Transcripts For CSPAN3 Politics Public Policy Today 20140804

Theres also a robust literature on Mental Health problems following abortion. These problems include, anxiety, depression, so on number two. State abortion restriction regulations are medically unwarranted. States have a compelling interest in protecting the health of their citizens and they have the authority to do so including state medical boards and departments of health. Historically states have regulated procedures by establishing standards that protect patients from injury and death. The fact is the patient physician interactions do not occur within a vacuum. The issue whether patients have access is a two sided edged issue. This is because you can have access to care which is inadequate being performed by incompetent practitioners or have access to good care. Zip codes do matter. In many zip codes in the United States patients have access to care which is inadequate. This bill would not protect the rights of patienstients because would remove the ability of states to regulate the practice of medicine. In addition, the scope of practice for different types of clinician is carefully defined. Recently there have been attempts by mid level practit n practitioners in several states to assume the role of providing abortions. Again, this particular bill would remove the ability of states to monitor and supervise the practice of medicine through abortion. One of the question that comes up in any of these discussions regarding the need for improved regulation, including monitoring of the access to clinics with widths of hall ways so that Emergency Personnel can enter buildings, is what is is there to fear from complying with the law . If laws are enacted in order to protect the health of patients and the health of patients in to protect really practitioners as well by providing they will with propt conditions to practice in, what is their to fear in this circumstance . The question really is to what extent are we willing to ve surrender states ability to regulate laws regarding the provision of medical care. Finally, the fact that the state does have an interest in prot t protecting unborn life is not acknowledged in this particular bill. Theres no mention of unborn children at all despite the fact that the purpose of the bill is to eliminate most regulations or restrictions on abortion. The Supreme Court has recognized since row w. Wade that the state has an interest in the potentiality of unborn like throughout the pregnancy because children and their mothers subject to exploitive matters. If we do believe that pregnancy begins at conception, rather than at implantation which is our standard medical definition, we need to begin to consider how to best practice the fetus at early gestational ages. This bill does not take into can the scientific vaient icientifi. So my conclusion i would like to say that this is a measure that seeks to overturn longstanding procedures in the courtsment it ignores Scientific Evidence but also Supreme Court rulings but clearly targeted state regulations which protect the most vulnerable citizens pregnant women and their children. All access is not equal. Zip codes do not matter. We want patients zip codes to provide care that is sensitive, affordable, comprehensive and competent. Thank you. Thank you, doctor. Dr. Parker. Good morning senators. I consider it a real privilege to speak before this body this morning. My name is dr. Willy par y park. Im here to offer testimony on support of the womens protection act. I have provided women with Sex Education, contraception, access to care and safe abortion care. If theres a war to defend the right to safe and legal abortion, then mississippi where i practice is on the front line. The front recently passed laws restricting the provision of abortion to gynecologist and those with hospital admitting privileges. This law which is cleompletely medical unnecessary shut down the one clinic in this state and would deny women access to abortion. On top of this this state has also mandated delays that are both costy and burdensome to the women speaking care. I woman should not be denied access because she lives in mississippi or anywhere else for that matter it should be determined by medical evident not her zip code. The proponents of their health say they are protecting the health of women but the facts suggest otherwise. There are far too many teen and unintended pregnancies. The infant mortality are extremely high. Far, far too many mississippians live in abject poverty. These confront every woman whether she was a desired pregnancy or not. What women need is safe compassionate medical care of the that need is urgent. That care should include abortion. These of facts. I made what i consider to be the moral decision to provide abortion care in this state. Now, invarably given the climate around abortion in this country, i feel questions from people regarding that decision. The most frequently asked question is why do you do this . Well the short answer is because if i dont, whose going to do it . If women in mississippi and states surrounding can find a way to travel from rural areas under hostile circumstances to access the abortion care that they are entitled to then i made a personal decision that i wanted somebody to be at that clinic to meet them when they came. One pash entient that i often t of is one of the first patients i took care of. A 35yearold pregnant women with five children. This woman found herself with an unplanned pregnancy. She confided in me at this particular point in her life she couldnt care for another child economically or emotionally. She had already travelled extensive distance to come to the mandated counseling that she was to receive. While she was completely resolute when she walked in the door and knew what was best for her and her family, she was still desired to be delayed in her decision to be political reasons that had nothing to do with her or her medical care. Other women that i saw owe that same day were returning for their procedure after having made the mappndated wait and th had recently completed a second trip from hours away to receive their care. These women made it to the clinic distance distance and travel costs. Child care considerations. In the 24 years that ive practiced medicine ive learned a few things. Every patient is unique. Every woman is different. When it comes to abortion every one of them is grappling with a dilemma. A define a dilemma as one has to make a decision between two undesirable outcomes and yet one does not have the luxury of making that decision. While the stories of women that i see might deliver what they all have in common is for them it is increasingly difficult for them to access abortion. As i said earlier, people ask me why do you do it . Well, i think the answer is very simple. I want for women what i want for myself. I want a life of dignity. Good health. Self determination and i want the opportunity to excel and contribute in a manner that i best can. We know when women have access to abortion, contraception and Sex Education they thrive in the matters that i mentioned. It should be same for all women because the ability to live the life that you imagine should not be limited by your zip code. Thank you. Thank you dr. Parker. Themr. Chairman p. Members of the committee. Thank you for giving me the right to testify. It is a nation wide federation of 50 state affiliated right to life organizations. We are the nations largest and oldest prolife organizations. We find the formal title or marketing label womens protection act to be highly misleadingly. The bill is about one thing stripping away elected lawmakers to provide even the most protections for unborn children. The proposal is so sweeping and extreme that it would be difficult to capture its full cope in any title. In it 1980 ruling in harris v. Mccray, the u. S. Supreme court said abortion is inherently different from other medical procedures because no other procedure involves the purpose termination of a potential life. Even americans who identify as prochoice struggle with the abortion issue because they see it as a conflict involving life itself. Many while not fully sharing our view that the unborn child should be directly protected inlaw, nevertheless support the kind of laws that this bill would strike down. Law that take into account what most americans recognize as a life or death decision. In contrast, the drafters of s 1696 apparently any woman considering apportion must be shielded from any information that may cause her to change her mind. Under s 6796 elected abortion would become the procedure that must all be facilitated. Never delayed. Never impeded to the slightest degree. What types of laws would the bill invalidate . The list includes, limits on abortions after 20 weeks, past the point in which unborn children can experience pain which are supported pi sizable majorities nation wide. Laws limiting abortion after vielet. Laws protecting individuals or private medical institutions from being forced to participate in abortion which about 3 4th of the people support and which the great majority of states have enactedment laws requiring that information be provided regarding alternatives to abortion which 88 pr88 of the c supported in a gallop poll. Laws providing periods of reflection. All of these would be invalid. Having failed in many cases to persuade the federal courts to strike down the laws they dislike. The extreme abortion advocates now come to congress and demand that this federal proabortion statutory bull dozer be unleashed to scrape everything flat. The bill would subject any law or government pollicy that affects the practice of apportion even indirectly designed to guarantee that almost none survive. T the same would be true of any law that is not abortion specific but has the affect or claimed affect of reducing access to abortion. It is apparent that those who crafted this bill believe that where abortion is involved, immediate ask is hes ccess to a any stage in preignancy is the only thing that matters. Mr. Chairman in a november interview with the news paper roll call, you said as the election approaches i think the voters will want to know will legislature stands on these issues. To know where every senator stand on s 96 would require a vote by the full senate. By all means lets see where they stand. In the spirit of prochoice how about giving the senate as choice as well. On may 13th, senator graham proposed april agreeme ed an ag would receive a full vote of the senate along with a separate vote on the Child Protection act s 1670 which has 41 cosponsored. The unborn Child Protection act would protect unborn children in the six month or later with narrow exceptions. By this stage in their development, if not sooner, there is abundant evidence that unborn babies will experience great pain in the second trimester mismemberment procedure. In response to senator grahams proposal, you made clear your opposition to his bill but you want onto say and my quote, i am more than happy to cast a vote on it along with the womens protection act. I hope they will be considered. This issue deserves to be before this body. End of quote. With agree. We challenge you and the leadership of the Majority Party to allow the American People to know where every senator stands on both of these major abortion related bills. Let the American People see which bill reflects the values of each member of the United States senate live or death for unborn children. Thank you. Thank you. Ms. Taylor. Thank you so much. Good morning. My name is chris taylor. Im a state representative from the great state of wisconsin representing the 76 assembly district. I so appreciate the opportunity to testify in strong support of the Womens Health protection act. I thank you Ranking Member grassly and Committee Members for this opportunity today. I also want to thank my senator Tammy Baldwin who we are very proud of in wisconsin for coresponsing this important bill. There is a consensus in wisconsin about what legislatur. It is not on aboring tion restrictions. It is on the economic issues. We have stagnant wages. Working families are struggling. Those are the issues that we want the state legislature to focus on. Unfortunately that has not been the focus over the last three years and wisconsin has become one of the battleground states where fights over a womans ability to access abortion care are being waged. We have only a few Health Centers in wisconsin that provide abortions and we have over a dozen abortion restrictions which have nothing to do with the health and safety of women and everything to do with politics. It is on the verge of becoming a state like mississippi where abortion is not accessible. A womans ability to access safe, legal abortion should not be dependent on where she lives or subject to the political whims of her state leallege lat u, legislature. Since 2011 weve seen a proliferation of abortion issues in wisconsin include requiring physicians to perform abortions to have hospital emitting privileges within 30 miles of their practices. The hospital privileges mandate is only imposed on physicians who provide abortions. I am very fortunate to serve opt Health Committee in the state assembl assembly. In fact, there was no Health Care Provider or organization who advocated for this bill at all. In contrary, the medical community vocally opposed this manned ya mandate including the Wisconsin Public Health Association and society which states this requirement interferes with the patient physician relationship and places an unprecedented burden on physicians and women. The effect of the law is going to be to shut down one of four Health Centers that provides abortions because the two physicians at this center are in ineligible for these admitting requirements. That means that over 1 3 of the women who seek aborings is going to have to go elsewhere. The affect is to increase waiting times. Currently there are delays of three to four weeks to obtain an abortion in wisconsin. With the closure of that clinic they would be extended to eight to ten weeks. We would have no Health Care Provider providing abortions past 18 weeks. A delay of this magnitude clearly impacts all wisconsin women seeking abortion care but it has particular affects on low income women who rely on Public Transportation and cannot afford an uncompensated travel time and work costs. These additional barrier maze be unsurmountable. The provider must also describe and dismay the image to the women. This is the most humiliating and degrading law that i have seen in wisconsin. It is certainly the government at its biggest and most intusive. Women are not able to refuse an invasive vaginal ultrasound. Physicians have no ability to taylor their medical care to the unique situation of the individual woman or adopt the best standard of care. The medical Community Also vocally opposed that restriction. They said the mandatory performance of an ultrasound before an abortion is not an accepted medical practice or standard of care. Does not add to the quality or safety of the medical care being provide provided ultra sounds are being used as political bludgeons. Unfortunately my republican kol keyi colleagues did not listen to the medical community. As we talked about this issue prior to the debate, we realized we all had our own experiences that caused us to make very personal decisions about Reproductive Health care. We had members who had experienc experienced pregnancy loss, still births, high risk regul pregnancies, sexual assaults. We decided although we might be ignored by other our colleagues on the silent. We decided to tell why the laws are so harmful to women and nothing to do with the reality of womens lives and experiences. It is not my role as a legislature to dictate the most personal private decisions of my constituents. I have no business as a legislature dictating in supp t supporting medical practices aas a physician whose ethically obligated to provide the best care for women and patients. I am suppose to make sure the people that i represent are able to exercise their most fundamental personal decisions about their lives. With states ledge latigislating their lives, we need this more than ever. Women throughout this country cannot wait. Thank you. Thank you very much to all of our witnesses. Im going to ask without objection that all of your full statements be entered into the record along with a statement from our colleague senator fine 79 and finestein. There have been some very dismaying and sweeping claims about the breadth of this proposed legislation referring to it as the abortion without limits act. It is narrowly targeted to certain kinds of bogus legislation. Legislation that masquerades as Health Protection but really is designed to prevent access to Abortion Services that are constitutionally protected. So i wonder if you could seek a little bit to the limited nature of this legislation, the fact for example that it specifically prohibits restrictions and im quoting from the act that are more burdensome than those restrir restrictions imposed on medically comparable procedures in other words it saids medically comparable procedure. Could you speak to that issue. Yeah thank you for that question. I think we did hear a lot this morning about the alleged sweep of this law but in fact it is very targeted to whats happening right now in the country of the its very targeted to this new tactic of the last several years in which state legislatures have been passing laws that purport to be about health and safety but are not. That has shown to be defied in many ways. I would definitely commend to everyones reading from the executive Vice President and ceo of the well respected organizations to which the vast majority of oggyns relong belon country. They strongly support s 16996. They do so from a scientific and medical perspective, these laws are not warranted. I think whats really critical about the bill which you pointed out senator is right from the start if this is something that is treating medically similar practices and procedures and servic services, the same, theres no objection. No, s nothing is going to be struck. Thats the starting point. Secondly, if there is a substantial safety basis for the regulation, well, then its not a law that is unwarranted. That law will stand. So if it is treating similar medical procedures similarly. If it actually advances a safety basis, then that they law will stand. I think has important. There are factors that courts would look at in that. Thats what is really critical if its a true safety law not about singling out abortion provision for the motive of shutting down clinics than that law stands. If fact, a number of the supposed ari d regulations that been claimed to be struck down by this legislation, the act would not be affected like funding or insurance or apparently consent. Other kind of regulations that are now in the books. Let me ask you in terms of these regulations, many have been struck down by the courts. Many have been found to be unconstitutional. Why a federal act that prevents these laws from being passed as a matter of statute as opposed to simply having the j jurisprude jurisprudentisa work its way. Were here because 200 of these under handed laws have been passed. It is not right that women should have to go to court year after year to get the medical services that the constitution guarantees them. So i think its important that it may be made clear what kind of these already are on record as i said. The American Medical Association on record against many of these laws, ocog against these laws, courts finding many of these laws unconstitutional. It shouldnt be a charade every year where women are under threat of losing access to services. We need to make sure that we have strong protections. Whats happening right now. We talked about texas which will go down to ten clinics in september if that law goes into affect. We talked about mississippi. We talked about parker practices hanging on by a court order and the unfairness of these laws in mississippi. The hospitals would not consider giving admitting privileges not based on medical competency but based on their opposition or other reasons that have nothing to do with the competency of the doctors so we need to make sure that there are strong protections that we dont have this happen every year. That women can be assured that wherever they live, that their personal private decision is going to be respected. While they are on the books, they have a very womens lives very severely restrictive impact on their legal rights and a very invasive and intrusive consequence for their exercise of personal choice is that correct . That is absolutely correct. Let me ask you finally on this round of questioning the issue of admitting privileges. Why are admitting privileges unnecessary, irrelevant, and in many instances, found to be unconstitutional . Well, thank you. Thats a very important question because that is one of the under handed tactics that has been sweeping the nation and again, i would commend the testimony that has been filed by the American College of gynecologists where they oppose that. Its also the case that the American Medical Association acog in a brief in the fifth circuit is one example when on record to talk about how theres no medically sound basis for this requirement. What is really, i think, important for us to keep in mind. The ama and acog talk about this in their briefs, abortion is one of the safest procedures. An example of how this under handed tactic has closed a clinic in El Paso Texas not open now because of it. 17,000 patients were seen in that clinic in ten years. Not one of those had to be taken to a hospital or transferred by the clinic. So these laws are unwarranted. They are unfair. I know that many of us here disagree about the constitutional issue about abortion. About the moral issues around it. I would hope that we could agree that state legislatures should be transparent in their laws. They shouldnt protect to be about one when thing when they are actually about another. To do so undermines our faith in the rule of law. Its unfair. Its undemocratic. Its unconstitutional. Thank you very much. My time has expired. All of the documents that you referenced will be made apart of our record without objection. You heard about this in my Opening Statement he had had been engaged in enterprised kill babies violating the law. Obviously violating the trust of these patients. State laws were in place in that state but as a grand jury report says authorities didnt do inspections for fear it would be seen as quote, putting barriers up to women seeking abortions. So my question wouldnt this particular piece of legislation make it easier for these types of individuals to continue to operate with impunity . This legislation would make it easier for them to operate. The law actually says this legislation actually says that if a provision would single out abortion, it would be invalid. Or if it would impede access to abortion. One of the factors to help determine whether or not it impedes access to abortion is allowing the Abortion Provider to determine whether or not the new law or any law would impede his ability to render services. So yes, abortionists like gosnel would be able to continue to practice to set up shops. Actually we did see that many of the state Health Departments decided after hearing about him and realizing that they as well as pennsylvania had not done any kind of inspection of the clinics when in and started doing them. They were finding some horrible situations in some clinics have been shut down because of that. This law would say that if the d if it is specific to abortion. Its invalid or if it would impede access to abortion. Even then, from there it has to go on to whether or not the state can improve its going to improve access for women Health Benefits for women. Even then there are so many layers set up in this legislation that practically any law dealing with abortion or impeding access in any way to abortion would be considered invalid. Dr. , some states have laws on the books that would require providers of abortion to be located near a Health Facility in the event that medical care is needed. That would probably involve the life of a woman. Some states also require abortion to have emitting privileges to hospitals. First of all, do you agree with the laws. Secondly, can you elaborate on why they make sense in your expert medical opinion . Yes. Thank you for the question. So this has been my experience as a practitioner, abortion complicate when abortion complications occur, they are told to present to the emergency room. They are not given any documentation. No one was told what was done and what the complications were. This has happened to me in practice. Patient experience e ed punctur her uterrous. Why did do this. You knew you perforated her at the time. Essentially he said that he knew that he did it but that he didnt want to send her to the emergency room. I said thats really malpractice. Its not appropriate. His response is well, he started moving. I said thats your issue. If a patient is moving during a procedure that is your issue. You should be performing an issue in such a way that its comfortable. To get more directly to your question, i do believe that physicians should have admitting privileges because that is part of the standard of care. If you perform a procedure on a patient, if youre caring for a patient, you need to be able to followup on the complications of this procedure. That is a surgical maxim. As a general surgeon oobgyn or whatever specialty you happen to be in. If they have a complication you into need to admit them to the hospital or arrange for transfer to the hospital so that that patient can be taken care of. Transfer greeagreements with ve important because they provide for continuity of care. There are a couple of issues here. Admitting privileges imply a level of competence in clinical practice on the part of physicians. If they cannot obtain admitting privileges, there are reasons why. Thats why peer review is generally the rule when patients are applying for privileges. When physicians can not get privileges it is most important because there are issues of competence, they have a trail in their background of malpractice events that causes their peers at the hospital to say this person is not someone that we want to be on the medical staff. Hospital credentially protects patients t. Requires that a physician has demonstratedcific procedures. Physician to physician communication improve the process of care. One of the major problems with mortality is the hand off. If you fumble the hand off, you lose the race. If you fumble the hand off in me is i medicine, patients are injured. If their skills begin to deteriorate after time, admitting privileges provide for a Regulatory Framework where physicians who are in trouble or causing problems with patients can be disciplined. This is one of the reasons why i think many people in the abortion industry oppose credentially because it exposes the fact that if they are not competent. If theyve had excessive number of complications. If they have a trail of injured patients and lawsuits, this is going to be exposed. Finally, i think that it establishes being on hospital staff or being part of a medical society implies that youre part of the medical community. If youre outside of that medical community, then clearly something is wrong. Theres some other issue going on. I hope i answered your question. I have an article that talks about what happens when the abortion industry is a loued to self regulate itself. I would like to request that this be added into the permanent record. Without objection. Senator grassly has some documents hed like to yeah. I have 15 different but id just like to mention five. Concerned women of america legislative action committee, a group of 30 female state legislatures across the country, the association of american physician surgeons. The American Association of prolife and gynecologist and several obgyn physicians, thank you. All of those documents will be made part of the record without objection. Senator. Thank you mr. Chairman. I represent a state of had a wey hawaii thats been a leader in protecting Womens Health. We were the first in the country to decriminalize abortion. Therefore protecting a womans right to choose. I want to say that the state senator kwe oor who led the cha the women the right to choose was a catholic. The governor who allows this very was a practicing catholic who went to mass every single day. Fw we in hawaii understand the separation of Church Versus state. Now, i do agree that abortion is a different proceed yidure fromr medical procedures because the foundation is a constitutional right. So in my view there should be a high burden on laws that limit or breach such a constitution right. Weve heard a lot of testimony from our panel members. So i wanted to ask. Because the right to make this kind of a choice is based on a constitutional right, do you think that antichoice law should be based on medical necessi necessity . An sbsoluteabsolutely. I want to say again all this bill is about is being sure that womens critical acticess to Reproductive Health care. Thats an issue for one in three women in the United States. Women in every state. Every congressional district. Every city and every town. Her health care is important to her. But this bill is about making sure of that because state legislatures cannot just blatantly ban abortion which is the desire of some people who sit in them. Some states have been pushing that envelope. North carolina has banned abortion. The state in responsive briefs in the case said they basically thought row versus wade should be overturned. You have that battle going on but you also have this under handed attempt to do what they cant do by the front door by the back door. So it is important that you make sure that regulation of abortion is not just about singling out Abortion Providers but is actually based on good medical practice and Scientific Evidence. So the response to even the doctors statement is look if outpatient doctors who are doing outpatient surgeries need to have admitting privileges, thats fine. You know, let that be the med he canal standard thats applied across the board. No objection to that. I dont mean to cut you off but i do have a question for my time is limited. Dr. Parker, you provide Abortion Services in mississippi even if you dont live there. I understand you were defied hospital privileged in mississippi. Is that correct . Great to see you again senator as you know. I used to live in hawaii and enjoy serving under your leadership. With regard to my decision to travel to mississippi to provide abortion care. It is in part in response to the fact that well over 85 of women live in a county where theres no Abortion Provider so as i said earlier my decision to go there was based on the fact that nobody else would go, whose going to go . I understand. When i made that decision, the regulations changed in the state of mississippi to require hospital privileges. I made an effort to apply to all the hospitals in the given area and many of the hospitals declined to evaluate my application. So why they chose to do that im not sure but in order to meet the law, i was able to do so because there were hospitals when simply declined to evaluate my credentials. Im not sure. I think your experience just points out how difficult these laws make it for women in certain states to have access to certain kinds of health care services. I would imagine that these kinds of restrictions would disproportionately impact certain populations such as low income women, women of color, and immigrant women. Would that be the case . That is absolutely the case. I gave the example in my testimony that in the rio grand valley which is one of the poorest areas in the nation, the clinic in texas that had been providing good care for a long time to those residents had to close. Again trk w again, it was under those circumstances where the doctors were not allowed to get the of privileges. Do you believe that row v. Wade should be overturned. Yes, i believe. Im sorry. The answer is yes. I believe unborn children should be protected. Thank you senator graham. Senator graham. Thank you very much mr. Chairman. I want to thank you for having thetopic. I would like to join with the recommendation that we have a hearing on my bill which is the unborn Child Protection act 1670 and have a joint vote on the senate floor and see where everybody falls out on it because its a subject worthy of debate. Lets see if we can find some kpl Common Ground about how all of these laws work. Is it your understanding that 1670 would prevent a ban on 30 trimeter abortions that protect with exceptions the life of the mother and rain and incest. 1670 . Excuse me. The other one. 1696. The one today. Yes, maam. Im sorry. Yes, this bill would limit it would prevent a ban on abortion in the last trimester. It would pre do you agree with that . The bill has provisions that track the constitutional standard that do say that post viability, there needs to be an exception for a womans live and health as the Supreme Court has said. So could a state pass a law that banned abortion in the last trimester accept for life of the mother and rape and incest. Your answer would be know. The standard would have to be that that the Supreme Court has recognized. What do you say . I think plorobably one of th best examples, the sponsor of the bill, the chairman was asked if this bill would ban abortions, it talks about life or health, he said the health would make no distinction, the exception makes no distinction between physical or Psychological Health. So it would be very difficult it would be impossible under this bill to ban abortions for health if psychologiy and psyc o Psychological Health is compromised. There are 13 states that ban elective abortions after 20 weeks accept in the case of rape and incest and the life of the mother. Would this bill strike those laws down . Yes, it would. Do you agree that . Like the 9th circuit did with arizona 20 week ban yes it would be unconstitutional and this bill tracks it. States that have waiting periods. Requiring a waiting period from the abortions performed. Would this bill strike that down. If you impede access to abortion in any way it would be struck down. Do you agree with that . I dont. It depends on what the court would look at. So as we were talking. You dont know how the court works. Yes, d rk, i do. Is this type of waiting period. The ones that youre familiar with. Can you name one state law with a waiting period that you think would survive . Well, i would say i think its important that we look at the factors in the bill. Does it apply to Similar Services name one state with a waiting requirement period that you think would survive scrutiny under this bill. Well, if it were able to say that it did not significantly impe impede access to services. If it is a waiting period that is not a particularly long one. You cant give an example. Does this bill ban state requirements that a person can exercise their conscience, right . Yes if someone says according to their conscience they cannot take the life an unborn child that would be impeding or reducing access to abortion. That would invalidate that. Do you agree with that. I dont agree. This doesnt address the issue of conscience objection. Should it. Would you accept an amendment offered by me to make sure that people of conscience dont have to do Something Like this . Well, i think we have important law thats are on the books that respect peoples rights of conscience. As to this issue would you accept an amendment by me to this bill to exempt conscience . Well, im not elected to make those decisions. Fair enough. I think the answer would be no. Dr. Parker, is it standard me c medical practice for if hesitph operating on a child at 20 weeks. Im not well versed in fetal surgeries because surgeries at 20 weeks would have to occur in utero. Yes, it would. What would be the standard of care there. Yes. It is. Thats because when fetal surgery is done. Im very well aware of this landsca landscape. Initially when this was being done, fetuses reacted we strongly to decisions and placement of catheters. So the standard medical practice to provide an athe, anesthesia when you provide procedures on 20 weeks. At 20 weeks, they can hear your heartbeat as a mother, they can hear your stomach growling an they can react to loud noises. Does that make sense to you . Yes, it does. Okay. Has anyone ever been born at 20 weeks that survived . As far as im aware, no. Not to my not to my knowled i can show you twins. Thanks. Senator hatch . Thank you, mr. Chairman. You know, congress has a few times today the states that they had to pass certain legislation, but only as a condition of receiving federal funds of some kind. Im in my 38th year here in the United States senate. And on this committee. And i dont recall congress ever passing a law that prohibited states from enacting entire categories of laws simply because Congress Says so. I dont recall that. Can anyone on this panel give me an example of that, and if not, why is abortion so unique that congress has this authority in this area, but not in any other . Anybody care to take a crack at that . I dont see it. Personally. Let me ask a question to you, miss tobias. States have been passing laws regarding abortion for almost 200 years. The Supreme Court took over in roe v. Wade decision and since 1973 the United States has had the most per mmissive abortion laws in the world today. Most americans have always opposed most abortions and the vast majority of americans support reasonable and common sense abortion regulations, at least thats been my experience. I dont think its a false experience. This bill attempts to wipe it all out to eliminate even minimal regulations that most americans support, and that the Supreme Court has already said are constitutional. I oppose this kind of legislation more than 20 years ago when i was Ranking Member of what is considered a day in the hup committee. This bill would not regulate abortions. It would regulate the states telling them what laws they may or may not pass. How did congress have the authority to do that . I think it would be currently the laws other than what the Supreme Court will or will not allow has thestateture people. Its a very good way to handle this. The states have been dealing with the conscience clauses. Setting up the waiting periods and informed consent provisions. The courts have been allowing these to stand, so its difficult to say that a law that the court has upheld is unconstitutional. So we certainly think that congress would be overstepping in passing a law that would completely override a procedure that the Supreme Court has said is different. This bill would prohibit restricting abortions based on the reasons for the abortion. The way i read the bill, neither states nor the federal government could prohibit abortions performed, because, for example, the child is a girl or because the child has a disability. Is that the way you understand it . Yes. Dr. Chireau, this bill sounds like its differential to medical judgment and abortion should be treated like any other medical procedure. Under this bill, politicians, lawyers and judges would make final decisions on such things such as which medical procedure which medical procedures are, quote, comparable, unquote. Which tasks doctors may delegate to other personnel. Which drugs may be dispensed. Which medical services may be provided through telemedicine. How many visits to a medical facility are necessary. The relative safety of Abortion Services. Which methods advance the safety of abortion or the health of women more or less than others . Now, from your perspective as a doctor, doesnt this bill actually compromise the practice of medicine . I think it does compromise the practice of medicine, and i believe thats on two levels. Number one, for the reasons you enumerated. Number two because i do believe that current legislation in the states to set clinic specified access to clinics and so on and so forth is protective to patients. So i think its doubly a problem. Number one, for those reasons that youve listed and also because the regulations that have been enacted were enacted in an attempt to prevent Abortion Providers from being exempted from the same sorts of Regulatory Frameworks that other medical practitioners have to operate within. This bill would prohibit restriction on abortions that are not also imposed on what it calls medically comparable procedures. That is just one of the key terms in this bill that are brand new and completely undefined. But this bill makes a pretty clear statement that theres nothing unique about abortion, nothing that makes it different from any other medical procedure. And that, of course, is not true. Thats correct. Whether proabortion or antiabortion. Even in roe v. Wade. The Supreme Court said that the state has unique reasons for restricting abortion because it involves what the court calls potential human life. And the Supreme Court of 1980 held that the abortion, quote, is inherently different from other medical procedures because no other procedure involves the purposeful determination of a potential life, unquote. I dont think that we need the Supreme Court to tell us that, but there it is. Doesnt that settle this question and completely undercut the entire theory behind this bill . Yes, i believe that it does, and i think that the issue of comparable procedures is really false. I believe that abortion is a unique procedure, as you said. It is the only procedure that terminates a human life. In addition, from the technical perspective, an abortion is a very different procedure from, say, completing a miscarriage or doing a dilation in curettage on a nonpregnant woman. Can i ask just a couple more questions . Were approaching a vote, and senator cruz is here, so i didnt see senator take all the time. Let me just ask one more. The Supreme Court created one set of rules in 1973 for evaluating the constitutionality of abortion regulations. Then the court changed the rules in 1992. This bill creates yet another standard. Prohibiting regulations a state cannot show by clear and convincing evidence significa significantly advance the safety of abortions. Its bad enough that the Supreme Court sometimes does congress job, but heres congress attempting to turn around and do the clerks jourts jobs. It gets worse. This bill applies rule and regulations to all state and federal statutes, to all state and federal regulations in the past, in the present, and in the future. Does this mean, for example, that states would be required to repeal any laws or regulations already on the books that do meet these new rules . Yes, sir. I think that thats a very important point. I think that essentially this law guts states rights with respect to abortion. It creates abortion as a special protected class of procedure and Abortion Providers as a special protected class of providers. Well, i cant imagine why any state legislature would support this. No matter their position on abortion. Im having real trouble here with this approach, but at least i wanted to raise these issues because i think theyre important issues. Thank you, mr. Chair. Thank you. Sorry to impose on senator lee and senator cruz senator cruz. Senator lee was here earlier, so im going to call on him at this point. Thank you. Thanks, senator. Thank you, mr. Chairman. Thanks to all of you for joining us today. There was a time where the humanity of an unborn child could plausibly be dismissed as philosophical conjecture. Today we know it is a biological fact. For every excited announcement, baby shower, every ultrasound image posted on facebook, all of this attests to this scientifically confirmed very deep human truth. The only difference is that unborn boys and girls are small and theyre helpless and theyre mute. They cannot speak for themselves. They rely on strangers. They rely on us to speak for them. I believe in the enate dignity of every human life and believe every Human Society is rightly judged by how it treats its most vulnerable members. The aged, the poor, the disable the pregnant mother in crisis and, of course, the unborn child in the womb. Neither are society at large nor our laws have to pit the vulnerable one against the other. We can choose instead. We have the power to choose instead. To welcome and to love and to protect all, even, and especially the weakest among us. Making that choice presents an enormous challenge to all of us. As policymakers, as citizens, as neighbors and friends. As parents and children, ourselves. But the haj of lichallenge of l after all, why were here. To use our strength in defense of the weak. We should choose to embrace that challenge and to do so with love and with open arms. We can choose life, and when this debate finally one day ends, i think we will. I think we will choose life. Start with a couple of questions for miss tobias if i might. At a rudimentary level, does s6096 even consider the possibility that there might be more than one life involved when a woman seeks an abortion . No, it does not. And yet this proposed legislation would have farreaching effects potentially not just for one life, but for two. In any given instance. Isnt that right . For every abortion that is performed, there is a human life that is destroyed. This bill doesnt mention it. Treating the child as a tumor instead. In that respect, its very different than other legislation that might just affect one person. Might just affect the health of one person. This one involves the potential in each instance for the destruction of one persons life, its complete termination. Yes. Many medical experts and Health Providers have strong moral and ethical concerns. As they have every right to have with providing abortions. And yet this bill, as i understand it, would have the federal government telling the states that they, the states, may not protect the rights of conscience for medical providers. My own state, for example, guarantees the right of a medical provider to refuse to participate, commit, or treat for an abortion based on moral or based on religion grounds. These laws matter. I can point to several instances in which absent such laws, university or hospital policies would have forced medical personnel to perform abortions. Notwithstanding and against serious moral or religious objections. So, miss tobias, let me just ask, what role do freedom of conscience laws and what effect would this bill have on those laws . And what concerns should we have and would you have with such an outcome . A lot of people go into the medical field because they want to take care of people. They two into obstetrics and gynecology. They become delivery room nurses because they want to take care of pregnant women and babies. If they are told, and they do not want to kill unborn children, if they are told that they have no choice that they will have to perform or participate in the performance of an abortion procedure, they will either be doing something that is very strongly, deeply offensive to them, or they will leave the field which means we would have a lot of wonderful doctors and nurses that could be helping pregnant women and their children finding Something Else completely Something Else to do. So i think that would actually be a huge detriment to the medical community. And this bill would strike down conscience laws because those laws would impede or reduce access to abortion. Thank you. Thank you for your answers. I see my time has expired. Thank you, mr. Chairman. Thank you. Senator cruz . Thank you, mr. Chairman. I want to thank each of the witnesses for coming and joining us today. The legislation this committee is considering is extreme legislation. It is legislation designed to eliminate reasonable restrictions on abortion that states across this country have put in place. It is legislation designed to force a radical view from democrats in the senate that abortion should be universally available, common, without limit, and paid for by the taxpayer. That is an extreme and radical view. It is a view shared by a tiny percentage of americans, although a very High Percentage of activists in the Democratic Party who fund and provide manpower politically. And it is also a very real manifestation of a war on women. Given the enormous Health Consequences that unlimited abortion has had damaging the health and sometimes even the lives of women. I have with me 317 statements from texas women who have been hurt by abortion. Along with letters from texans opposing this bill. Along with letters from prolife doctors, nurses, lawmakers, across the United States that with the chairmans permission i would like to have epterntered the record. Without objection. A number of the restrictions that this legislation would invalidate are restrictions, common sense restrictions the vast majority of americans support. For example, restrictions on lateterm abortions. The overwhelming majority of texans do not want to see lateterm abortions performed except in circumstances when necessary to save the life of the mother. And, yet, the United States laws and the law that would be reflected in this bill is extreme by any measure. Today, the United States is one of seven countries in the world that permits abortion after 20 weeks. We are in such distinguished company as china, north korea, and vietnam. Those known paragons of human rights. If you look at some other countries across the world, in france, abortion is prohibited after 12 weeks. In italy, abortion is prohibited after 12 1 2 weeks. In spain, abortion is prohibited after the first trimester. In portugal, abortion is prohibited after ten weeks. This is the norm across the world, and yet this legislation would say that the 23 states who have enacted limits on lateterm abortion, their laws would be set aside. I question i would ask dr. Parker. Is it your view that these nations, france, italy, spain, portugal, that they are somehow extreme or manifest a hostility to the rights of women . Senator cruz, thank you for your question. I am not an International Human relations expert. I can tell you that when abortion is legal and safe, that the known mortality related to women taking Desperate Measures when abortion is illegal is greatly minimized as demonstrated by what happened in this country after 197 3. I do know that internationally in a country like ghana where ive traveled, Great Strides to reducing their Maternal Death rate by having better access to maternal care. The major cause of Maternal Mortality in ghana is related to unsafe abortion. So if the access to legal and Safe Services for a reality for women like an unplanned pregnancy or a wanted lethally flawed pregnancy protects rule rights values, then countries that restrict that, we would have to question their commitment to the humanity and safety of the women in fair populati populatipo their populations. Thank you for your views, dr. Parker. I would note the suggestion that italy, spain, portugal, much of the sicivilized world is someho insensitive to the rights of women is rather extraordinary, and the idea that america would rush out to embrace china and north korea for the standard of human rights is chilling. I would note that this law would also set aside state laws prohibiting taxpayerfunded abortion. 32 states have laws to do that. This law would also imperil state laws providing for parental notification if your child needs an abortion, that at a minimum before that serious medical treatment that a parent has a right to be notified. 38 states have that law, wryet this extreme bill in congress would imperil every one of those laws. If i may finally, if i may have another 30 seconds, to just share some of the stories from women in texas. Nona submitted this story. She said, i was told i just had a blob of tissue by planned parenthood after they did my pregnancy test, and then referred me to a nearby abortion clinic. I was not given the option of having a sonogram. I was not given the option of hearing my babys heartbeat. Had i been given the opportunity of seeing my baby and hearing the heartbeat, i can assure you i would not have chosen abortion. I would have chosen life instead of death. How can anyone believe that abortion should be legal after seeing a baby living in the womb of its mother on a sonogram and hearing the heartbeat of that baby . I felt i was pressured by planned parenthood because they told me that the best thing i could do was have an abortion since i was so young. I was 15 years old and still in high school. That abortion ruined any chance of me giving birth. As a result, ive had five miscarriages. Three of them have been tubal pregnancies requiring emergency surgery and were neardeath experiences. Ive suffered from bouts of depression and attempted suicide, selfmutilation. My experience of Emotional Trauma after abortion is the same as millions of other women and their families. I have 317 statements. Each as powerful of that in terms of the human consequences of what this legislation would produce. Thank you, mr. Chairman. Thank you. Miss northrup, would this legislation prohibit the use of ultrasounds when a patient requests them . Oh, no, not at all. This law, again, is just very focused on those underhanded type of restrictions that are treating abortion not like similarly situated medical practices that dont advance health and safety and are harming access to services. In essence, it would be irrelevant to the instance that senator cruz has just described . Yes, absolutely. It also very explicitly does not cover the question of insurance funding. Its not addressing that. It would invalidate those laws. Has nothing to do with minors. It specifically says it doesnt address issues about parental con sense and notification laws. Dr. Chireau, have you ever per formed an abortion . No, i have not. Dr. Parker, how many abortion have you performed . I dont have the numbers right off the bat, but i can tell you that over 20 years of patient care, ive seen thousands of women and some of those women have needed abortion care. And in your experience, over how many years . 20. 20 years. Has the width of a hallway in those clinics where you have performed your medical Services Affected the quality or expertness of those medical services . No, senator. Has the admitting privileges within that state affected the quality or effectiveness of your medical services . Only to the extent that they prevented me from providing care to women. They barred you entirely, but admitting privileges are irrelevant to the quality and excellence of your medical services because anyone in need of a hospital will be admitted to that hospital. Correct, senator. And the waiting period, is that relevant to the quality or effectiveness of your medical services . The reality, senator, is that women are extremely thoughtful and most women that i meet when they present to me to be co counseled about their options, theyve. Thinking about what theyre going to do about their pregnancy from the minute that they found they were pregnant. So i know women to be extremely thoughtful. Ive not seen any womens ability to make this complex decision enhanced by being forced to wait longer than shes already thought about it. Thank you. Miss northrup in response to a number of senator grahams questions, you essentially said that the limits embodied and incorporated in this bill were the constitutional standards. Is that correct . Thats correct. For example, most states under the Supreme Courts constitutional rulings can ban abortion later in pregnancy and do and as long as they have an exception for Womens Health and life, those laws are on the books now and would still be on the books. In effect, this law enforces the constitution. Every womans constitutional right to make the important decisions to her herself. No those countries, a reference was made to a number of them, where abortion is made illegal, is it made safer . No. Around the world, many of the places where abortions happen, women are terminating pregnancies where it is illegal and it is unsafe. And whether you see this country before roe v. Wade, or you look at places in latin america and Subsaharan Africa today, women dont have access to safe and legal abortion, they are harmed. You made reference, speaking about the state of texas, to women in texas going across the border to mexico so that they could buy on a flea market drugs necessary they thought for abortions because they could not get that service in the United States. Yes. As the clinics have been shri shrinking in texas because of laws that, again, i commend the American Medical Associations brief in the fifth circuit talking about the medically unnecessary laws that have been passed in texas. Thats the ama. Very mainstream medical opinion. Because its taking clinics from three dozen, cut by a third, and it will be down to less than ten if its allowed to t ee eed to effect. Women have been going over to the border in mexico. Theyve been buying medication on the black market. Theyve been trying to selfabort. And the situation is going to be worse. Women are hurt when they cant get the medical care that in their decision to make a decision about their pregnancy that they need. Miss taylor, in your experience in wisconsin, have the restrictions on womens access to reproductive rights made abortions safer . No. No, mr. Chairman. They have not. Have they created confusion, in fact, discouraged women from seeking to exercise their rights . Absolutely. Theyve sent women out of state. Thank you. We are voting, so i apologize. Im going to have to close the hearing. My colleagues are on their way there. I want to enter into the record without objection various statements including planned parenthood in southern new england, a statement thats been submitted for the record. As is our custom, our record will remain open for one week in case my colleagues have additional questions. And i, again, really want to thank every one of our witnesses for participating in this very, very important hearing. Thank you, all, for attending. Pleasure to meet you. Even though we may differ, i thank you for bringing this as a full conversation. Absolutely. Absolutely. 40 years ago this summer, events at the Supreme Court on capitol hill and at the white house quickly unfolded leading on august 9 th, 1974, to the only resignation of an american president. On American History tv this week, we take viewers back to 1974 and president nixons last weeks in office. Tonight the audio of the Supreme Court oral argument, United States v. Nixon, at issue could president nixon claim executive privilege over his oval Office Recording . Tape sought by the Watergate Special prosecutor. See that tonight beginning at 8 00 p. M. Eastern here on cspan3. On cspan, the National Association of latino elected officials annual meeting held this year in san diego. Speakers include california governor jerry brown, labor secretary tom perez and former attorney general alberto gonzalez. Topics include immigration, civil rights and the 2014 midterm elections. Heres a preview. When i was in the civil rights division, i traveled the country and saw all too frequently that there were too Many School Districts that remain. So many years after brown, separate and unequal. I saw the schooltoprison pipeline result for black and brown kids all too frequently. Access to opportunity being denied and being denied really remarkably perversely. I did an event once in meridian, mississippi, with about ten kids who were sitting up on a dais just like me and you were sitting right down there, and i could see under the table theres footwear, and what they all had in common was that they had an ankle bracelet on. These were kids, 13 and 14, who were already in the system. And i asked them, what did you do . We well, one person had the wrong color tie, one person had the wrong colored socks. One person spoke out. One person was guilty of flatulence. Im not kidding. Im not making this stuff up. And that got them into the schooltoprison pipeline. Watch all of that event tonight beginning at 8 00 p. M. Eastern on our companion network, cspan. With live coverage of the u. S. House on cspan and the senate on cspan2, here on cspan3, we complement that coverage by showing you the most relevant congressional hearings and Public Affairs events then on weekends, cspan3 is the home to American History tv with programs that tell our nations story including six unique series. The civil wars 150th anniversary. Visiting battlefields and key events. American artifacts. Touring museums and Historic Sites to discover what artifacts reveal about americas past. History bookshelf with the best known writers. The presidency, looking at policies and legacies of our nations commanders in chief. And our new series, real america, featuring archival government and educational films from the 1930s through the 70s. Cspan3. Created by the cable tv industry and funded by your local cable or satellite provider. Watch us in hd, like us on facebook, and follow us on twitter. Next the alliance for Health Reform hosted a discussion on the adequacy of the Health Care Provider network, postAffordable Care act. Panel sts like at cost, access and quality. Representative from the largest Nonprofit Health provider Ascension Health, takes part in this 90minute discussion. I always enjoy speaking the at alliance for Health Reform events, and so today im going to talk about net ive been using the term limited term. I think its less value charged. And really about why we have these plans that really have been around for a long time, but with the development of the public exchanges, became far more prominent. And just put the issue on the radar screen of a lot more policymakers. And i want to start being the economist saying that limit networks do have the potential to substantially lower costs. Basically they do this, the beginning is identifying which providers are lower cost or higher value. And insurers in developing these networks do have the opportunity to use broader measures of costs than just unit prices. And one of the ironic things is that some of the measurements of providers to assess who to invite into a limited network are very parallel to some of the payment reforms that youve heard about, like episode funding, patientcentered medical homes. So quietly, theyre moving in the same direction. So where do the savings come from . The savings come from steering s volume to lower cost providers. Thats a direct thing. In addition, if youre successfully steering patients or have a good prospect of it, you can negotiate lower unit prices with some of the providers in a market. When enough plans do this in a market and enough people are involved, this will strengthen provider incentives to lower costs. Limited networks can also support integration in tlideliv, and this is fairly new. If were going to have providerled plans playing a bigger role, whether theyre the providers, the insurer, or in partnership with an insurer, you know, limited networks are critical to their being viable because its really important to steer to the Delivery Systems providers. This approach, you know, through our work of the center for studying Health System change since the mid 9 90s, we saw providerled plans develop in the mid 1990s and the whole purpose was the expectation they could offer plans with Networks Limited to the systems providers. And these were abandoned for the most part when limited networks disappeared back then. I want to briefly mention the highlights of the mackenzie work about the experience in public exhachanges and they estimated that Narrow Network plans were available to 92 of consumers using the exchanges. And the broad Network Plans were available to 90 of Narrow Network plans, a candidate for 48 of the offerings and 6 o in metropolitan areas. And the key thing was that Broad Network offerings had premium increases 13 to 17 greater than the Narrow Network offerings. So whats behind the rapid growth in limited networks . I think a big basic reason is that Health Spending now is increasingly higher in relation to income. So and we all know thats about from advance in technology and higher unit prices, and its led to a situation where broad provider choice is a luxury that fewer people can afford. But the key break with the past really was the developments of public and private Health Insurance exchanges. I would say there are two key things. One is the freedom from onesizefitsall requirements. If youre an employer and youre offering your employees a plan, theres strong pressure to make it a plan that almost everybody is going to find attractive. Thats not the environment to offer a limited network plan is. But with exchanges, youre freed from that because there are a lot of competitors in most exchanged and a plan can be very successful on an exchange if it appeals to just half or even less of the population. This would be a disaster in employerbased coverage unless that employer was offering a wide variety. The other aspect is the fact that the subsidies to consumers are fixed. You know, theyre based on the secondlowest silver plan premium in a marketplace in the Affordable Care act or in private exchanges. Theyre also fixed. So it means consumers are spending their own money for the marginal cost of a more expensive plan. Okay. Now, to do this, some basic tasks need to be done well, and they havent always been done well over the past year. Or this year, to date. One is accurate and accessible Consumer Information on the Network Status of providers. And their roles for both plans and exchanges. Im often, you know, surprised that we dont see more products on exchanges like what the federal employees Health Benefits plan uses. Its a tool from consumer checkbook where people click on a plan, they put the names of their providers in and see which plans those providers are in the network of. Theres a need to monitor the Network Provider capacity. You know, theres the possibility that a lot of plans have the same providers in the network and those providers are overwhelmed. This will straighten out over time, im sure. Also, there needs to be recognition of some of the subspecialties and the attention to physicians hospital admitting privileges. Specialties like ophthalmology and orthopedics are pretty specialized. Someone who has a problem with a retina or a problem with their foot probably doesnt want to go to any old ophthalmologist or orthopedist. There needs to be speedy exceptions mechanism to meet them at network pricing. Also, something that perhaps a responsibility of exchanges is ensuring that broad Network Plans are also available. Just a few comments on regulation of Network Adequacy. There clearly is a need for regulation, but theres a very high cost if the regulation goes too far. I think the key needs are basically the transparency needs and the basic tasks i mentioned. Also a need to prevent risk selection strategies based on poor coverage of some specialties. And a Consumer Protection needs, which i would describe as basically if theres some networks that very few informed consumers would find acceptable, its probably best that they shouldnt be on the market. I think some of the dangerous is disarming the most powerful market tool thats available to address the effects of increasing provider leverage in negotiating with insurers. You know, prices have been going up rapidly. Theyre explained most to the rise in spending. So the success with limited Network Plans is going to be important for Health Spending, especially for lowerincome consumers. Also, im concerned about interfering with some of the steps toward clinical integration. Let me just talk about the politics. Its inevitable that pressure from providers to be included in Narrow Networks will happen. Weve seen it now particularly from pediatric hospitals being particularly outspoken. And weve had any willing provider laws in a number of states that actually have been around since the 1980s which seem to be a particularly misguided response to this issue. But in contrast to the 1990s, consumers see much more of a stake of having lowercost products available as a choice. Federal government also has a stake in how high silver plan premiums are. Im suspecting that well have a much more nuanced reaction to these issues. Thank you. There we go. Well, good afternoon, everyone. Its a pleasure to be with you today. I plan to briefly cover five topics in my presentation. Ill start with some of the latest Consumer Satisfaction polling, and then ill turn to how networks are focused on delivering value to consumers. Then a little bit about the importance of increased choice and how those choices enhance the Value Proposition. Then a little bit about how networks are built based on a recent study that we commissioned by milliman. Then finally ill wrap it up with our commitment to consumers which really focuses on accessibility. The Commonwealth Fund recently examined attitudes about satisfaction of coverage in exchanges and found that nearly three out of four are satisfied. This is consistent with the recent Morning Consult poll that showed 74 are satisfied with their health plan. And directionally, this matches with what we have seen in private polling showing that more than nine out of ten registered voters are satisfied with their private Health Insurance coverage. Consumers preferences for balancing provider access with cost is another very important consideration. A recent poll indicated that 50 57 of small employers would choose a smaller Provider Network if it resulted in a 5 reduction in their premium. And this increased to 82 if the result were a 20 reduction in premium. In another Morning Consult poll of consumers showed a similar preference with 58 preferring a less expensive plan with a limited network of doctors and hospitals. While health plans are focused on value by finding the right balance for consumers between quality, affordability, and choice, plans are constructed on the premise of ensuring the highest quality at the lowest price to deliver that value to consumers. The milliman report i mentioned finds that highvalue Provider Networks allow for more affordable Coverage Options with 5 to 20 lower premiums compared to broader Network Plans while placing an emphasis on quality and effectiveness of providers. The mackenzie report found similar results. Many consumers are looking for this type of balance that delivers value, affordability, and choice. Regarding choice, the recent mackenzie report that paul summarized in his presentation shows that consumers now have expanded choice of Network Offerings on the exchanges. Broad networks are available to close to 90 of the population. Narrow networks are available to 92 . This increased prevalence of Narrow Networks gives consumers a wider range of Value Proposition and prices among health plans. Importantly, mackenzie found that there is no meaning for performance difference between broad and narrow Exchange Networks based on cms hospital metrics. The milliman report explains in some details that highvalue Provider Networks are specifically geared toward providing personal and comprehensive care to patients in an environment where providers effectively communicate and coordinate with each other regarding the best treatment for patients. Highvalue networks are developed through a deliberative evolution process with providers that consider more than just fee levels. Active cooperation and collaboration between health plans and participating providers is really the hallmark of success for highvalue networks. Performance on quality measures is the key part of the criteria used for provider selection and inclusion in a plans network. In addition, health plans must meet robust standards for Network Adequacy and access to care. Professional accrediting organizations like ncua require plans to meet standards for access and availability of service and measure themselves against these standards on an annual basis. State and federal Network Adequacy laws ensure that consumers have access to a sufficient number and type of physicians and hospitals and health plan Provider Networks. Importantly, Network Development is now occurring in a reform market where health plans have new requirements that restrict their ability to very plan and design control cost, including essential Health Benefits, preventative coverage requirements, limits on cost sharing, and restrictions on age rating. Variation in Network Design is one of the few tools for health plans to keep costs low for consumers while ensuring quality. I think im missing a slide. There we go. Well try to go backwards. Ah, there we go. Bingo. Sorry for the delay. So heres our commitment to consumers. This is an important slide. So ill spend a little time on this. Our Health Care System is in a period of significant change, which means now more than ever patients are looking for value and stability in their coverage. Understanding this, health plans top priority is to provide consumers with the information they need to navigate the new system and make the decisions that are right for them. One important step health plans are taking is to improve transparency. I know paul talked a lot about this. While the use of Provider Networks has been a key tool in delivering value by preserving benefits, mitigating the impact of rising cost, and promoting quality of care, consumers may not be aware of the Critical Role networks play, how they work, or understand which providers are in their networks. Consumers should have the information they need to make the right choices for themselves and their families, and that is why health plans support ensuring Greater Transparency of Network Design by providing Greater Transparency of design by accessible, understandable, and uptodate information about which providers are in a network and timely notice to consumers when providers leave the network. Providing a summary of information about how plans put together their tailored networks to balance cost, quality, and access considerations. Providing information on how consumers can appeal plan decisions, submit complaints, or obtain referrals to outofnetwork care when necessary. And we also support continuity of care for a minimum of 30 days for individuals undergoing an active course of treatment for conditions that require more complex care for serious terminal illnesses and for Mental Health. That wraps up my presentation. Thank you, and i look forward to our discussion. All right. Thanks very much, dan. Well turn now to Katherine Arbuckle from ascension. Thank you, everyone, in the room. You better get close. Hello . Press it and then wait a couple of seconds. That will do it. Theyre temperamental. Okay. Very good. Well, thank you, all, everyone in the room, for allowing me on behalf of Ascension Health to have this opportunity to have this important discussion with you today. Just a little background. Ascension health is, as ed mentioned, the u. S. largest catholic Health System as well as the largest not for profit Health System. We have more than 1,900 sites of care in 23 states and the district of columbia. And all the Health Systems that are sponsored by Ascension Health offer plans on the exchanges. However, these participation decisions are made at the local community level, and as a result, we have experienced pretty much on all sides of the issue. In some communities, were the name providers in the Narrow Networks and named in all of the Narrow Networks offered. In other markets, we are included in some Narrow Networks but excluded from others. In some markets, we offer our own offering as a Narrow Network plan of our own. Finally, we participate in the nonnarrow market, the broad offerings as has been described with other providers in those markets. I would generalize that overall in most of our markets, were in some form of Exchange Product because generally it fits with our mission to serve the low income and vulnerable since thats whos accessing these products on the exchange. So i do want to comment about these Narrow Networks and how they can benefit payers, patients, and providers. And we do believe there is benefit in Narrow Networks. It can be done through the offering of what we call clinically integrated care. And thats especially helpful for those with chronic diseases. So some of these benefits that you can outline when you have this tighter integration is that providers can communicate more openly and easily, sharing information between them about patients. And thats especially important and helpful with Electronic Health platforms when the providers are on the same platform. This can reduce duplicate testing and even conflicting treatment. Payers and providers can share more Meaningful Health care data, Work Together on Health Care Analytics to determine what is the right improvement we can make to quality and cost. The providers within a clinically integrated network can be more familiar with each other, not just their medical practice protocols but their administrative practices, allowing handoffs to be much smoother with less error. And then also, these tighter relationships allow these providers to comment with the payers back to them where there are Service Needs and things that need to be improved. So ill go on to what we also want to talk about, though. That is there needs to be adequate Consumer Protection and education, especially for these families who are accessing these products offered through the exchanges. According to hhs, 85 of individuals that are purchasing products on the exchanges qualify for an insurance subsidy. So i think, therefore, we can conclude a couple things. One, they tend to be at the lower end of the income scale. And two, a good number of them did not have insurance previously. In fact, one study weve seen 57 did not have insurance before. So im glad were talking about this question today. So starting with Consumer Protection and education. Weve invested as Ascension Health in 200 individuals to become certified application counselors. Theyve received federal training, and they are there to help patients access the networks and understand the website healthcare. Gov. But what weve learned is this counseling takes a lot of time. Not just for those patients who arrive asking for this counseling and this help, but many times when they arrive with the need of medical care. Thats hardly the time to learn thats when your provider of choice is not in your network. This leads to confusion. It leads to frustration and sometimes anger. And i will tell you in one example in wisconsin, a patient arrived at our emergency room in Critical Condition and needing immediate intensive care. Unfortunately, he had just signed up with a health plan that did not include us in his network. We admitted the patient because thats what the patient and the family wanted, but neither the family nor us knew what that patients liability or financial obligation would be for that bill when it was completed. But we were fairly confident as Ascension Health knowing we had admitted that if this patient is lower income, which likely they are, they will qualify for charity, and well be left with the uncompensated care, again because of the confusion of which provider is in the network. So its obviously important for patients and families to understand their networks when they sign up for the plans. They need to know they may face higher deductibles, higher copays and coinsurance and possibly their providers not covered at all. We would advocate to you today that the insurers need to be more accountable on educating their customers on their products. That includes ascension when we offer a product on the exchange. The education should focus not just on networks and whos in the networks but education on the related deductibles, copays, coinsurance, and even education on tradeoffs to be made when choosing a lowcoverage, lowpremium product versus a highcoverage, higherpremium product. This is especially important with folks who do not have experience with insurance and have cultural and language barriers as well. Weve found the online directors are often incomplete. Theyre outdated. Sometimes inaccurate information. Hard copies are not existent. Its also not unusual in a community for several practices or providers to have very similar names, and that can add to confusion. Finally, the access hours and the capacity for those new patients to access those providers is also important. When an individual is enrolling on healthcare. Gov, they have to leave that website and go to the various insurers websites to determine more about providers. And, of course, we believe that information should be accessible through the healthcare. Gov website. So i want to move on to the quality standards. Ascension health has been a leader in Patient Safety over the past decade. Were very proud of our quality record. Our work in the last decade on pressure ulcers has resulted in our pressure ulcer rate being 94 below national norms. Our systemwide work in birth trauma has made asession hospitals among the safest places to deliver a baby. We believe we should streamline the existing web of quality programs into an outcomesbased, uniform National Core measurement set used by both public and private sectors. Ascension health and americas Health Insurance plan, ahip, made this recommendation last spring in a document published called partnership for Sustainable Health care. A defined set of outcomebased measurements can provide the consumers with more understandable and meaningful information to be able to compare providers within their communities. Current practice allows an insurance Current Practice allo assurance to develop their own Quality Metrics of their choosing. Sometimes theyre the same or similar as medicare but not always. I believe is in your packets, found that the primary measure used in evaluating Narrow Network providers are quality nshs. And the sdtudy goes onto descrie how these quality managers are used. There are several different types. In one of our health plans, there are three assurances. One is graded as a three star, one a fourth star and another a fifth star. That causes us back and forth with the insurers to sort out is it the Patient Population that was looked at, is it the time period, what are these differences in whats driving them. Frankly, its a mystery for patients. Considering there should be uniform, helpful quality information as part of the patients decision on these networks. So what is a sufficient number of providers and services to include a Narrow Network. I understand the work is in progress and it will continue to evolve and im glad nhs and naic are further working to define this dech stigs. First of all, the individual market place includes many families who are vulnerable. Sometimes theyre not similar plisically solved by miles. 10 miles away may not seem very far, but if you have no transportation and you rely solely on Public Transportation, that could be a hundred miles to you. Also, we have folk that is are buying on the exchange that is have complex childcare needs. And so their information regarding providers accessibility within hours after hours, et cetera, is also important. Weve seen a few holes in solve ra coverage, for example. We found one of the networks had no access to pet scan. We can provide those services, but getting out testing at your hospital may not be as convenient as some of the labs with better parking and better hours. Finally, id like to reemphasize that the reality of the marketplace is still price dominates. The accounting care act still leaves large, outofpocket medical expense that is can be unaffordable in this population. Most have negative net assets. I will give you an example of a married couple both age 49. Their premium is subsidized. They pay 3600 in annual premium. They have a 3600 deductible and theyre subject to a 12,000 outofpocket maximum. Working through the numbers, if one of this couple needed a joint replacement, their share of this procedure, including the procedures, the premiums, the detud deductibl deductibles, et cetera, is 16,000 which is 34 of their total income. They are not only unaffordable, they lead to poor care. Its welldocumented that people will have difficulty adhering to their treatment plans when theyre faced with large, outofpocket costs. So moving forward, the one priority we have for initial attention in this area is education providing clarity and transportation excuse me, clarity and transparency for the consumer so that they know which and who providers are in their network, how available those providers will be to them, how much caution theyll be responsible for and the quality by those providers. At the same time, as this more rigorous information is developed, we believe its more important to remain flexible and to respond to any particular egregious situations that come up. Thank you. Thanks, catherine. Lets turn to brian, brian webb from naic. Thank you very much. Good afternoon, everybody. My name is brian webb. Im with the National Association of insurance commissioners. We represent the commissioners from the 50 states, washington, d. C. Which just became more important to some people in the room last year, and, also, the five u. S. Territories, which was clarified last week, are not state states for htitle i of the Affordable Care act. One is to develop regulations that state cans choose to use. Were bringing stake holders from all various areas. Were trying to develop one. And one of those that we have is the network moderate act. Number 74, basically, was developed in 1996 and, looking around the room, it looks like about half of you were in kindergarten. So it was a long time agoo. And now we are starting to look at it once again to see if it needs to be updated given the new environment. Looking at the existing model, one was to make them set up in a way that theres reasonable assurance that somebody can get to in that work provider in sufficient numbers and types in a reasonable amounts of time. And we leave it up to the carriers for the most part. We want to make sure that that definition of reasonable is reasonable. When you look at the time it takes people to get to them, any waiting periods, any distance issues, you make sure that everybody can get to spb in a sufficient way. And if not, what the model does was an insufficient network that can go to the doctor. Another provider. And that they would not be charged more for going to them. So there is an alternative mechanism set up. And to regulate them, what they do is require the carriers to file an access plan with the commissioner prior to offering the new managed care plan. That goes into the description of the network. They also say how theyre going to monitor that network on an on going basis. Notification, how are they going to notify the consumer if theres a change in that network. Either they are term nated by the company and also, this is very critical, the continuing of care. It also goes into the contracts. You want to make sure that the con trakts that are being set up are not done in a discriminatory way. Youre not only with certain kinds of providers so that certain consumers cant get their care. You want to make sure theyre getting providers to make sure that theyre not providing certain medically necessary care. All of those are rolled together into our model act. About 10 states have taken and adocumented our model verbatim. Even if youre on that state, they work with the carriers, the carriers do use a lot of these standards in developing their networks. If you want a copy of it, you can go to the model, go to store and go to free. Theres a whole section of free materials you can get, including our models. We also have a white paper that we did on this going back a couple of years. We have set up a subgroup sch is currently doing regular phone calls. They are open phone calls. Anybody, anybody in this room can sit in them. If you have nothing else better to do with your life. I always picture a 4yearold man in his mothers basement, but i dont know why. Just sitting down there and calling in. You can do that. Anybody and everybody can provide kpents, suggested changes, however you want to do i. We gone through a series of calls now where weve hood all of the stake holders, the providers, the consumers, of course, others that have come in and brought us their ideas. And were going to soon t