all of what we propose to do in response to the benchmark was sacked a level this but the funds provided are above the fee-for-service two things. medicare and not surprisingly some of what the independent city brought forward our ideas the plan did pretty close with we are well familiar with, that cannot do because the limitation of the computer capacity. the government promised they would get paid. the plan coupled with investments proposed in this if the competition is that said budget that is on track to make a fourfold increase in the capacity of operational supercomputers by 2015. the government is telling you the competitor to what is so let us note back to par, tdd willing to pay, that might influence your page. assimilation with the leading outfits in the world and you don't get the lowest possible bid. accelerate transition of critical research capabilities probably the strongest sense for into operation. efficiency and that's precisely what has happened over the years >> you check my memory as he chose supercomputers, we have a pitiful one in fairbanks, alaska. . of the dataset.for you. the idea behind full competitive also, we've talked about before model is to have other plans bid with spokes within your agency including reform traditional and this is the modern train of medicare, which islet just briefly at the end. groundfish in alaska and around the country and how to use thank you on the dating is to electronic monitoring. reverse the flow of information i'll be banging on your head in the way it is now, with the forever because for all the government basically tells the things you just said, all of the plan what it's willing to pay and let the plants tell the government what they think it weather patterns and other going to cost to produce a fixed benefit. things, the system today has said people want to believe changed a little bit, but it's premium support his people people. electronic monitoring is another vouchers and sends your grandmother out into the excuse history is not accurate and it seems logical that we should be trying somewhere difficult health insurance market without information or instead of getting our personnel protection. that's not a reasonable reform to put onto operation or shapes and most proposals that instead that may not have capacity to do it. for electronic moderates seem so logical. not only in alaska, but in visit beyond the basis to be the senator cowan states with some of the folks they are in the technology impressive. one we have today. the habit of the federal it could be a slimmed-down government is study things to death. i get it. benefit, the plants had been on the best study is get it in the the basis of the same benefit. water. sooner than later and in large the private plans would be able to enhance that benefit if they wanted to. volume. if i look at massachusetts, their assessment has significant they have to bid on the basis of problems because the length of the basest medicare benefit. time is creating huge gods in so that's one projection. understanding their fisheries. we're fortunate. the medicare program currently we do them every year. under the future certify the we put in a lot of money. plans bidding, basically provide protection to seniors to be it would just seem like every certain the plans they are considering are not only three months i have this conversation with someone from legitimate players, but can follow through on access to the noaa are fisheries sitting where service is that are guaranteed you are in you are the top under the medicare law. doggedness. i am looking to you to say let's so it's not quite sending get on with the show and misuse someone out to the relative out the technology. there. it's very much spare at of i know whatever is going to say. we're not sure how accurate it is. if i go to massachusetts now markets that have a reasonable working well the way they do degree of regulation. their system now and in certain fisheries we have. so from there, the question as, well at work quakes occur at i'm asking you to accelerate this kind even if we pick one or two areas to do a high this sound, fee-for-service, and concentration of technology unlimited subsidy for the whole set here. versus human doing the testing of the census estimates. when you think about it, the we know canada has been doing average medicare beneficiary it. doesn't see a dollar. it seems in this world we can put a thing on mars and watch us it is directly sent to the plans i know that the medicare pick up dirty now exactly what advantage plan. they are and find out there was water up on time. the subsidies to the health it just seems we can do this. sector. if you don't change the terms, you won't be changed in the late i would challenge you to health operates. accelerate this as an opportunity for cost savings, if you change medicare, you're but also engaging the technology of this country under something likely to have ripple effects. it could be very positive for desperate for a food supply that the rest of the health sector. needs more accurate assessments. can you quickly respond to that? the question is can you get it to work? i just get so frustrated. in particular, tv and a cap on? i'm afraid i'm going to see fishermen today. i would argue he's got a good i'm not sure i want to because they know what they're going to ask me. cbo score that way. that's really the wrong way to >> senator, we hear your concerns and share interest in the possibility of electronic monitoring be more efficient go. that is the top-down approach than the observer system we use and in fact come to the idea today. we are familiar with work being behind the structure is get done in canada. information out of the health sector, rather than to give them we been up to see the corporation and make sure we are the price they can somehow learn to live with. the question about what the familiar with the best gear out there. as you know, we launched pilot subsidy should ease the difficult question. studies in your home state waters this past year. it could be tied to some combination of a low bid. this version includes $2.5 million to keep moving our. but the question is tied to we share your interest in listen the same thing is exactly equal to. understand concerns and that is the political question that has to be addressed. interests this represents for it's a separate question about constituents and i promise you we'll stay on on top of it. >> accelerate the opportunity. what a medicare plan cost, but return to senator colin and then it is an important political senator nelson. >> thank you, chairman a cage double address what is largely for referencing the fishing industry in the commonwealth of avoiding political discussion, massachusetts in thank you for but we won't be all to avoid it forever. so i would argue it is a connecting this hearing. terrible idea appeared to i have a more lengthy statement output on the record. for the sake of time, just a few question this cannot work? and couple things about leading questions for you as you are a can or cannot wear. chairman begich reference people point to the medicare part d program and point out the challenges and concerns in the commonwealth, which i trust you know well. fact part d spending has been i will preface my question with much lower than originally this because i want to be candid with you. projected by cbo. right now is on a great deal of faith and trust in the that does ccp was not a commonwealth about the decisions in the actions. many in the industry believe fortuneteller and projections that what doesn't care and is are fairly salty. content to see the industry go in fact, the program has done away. i trust you understand i am not better in terms of per capita one of those people. prescription drug spending than the fishing industry is 300 the rest of the country. years strong in massachusetts it's a pretty good indication. and is to be there for the next 300 years. the last one i want to mention this to seniors make good the primary question that comes choices? to mind is how does this budget and this is a fair avenue and proposal for 2014 support aid has to somehow wouldn't select take it plan. i will go to part d again. the fishing industry that great commonwealth of massachusetts? if you could also address in what a lot of analysts who don't like the idea have said is in light of the fact acting secretary planck issued the first year of medicare emergency for the fishing industry and are still waiting beneficiaries didn't hit plants. for fun and, why is there not they paid more than they needed funding proposed to address that to. a recent study in the american economic review calls thinking, emergency quite >> thank you, senator. i assure you i'm a deal on a sending our money to spend and what it says something wide sea fisheries disappear and heartening for for all of those i assure you no one in the that when you turn 65 he don't fisheries service is a statement lose your ability to think. in that direction. it's a tough situation with what basically happened is not surprisingly it is pretty confusing for most people. depleted stocks in changing climate decisions. our regional director, john the second year they looked around and said maybe there's a bollard has been in the towns on better option. it seems kind of expensive than the docks everyday since he came for very large sample, the aboard working with constituents average gain from shifting plan and fishermen, trying to employ every degree of flexibility to was $298 a year. help them through this difficult that's a pretty good indication time. this budget proposes modest they can work up its thumb on in increases, but significant the right direction. increases to go along way to improving stock assessment i don't have time to talk about survey monitoring work. other reforms in medicare. as the be prioritized or is most i largely agree with the critical economic species of suggestion to talk about either. which beneficiaries will say it may. it includes additional >> thanks, joe. investment civic and bse and collect data to improve science dr. randolph. >> afternoon. i am pleased to be a part of and underpins management actions were charged with taking. today's pay not to discuss the need to reform the medicare program. my professional career has been dedicated to the health and we're pleased that includes a well-being of seniors. $10 million request for the interaction of consequences and after finishing the fellowship in geographic search in private practice taking care of patients and their home in long-term care focus on the new england ground nursing settings. today i'm responsible for manning the clinical strategy, issues. >> as for the question about the emergency disaster relief e-business at the united health group dedicated to the health funding, and that did not and well-being of our than propose budget when it's big 9 million people nearly one in five medical beneficiaries. clear, certainly from our side my coworkers and i are committed of the table that there's a need to our mission to live healthier, more secure lives and and noaa has expressed a on a regular basis collaborated appreciate the need. i'm curious why you would not seize this opportunity to put it with health care professionals, physician and federal government on their when the need is to identify new and innovative increasing by the day since the ways to serve beneficiaries, fishing industry at which is why today's gathering is so important because to seize massachusetts is facing a the opportunity and overcome 70-cent cut next week. challenges that the aging we've got a problem. what is noaa's proposed population come it's going to require an interprofessional solution? team. >> we did make soured and contribution from the primary actively preemptively issue a care physician to the social worker visiting people in their disaster declaration for new england fisheries for just that home into the federal reason. there is not a sign or a request government, policymakers and larger share in the country. from it gustation attached. it's an exciting time to work in this field. population we serve gross to the declarations made by the determine his paces baby boomers executive branch and appropriated by the legislative branch as the congress sees fit. grew to their years. >> these aren't normal times, you agree? >> they are challenging times. these leading edge boomers, those who agent to medicare the >> let me ask you this. past two years as they're some of your colleagues from sometimes called represent the beginning of an epic wave of noaa testified before this growth statistics are mentioned committee recently and i sent them a letter opposing the earlier. question, dr. sullivan and by the end of this decade, 64 million people will be enrolled in medicare. asking for a written response, that's about 14 million more are eight days ago. 20% more than a roll today. >> i'm not familiar with the in addition to their exponential growth in size, the medicare letter, senator. population lacked very >> i'm waiting for your response and wondering, is there any differently as the boomers age because per-unit qualities and particular reason if you know at characteristics. we fully expect them to interact with the system very differently this time why noaa decided not than their parents and to respond to the written grandparents generations did. request for information. this represents a dual challenge >> i don't have the answer, but i will surely look into it at and opportunity not only to the end of the hearing. serve a larger population, the >> can i have your word what the tailor plans and products to meet unique needs of the growing response by the end of the week? medicare beneficiaries. >> my responses need to go i'd like to share with you what we've learned so far from our through, but i assure you will get on top of it. >> i bet you can answer today. members who are baby boomers and diverse characteristics. >> i was going to give you the they are very interested in end of the week. managing their health and making >> your new. the number one choice sah for >> out of per share follow-up, their medicare plan. dr. sullivan and your commitment emphasize consumer choice because that's what rumors are all about. that noaa will work hard to find we don't expect them to change a solution to that does the fishing industry in habits because they're turning 65. massachusetts. at the corner, the dynamics that there is stress that needs to be they get them working years rebuilt and noaa a search engine shaped him into status conscious that. >> we recognize that it will work on it. sophisticated buyers piercer >> senator nelson. rather than sticking with the tried and true number we expect they are more likely such products if they don't find one >> mr. chairman. that meets their needs. bottom secretary. the level of sophistication and >> admiral, if we had another bp shopping habits has spilled into still today, who's in charge? health care as well. we fully expect them to apply how the issues in medicare >> the coast guard is in charge for response to this though, benefits. they'll have high expectations sir. for personalized health care. >> to sending you? one-size-fits-all approach is unlikely to satisfy them. >> yes, sir. >> you would be the authority? the united health group come within the last several years >> is certainly my reprint medicare organization responsibility. i may assign people that might for the genetic shift and be the primary response person, already seen a change. we have 1.2 million boomers whether it's a district enrolled in a medicare products. commander for incident the majority of experience life commander. and her employer and individual business, those today purchasing >> what happened after the bp health care is an individual or spilled that it was described to through their employer. me by the coast guard that the younger medicare eligible consumers demand more customization and access to coast guard is in charge 51% npp products and information that give them more control over their own health care. is in charge 49%? we expect this is the beginning of a broader trend. >> 's ear, i've heard various boomers who once backed and demand more from health care quotes like that and i don't know who to attribute them to plans. the boomer beneficiary will not specifically. i think when people are being hesitate to do several of the plan is not meeting their needs. interviewed either insurance or press conferences and other we see consumer preferences name, one of the things the having a positive impact on coast guard has traditionally in driving competition and order to be prepared for innovation. we're well positioned and ready for the shift in health care. incident responses is to partner both at the federal state and we no boomers are expecting to the blogger than their parent local agencies and 10 to 10 and study showed that will live longer than their parents. industry because industry will to do so, they need to manage have to pay far, but the ultimate solution. their own health. this expectation runs contrary we bear the responsibility to direct industry. as far as i'm there, it's 100% to the reality for aging boomers. most of whom will live with at least one chronic condition as we age. at the coast guard shared with that leads me to my second others along the way dependent point. boomers will challenge the upon regulations have a health care system that just particular impacts there are for the incident. because the numbers, but they but we hold companies accountable for the cleanup if struggle than generations before they don't have the wherewithal can we can authorize them. expenditures in the oil do a bit more extended and pollution response fund and the complex than those the previous coast guard will take point on generation. today, you're more likely than this. not to have at least one chronic >> in your mind, as the head of condition. two adults fall into this group the coast guard, was there a of more than two chronic lesson learned from the bp still conditions. the reality is chronic with regard to who is in charge? conditions and decreased quality of life. >> i think it is more the way we talk about it. they have no approach is to help once again, in order to be ease the effects of diseases and prepared and with the oil their associated costs. reacted 90 was constructed, the we know the largest driver of supposed guard responsible for condition is lifestyle choices. the cleanup and responsible obesity, smoking, conditions plans to get the cleanups done. like diabetes, heart disease, cancer and others. for many years, we work in we know transparency tools and partnership with companies. programs to be a key component the petroleum companies. to helping people choose healthier lifestyles. in order to move forward the we think because of this is an incredible opportunity to evolve safe design practices, we need to work in partnership. in a way that allows for seniors to access higher-quality care unfortunately, that is within and they're able to do today. our for not doing that's really we look forward to partnering to talk about it from time to time. bring out the innovation in your people are put off by the fact we talked to some of my people and our partners and industry. sitcom. medicare advantage is a strong we clearly know and we've record of pioneering new innovations and strategies for improving health care quality learned a lesson that we are in and promoting delivery of health care services and of the teen evidence based health care charge. we hold people accountable for system. for example, the model of care cleanup and that is one of the can't ever care was a program many lessons we've learned from them. >> i would respectfully suggest invented by two nurse to you that on the basis of your practitioners working in a nursing home and found the response that the administration quality of care that the outcome and the matches began of the patients were receiving lists of coast guard, has not learned the optical. they knew they could take care of individuals who were shipped out to the hospital better and more effect does with the skills lesson. because on a daily unfolding and qualifications in a nursing home. that not all became a permanent disaster of the magnitude there was the bp disaster, the part and has been shown more effectively primary care can arrangement that was occurring save costs by reducing where there is so much different hospitalization. same holds true for members of to the oil company, it led to diabetes. management can improve outcomes. the oil company basically been a study published last year demonstrated individuals who had in charge and without delay over diabetes when they were seen in their home by a nurse practitioner who did a comprehensive assessment and get and over of getting our arms their care coordination started, around the problem. a full physical examination was i'll just give you an example. a component asking about medical health, social history of you remember that the oil company wanted us to think that behavioral health. increased primary care business they're in less than a thousand significantly and decreased barrels a day th were gushing unnecessary hospitalization and from the well. readmissions. the medicare program offers a combination of proven solutions for modernized and her program it is not until this committee to meet needs of generations. and the environment committee of we look at this as two sides of the same coin. the consumer choice and the senate insisted otherwise that we get the actual video, sophistication and an the live streaming video of what was occurring 5000 feet above unavoidable truth that the rising medical costs related to the surface, that and scientists chronic conditions will continue can calculate the flow rate and to have a significant impact on see that it was in a barrels a the medicare advantage program. day in each of those were the most viable way to achieve sustainability is addressing revised upward by bp trying to medical cars are health care keep the minimum that ultimately quality and engaging consumers to become more activated their own care. people with diverse backgrounds was close to 15,000 barrels a and professional responsibilities are gathered in the room right now. day. if you look around, the person a lot of mistakes that were made next to you has a different job but that common mistakes made than you do that's going to take all of the sectors of the society working together with comments come out of the white house that there is no oil constructively to renovate the solutions necessary to serve as left after the well was to i we age. we put the private sector plays an essential role in both sides think egg for a change command of the equation. for helping beneficiaries improve their health. structure, one that is the military command structure in an with health care professionals, unfolding or promotions that occurred there. we are transforming the way health care is delivered in this i simply share this with you, country. were excited about possibilities and look forward to continuing to play a role in this country. admiral, the admirable admiral thank you. there from your comment, it >> well, let me take this doesn't sound that has been opportunity to thank all the instituted and understood. madame secretary, let me ask you panelists for their concise and as a result of this magnificent well focused presentation. here at brookings, despite our that we now find recoverable oil disciplinary backgrounds and unsure, not only to natural gas, that the onshore oil producing kinds of new reserves, to what policy matters, there is one believe, an article of faith to degree is that true? unite says in this building in a number two, does that in any way common mission. you can call it jeffersonian lessen the pressure to drill naïveté that democracy does not offshore because of the new oil reserves onshore? work well unless and until the people themselves understand >> senator, i am not conversant for either onshore or offshore real choices that confront a citizen and we confront as a oil. it's more the domain of our colleagues in the offshore country. they believe what you just heard in the past 50 minutes energy group at the department of interior. we'd be happy to follow up their staff if you'd like. constitutes a superb i don't have figures at hand. introduction to one of the most important policy programs we >> okay. i've now, let me ask you about face. i am grateful to the panel for the budget. getting us up to a strong start. lester on the maritime oil spill i am going to struggle to be a moderate moderator here because program at a budget of i have all sorts of questions 238 million in this year it is that i would like to put to the panelists. i know they have questions that they could put to each other and down, let's see, last year's level is 289 million in this you have questions or that depicted them. i'm going to surprise my tier 238 million. questions and they can buy a issuing an invitation to each are we prepared for the next member of the panel. please be brief and pointed in deepwater horizons so with that kind of funding? taking up my invitation. >> sera, the specifics of the if you've heard an important proposition put on the table in the past hour with which you amounts in the budget i'm not at that level of detail to respond disagree, which you state that what are the fact that for us. proposition and who put it on we've had reductions across the board so it does not surprise me the table and why you disagree with it and go from there. to see something about a quarter of a million dollars reduced by everybody agrees. reducing expenditures for both i have a list, but who wants to cities and people at the same time. start? while i can't explain the >> there is rampant consensus difference was probably 10 or here. $20 million in that particular >> i'm not so sure. line item, i can say we're christ. working closely with the >> you see, i am in my department of interior. bipartisan note, so i have to be the department of interior permits streamlined with learned somewhat constructive. a lot from the deepwater horizon press says they will evaluate, will work with the department of interior to the code and the i think one area that i'm not companies and safety of the sure i would say i disagree, but traveling evolutions in those lessons are the things we care i do think one of the challenges for our. with the policy in the past really have been notwithstanding >> mr. chairman, last year was the fact that you have innovation approaches to mention costs come and have shifted savings to the program in any $289 million for the oil spill significant way. in fact, it's increase caused no response for the coast guard of late to medicare program. budget and they are proposing to and now, one area i believe that fund ad from 289 million to is really important talking about modernizing the program is 238 million. this committee deserves an answer as to whether or not in ensuring medicare beneficiaries fact that's enough to why was it still do have a choice of where they want to go to make it not so substantial disruption. if we went to a premium support cut in light of the fact we could face another deepwater rely totally on fee-for-service, we would have major problems in horizon oil spill and quick terms of cost and chances than achieving savings. >> senator nelson, let me if i our motto, which i hope we can can't. i've got information. talk to little later if an correct me if i'm wrong, but also take the question that in attempt to take advantage of both of those and address those shortcomings. i think this sort of premium 2012 we had about 213 million give or take. support only model would create now 2013, 289 and 14 to 38. the type of disruption and he kind of went like this. wouldn't guarantee the quality we want to see in the program it does state the question. first of all, less than 13 is but also show significant cost risk to beneficiaries. that i think we would say in the hope is we find a balanced approach to doing this. that gap is senator nelson and i asked by the way up we went to a fee-for-service approach and maintain fee-for-service country agree with is what is the operational and pack and the continue to drive up costs and have the problem on the volume site. spell of the magnitude equal or or tried to get to a balanced greater than what occurred in the golf. approach and the initiative that's an important question would lead on the table last week attempts to do that. again, we critique in a because if we're lowering the fund independent dissipation of significant way the fee-for-service as we do the shortcomings of what we perceive to be the support policy. non-catastrophic, which we would never want, desire creative >> again, what i was talking population as you are moving about was not the support policy forward burgett with oil spill that chris and a lot of people that could have been in the don't like to soak and often care to rise. gulf. that's a sizable amount, only 15% of your budget of that unit. as i try to make clear, the medicare program will be >> mr. chairman, anything i subsidies if the government will could be no spears speculation. still have responsibilities to there's so many ups and downs of inconsistencies in the budget as they face productions, making ensure the plants operate in an appropriate manner and take tough decisions and also the action in a few cases that might not have been. fact that the budget was enacted as far as the program shifting six months into the fiscal year, many time we make judgments are costs to the government, the going to have to carryover money medicare advantage program shifting costs to the government, there was a and transfer things around and conscious political decision. that affects the levels we ask its roots are back in 1997 when for is slow. it is the republican congress on the cost-cutting move in rather than sit here and speculate, i'd rather give you an answer for the record, what you deserve. severely cut payments to private >> that would be appropriate. maybe the drawback to starting plans and medicare are not the plants drop out within three or four years. their analog or focus if there was the carryover or whatever occurred. in 2003, republican congress in the detail would be helpful for senator nelson and myself as well as others who may be passing the medicare modernization act, the built-in interested in this. senator nelson. is relatively guarantee payment >> mr. chairman, may we expect the answer to that by the end of the week? >> he's given you a lot of extra that is at least as high as traditional medicare and often time. times higher. i was going to give the end of the day. that's not what a sensible >> fantastic. competitive eating process does. >> we should ask for a week all the time they respond with end as i say, that is basically a of the day. thank you for that. top-down approach by this time does that satisfy the request? the plants come here is how much >> fantastic. if i could do two quick ones, money were planning on offering you. which is a tidbit? pending apart from the standpoint of increasing the plants available. one for you, admiral and then but it didn't balanced approach rarely government cost with one is saying a united states these options for beneficiaries effort in regards to housing for pay beneficiaries tended to get a much better day of, tended to men and women of the coast guard, which akp huge credit for. you actually had to live in it have lower costs. that's no lie. the third-party was indeed at times and there's a great need there. overlooked. is that one that has impact? >> well, i have first of all, probably one of those things you you know, i think bob was have to push off. besides my money, is this still certainly onto something when he uttered the phrase, rant that on your priority list bringing many inside, this is a pretty consensus because there is a very important analytical point important thing you believe we should be focused on also? shared across the panel and that >> absolutely. you know have an aunt in alaska is that the fee-for-service model of medical payments is a with me and linda has been one of our highest priorities to very suboptimal way of improve housing. we are really grateful that organizing a system and hopes to congress give this $10 million in the fy 13 budget and i'm capitalize a suboptimal way of thinking about health care happy to report to you that is delivery. that's importune and i suspect going to construct extra homes where we have the highest need. most people regardless of their it's going to construct about 10 homes. out of the 20 we need to political or policy priors would probably agree with some form of that statement. construct a bite to be able to the question i want to put on construct more and look at other places we need it as well. the table as a question that if the continuing issue for me. appeared to me to be an issue to some extent between bob it was a reasoned response face reischauer and jim capretta when of the fiscal realities they fear that the workload of my you look at the overall health care system, who's in the people. the congress gave us in excess driver's seat here? of $250 million for storm jim said medicare understood repairs for hurricane sandee. that work and getting executed correctly is the engine for is a huge workload for civil features of the health care engineers and contracting people system we don't like and may not come this will be fully engaged kidding ourselves reconstructed afford in the long run. and was a reasonable decision to he said god had a different defer housing because of the other money that needs to be analytical take on the overall health care system. spent. >> i might've mentioned this once before. sounds to me is that you a i can't remember our final chance to respond. response or if we are good discussion. the military has done some >> i hope the chair more successful on-base housing disagree with me, but it's a partnerships with the private two-way street. sector who went in with capital the private sector affects dollars and designed long-term come in maybe 50 or contracts medicare and medicare affects the private sector and you can get hung up on which impact is and operated the quality of the housing genetically. as you know, how schematically larger. when you're talking about all of this, but we want to be focusing changed. they're more winter prone on either three dimensions of housing and also more designed for the family today versus the family 50 years ago. importance. is that something the coast one is cost, but the second is quality of care. guard would entertain or the third is innovative ability euphemistic by legislation you can't put down that path as they and a fee-for-service site did have done with the military unrestrained fee-for-service losers sunk cost. bases? >> three issues there. public-private ventures or houston is a good thing. it loses some quality because they have mouse -- they have it's difficult to integrate care and managed care when we have huge units. on the dorff richardson and one of them. lots of little different the reality is we get to the providers that aren't cohesively average that. we've coast guard people and beautiful housing may enjoy. operating in coordinating their same thing happened in hawaii care. on the other hand, it's great for innovation because we for the department of defense is heavily invested to public-private ventures and basically have an open spigot. numerous other locations. as many people people on my go out and invent something. staff and headquarters at this claim it improves care. f-4 belfort in private housing. it will then get approved and i myself live in private housing on the air force base here in even if it improves care town. marginally and only for some of so i'm a big believer. the people, will pay for it. the challenge for the postcard but a thousand flowers bloom in a few of them are pretty. is housing areas are generally and you know, one worries under small. doesn't make it economically feasible for a comp me to come in and make an investment for some and so small and the a premium support system and i practical point is because of the breathalyzer but, you have confess, sympathy is afraid they to score of money in advance of don't pay me and support and i the huge levels of money we share the same criticism that would not observe the thinner patch it. >> you just reminded me as you chris has come in now, there were saying that, this is the cbo classic, which makes no might be a problem with the amount of innovation that takes sense. you'd have to say that. i can say that. place because even in a competitive world, entities that i won't get my commentary about are large and compete with each the video, but i forgot about other often mirror each other's behaviors as opposed to going the aspect that you have to show it on the front and when reality off on a new tangent because it's a longer product. it's high risk and you have a i have a question for the record lot at stake and don't engage. there's no right or wrong answer to this. it's a matter of weighing these in regard to agency one for four that she don't have fun and come attributes when you think about of that interest undersea 27 and how you want the system to must admit that for the record is there something we can help reform. i think even the staunchest defenders of fee-for-service you. >> is very important, senator. believe changes are needed to >> we can help a combination of units we are reviewing. if you could respond to that, introduce more in the way of that would be great. coordination that will improve quality over time. last thing he cannot have a >> respond to that none will go couple more for the record, they to questions from the audience. >> albeit brief. first want to thank you thank i basically agree with what i've you. the delegation came regarding just said. the issues that the environmental impact statement on oil and gas and i would argue the reason i brought up the metaphor is there has been and what i was hoping senator nelson is shifted in the last couple would stay to do arctic years the prevailing view of 15 development in oil and gas up short on done the right way and or 20 years of someone say we that's the critical thing we don't fix medicare, the medicare know what to do with potentially is eyeing for the larger system. 40 billion or more barrels of oil as far as gas. it misses important point that in the supplemental draft issued medicare is a big part of the a few weeks that the definition of drilling program could trail reason for the system is organized the way it is and you might focus on what it's doing one well at a time in either to influence the organization of the system. theater. there's more recognition now than there has been in the past, over 600 leases in that area. frankly. that's a good thing. one subtle thing about why one my wariness between that in might think of the difference education measures which reduce the timetable they can trail, it between which i was put forward, is really putting a stranglehold would i support of what chris on the ability to be successful has put forward is a question of in striking the largest oilfield how one views the likely success on the contrary one's head. within our current political economy and how medicare is run. can you give me your assurance is the design of the program is not in tended to restrict it looks so it does for a reason because it likes the way medicare fee-for-service looks capacity from an economic standpoint because that's the and operates. worry they have. the question is how can you break that cycle? their god and a lot of the with the level of familiarity exploration is done in multiple, sometimes two or three, special with the bipartisan policy center, their interest and mchardy. recommend nation to rely quite help me understand the restriction, which is a pretty tight restriction. heavily on the cms and federal government managing the >> my understanding about the transition to an effective delivery system. joe's approach and the one i draft is still a bit incomplete support relies much more on a quite frankly. we will follow-up with you on system by the government can't mess it up again and the it. by understanding of the consumers will select with the supplemental is that does that flexibility in terms of how many proper incentives the highest value delivery system if they wells and in which theater or wanted to do so. theaters. but they get the additional >> you got my juices flowing. details and follow up for the i'm sorry. record. >> would you do that? you know seasons work that now >> you can overemphasize how is the time to resolve a lot of much medicare can influence the issues so they can move into it next season. rest of the health care sort or but we had to say thank you very because there isn't anything like medicare. much. medicare as you say in five did members coming in and out and asking important questions. to both of you, respectfully to resemble hope insurance, but it sure doesn't now. your employees that work for you, your employees do in one of the world for the incredible work. sometimes the sudanese meaning individual purchase everybody is to bang on your head to get answers in your very responsive. sometimes it's frustrating to have to take it from us at intervening in some way to steer or manage patients. times. that's how your employees do an exceptional job. there isn't another system withers at mr. prices and this also around the country may there be differences at times and have individual incidents. is because the student said the i can only say we have a great work force and should be proud 800-pound gorilla. of your teams out there every day on the water, on the land and in the air. nationally we adjusted for price differences across the country. thank you or both of you. the record will be up in two take it or leave it. if you need to come you don't weeks? it will be open for two more weeks for additional questions get any business and that's too big a chunk for any provider and thank you both were attending today. this hearing is adjourned. except boutique providers could face up to. medicare has tremendous [inaudible conversations] political advantage and that it gives consumers the most choice venue in the past. when you have the most choice anyone could have come you can't be unhappy. you can't criticize. the decision to make result in some pretty poor quality often are your responsibility. they aren't plans and so vote for the single-payer as the government's fall. if you're in a managed competition situation, is the plant's fault and we are hesitant to move in that direction come of it this changing generationally as rhonda said that we have a preponderance of elderly now who's still remember the old blue cross systems where you could go anywhere and there is >> in a few moments come i no management or anything like brookings institution forum on that. younger generations aren't plans medicare. if you go outside the networks where they have restrictions on exactly what services are covered. you know, is it 30 group sessions of therapy, or is it 15 >> the fbi briefed the house individual sessions? intelligence committee on wednesday about the boston marathon on main. were used to that is supposed to i'm just going to keep going. i was in a situation. an individual who used to work and he goes into the emergency room of one hospital and they can't find anything wrong with you. start the next day. went to a different hospital and at the same thing. the third hospital the third night. three nights in the hospital, >> i tell my kids, look, if two medicare started paying for each one of them. car pulls up and one has a turned out to be the mexican stranger and the other car has dinner he had. dick cheney, you can in the car with a stranger. there's no other system that would tolerate that. >> if you you took out the money republicans spent trying to stop health care and other money >> well, on this delightfully trying to get health care, could have had health care. disquieting note, i would now it's amazing to be in washington like to turn it over to her d.c. with all this history and amazing building and here we are patient audience than just a at the hilton. word about the procedure from >> it's hard to be funny with here until the end of the the president of the united states what cannot you, yet some session. razor and come away to be in country away day in and day recognized and when i recognize out, joe biden manages to do it. you, wait until the roving microphone arrives so everybody can hear what you have to say. please identify yourself if you have an institutional affiliation if they took it on the table as part of the identification, great. and then ask a short question and identify the person or >> now, a brookings institution forum on medical costs. persons to whom the question is this is an hour and a half. addressed. with that, the floor is yours. >> at afternoon, one and all. there is a woman in the aisle towards the back. i am though galston can a senior fellow in governance studies here at the brookings >> i am dr. carolyn coughlan. some of you know me pretty well. institution. i would like to begin by welcoming everyone, including our c-span audience to this you've talked about cost and the system as though it were the discussion of options for reforming the medicare system. same thing as price and a the importance and timeliness of competitive market, price and this topic should be clear to cause our closer there are competitive markets and medicine, primary care is one. everyone. medicare is a big piece of the health care site or come which generic injectables and another constitutes more than a sixth of nurse shortages because the the american economy. competition is stiff. it is a cornerstone of security steve earle's article and not for tens of millions of americans. the growth of the program would ago showed huge profits another only separate as more and more baby boomers retire as a prime area and if you're reducing volume, would you give to driver of long-term fiscal providers is my money for fewer challenges. there is a lively debate as to services. you could reduce cost by whether the slower rate of growth in recent years means we finally turned the corner or reducing price and that the approach they take in europe, will begin to accelerate again as we continue to recover from where they have a lot less the great recession. expensive per capita. health care are better than to explore these issues and possible responses to them, what ours. have i am delighted to say assembled an all-star cast. >> so, whoever would like to respond to that is free to since full biographies are available it was not specifically. at this event and also online. >> your sister. so i was just hit the high points in order of their initial i'm going to confine myself to presentations. brother ray schauer to my medicare. the problem medicare has had all immediate left is president emeritus of the urban institute along is they can't find out what the prices. and former are the congressional budget office serves as a public medicare fee-for-service attempts to micromanage prices. trustee of the social security medical trust fund. to his left, james capretta, there's literally tens of thousands of codes and i would former associate director for social security education and argue it's impossible to get it budget is now a senior fellow at right. the thing about price setting the public policy center. and i have a former rate to his left, christopher regulator, so i speak with experience of it. you only find out when does he jennings, former senior health care adviser to president clinton is now president of jennings policy strategies most pay if they think the price is recently served as a senior too low. research of the bipartisan policy center's comprehensive you never find out. report on the reform of the u.s. that's why you need a competitive basis. health care system. to his left, joseph antos, the >> caller: . in our experience in some of our wilson h. taylor scholar in friends earlier when price comes health care and retirement policy at the american down, volume goes to. enterprise institute has served as assistant director for health in my experience, is not so much and human resources at the congressional budget office ms control in the price it is commissioner of the maryland health services cost review completely changing the payment commission. methodology to align the incentives of the pair, health finally, rhonda randall, a care professional and individual board-certified physician in have incentives around their goal of care. practice serves as the chief what i mean by that is if you medical officer of united health have an individual approach in the end of life end-of-life care medicare and retirement. medical care is to maintain functional status to remain each panelist will have 10 minutes for an opening independent as long as it's possible to do so. presentation. a timekeeper in the front row if a ticket is a significant significant impact technology, will flash to cars of two-minute that causes them to be in a warning and maintains that. restrictive setting and not assuming compliance by all maintain independence may be contrary to their a and speakers come within a few minutes for discussion about having the discussion so the goal is aligned to the member panelist before moving to audience questions. three final preliminary points. school, the patient's goal. the second is transparency. first, this includes the you mention it nicely around the panelists. please do not permit any devices cost so everyone is clear what the total cost is that the that could erode briefly during the proceedings. consumer, health care professional very common for us second are the young at heart to have discussions at the among you, you can follow this primary care physicians network on twitter. who ordered medications on the the hash tag is medicare. formulary that had no idea how much the drug costs and her patient came back and complained third, concerned about the future of medicare is why they about the cost of it. shared not only the country, but the transparency is important within the four walls of the brookings institution. and last, the methodology and payment mechanism with the i'm happy to spread the news the desired outcome, not just the next monday and go burke center reform will bring a process. comprehensive report created >> with respect to compare since through broad consensus that internationally, obviously there is great diversity, but it's provides a framework for aligning health care quality and also great defense across countries they are. financing reforms in medicare as one uniform rule is that in well as medicaid and private health insurance. systems that rely on a price and this'll work as a continuation insist on to keep their costs of bending the curve series. under control, the price of check the website next week for the full report. existing ferry project to pull i missed the show. in basic economics that is supply control. >> thank you, bill. essentially reduce the supply of i have been asked to set the accident that care to some stage by saying a few words degree. that is the way it works and about the fiscal challenge posed by medicare. that's the intent of the way it's supposed to work. after that, they tunic for by and large does not indenture general observations that will mental thing which is in supply provide a context for the remarks of my fellow panelists. to a pretty good degree, which medicare has been and will be in the future of major source of most of these countries do have the growth of federal spending. the underlying reason is held in a large portion of the population. the problem comes in that highly the public and private sectors has been growing and has been tech goal, very trained expected to grow in the future personnel to perform some rare under their income or the economy. cbo has estimated the growth of but important procedures on patients. outlays for medicare over the they tend to underinvest and next decade will be 22% of the that and that is also picked up in some data that compares total growth for the federal government will be accounted for by medicare. internationally. >> for me please say something. this is a period in which ideally, when you have prices, largely because of the you would like those prices to affordable care act, the health reform act is expected to grow be for outcomes and quality. at historically low rates, only at about 3% a year, which is roughly the speed at which we and not for influence particularly. and now, both outcomes and expect the per capita economy to quality are difficult to measure, number one. grow. number two, there isn't a direct .. line between the output of the quality of the output. it might work for him, but it won't work for her and will work somewhat for him. so what cheney to do is have a large group and treat average quality average joe, versus price. it's very hard to do when you have a lot of the delivery system in mom-and-pop kind of organization is supposed to it is expected to grow at 3% or supermarket. slightly above 3 percent per year because medicare spending it is a challenge overture to grows along with health care move in that direction. costs which historically, as i but it's not going to be fast and it's not going to be easy. said, has grown faster than income more the economy. medicare spending is expected to grow more rapidly, even after oneok >> actually, you know, i feel the baby boomer generation is safely tucked into retirement. when enrollment will plummet, it compelled just for a second trip in admin moderators moderation will be less than 1 percent per year after 2035. into eye to the question on the as a result of their growth floor. blaster event the mckinsey study that compares salaries in the medicare spending is going to health care profession around the world. suppress social security spending by the middle of the one of the things you notice is century. because of the way medicare is salaries at the data in the u.s. medical profession are financed from all we cannot allow funds as medicare spending substantially higher than they are in europe and presumably increases. the loss will insurance that is baked into the price is component of medicare, which amounts to about half of medicare spending is financed about the the services being much like social security. delivered. all workers paid payroll taxes how did that come about? advocating what we are paying for it? into a trust fund, all employers pay the same payroll tax into became emperor because we have that trust fund. and out of that trust fund comes been in constrained budget for all of the spending for part a health care services. services, primarily hospital people who are demanding the insurance spending. service is hard to worth the the age i trust fund has exceeded revenues since 2007. price or the cost of this service. what that means is that the when you go out and buy a loaf of red, you know if you buy the balance of the trust fund, the assets that are in the trust fund have been declining, and bread you can buy the porch of they will be totally depleted because you don't have enough sometime in the middle of the money to buy both. next decade. we pay health care through says the trust fund cannot borrow, if current law is insurance provided in large unchains medicare will be unable to pay full payments for charges measure for the under 65 population by employers. in the age our trust fund and employers pay for their fair will only be able to reimburse share of insurance through providers about 85% of what they reductions in our wage income. are charging. total compensation stays the so clearly some positive action same, but more of it is devoted has to be taken before then. to french benefits and we go to added to raise taxes are to slow the growth in spending or the doctor and for our practical preferably probably a little bit purposes is close to free. above. now, by my reckoning i have we pay the $20 copayment, not completed my assignment under my allotted time a couple of the $98 there's arguments for why should be that way. at the same time, it creates general observations we should little restraint on the part of make clear what our goal is. if our goal is to up model their the provider so they can run up growth of medicare cost his the prices. costs are we talking about, the the insurer in the old days, federal government cost, the maybe less so today was like the water company. federal government and beneficiary cost or are we talking about the federal and now, he took money from the government cost to beneficiaries employer, sent it to us by and and the cost borne by states, localities, and private payers. in other words, when you talk went out to the hospital or doctor's office and say send off about medicare reform or cost a little. savings, you can reduce the over what are they went through medicare program's federal the pipe, the more it safe costs, but at the same time enough. it really didn't care that much increase the burden on beneficiaries are increase the hospital cuts are good at a burden on states, localities, great rate on the employer private sector payers and, in didn't want to take off employees by saying you have to fact, pushed up national health expenditures. my second observation is that in go to holy cross hospital. our discussions we should clearly distinguish between true you can't go to some of the reform and traditional cost other more expensive hospitals. restraint measures. true reform changes the that's a situation wherein. structure of the delivery system or the fundamental behavior's of >> i just want to say it's a providers, suppliers, medical researchers, and beneficiaries. very good conversation. true reform and save money of a long run, but is unlikely that we're going to generate huge i do believe cost and price in amounts of savings over the next decade from true reform. reform requires institutional evolution, behavioral unison underlines how much are paying for it. adaptations, changes that are the salaries and that it did best introduced gradually. not. there is no question they spent too much money on health care many of the suggestions that have been put forward to reduce the growth of medicare costs are relative to the weekend in return for her. not true reformers but rather a the question is how do you traditional cost saving restraint measure. they can generate quick savings, squeeze without undermining quality and access and health but those savings can be care? i have a feeling of this country difficult to sustain a long haul really spent her than any other and make compromise quality. country. the question is how much less can we span while still getting my third observation is that we are unlikely to succeed in a better return on the reforming medicare without reforming the broader health investment? these new models are being care system. constructed to try to squeeze this is because medicare out some of that. beneficiaries receive there care there is no question the first through mainstream providers to practice one form of care and surveys -- is much better on the pricing, but terrible on the delivery systems that serve both use. the utilization of dunces are private sector, medicaid, and medicare and the insured. significant under finally, i want to say that many of the reforms that are being fee-for-service. how can they find ways to focus discussed might do more to as well? improve quality than to reduce cost. while the current system is it has to be fee-for-service and marked by inefficiencies, competition, with these out in duplications, unnecessary and terms of how a basket and low value procedures and even enhance health care delivery fraud the there is also a lot of the unmet need and insatiable system. on this policy proposal on the desire among the public for the latest and best interventions medicare now works is they are and the continued development of provider that underpin it, they new devices, new procedures and equipment and all of that cost a will learn how to allocate whole lot of money. >> well, thank you, bob, for resources to improve outcomes. as farmer coordinated. that exemplary stage setting, exemplary in all respects. we're going to the first time jim. that two-sided risk. >> under budget. we're going to have shares thank you for inviting me to be savings far better than the acl a part of this discussion today. it is quite an important topic. very pleased to be a part of it. model. at the end of the day, if we i participated with my colleague don't find some amount the here in a project that he helped nation, we continue to face that organize that provided -- we do today, which is uncertain, produced three papers there were released last week by the unpredictable and almost always american enterprise institute. higher health care costs. joe, i know, will be speaking now i can say the current system about one of them. is working. i will speak about the finding from a study that i did. there was a third paper, it is working now. i would say we have a temporary colleague from the university of pause on hot care costs. minnesota as well as art : from health care cost growth in this country and a per capita basis, the college, all of those papers medicare is better than are available on the website. everyone. and they're all related to there's no question about it. today's topic of medicare reform it is true that no one is also and its future. say maybe 90% of the health my topic is the examination of medicare's role in the broad health system. economies in this country will and specifically, picking up a say it cannot be sustained in little bit on some comments that the absence of more delivery bob just made, want to talk a reform changes in delivery and little bit about my view of how financing changes. the medicare fee-for-service has >> now back to our regularly broadly influenced the organization of american health care. scheduled program. the woman at the end of the in my judgment medicare aisle. >> thank you. fee-for-service is, the 800-pound gorilla of american i'm a licensed clinical health care and unless it gets reformed, the broader system and psychotherapist. rmi sociology class at the not move in the direction we university of maryland, one of would like to see it move. my professors said change once to begin, like to start with the the sending it to change another. i would like to say it's metaphor that bob is initially alluded to. i will put in 70 different reforming medicare. and mr. reischauer say we need terms. i think the prevailing view is that the health care system is to reform, change attitudes, something like a runaway cost train heading down the tracks of behaviors, price structures but have you along with and i do a very celebrated rate. and medicare is sort of one car agree mr. capretta make comments attached to this very, very rapid one rate -- runaway train and mr. antos. my question to all of you in and therefore, to slow down medicare you have to slow and united health care, one of the the whole train. largest companies. otherwise you are picking up on one portion of it. it could create inequities many of us have to have a probably would work if he is focused on one part of it to supplement to medicare, which i make sentra. don't understand two-part the. i like to take exception to that sort of metaphor and think, it's down the road. well, what if medicare was not if you're talking about the just one car attached to this first surveys. trend but actually was the engine at the front of the train pulling the rest of the cars i like competition, which you down a track or if not the only have an address to a major part engine, at least one of the health care reform, the issue prairie engines of the train. and if one thinks of medicare in after dark the in the not too that kind of context of the new site tomorrow, when his second. maybe we need to focus on scott not been if the patient medicare and its role in american health care first and foremost. that is actually one of the points my paper. has enough here the talk has to cover themselves. to begin, medicare is the largest single payer in american if they don't, they look as health care. of course in any given community feared and that is better than the combined buying power of part of the health care medicare various employers in the or affordable parent discussion. marketplace might exceed the i've had to get malpractice value of medicare's purchasing insurance. power, but they are dispersed so where are we with this? down the road. and did not act as one. medicare is a single purchaser with a single regulatory not today, not tomorrow, but structure, so it is the single we'll get into medicare and does largest factor in any given marketplace. need to change. thank you. if you look at the financial health expenditure data medicare is roughly the little bit more than one out of $5 of personal >> there is a lot there. health spending, wedding that i will address the portion of understates the role of substantially. first of all, even in that that divide by panelists to help accounting private health spending that wraps around medicare is counted as private me. medical liability needs to be insurance come in a public insurance. for instance, the wraparound reformed. the health care law passed in plans which are really just add-ons that cannot influence 2010. delivery of care, those are probably more of an opportunity now than there has been in the counted as private spending. so if you pull back from that past in part because the budget and actually look at the office says it will save a national health expenditures by little bit of money. age, roughly one out of $3 or so they change 93, four years four, the population is 65 and ago and at some point the block older. that is quite substantial. away, the policy might get and then medicare influence goes beyond that to the disabled who pushed along by the fact that are on medicare programs as can be used to pay for things in well. when you put those dollars and every political environment. you're getting close to about not to say that a vote because four out of $10. it political coalition against furthermore, medicare regulatory his power. payment structure is widely used there's more of a possibility by the broader system. then in the past is that any and in part due to a recognition that the delivery system becomes accustomed to it and other private payers piggyback on top father. >> let me address the of it. if you look at private insurance relationship. come of all the insurers that are out there offering coverage, three out of four of them in at one of the criticisms that least one of their main plans is offering a plan that is traditional medicare is an piggybacking on medicare's fee uncoordinated system that's schedule for physicians. that does not mean they use correct. the coordination is in the train every dollar amount that medicare uses, but to use the structure and data onto a or patient and doctor. adjusted to some degree. of course, medicare erg system they can get in the way of that. for paying in-patient hospital services is widely used by every the failure of traditional medicare to provide and pair pretty much in the country so and then make a change the incentives that encourage coordination across the continuum of care. it's a very difficult system. medicare is not unique, the medicare could take a leading role in trying to resolve the problem is a difficult issue. in the end, what we need is house plans, whether it's medicare or plans that focus on this and that is driven is financial pressures in the medical sector and growing awareness of younger people that can be served better. the internet isn't such a bad thing. they find out things and sometimes it's right. younger people know things could be better and are willing to speak out. >> we have time for one final question. the woman with her hand up ratepayer. >> hayek, my question comes directly from my affiliation as a foreign national with the u.k. government along the lines above we have been referencing turn the other sense to us. the demolition to commission groups. they mention, how do you put more power into the plants across the board? used evolving systems to these groups. do any of you have ideas how to work in practice thursday night dates? >> let me turn this over to bob. your ratio is two have position so they are charge. when i visit my doctor, the question really is a financial question that the financial relationship cause scary know what relationship days. the doctors responded to two people, the patient and the pair. the waiter luckett says his server, financial and be a thespian we can deal with. it was change the behavior. >> involves partial capitation to the health groups and everybody here would sign onto that, but it worked better in california but there is multiple group practices are not civil in nature's the, which has doctor well be alive and well and dominating. >> i would say you look at some of these new provider networks as opposed to traditional fee-for-service. they are sharing and managing those costs better. that is an encouraging trend that parts of the country will move more quickly. there's no doubt in this country we see each consolidation of our health care industry and are moving and particularly on the reform receive their opening up the door to anything under then the old way if we don't have to do an annual five of her physician payment. so that actually has been an encouraging development that may lead to reforms that direction. >> well, we have now come to the end of our session. i may just be a couple things in conclusion. first of all, i have found personally this a very clarifying session. i think there is agreement and as far as i can tell a well-founded agreement that the current fee-for-service system is defect is in two respects. first of all is put upward pressure on volume, which is not very well compensated by the quality of outcomes in prthupward pressure. secondly it's tough to sustain its useful lifetime a system of uncoordinated care across different services and a system that creates better integration with the better idea. not before the summer company but before the congress and countries that this system is not affected and not sustainable , what should we replace it. the fact there is not total agreement does not gain the fact that increase in these analysts in the society work on main to the definition of the problem. that seems more than half of the path to a solution. so thanks to the panel for making that so clear and driving home with different days. second and finally, please join me in thanking panelists for a superb hour and a half. [applause] [inaudible conversations] .. >> win the affordable care act was being developed developed, some of us thought not just as a way to pay bills but had to repay the bills? how do more efficiently and effectively? how do we redo and -- produce wellness programs? in other words, a change to think about the health care system to support people from the earliest times to every aspect not justin in a clinical setting. that is important but workplace and schools and communities with a regime of wellness and prevention in this country. prevention fund is working and children are immunized immunized, people are quitting smoking and communities on earth fighting diseases moret people screened hepatitis c. these efforts could improve people's health but it goes again as the very mission of health care reform. rating them for pension fund to figure how to pay the bills are set up the structure perpetuates perpetuates, perpetuates our unique costs the american sick care system. this administration doesn't seem to get a. i just don't seem to get it. it was of $5 billion trade last year of the prevention fund this year it is another $332 million raid on the prevention fund. madam secretary i read your statement last night. does not even mention prevention only mental health and the infectious diseases program they have done over 50 years it is like the prevention fund it is an after thought maybe? it is not in your statement. >> to the museum is to help a visitor relive the first eight years of the country to have the decision making process as president. we hope it inspires people to serve there community or country. we did not want to be a school we wanted to be the do tank apart from the museum from which programs the verge >> i walked into the kiosk i am here to report. a guard came up and said i knew what of your campaign managers in ohio. got down in there and the guard said here you have some hate mail i remember in massachusetts they gave me the male and hugos suze part of the strip down then i got into the intake, i got into prison down into the courtyard of not use the language i do in the book but they said he can find his own way and i did not know where to go or what clothes to get light pajama pants and another prisoner said where is your escort? i said i dunno some little guy in a suit yelled foul language. he took me to help the back of the laundry room and a man was sitting there and said are you the congressman? i say it used to be. he said you are a republican? i said republicans put me in here. he said i was the mayor of east cleveland for i will get you some clothes. [inaudible conversations] as. >> good morning. the subcommittee of the oversight and investigation with the department of health services' management with the affordable care act as we approach january 1 in 2014 deadline. mr. cohen director of the center of information and oversight is here to testify on its behalf to and many changes to the private health insurance market. mr. cohen has his work cut out for him as a full implementation will take place and on that day americans have the ability to purchase health insurance through changes. the american people a been promised good coverage that is affordable. also the many promises made in the rush to pass the bill with any means necessary if you like to the coverage you could keep day and now the doctor shortages and if it continues to provide coverage and that decision with the promise that would be broken and that america did she get ready for the premium rate shocking in some sahey could go up by $1 million of cost yet the promise that the health insurance exchange will be ready for enrollment with full implementation on january 1. lome 18 states and i was is preparing the federal exchange that will cover 26 additional states even with the seven other states and i hope we can hear about the progress we've made. above his budget has confirmed there is seeking additional funding to operate the exchanging -- exchanges that is meaning it has already been extended to today i expect with regard to the exchange's to know they are in a partnership with states. since the passage this committee had many questions and most recently we have heard stories about the health care laws and most notably it is utilize to have health care navigators to assist the public to sign a four obamacare plaza also heard that funding has been used on different projects we are concerned it is to throw money act or hide the problems inherent. we hope mr. cohen can address the utilization that has become so common that "the washington post" calls it the incredible shrinking prevention fund. we have concerns including how they would be trained and supervised as teeeighteen with those that have received any compensation are prohibited from becoming navigators. recognize the need to have impartial navigators' but the market indicates those who have been selling insurance for many years may have some expertise and we have questions that we're not simply paying groups to have the membership rules and seven with experience and training is not qualified wes someone without experience has to stand at the front of the line but this only scratches the surface. today i hope we can discuss teeeighteen ability whether health insurance premiums are legitimate as some have already warned of a great shock and obamacare consists of a promised lower cost now we all hear that there are tax credits for research studies show only 8 percent will qualify for those subsidies provide help we can hear from the witnesses today with the other 92 for cent of us can expect. now i would like to recognize the ranking member for the opening statement. >> welcome. and thanks to the affordable care acton's of millions of americans who would otherwise be uninsured could receive health insurance for the first time americans will enjoy protections from the worst abuses of the insurance industry precision had coverage and denial that cut off coverage for those that need it most these are all changes and the time to implement is coming up in just over five months is a sense than sign a for health insurance through the federal or state marketplace. while signing up for coverage should be easy implementation will be a complicated process. not because of flaws but it is a new approach to provide coverage nationwide and these are difficult to implement. by the way the cbo has predicted overall consumer cost will go down once the marketplace is implemented for go there is no reason to think it will work here worked great in massachusetts under mayor romney but we have to educate millions of people about the marketplace. to set of complex data systems the mr. chairman i am glad you we're doing the oversight and i think we need to hear from mr. cohen not just a day but through the summer about where there are challenges and how the agency expects to address those challenges. but we should conduct the oversight with prospective. i wish with the naysayers raise the increase of premiums for young healthy people they could put it into perspective that the tax credits kath out of pocket costs to sharply lower overall cost for millions of other americans and i wish those who have the highest and the specter could add to the prospective the men and women of all ages who will be discriminated against because they are female and when people complain about the fact the obama administration is spending money to make sure the citizens understand the new law which they would take the perspective to remember the bush to administration did the same thing to spread the word about medicare and spending $300 million on the public relations campaign for medicare part deaver i will say i voted against medicare part d because it did not allow negotiation by the secretary of hhs to lower prescription drug costs but even though i voted against it, i had town hall meetings all from a district with internet training to help my constituents figure out how to sign up for it. i think we need to have that bipartisan cooperation as we implement these exchanges at the national and state level. i hope we take that perspective and you set as the affordable care act is implemented. as we implemented the medicare part c program to be described as the initial nightmares many have resulted in some seniors being turned away by that prescription drug program. the implementation of the law was "public health emergency. those problems are almost forgotten until today and ultimately it got off the ground and those who voted against the bill to a kiss taken it to fix the problem. the biggest problem, the doughnut hole was eliminated by the affordable care act. so there is a lesson to be learned i hope the implementation goes smoothly and a survey helped it goes more smoothly than the implementation of the medicare part d but i am not naive enough to know it would be completely wrinkle free. to identify and fix them to score political points. with health insurance coverage. there represents an effort by everybody in this faq for having the hearing. i yield back. >> says as the rigorous oversight of the implementation of the health care lot of we have had this three times and with the promises made it did not quite match up with reality. it was granting waivers to individuals with a large premium increase was a loss of coverage. we also found that through the implementation of the reinsurance plan can dangle millions of dollars even more troubling was the fact the early retiree plan was the $5 billion allocated so quickly that it stop to accepting applications may 2011. more than two years before the program was supposed to and. this is the same amount of money given to the pre-existing condition insurance plan. this has been a lot of the way and three years emir just eight months away from the full implementation and the administration doesn't have its act together. that doesn't bode well when last week the leading senate architect publicly warned that hhs secretary he sees a train wreck coming. with the changes be ready? hokan families prepare? can they rely of the promises it to like coverage you can keep it? could young adults afford higher costs? alarm bells over how obamacare will run are louder by the day and costs are going up in insurers are where increases and businesses are struggling if they can provide each employee with coverage. patients need certainty in employers need certainty. i hope hhs will show us what they're doing to implement the law. finally with a bill that targets to give that money to those that need them most. americans with pre-existing conditions only to find the program was close to applicants a few weeks ago the pre-existing plan is the problem with obamacare the promises don't match reality and i yield the balance of my time. said i thank you for coming back to our humble subcommittee of course, my interest in the cciio predated right after the affordable care act provided not get a hearing on negative sharing but he was good enough to come into my office and he was in a couple times but is has been very difficult to get information out of the teeeighteen the ranking member says we should be an impostor to work together but it is difficult to do that when the most basic questions remain unanswered. we have october 1st coming fast, five servants away and there are more questions about the readiness of your office and the administration to get the answers that people plunged. you yourself went to the american health insurance plan conference this month" end quote. mack it is only prudent to not assume everything will work perfectly on day one. i agree but i think that this committee we need to hear from you where are the concerns, it used to the light blinking on the dashboard and what you doing to prepare yourself and your center for that day with every dagos online to sign a for the programs and senator rockefeller actually said it will be in their day. people will get a bad impression and it will stay with them. references are easy to make but it that happened after two years of preparation you had three years of preparations so that could turn into more weeks or months or years when this program is unfolded next year. the application is lengthy and complex people have to estimate whether or not they think there employer will provide insurance with their earnings will be, these are tough questions that need answers and we hope we get some today and with of period they are allowed. >> now we recognize mr. waxman. >> said republicans on this committee and the health subcommittee held five hearings since december on the affordable care act. in each of these five hearings repeats the things that they express when they oppose the bill. they certainly never expected this to become law. republican members cannot except the health reform as working and is now a lot of the land. they toasted the beginning and until today the president signed the bill into law. until the supreme court ruled it unconstitutional they said it is not. and tell obama was reelected they insisted they would vote them add of office to overturn this lot. none of that have been now it is an oversight hearing because they predict all of the terrible things to happen. they're not predicting there wishing. this is not a hearing to be constructive it is a hearing to attack the lot to hold it doesn't work. the affordable care act will go fully into effect in the americans will lover again have toward the high get quality health insurance and republicans are saying the implementation will not go smoothly. implementation of any new program has its kinks but the affordable care act is proceeding on schedule and has done there remarkable amount of good for people. over 3 billion yen the adults now have health insurance. over 100 million americans have received free preventive health benefits, more than 6 million seniors has saved six point* $1 billion of medicare part c. and tens of americans who would be without health coverage will have dependable quality health insurance. a republican colleagues one certainty but the certainty of no affordable care act is that millions would be discriminated against because they have pre-existing health conditions and they offer a risk to do everything they could to get coverage if it costs money and that is what we want to use change. republicans still oppose the affordable care act and they are not taking a constructive approach. they say what can they do to take the implementation go more smoothly? what about those that supported the of lot? i am pleased they have the hearing today with mr. cohen news here in december cciio has made huge progress with the affordable care act that does not change and makes them more determined something they can criticize we will vote on a bill they will produce because under the affordable care act we have a high-risk pool for those of pre-existing conditions space for waiting until january to buy health insurance. without being charged more many because of the pre-existing conditions. we spent $5 billion on a program to help people with pre-existing conditions to be in the high-risk pool and we ran out of money. a rerun of money for everything the government does but they supported the idea of sequestration and be run at of money for all sorts of places where the government has the obligation that we have run out for that pre-existing pool that medical problem pool until the last few months of this year's other republicans said and the concerned about people with pre-existing conditions made sure the fund had enough money to go on for the rest of this year but they find it by taking away the public health prevention fund until 2016 it makes no sense whatsoever. we're happy to support the continuation of the pool to the end of the year but surely we could have found a better funding source and the republicans have denied any other opportunity you have to question house since year they are about wanting to help with the pre-existing condition to see a smooth implementation. they want the bill to fail to go back to the time when millions of people had no chance for insurance that is what they want to offer and has led us to have the affordable care act passed into law i commend t. nine -- mr. cohen and his agency so we can see what happens now that it is the law and they lost their last chance to repeal it expected german yields back. mr. cohen you are where we are holding an investigative hearing and in doing so will take testimony under oath you have any objections to testify under oath? >> no sir. >> the chair advises you under the rules of the housing committee are entitled to be advised by counsel if you desire. >> kisser please rise and raise your right hand. do is read the testimony you're about to give visitors, the whole truth and nothing got up -- but the truce? thank you. you're now under oath and subject to the penalties set forth of the united states code and you may now give a five minute summary of your written statement. >> good morning to the members of the committee i appreciate the opportunity to tell you about cciio accomplishments over the last year of what has happened since implementation in real life to us when the progress made and how i know we're on track for open enrollment this october. we achieved a major milestone when we opened the window for issuers to submit plans to be sold through the marketplace. we said that would happen april 1st and it did on schedule. we had an encouraging response and we expect to see robust competition for the business of millions of americans who will be shopping for health insurance in the marketplace. . .

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