receive. it is unacceptable that patients must fight their health insurance companies for coverage while fighting disease at the same time they are insured. it is unacceptable that parents have to help the child overcome the crippling illness while struggling to overcome a crippling medical debt by postponing this is the treatment skimping on food and even exhausting their savings so that they can qualify for medicaid. it is wrong for the health insurance companies to deny coverage for critical treatment when families needed them most. . for being there to share their experiences. i especially want to welcome these two beautiful young girls sitting in the front row. we are thrilled they have taken the time out. i bet it is a day out of school. we hope they see this as a learning experience. mr. chairman, i did thank you for the hearing. we are all concerned about coverage for pre-existing chronic conditions. we are so concerned about the recission issue. i think where you are going to see the differences is how we approach the badly needed insurance market reforms that are out there. i'm one of those who wants to keep things patient-centered, patient first, free-market oriented and i would like to see more competition in the marketplace if we seek to address this, allowing purchase of insurance policies from across the lines, so that families have more options and more choices. in tennessee, where i'm from, held a savings account are very popular. we would love to see it the contribution and allowance limits their enhance. and to see incentives for individuals would healthy lifestyles. liability reform has already been mentioned. the practice of defensive medicine does drive up costs, but it also plays in sometimes to the recision issue and we are aware of this. and we seek to address it and address it in good faith. i want to give a special welcome to mr. brock who is here. you will love hearing from him. the program we are very pleased with intimacy. page two, second paragraph, i want to highlight one thing. the greatest impediment to the programs is regulation in 49 states preventing welling practitioners from crossing state lines to provide free care. in tennessee we have addressed this issue. dr. burgess talked about it. it came to light after katrina. i am looking forward to hearing from him and welcoming them today and i yield back the balance of my time. >> opening statement, please. >> thank you, mr. chairman, ranking member. the stories that each of you told really summarizes i think what can only be described as the failure of the american health insurance industry. the health insurance industry in fact has served its own interests very well has failed the american families and consumers, it has failed the small businesses that pay the premiums, it has failed our taxpayers, it has failed our doctors and our nurses and health care providers. what it has done is served its own interests very well. the ceo's some of whom make $24 million in a year. wall street analysts who cheer every time the medical loss ratio goes down, meaning that each of every premium dollar has less spent on health care and more on dividends, ceo salaries. because it serves its own interest -- essentially it is based on a model we heard described here. that model says if you are healthy and wealthy and on likely to need it, we will ensure you and we will keep increasing rates. but if you are sick or likely to get sick, if you are older, we will not ensure you or if we do we make policy so confusing and late in what some of the loopholes that you want to get much benefit for the insurance you thought you had appeared as mr. markey said, you are short but not covered. another example to add to the laundry list of horrors. this is much smaller and more mundane but it shows the balance in -- alice in wonderland world the insurance companies operating in. there is a woman from vermont to have a policy should thought covered wellness' screening. she got a colonoscopy. she was told it would be covered. lo and behold a colonoscopy in fact diagnosed something and the insurance company said that the procedure was no longer about wellness, it was diagnostic and it was not covered, and made her pay the $1,000 bill. those days we have to put behind us because the insurance company has had its chance and it failed. and when a person buys insurance, when a small business pays a premium to cover workers, those folks should have assurance they are getting something real. health care insurance and coverage when they needed. thank you for this very import hearing and i yield back. >> mr. burgess, for an opening statement, three minutes. >> thank you, mr. chairman. i will abbreviate my statement and submit it in its entirety for the record. i really believe this is a two- fold problem. on the one hand we have hard- working americans who did the right thing day in and day out, they go to work and buy health insurance and when it gets sick the medical insurance does not cover their bills. if they work harder and make tough choices and other areas of their life, this still struggle to pay medical debt. in a town halls what i heard over and over again, people are generally frightened about what congress will do to health care in this country and they are probably justified in that skepticism, but the one thing that everyone seems to agree on is of the issue of excluding someone from insurance coverage because they have had a tough medical diagnosis or the issue of excluding someone -- or insurance decision when a tough diagnoses is rendered for someone already insured. those are the processes that have to stop. nothing infuriates people more of thinking that somebody paid their dues and when the accident -- need the service they find it withdrawn. people are responsible and do what it takes to provide for themselves and of one's are in fact should be commended and are not to be put in positions that are just absolutely untenable. we do have the issue of insurance as a whole. you do want to protect people from those contingencies and life from which no one can anticipate and no one can reasonably be expected to save the amount of money that would be required to pay for some very, very tough diagnoses. the cost of care has gone up significantly. there is no question there is advancing complexity of what we are able to do. when i think of some of the saves i saw during my medical career, late in my career we would never seen it in the beginning. those things are very important and we certainly don't want to in our zeal, to cap costs, we don't want to cap innovation or remove the innovation that has really set american medicine apart from medicine practiced in almost any other country. mr. barton referenced transparency. three congresses ago i was charged by the speaker of the house who was then a republican to work on the issue of transparency and i introduced legislation that year. it finally did find a place and hr 3200 as it left the committee this year in september. i don't know if it will survive the cutting room floor over at the speaker's office but i am hopeful it will because transparency is important. another provision that was in the bill that i partner with mr. dingell on was internal and external review boards. if you have, whether it is a public option or private insurance company, if they denied coverage, patients ought to have the right of appeal, they ought to be able to appeal not just to internal review board in the insurance company but external review board as well. it should be true whether it is that net, signet, united, or a new public option. if care is denied for any reason, patients also have a right to appeal. it does not mean we need to be spelling out everything that is involved in someone's health care. i told the chairman i will abbreviate my statement and submit the balance for the record, and that is what i will do. i do find the witnesses for being here. this is an important part of the process. i would just say -- [no audio] >> we are having some technical difficulty with a house hearing we were showing you. we hope to resolve it and show you the program shortly. justin let you know about house and senate, they are out today. the house had a brief pro forma session today. it returns next tuesday for legislative work. next week, work on bills boasting solar energy technology and reorganizing the coast guard. the senate next week will debate on a bill on medicaid payments to physicians. some technical difficulties on a house hearing and we are working on it. >> we are hoping to get a house hearing back to you, the hearing on the under-insured faults. we will work on that and see if we can show what he later appeared in the meantime, a look at items in the news and your phone calls from "washington journal." twitter address. the front page of "the washington times" this morning. they had an interview with james jones, national security adviser. in an interview, the former marine general and nato commander acknowledged his views on afghanistan have soured in the three years since he left the military. he said security in afghanistan has deteriorated because of the u.s. failure to see the interaction of security, development, government, and rule of law. this is a quote -- i think it is becoming clear that the failure, the tendency to focus much on truth -- troop strength and not so much and other factors to develop a national afghan police, for example, which was on life-support for so many years, the development of the afghan national army, which has never drawn fast enough, those are things that as we develop a strategy released in march, we are clearly highlighted, and not everybody is turning full-scale attention to them. this interview is an "the washington times." if you would like to see the full article. if you -- this is from "the financial times." white house denies decision made on troops. it says barack obama has not made a decision yet on how many troops to send to afghanistan. in spite of afghan claims than an announcement of a large increase was likely. the first call up, west virginia. carl, republican. please go ahead. caller: what i would like to talk about is this thing with a rush limbaugh. you know, the way i see it, it is dangerous. it is censorship. it is trying to prevent a man -- i know he is a rich man, but it could happen to anyone. this political correctness thing, mr. zee or whatever his name is, who owns a portion of the new jersey nets, he comes out with all kinds of songs downgrading white people and all of this stuff and yet they can't let him on a sports franchise. political correctness in this country is getting dangerous. this whole thing is dangerous because what you people in the news media are doing by demonizing people, prevent them from making a living, it could happen to anybody, poor, rich, whatever. host: and if your interested in reading about the situation, "the wall street journal" editorializes about it today. they'd county, florida. caller: two things basically. we talked about the media and how you can really help wash limbaugh was basically a 15,000 or $60,000 a year employee in the sports -- $16,000 a year employee and a sports stadium. what happened is there was a need for this type of person to reach a certain type. when you look at slavery, there was a certain type person that was needed to be more or less the captain's or those in charge of the plays, who had no real heart basically was whipped and beaten because they had to serve and cater to the owners. so basically he was needed during the reagan era to help get in. and what was happening is you don't get the fairness when they reach the millions and billions. and secondly, the johnson woman, she could have been so much help along with rush because when you think of the kids that speak ebonics and you have the power with the video -- media, she could help comment on the race in virginia, which she had the opportunity, to help do the program at the station her husband owns -- host: let us leave it there. a lot on the table. long branch, the jersey. cathy on the independent line. caller: good morning, how are you? i'm fine, thank you. i am putting my vote for john corzine. i would not vote for chris christie anyway. i go to the gym every day. all of that being said. my taxes really have not gone up at all. a lot of that is local stop. people don't understand taxes are assessed locally in your town and its municipalities. all that being said, i watched the debate. i do like chris daggett but i will vote for john corzine because i know him. i heard chris christie said new jersey has the highest unemployment rate in the nation, false, and michigan does. i heard jennifer grant home, 10 minutes before -- it was a real -- jennifer granholme live state interstate had the highest unemployment rate. people need to call this man out for what he is. host: what do you do in new jersey? caller: i just volunteer with animals. i am wife. my husband works. host: does everybody in new jersey topped that fast? caller:no. i'm a county committee woman. it does not mean much. we don't get paid, so we are not on the take, that is how i put it, that is what i told the screener. i'm a county committee woman. because my congressman is frank browning. host: are you still with us? ok. thank you for calling in. new york. alex, republican, good morning. caller: i watched the thing last night. anita dunn awards for the white house, i guess she is one of the czar people. host: she is communications director. caller: in her words she said the two most top political philosophers she looks toward on a daily basis or to the most are now say tong and mother teresa. -- mao tse tung. i understand mother teresa. host: you heard that she reads mao? caller: the two political philosophers she likes to the most and looks to on a daily basis for input on policy is mao tse tung and mother teresa. host: youtube? caller: live on television, and i saw it today because i recorded it. she was speaking to high school students. she went on and on and quoted stop from him. that seems even worse than the stuff van jones -- i'm wondering if she is going to be next. host: all right. chicago, bob, democrat. hi. caller: how are you doing? i was going to talk about what this -- i was going to make another point but it is something so important that needs to be said. you know, the terrorists know of this country way more than americans. i watched a few talk shows and they ask americans who was the secretary of state during the bush administration and they could not say -- gates, condoleezza rice or rumsfeld. however, the terrorists know this country and the politics way more. so they realize how terrible bush was running this country. he was basically a terrorist himself. and they know obama in his heart really wants to help this country and move it in the right direction so they are more likely to attack us because they really hate america because he really wants to move this country ahead. and my >> here you are looking at the coverage of folks who don't have enough to cover medical expenses. this is from yesterday here on c-span. >> let us go to ms. christensen, please. >> thank you, chairman stupak. and thank you for holding this hearing. it is important to highlight while health care reform and providing affordable secure insurance coverage without caps to everyone is so critical, not just the physical but the economic well-being of our families and country. i also want to welcome the witnesses and their families for being here this afternoon and sharing very personal and painful stories and provide more insight on the need for affordable adequate insurance coverage. under insured americans are too closely resembled the uninsured but they're often forgotten. currently 25 million americans we have heard cannot afford to pay the gap left by weak insurance coverage. i am surprised to learn that even an stage renal disease patients may find themselves uninsured even though covered by medicare. it is also a contributor to help a disparity. despite the presence of full- time workers, racial and ethnic minorities are disproportionately underinsured or lack coverage altogether. because of the with the vicious cycle -- it causes a vicious cycle that forces all too often people to forgo treatment after they paid for insurance. even more dramatic is the fact that people don't realize they are under insured until they are already facing those mounting health care bills. as we will hear, the average working family can faithfully pay their insurance premiums for years but still going to medical that or face bankruptcy when they get sick. a study released this summer by the american journal of medicine found that in 2007 a family filed for bankruptcy every 90 days -- 90 seconds due to excess of medical bills. if that is not shocking enough, 75% of those americans already have insurance. these are hard-working americans who did not choose to wake up with an injury or illness that would not only deplete productivity but deplete their bank accounts. the insurance companies profited millions by insuring their policies are structured to defy the very purpose as chairman waxman said of having health insurance. on insurance and under insurance is not acceptable, period, and i look forward to passing and have the president sign a health care reform bill once and for all. thank you. i yield back the balance of my time. >> thank you. your opening statement, please? >> thank you, chairman stupak. i would like to thank all of the witnesses. i certainly look forward to hearing your testimony. as if in this general practice for over 30 years, one of the most important lessons i ever learned is that a medical solution for one of my patients was not necessarily the best solution for another patient. each and everyone was unique. but their needs were the same -- ultimately to get better. as this congress debates health insurance reform and what type of insurance americans should have, i believe we must bring it in terms of what is best for the patient. with respect to the debate, h.r. 3200 and everett of the federation of the democratic majority proposals purports to create access to affordable health care. which i agree with. but they do so by requiring that all health insurance products meet a one size fits all mold through various federal mandate and, yes, cost sharing limits. unfortunately, studies have shown these same mandates and limits on cost sharing will drive off -- up the cost of health insurance products by as much as $4,000 a year for a family of four. in their plan, my democratic colleagues, they seek to combat the cost increases with affordability credit. unfortunately in h.r. 3200, it does nothing to curb the cost of health care in this country. in fact, the cbo recognized h. r. 3200 would increase the cost of health care in this country. so these affordability credits they give patients today will be worth less tomorrow, while the overall price of health insurance will continue to climb as it has done so for decades as already been borne out. only now at a much greater rate. one doesn't have to have a medical license to figure out that my colleagues are setting up a framework of unsustainable systems. where does that mean an -- leave americans? if we were to leave the state of massachusetts as an example we find people losing health-care benefits to offset increasing costs of care. this past june 92,000 low-income patients lost their dental insurance because the states needed to trim costs. 92,000 lost the dental insurance. usually -- using the definition of under insurance -- i cannot find it in the dictionary -- those individuals who lost their dental benefits, would the qualify as under insured? i would suggest to mirroring a health reform plan after massachusetts could end up hurting those patients who truly need help a long run. mr. chairman, while we do need reform to increase access to care of patients like those here today, we cannot simply slap but term reform on just any bill and assume that it will improve the quality of health care. in fact, the wrong kind of reform crates a system where these testimonies are the rule and not the exception. and i yield back. >> mr. doyle, opening statement. thank you for opening -- holding this hearing on under insurance in such irrelevant time. the last few months congress and the country has been engaged on a debate largely focusing on the 45 million uninsured americans and leading -- leaving out the 25 million americans under insured. i look forward to the witness' testimony that will shine light on the problem. a problem that unfortunately is growing at an alarming rate. in just four years, from 2003 until 2007, the number of uninsured americans rose 60%. this is a problem that must be highlighted and will be addressed in the health care reform legislation that will go before the house soon. under insurance is when a policyholder believes he has adequate health care coverage and then when it is too late, they are proven wrong. when individuals buy insurance or are provided with plan options from an employer, the small print of their contracts is often overlooked. text which contains vital information. this is exactly where people need to be paying the most attention because it is here that often information on lifetime or even annual limits, copayment requirements, treatment exclusions and other limits on coverage is hiding. we all know we are supposed to read the fine print, but we also know people don't always do it, which brings us back to the big picture. people don't know what they need to know until it is too late. i believe that if you buy an insurance policy, you should know what you are getting and not have to hire a lawyer to understand it. hidden traps, fine print, and at times misleading marketing ploys prevent consumers from making an educated consumer. this is why it is still in port we pass meaningful health care -- health care reform that will require insurers to provide a minimum set of benefits that will take care of patient needs, limit out of pocket expenses and prohibit insurers from imposing an annual or lifetime caps on coverage. i look forward to hearing from our witnesses. mr. chairman, i want to thank you for this hearing today. and i want to thank the committee for highlighting this very serious problem. >> thank you, mr. doyle. ichairman emeritus, mr. dingell >> i commend you for holding this very important hearing on an issue of great importance, are consideration of health reform benefits and health reform efforts. i wanted to commend you for the hearing and i want to thank our panel witnesses for being here today. we are grateful for your assistance and i thank you. in our fight for health care reform will focus on the 46 million americans without health insurance. that is very important. but has been observed already, under insurance is an all too common problem. in fact, by some estimates, 25 million americans work under insured in 2007. -- were under in short and 2007. -- under-insured. in more simple terms, there are far too many americans paying for insurance policies that do not cover the medical care they need. some of the policies are sold by practices close to fraud. whether it be ungirt insurance is caused by annual or lifetime caps or excess of cost sharing or whether the policy does not cover the needs of the policyholders, the result is the same. underinsured creates an undue financial burden on for two american families. in 2007, 20% of american adults reported caring medical debt. of the under in short, 46% reported using all of their savings to medical debt. with statistics like these, it should come as no surprise that over 60% of personal bankruptcies are due to health care expenses. these numbers are staggering, but the personal stories are even more moving. just this week, the detroit free press ran a story about uninsured -- and under insured michigan residents of my home state. one of the families profiled was the hurleys from canton, michigan. they had employer sponsored insurance but were forced to buy extra policies to cover the needs of their children, won a seven-year-old with severe asthma and the other, a 10-year- old with skeletal disorders. without the extra insurance policy they could not afford the $50,000 fines surgery their son need every four months. i am particularly grateful to our first panel and to them for having joined us today to tell the story about hardship due to under insurance. i want them to know the testimonies are to remind us and others of why it is so critical and so crucial we pass comprehensive health reform legislation this year. finally, i would be remiss if i did not mention the aggressive steps we take in h.r. 3200 to make under insurance a thing of the past. this bill would remove all annual and lifetime caps. salons it, limit the out of pocket expenses for everyone. 3, provide affordability credits for lower and moderate income people to assist them with premiums and cost sharing. lastly, it would enable all to know that all insurance policies provide a minimum level of health benefits to all americans. and of course, we would see the nasty things like precision of policies and pre-existing conditions. we would see them end. so i hope today's hearings will serve as a call to action and reminders of the importance of the task before us. thank you, mr. chairman. >> thank you. we have two votes on the floor. i would love to get all the opening statements in before we break. next, mr. green? >> thank you, mr. chairman. ask unanimous consent for the full statement to be placed in the record. under insurance is one in individual actually has insurance but the policy does not adequately cover health related expenses. it is such an important topic that i am glad we are having this hearing. last month when our committee work on or has been a continuing to work on the health care reform bills, we addressed a great deal and h. r. 3200 as our dean, chairman emeritus, dean of the house said. insurance premiums have risen steadily. 131% in the past decade. and individuals are paying at least 10% -- under insured, 10% of out of pocket expenses. we will hear from the second panel, 25 million americans are under insured in 2007, which is a 60% increase over 2003. all of us have constituents who call us and assist them with problems, whether it is very low caps, like in our case, or either that or they do not provide coverage for certain services -- like experimental cancer treatment of certain drugs. that is why i am glad to have our first panel here today to talk about real life experiences. but again, our committee made a grit step on h.r. 3200 the great step on a dark 3200 and hopefully we can vote on it sooner or later, to solve the problems, not only the uninsured but the millions of under insured. i put my full statement in the record. thank you. >> thank you, mr. greene. >> thank you, mr. chairman. first, let me thank my what -- the witnesses. i read all of your testimony and i read it shaking my head. i heard the stories before but yet to hear the particulars are so disturbing, and i really look forward to telling those stories yourselves. here is one that was on the front page of "the washington times" yesterday. it says ian fought for his life every day of his 37 years, confined to a wheelchair and put to a breathing tube, the muscular dished of a victim of refuses to give up but his insurance company already has. legally barred from discriminating against individuals and some at large claims, the new york-based insurer simply canceled lines of coverage altogether an entire states to avoid paying high cost claims like mr. perle. in an e-mail, one the guardian life executive called high-cost patients like him, dogs, that the company can get a "red of." this, by the way, and the meantime his family is paying $3,700 a month for his care. these are the kinds of horror stories that people face every single day in our country. mr. null, you asked in your testimony, is that american? i want to say that i hope at the end of 2009 you will be able to look at the kind of health care we provide americans and your daughter and say, yes, this is american. and the kinds of things we are going to do i hope are going to resolve the problems of all three of you and did millions more in our country. we address the problem of high deductibles and cost sharing by giving individuals access to group rights through the exchange would annual out-of- pocket limit of $5,000 for individuals and $10,000 for families. we are sure of the coverage is adequate, eliminating pre- existing condition exclusions and establishing basic benefit package. we require the planned network adequacy requirements for consumers especially those with disabilities or ongoing health- care needs have access to the providers they need -- eliminate annual and lifetime limits that these -- leaves consumers with huge medical bills when their coverage runs out but their health needs continue. i believe your testimony today will contribute to getting these kinds of reforms. thank you. and i yield back. >> thank you. mr. burleigh for opening statement? >> i wanted thank you and a ranking member will unfold in this important hearing. i think all of us learned that when health care policy is abstract, the american people run away. and the reason why your appearance here is so important for us and the entire country is because until health care policy becomes a personal, people don't realize how broken our health care delivery system is in this country. this little boy you see up here on the screen is the faith -- face of health care for me and my family, this is tucker right, he lives and now, iowa, his father is my nephew. when tucker was 18 months old he was diagnosed with liver cancer. he had two-thirds of his liver removed. he was lucky that he survived. but every day he has an ongoing lifetime medical challenge of survival. he continues to accumulate exorbitant medical costs, many of which are not covered by his insurance policy. his family already incurred tens of thousands of dollars of uninsured medical costs. they hold fund-raisers to try to raise money not covered by their insurance policy bearded and his parents -- policy. his parents are both employed full time and had what they thought was good health insurance. by the age of 20 he is 90% likely to have another form of cancer. he goes to do more in, iowa, every month to have expensive diagnostic imaging studies to monitor his health condition. and until we start looking at health care as this type of case and the faces that you present to us today, we are never going to get the american people to rally behind the need for comprehensive health-care reform. your voice is here today, tucker's face and the people in this country just like him and just like you are going to be the unifying force and we need to transform health care delivery and the way we pay for it and the way we are insured in this country and that is why i am personally so grateful that you took time out of your busy lives to of us put a human face on health care reform, and i yield back the balance of my time. >> thank you. this sudden by -- mrs. sutton from ohio? >> i want to thank the witnesses. with your voice as you speak for so many americans who are facing similar situations. that is why we are so intent on this committee and this congress to make health care work for you and the people that you love and all of us out there low turnout in the committee room but whose voice you bring by your presence. during the august work period and held many meetings with constituents and i heard their views about health care reform. among those whom i met were a couple and ohio. the husband is 56 and the wife is 53. february of toboggans seven the husband was diagnosed with prostate cancer. as he thought the cancer and was fighting back later that year, kathy was diagnosed with breast cancer. then help insurance through the husband's job at the steel mill. but with them both receiving treatment for cancer, the cost began to add up. out of pocket spending became overwhelming and they are now using their pension fund to pay for their medical bills instead of saving them for retirement. kathy told me she felt guilty about having their family pay out of pocket for her cancer treatments despite the fact that they have insurance coverage. i want to repeat that -- she felt guilty because her insurance plan did not provide adequate coverage. many of the plans are far from adequate. when it came to my office they broadband stacks and stacks of insurance and voices. they have bills, explanation of benefits, in addition to explanations as to why most of the treatments were not adequately covered. he showed me aside from being sick, aside from anteing savings, they also were keeping a full time records to make sure they kept up with their payments the best they could. dash has been working out arrangements to pay when he can. he tells them, i'm willing to pay, but it will take time. he continues to work to make sure they keep the inadequate coverage that they have the and in these uncertain economic times, he is concerned about whether his job will be there tomorrow. he told me he would like to retire but is fearful of doing so before the couple becomes eligible for medicare. and if the job of the way, they were a they led in fear because they will not able to get insurance having had cancer. he could not imagine, he explained, what individuals who get sick without coverage do and how they cope. they came to my office to offered their story and to offer help, just as you did today. they want to do all they can to make sure that meaningful, comprehensive health care gets passed. dash told me when i asked about using this story to convey what they were experience -- experiencing, he said absolutely. i am willing to do whatever it takes. i don't think we and congress should offer any less than what dash is willing to offer, whatever it takes to pass meaningful health care reform. we have to do what it takes to make sure american families are not spending their retirement funds just to stay alive. that is what far too many insured and uninsured americans are facing. we have to do what it takes to hold ensures accountable for the benefits they promise us and in many cases, that people pay for. we have to do what it takes to pass health care reform this year. i yield back. >> thank you. that concludes the opening statements by other members of the subcommittee. we are going to stand in recess. we have three minutes remaining on this vote and we have another vote. let us try to be back by 2:50 p.m. or 2:55 p.m., and if you would like to join your father at the front table. testimony, you are welcome to do so. we will be in recess. >> the committee will come to order. our first panel of witnesses, we have ms. catherine howard, policyholder from san francisco. welcome. >> thank you. >> david null, from garland, texas, and his daughter has joined us. thank you. mr. nathan whelks from englewood, colorado. it is the policy to take all testimony under oath. the rise to have a right to be advised by counsel. do you wish to be represented by counsel? i see everyone shaken their heads, no. therefore i will ask you to rise and raise your right hand to take the oath. do you swear or affirm the testimony is the truth, whole truth, nothing but the truth in the matter pending before this committee? let the record reflect the witness is replied in the affirmative. you are not under oath. please, sit down. we will begin with opening statements. ms. howard, we will start with you. you may submit a longer statement for inclusion in the hearing record. your light is on, i take it. five minutes, please. >> mr. chairman, members of the subcommittee. thank you for inviting me to testify today. my name is catherine howard and i am from san francisco. five years ago i was working as a documentary film producer. i was not making a lot of money but i knew maintaining my health coverage was a big priority. my employer did not offer coverage so i went out and bought myself a private plan. this plan seemed perfect for a young, healthy person. it was affordable, only $140 a month. but i had no idea what it would really cost me. i was afraid that i would get hurt in some minor way, take a false snowboarding, need a couple of stitches, not living with a life-threatening illness like cancer. after my breast cancer diagnosis and august of 2004, i thought i was covered. i thought, i was so glad i have insurance. but, boy, was i wrong. i discovered that the health plan i was praying for didn't cover a large part of the cancer care that i needed. i was on the look for tens of thousands of dollars. i had chosen one of those low- premium but high deductible plans, and i had to pay for 30% of all of my treatments and a hospital. it didn't even cover all the services that i needed. i remember staring at this one shot -- it cost $2,100 per shot. the insurance company said, well, that is 30% for you, so and that needle is $600. i endured surgery, grueling chemotherapy, that left knee too weak to work full-time. i was told the key to my recovery was to minimize the stress in my life. and tell me how do you minimize stress when you all the hospital more than you earned in the past year? as the expense is piled up, i was able to pay for some of them, my family helped me. other things, i just put on my credit card and i thought if i don't die, i will just deal with this later. well, i didn't die. this is later. i find myself a hundred thousand dollars in debts between medical expenses and living expenses for while i was sick and couldn't work. by the end of my treatment, i owed $40,000 in medical expenses alone, and i have been paying this off over time slowly, using payment plans, paying down on those credit cards. but rather than saving money to put a downpayment on a house, buy a car, or even have a savings account, i spent $1,800 a month in essentially all the money i have after the basics, to pay toward my debt. i live like a pauper to pay for the privilege of surviving cancer. people of asking why i don't just declare a medical bankruptcy and wash my hands of all of this. but bankruptcy to me really seemed like a cop out and i don't cop out on my commitment. i made recovering from cancer my mission for the last five years. as i look ahead to the next five, i would like to see myself out of debt and i would like to make sure that this doesn't happen to it anyone else. in my work as an innovator i know things can be different. i am fortunate my employer offers comprehensive coverage because if they didn't, if i was back on the private market, i would be totally uninsurable because of my pre-existing 10 -- condition and i could not even afford to buy the same crummy coverage that left knee and is. the kind of health reforms in the house proposal would have kept me out of this devastating debt and the financial circumstances. limiting annual out-of-pocket cost and prohibiting junk policies would save other young people from facing the same circumstances i am in now. thank you. >> thank you. mr. null, if you like to pull that microphone up. and longer one would be submitted for the new record. >> good afternoon, chairman stupak. we appreciate the invitation did it is quite an honor and we think the entire subcommittee for taking the time to hear our started our story action of the lens -- begins in 1999 when i became self-employed. we employ 12 people. we had group insurance and then 9/11 hit and like for many americans it was difficult. within six months we had to drop our company-sponsored insurance and i had to enter into a world of individual insurance. january of 2005, we have been without insurance for about three months. we had a short lapse and a quick trip for -- to the e r four and $800 liquid bandage for my daughter is chin was a costly but excellent reminder of the value of insurance so began looking for a policy. we spoke at length with an insurance agents. i explained i don't mind paying for the doctors' visits, it is the big catastrophic hospital visits that we need. i told about "i need coverage for the big, oh, no." hib looked at me and i and told me i'm a very savvy shopper and this was a policy for us. by the time he said we factor in our negotiate rates and what the policy pays out, you hardly have to pay anything, the way he explained. we felt like we were getting what we asked for and we were relieved to be protected again. three months later tatum was 7, the first night of our family vacation and tatum posset touch of stomach flu seems to worsen and hours later she slipped into the coma and before sunset the next day they said she required a liver transplant. while she was clinging to life the transplant department administrators said we need to talk about insurance. he walked into a room. as we walked about myself, i wonder what he wants to talk about. aren't i glad we picked up this policy when we did? we reached -- reached the room and he said insurance kept out at $25,000, basically the night before. from that point forward tatum would not have insurance and it was hostile policy to collect a $200,000 deposit for them to proceed with a liver transplant. i honestly couldn't believe it was happening. could this be true? surely it is a mistake because this was the big thing i was buying protection from. suddenly was i not only facing possible death of our child but also financial bath or family? we have insurance for this. a donor was located and tatum received a transplant, probably less than 48 hours to live. once she stabilize the hospital helped me apply for medicaid and we were narrowly approved. the coverage was retroactive and recover the entire transplant, well over $500,000. our so-called hospitalization policy covered less than one- tenth. even with insurance we were left with a balance we could never bear to pay debt. tatum and our finances both had near-death experiences and although we did not know at the time would allow medicaid would means our family -- our daughter had be on my support for a week and now the finances would be on life support for the next two years. post transplant is medically expensive. we never knew what each day would bring but we knew we could not afford one without insurance. we began to look for it insurance for post-transplant expenses so we didn't medicaid but i was told by insurance agents not to waste time, paper, work, think, because they would refuse even accepted. we now have nowhere to turn and now we were somehow stop on medicaid. it was simply the insurance industry would not make a policy available to us and the individual market so and ordered to receive -- we had to drop in income to near poverty. the allow the monthly income on medicaid was a shocking $1,613 for a family of four. this barely allowed us to cover mortgage, most utilities and some food bills. this meant i would frequently have to pass on work and it was suggested that even sherry and i should get a divorce for financial reasons. these were tough times and we find ourselves in the bed every month. interestingly with medicaid whenever incurred costs. we actually owe nothing due to medical that at this time. the cost of staying on medicaid is on the backside, trying to survive on $20,000 a year. we took tremendous debt on the, eliminated savings and retirement and put growth on wall trying to survive was to get health care she needed. every two years -- she begins to reclaim it new life, now more good days so mother returned to teaching, a group health coverage and an entirely different insurance experience. i found it interesting when we transition to group coverage tatum was accepted without question. it would appear individual policies and a group policies exist in completely different universe is. her mother and i thank all for tatum causing physical recovery is quicker than finances. she is growing and giving back. she rarely appears on behalf of the children's medical center and make a wish. her life has been a joy and inspiration to many. we would do it all again for her sake. we are thankful medicaid was there for us. we are thankful to be off of medicaid. we do hope our testimony illustrates how hospitalization policy was worthless. we learned the language of the policies can be confusing. in spite of both being college educated we did not understand 25 -- $25,000 maximum for miscellaneous basically meant all hospital expenses. even today we find the wording a little counter intuitive or misleading. but i asked for in very clear language -- a policy that would protect us from the big fromoh, no, and we ended up with a policy that would do no such thing. while the thing should be labeled grossly underinsured but we learn traditional million dollar policies and a challenge for long-term life-threatening illnesses. i got a call on tuesday that a hospital added up tatum's costs at children's medical center and as of right now her cost is 1 million, 284,000 of $385, and that does not include any of the doctor's bills can -- $1.2 million. being under insured is pretty much the same as being uninsured. it leads to the same end. under insurance impacted our lives. got carried us through and we believe he will do so. we learned from this experience and we're trying to move on. it seems like the story ends here but you know it is the beginning for tatum. under insurance is probably not the biggest tragicomedy ask me. herstory encompasses other shortcomings that you need to do something about. what continues to set her mother and i is issue of budget pre- existing. tatum will grow up and one of these days she will need insurance. we are lucky because sherry's dream has been to teach and that gives us access to group coverage and benefits. but that might not be necessarily everybody's dream. i don't think it is really fair and i do not think it is american. i ask you to consider this -- when tatum was just four she went to new york city and stood transfixed at lady liberty. they told her then that labiate -- lady liberty and by its people to come to the land of opportunity and yet tatum, born and bred american citizen, might not be able to share in his dream through no fault of her own, simply because the insurance industry developed a system that won't allow it. our tatum has a much potential but for now to the not have full access to the promise. she cannot pursue little girl dreams to be an artist or have a restaurant or self-employed and any action that requires individual coverage. when she asked me what she should be when she grows up, i cannot tell her the same thing you can tell your kids. i can't tell her she can be anything she wants. you guys need to fix that for me. do i tell her of the government before heard today, for the people, by the book, refuses to take the steps to also protect her right to life, liberty, and pursuit of happiness? what do we tell her? in closing, while my purpose is to testify and answer your questions as an american citizen, i come to pose one question to this distinguished committee as a father, which of you would commit itself today to be able to look tatum in the eyes and tell her that you would be helping lead the way and see to it that when she grows up she will have affordable access to adequate health care regardless of her eye occupation and that today she, too, can start pursuing all of our american dreams. we sincerely pray that god bless you and guide you and god bless america. thank you, and please be an organ donor. . it has been a constant struggle for me. i will tell you about what we have had to deal with anti how i have dealt with it. -- and how i have dealt with it. eliminating the practice of health care caps. my son was born and diagnosed with severe hemophilia. treatment means he has to have a replacement clotting factor. it is very expensive to treat. if he does believe, he has to be treated quickly or death could occur. it could cause significant long- term damage. on the day he was digests, hematologist can to help us. her first question was, do you have good insurance? i said absolutely. we have the best plan and they have struggled to maintain that. in 2004 we had to start treating him. the cost of the treatment that year was roughly $500,000. the result was that in 2005 the insurance company forced us to accept a high deductible plan. they shopped around to other insurance companies, all of whom refused to cover my company previously because of the high cost of claims. in 2005 the claims rose to three-quarters of $1 million a year. these treatments were necessary for my son's well-being. today he is happy and productive. one of the things they add it was a more million dollars lifetime cap. -- they added a $1 million lifetime cap. we knew [unintelligible] it was running out on us. we knew we had maybe one year before we had to find some other solution. we discovered we had choices. we had six choices and i have documented them here. i think he will understand we did not have any choices at all. i could quit my job and the work in a larger company where i could hide in the shadows or not let them know my son has a serious illness. work i could work for the government, but it does not pay enough. i could have my wife go to work. she made a decision to stay home and take care of my son. we cannot afford putting kids into day care. we tried to turn to medicaid. colorado is a difficult state to get medicaid. we aren't too much money. we already have been racking up significant middle school debt -- significant medical debt. if we got a divorce then the kids could qualify for medicaid under this. we did not want to do that. that was not in our family values. we could put thomas in the state high risks pool. once he did cao out, -- once he did cap out, he was in a high risk pool. that is normally insurance of last resort. finally, the option was to start my own business and try to get myself individual insurance. or you can get in short by the government if you are impoverished with a disability. -- you can get insured by the government. i decided to become an employer. the struggle that we faced and there were years while we were paying $25,000 a year in out of pocket expenses. this left us fighting to keep up with bills and stay afloat. the worse our credit rating got, the more we ended up paying for everything. we struggled to get provider's paid for everything. it took us over one year to set up our own business. when my son nearly exhausted his capture -- exhausted his own cap -- i had to quit my job even though my employer tried to keep me on board. they were fine with paying rising premiums and the other companies were not willing to take me on they did everything they could to work with me. ultimately, i had to quit my job and take a pay cut. now we are covered by another high deductible health care plan. this one has a $6 million cap. it will not be long before we run out of that as well. thinking about where we are now as once we were hanging by a thread -- anything that stops the income through my business or serious illness that puts him in the hospital for many like that time it means we are out. -- for a length of time means we are out. this chart shows our premiums over the years. when we started the claims are cost of care went up 35% the next year. the other point i want to make is that the impact of the high cost of his care was not just felt by my family but by everyone i worked with. there were only 150 employees, but moving into the high deductible plan meant everybody was paying for medical care out of their own pocket. i had a co-worker who got his leg cut and did not have the money, so i had a friend stitch up his leg. another case, a young co- worker's wife was pregnant and had to have a see section, because of the deductible they were faced with putting $9,000 on their credit cards. -- she had to have a c-section. maintaining health insurance has been a struggle but it has allowed my son to have the insurance needs. without reforming this system the struggle will continue for me. it is important that the individuals taht face health care costs see reform health happened -- see reform happen. i am concerned for those of us that are currently in short that these changes will not take effect until 2013. -- who are currently insured. they don't take effect until 2018. i tell people that in the individual market, [unintelligible] what happened to us, we have always been in the group market, highly deductible health plan and caps have been had they weeded out us, and that has to change. our country needs health insurance reform. we want to eliminate lifetime caps on benefits and help reform. >> thank you all for your testimony. as many members have said, you really help us put a face on what is going on with health care, those folks who are unfortunate enough to have medical problems. i will ask the chairman if he would like to go first. if you would like begin questioning, we will have a question for five minutes. >> that they should face a future where she might not get insurance under the way things operate. bankruptcy becomes the only way to wash your hands from this debt. you all have insurance. i want to assure you that he -- the honey enact legislation -- if we enact legislation, in your future will be very bright. insurance should be that we spread the costs over a broad population and those who need the care will have it available to them. but the insurance companies look at it differently. they want to avoid having to pay money, so they don't want to cover people who might be at risk. they will exclude you if you had a pre-existing condition. they have annual limits on out of -- costs they will pay. there are some many things they do to avoid living up to what you expected that you bought when he paid for your insurance coverage. you thought you were buying insurance coverage that would protect the of. you knew he would have to pay a lot of money up front, but if it was a huge amount you would be covered, isn't that what you were thinking? >> that's what i thought. that was wrong. your policy said if your costs exceeded $5,000, then the insurance company would pay for all of the. >> they did say that. >> what happened with you is you spent more than $5,000 because every time you got a treatment they did not count that towards your out-of-pocket limit. they disqualified costs of out of network street and some and what you pay for prescription drugs. >> that amounted to $10,000 per year. >> tend thousand dollars each year -- $10,000 each year. >> they did not step up to pay the rest, they said what you paid it does not count towards the $5,000. it is almost like they kept moving away further and further from you. when you tried to stay within network, and did you go out of network and its how difficult -- did you go out of network? how difficult was it to find someone in your network? >> there were some services not in san francisco. >> san francisco is a big city, so i would assume you're talking about hundreds of miles. >> i made the choice to get the care i needed regardless of the cost. that is why i am alive today. >> each time you had a prescription filled you had to pay 30% of the cost. , chairman of pocket -- how much al of pocket did you spend with insurance? >> it was over $40,000. >> 40 years you were protected -- for the years you were protected, you spent $40,000? >> yes. >> your policy had a cap on out- of-pocket expenses, but they have limitations. can you estimate the total out- of-pocket cost? >> in the sixth years, i would say well over $50,000. there were some claims at the very beginning they said they did not cover because it was out of network or because it exceeded the cap. they were $50,000 and $80,000 each. we have opening statements today. some of my colleagues who are opposed to health insurance reform said we don't want one size to fit all. we want competition in the system. there is no competition when one insurance company can sell a plan that doesn't pay over a certain amount, -- in other words, what they are saying is competition is competition to exclude payments. what we need is legislation that would ban the lifetime caps, that would have no limits on out-of-pocket costs. what we would like is a defined benefit package so you could shop around between different insurance claims and you'll know you're buying a plan that will cover your needs. you will choose based on price or quality, but not based on what they will cover or will not cover when you find out you need the coverage. i hope we will get that bill passed. i thank the chairman for allowing me to proceed. >> mr. walton for questions. >> there are many of us on this side of the aisle who have supported health care insurance reform. during my days in congress, i will continue to. i support the pre-existing condition issue, dealing with the caps issue, dealing with the competition issue. insurance should be available across state lines. i was on a hospital board for five years and we look at the uncompensated care we wrote off and dealt with everybody involved. i was a small employer. we had 15 employees and virtually no option for insurance. i never could throw the dart high enough to figure out what my premium increases would be. i am sympathetic. you heard my own personal story as a parent. i am cio doesn't california regulate the insurance policies like the ones that you have? you don't still have that? >> i don't have that policy. >> would that policy have fallen under the regulatory scheme of california? >> when i realized expenses were melting in a way i had not foreseen, i called and said how is this possible? they pointed to my signature on the contract and say you signed up for this. >> what good is the regulatory scheme in california to make sure -- don't they determine anything to do with the policies? >> at the time i was facing this i was so ill that i had no strength to learn all of those things. it is only in retrospect that i have attempted to piece together this story. they refused to hand over my records to me. i understand they handed them to the subcommittee. >> they would like give you your own records? >> no, because i don't have that policy anymore. >> that is amazing. >> but i assume we subpoenaed them or requested them. >> maybe i can look at them. >> you can come up after and we will give you a complete copy. there needs to be a change here. there is no doubt about it. i guess that is one of the things. we have to have this regulatory scheme state-by-state, but i think that your story did not protect you as a consumer. i am sure -- when we shop for health insurance, trying to read through those policies to figure out what is covered is a challenge. i leave that up to my wife and she makes pretty good decisions, this is still a challenge. i want to make sure you are not tied to a job in order to have insurance for your kids. what i am not convinced this bill is the one that is the best way to achieve that, i do believe there are ways to get their. i don't have any further questions. i know we will have the votes in another 15 minutes. >> i have to compliment you because you have helped us get her records. in meeting we have on tuesday has been adjourned a couple of times because small businesses agreed we could look at their policies but the insurance companies have refused to give us the records. we finally have some records, but it is a hassle whether you or the patient or the policyholder. they don't want to give up those records. >> maybe we can have an oversight hearing on hit the -- and oversight hearing on hippa, too. >> these stories are heartbreaking but unfortunately not unique. if i go to the first slide. this survey provides remarkable data. this comes from the commonwealth fund report. i would like to highlight the label, and during short -- underinsured. there are 25.2 million underinsured americans. they burned through their savings in order to pay through their medical bills. that is a 11.6 million americans who spent all of their savings on medical expenses. 33% of those underinsured took on medical debt. they are relying on credit cards with high interest rates to cover medical expenses. there are just one step away from being uninsured. you said your family rely on credit card and home equity to stay afloat. how much medical debt did you financed through credit? >> it was spread out around several years. i even had to cash in my life insurance policy and spend out our savings. we get stacks of statements and bills from the hospital, so it is impossible to keep track. even the insurance company could not keep track. >> you requested -- >> in 2006 we said give us a line item list of the bills. we got that 22 months later. >> what would have happened if he were waiting for this information and you go over your cap? it takes them 22 months to get you the impression. that would have been out of your pocket. >> -- to get you the information. >> had we waited another week it would have been well over $1 million. >> i had -- 2002 there is a green line on the bottom. this is your total annual premium, right? >> it is employee contributions. it is a minor portion that comes out of your paycheck. >> the blue one starts at $7,000, is that employee contributions? >> yes, that is the full premium. >> you went from $7,000 to over $17,000? >> it was basically a 12th thousand dollars a year premium. -- $12,000 a year premium. it was well over $22,000. that includes finding the hsa that we had. >> it is basically $17,000 for a premium but a $10,000 deductible first. >> $10,000 out of pocket with some co-insurance. it was a lot of money out of our pocket. >> even with the deductible -- fellow employees had to pay for a c-section for the birth of a child. >> they were all casualty's around us. they were paying this premium per family, but every time they had to go to the doctor then they were paying 100% because they had not come close to their deductible. >> one way to get around it is to file divorce and have one spell go on medicaid to pay for expenses. i am pleased to see none of you chose that route, but it makes you think once or twice. you had to reduce your annual income to $16,000 in order to qualify? >> you have to maintain below that level. i am sure you had to invest your assets and get rid of a savings account. >> absolutely, they do a complete asset search. >> how long were you on medicaid? >> about two years. >> i think you said you had to avoid work because you were afraid to go over that. what would have happened? would you just be without insurance? >> they would drop us immediately. >> deede you look for other insurance companies -- did you look for other insurance companies? >> none other would write because of the pre-existing condition. they said they would not even accept our policy for review. >> it was only when you went from an individual plan to a group plan that you were able to get insurance? >> correct. >> you indicated she is blacklisted from insurance. >> this is because of her pre- existing condition. we could not find any insurance companies that would except her application. >> if you did not put your name on it, it would be rejected because she is not covered, right? >> there is no way around that. >> we all want to compliment you for the struggles you have been through, but i think he said you did not want to file for bankruptcy. why did you not want to go bankrupt? you could clear of your debt. in seven years you could get your credit reestablished. >> i figure in the next seven years i might be able to pay this off. i would like to be able to say i have stood up on my own throughout all of this. >> i think you have to respect everybody for trying to do what is right. 62% of those have insurance. we, you for trying to do this. >> questions, please. -- we complement you. >> i want to thank all of you for sharing your stories and the courage that you had exhibited in trying to deal with a very difficult situation that all three of you had experienced. i wanted to direct my first comments to ms. howard. i want to commend you on your steadfastness with taking responsibility for your own medical debt. could you comment on how that has affected you personally and did you ever consider medicaid? could you talk about that again? were you able to obtain medical care from any other group? was there anybody out there to help you, other than that insurance policy? >> yes, for part of 2005 i qualified for a program for california for low income breast cancer patients. they offered me some help, but in the long term it was just a drop in the bucket. i am lucky that through my employer i am covered by excellent group coverage, but i know if i was in the individual market that no one would cover me. >> in california, i know in georgia and it is underfunded but they have something called state aid for low-income cancer patients. do they have something similar in california? >> they do for breast cancer. i qualified but the outcome was minimal. i was grateful for the aid, but it was insufficient given the extent of my dad's -- extent of my debt. >> how about the providers in california? did you run into any difficulty in regard to physicians expecting -- physicians excepting state aid? >> it is somewhat of a blur, but i had an excellent oncologist and group that was caring for me. they said we will figure this out together. we figured out that i have both them for a lot of -- showed them a lot of money. -- owed them aa lot -- a lot of money. mr. waxman commented that many on this side of the aisle don't feel that we need to have health insurance reform. maybe my opening remarks led him to believe that's maybe i didn't feel we needed to have health insurance reform, but i personally believe we need health insurance reform and i think most members believe that. it your testimony today is -- it supports the need for reform. usually we can do that without throwing the baby out with the bath water, but mr. waldon mention many things we are supportive of. some of the egregious things you have described like denying it the ability for people with pre- existing conditions to get coverage. maybe they can get it but it is five times standards rates they cannot get it. you mentioned you are under group coverage and when you had to get into the small group market because of the pre- existing condition of your son, it was virtually impossible. i want to ask you your opinion. anybody -- say a young, healthy person with a family and lack of expenses, you can hardly afford to get on the company's group policy, but you do it anyway. you make that sacrifice every month and pinch pennies. maybe for 15 years -- you have done that and then something like this happens. don't you think an insurance company should be obligated because you have had this credible coverage, if something happens to you or one of your family members, that they should continue to cover you at those standard rates until you are eligible for medicare? because you have bought into that system and they have made a nice profit on covering you until you finally did have those claims. tell us what you are thinking about. >> because of the way the group market works, insurance functions best as a large pool. the employers are all these tiny pool.s we had the high cost and they paid the price. we were blessed and -- we were blessed in colorado. they enacted a law created a modified community rating. that is the only reason i can't afford small group coverage, because we have modified coverage. i want to speak briefly about selling insurance across state lines. we are talking about underinsurance. that is a bad idea because it invites underinsurance. there are 45 things that have to be covered under insurance plans. we have 51 in colorado. breast cancer screening, whereas in idaho they only have 16 that have to be covered. if you invite selling across state lines, and the united healthcare in colorado will try to sell a low-cost plan that doesn't cover those things. then you create more problems we are having -- breast cancer is not covered anymore, liver cancer is not covered. >> i don't have time, but thank you so much. your daughter looks great and healthy. thank god for that. >> mr. dingell for questions. >> thank you for your help. the first question is [unintelligible] what is striking about each of your stories is that in medical emergencies that your insurance policies had shortcomings, which has limited your career options. mr. null, you mentioned you had to lower your income in order to qualify for medicaid. because you are a small business owner, that decision under affected your business. it probably related to having to turn away business to reduce your income. is that true? >> yes. >> tell us more about it. >> hillen it was $1,613. -- the limit was $1,613. i know exactly how much i would make. if i knew i would make too much to qualify we would have to turn business away and i would be unable to take on that business because i would make too much. >> thank you. mr. wilkes, you told us you had to leave a company you liked in order to get better coverage. what would you like to tell us about that? >> they did not want me to go. i was the lead engineer of the company. the company survived the dotcom bust. they kept me around for over a year while we are dealing with this. i walked the halls of the company and felt i had a big target on my back. i am very close to other members of the hemophilia community. i have heard horror stories about them playing -- being in a top job and as soon as somebody found out they had a kid with hemophilia they were terminated or let go. i had that target, that. -- i had that target on my back. they did not want me to go. they worked with me, they did everything they could. i feel blessed that the guardian angel is looking over me and my family. but i know that is not the case for a lot of people >> -- for a lot of people. >> i gather you've had to shop around for insurance policies in order to meet your needs. did you find that to be an easy process? did you had an easy time comparing your choices amongst policies to come up with the best choice? did you find it easy to know what the benefits would be, what the constructions were, what would be the costs and what would be the duration of the policy and the other circumstances, including pre- existing conditions. did you want to start, mr. null? >> we found shopping for insurance to be very confusing. in texas they require a licensed agent to come talk to you about policies. i went and i are both college- educated -- my wife and i are college educated. this policy we were on when tatum had her own nest. it was only 25 less than the one i was done previously. it was only 25% less and yet the cap was 1/40 of the previous policy. we did not recognize any thing on those lines. had we had seen something like that, it would have raised red flags. we would have recognized it for being be worthless piece of trash it was. >> we have been dealing with this for over five years by the time it came time for us to shop for a plan. the policies themselves were very difficult to comprehend. one thing that was my favorite that i was able to find an insurance broker who had cancer herself and believed the private insurance market has no business existing and new what to look for. i had her in my favor who was an advocate for my family. there were 20 something different insurance companies. we went to our hemophilia treatment center and said which of these is least likely to deny care? is least likely to cause us problems? out of those there were only two that they said they had the least problems with. in the end, we had two insurance companies that were even an option for us. beyond that, we had to work with our insurance broker who knew what we were dealing with. >> do you have any comments to the last question? >> i feel there is a need to provide consumers with assistance in making sense of these plans to give us an apples to apples comparison. i now have a master's degree and i could not make sense of that policy. i feel like it behooves the subcommittee to write into the bill that we have to understand what we are signing up for. what would the coverage be for the common conditions like my own, like breast cancer? what would the ramifications before an individual or family? >> thank you for your very fine testimony. >> for questions, please. we have two votes. >> i want to express myself what all of us feel. you are amazing to have gone through what you have gone through with the anxiety and getting bad news, and learning that you did not have insurance. in a time when you need to have a total concentration on your health, to find that you are in warfare with the insurance companies is astonishing. what i am amazed at is you seem to be very normal people and it has worn you down. he may be fooling us, but i don't think so. -- you may be fooling us. he should not have to have that strength. what you have given us is a vivid examples, if you're going to have insurance, it ought to be real coverage. it should not be someone with extraordinary personal reserves to get through it. what you're describing is a business model where insurance companies make their money by denying coverage or writing policies with loopholes that make it impossible for people to get the coverage they need. it is our responsibility to change that. i think there is some ends at -- some desire to have reform. this has to be with some consumer protections, so if you buy a policy from another state, when the diagnosis comes and you need care, one of your worries is not if you have coverage. you have done a tremendous service for us here. i think all of us really admire the personal strength each of you has displayed, but we don't want others to have to go through what you have. thank you so much for being helpful. >> i yield back. the committee has been -- we had the same situation with medicare in advantage. people sign up and had no idea what they were signing up for. for questions, we still have nine minutes before we have to vote. that's get some more questions. >> -- let's get some more questions. >> another troubling aspect is it encourages policyholders to put off care in order to cut costs. people don't pay for home heating or food, all of that is needed to sustain your health. those with chronic diseases don't take proper care of their health, so i would ask each of about your experiences. would you ever avoid taking thomas to the doctor because you live near he was -- because you knew he was near his cap? >> absolutely. there were times when thomas would complain about an injured joint, and the normal procedure would be treated right away, and every dose was precious to us. we would wait and see. we did not know if it was his leg falling asleep or what. we would wait a few hours or overnight, and it would actually turned worse in the cost us $80,000. >> and probably damaged -- >> he had one believe where he was confined to a wheelchair. -- he had won bleed. >> did you ever skip any treatments? >> i did not. if i don't die i will figure out how to pay for this later. it has come at a tremendous cost to my family and personal finances and has affected how i choose to live my life. >> know, we never let that be a consideration. >>n >o, -- no, we never let that be a consideration. >> we have great admiration for the strength and courage. thank you. >> there are five minutes before we have to vote, so we will keep it at 5. >> i can walk faster than 50 older members, so maybe i will make it. ms. howard, let me just ask you. i did want to come back and visit with you. we heard mr. wilkes talking about how confusing insurance policies can be. i don't know if any of you have taken the time to read through the legislation this committee passed on july 31. it is pretty confusing as well. for many people it has been hard to discern whether people's lives will be more complicated if this bill passes. you referenced in your testimony having at least paid attention to one amendment that was passed. i want to commend you for your ability to sort through a large number of words that dug up pieces of miniscule events. that was very important to get that included. i was concerned about the development of a public option without internal review being available. would that have helped you in your situation? >> absolutely, i previously had a group policy with the same provider that was excellent. when it came time for me to buy a private policy, i went back to them willingly and said what do you have to offer? i had been a great customer of yours. had i been able to compare the disparity in coverage between private and group planned, if i had been through the same illness under a group plan i would not be in the financial circumstances i am now. if i could have seen that apples to apples comparison and told if you get cancer this is what it will cost you, i might have made a different choice. i don't know if there would have been anything better. >> this gets to the larger point when a larger corporation is negotiating for insurance coverage, they bring a certain amount of clout to the table. i have a policy in the individual market at one. and you are negotiating as a single individual. -- at one point. there are many of us who believe if we would permit more aggregation of consumers, it doesn't always have to be working for this same company. it might be members of the same church where people in dentist'' offices, i was stuck with having to provide a competitive insurance policy for 50 employees. while that is better than fighting for one individual, you are restricted in that. we don't seem to be sensitive to the fact if we would allow aggravation of larger groups with some sort of similarity in the business models that we would get people more purchasing clout. you have chosen to work out a payment schedule. while it seems aggressive, i was a practicing physician for years and can recall as long as the patient was making an effort to pay off the bill, that was all our office would do. the hospital being owned by a big corporation, -- they were less likely to work with the patient, but as far as the individual physician's office -- i could talk to a hospital in ministration and say you could put them in a collection agency and he will get 35% of what you would normally get or you can wait a length of time until they can pay. i commend you for doing that. your payment schedule is aggressive. i never had a patient who paid me that probably, but i don't think people are aware this is available to them. i practiced for 25 years and i can remember probably getting two bankruptcy discharges in my practice. not that i pushed them into bankruptcy, but as a creditor i had to be notified and i could cease and desist. it was such an infrequent occurrence, and i sit here listening to opening statements and it seems like it is rampant. one final thought, did you talk to the texas department of insurance about your problems? >> no, i did not. >> we have to cut you off. time is expired. mr. doyle, go ahead. >> i will try to be quick. thank you so much. it is a tremendous help to us to put a face on this. mr. null, i wanted to put your policy on the screen. i was reading your policy. i am licensed in all lines of insurance. i was having a hard time understanding your policy. when you look up there and it shows you the surgical 100%, how did you read that when you first bought it? did you mean that to read they would cover 100% of surgery? >> in texas that is what that means. >> then you go a couple of pages further and there is another schedule that lists different procedures and what they will pay for it. did you have any idea what these procedures actually cost? >> no, i have no idea. i have never seen a medical bill before this. >> when we talk about transparency, this is one of the things that we have to help consumers with. if it says he will pay $5,000 for a procedure and it costs $25,000, would you have bought the policy? >> no, that would not seem like 100%. >> people buy insurance policies all the time that had these schedules. your daughters surgery was not even on this, correct? >> it is not on there. >> you just assumed it would pay 100%. >> unless listed otherwise. >> the need for health insurance reform is so obvious. the thought of companies selling across lines and nobody watching how these are written would be a nightmare. people need to know what procedures costs and what procedures -- what companies will pay for. as an insurance agent, i still don't understand your policy. i see what you have gone through and i am sorry you have gone through it. >> thank you, that makes me feel better. >> tatum, did you want to say anything to this group? >> i just want to say that knowing what is going on right now, i do want to be able to live my american dream. right now i am not able to, so hopefully you can fix that. >> i hope we can, too. >> if i could thank them so much. i know you have been here for a long time. we had a couple of votes, so i will be waived my questions. you are emblematic of what could happen to anyone in our country. everyone is one catastrophic illness away from the kinds of problems. i would love to know who told you to get a divorce. i would also be interested -- i am sure you spent endless hours of your time in the face of illness dealing with this. we will address this issue. i thank you for your contribution. >> we will stand in recess. i urge members to vote and come back. i will excuse this panel. we can follow up with questions in writing. we appreciate you for being here. we are in recess. i urged members to come back immediately and get to the second panel. [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2009] >> i would like to thank both of you for being here and being patient with us. it is the policy to take all testimony under oath. you have the right to be advised by counsel during your testimony. do you wish to be represented by counsel? both witnesses indicated they do not. please take the oath. >> do you swear the testimony you are about to give is the truth and nothing but the truth? let the record reflect the witnesses were applied in the affirmative. we would like to hear a five minute opening statement from each of you. dr. collins, we will start with you. just turn on the microphone and you can start. if you have a longer statement that will be included in the record. thank you for being here. >> thank you for this invitation to testify on the growing number of people who are underinsured. the recession is leaving many working families without insurance and medical expenses that consume a large share of their income. 46 million people lack health insurance in 2008. among people who do have insurance, in 2007 25 million working age adults had such high out of pocket costs that they were underinsured, an increase from 16 million in 2003. both these trends have had serious financial consequences for families. this committee and the other health committees in the house and senate are to be commended for pursuing health reform that will help families secure access to health insurance. the combination of rising costs, slow-growth in family income, and greater posturing and health plans is contributing to the growth in uninsured adults. . . almost 1/4 of adults under impoverished or underinsured. this is up from 19% in 2003. the problem of cost exposure is moving up the income scale. the most rapid growth occurred among adults are in between $40,000.60000 dollars. underinsurance is associated with health plans that cover your health benefits. more than one coquarter of adults -- 48% said their health plan placed limits on the total dollar amount their plan would pay for. 90% reported that their health plans limited the number of times per year they could see their positions. underinsurance is also associate with reports of health plan problems. 44% of under insured adults reported they had had expense of medical bills for services that were not covered. 38% of underinsured adults reported that their doctor had charged in a higher price. they had to pay the difference. adults with health plans purchased in the individual insurance market are more likely to be under insured. 30% of adults who purchased a plant on the individual market or underinsured compared to about 17% of adults who were in employer-based health plans. under insured adults report on getting needed health care because of costs at rates that are nearly as high as people without insurance altogether. 60% of under insured adults reported at least one cost- related problem getting care. underinsured adult report i read the medical bill problems. three of five of them report a problem paying medical bills. this is more than double the rate of those who have adequate insurance all year. nearly half of adults were underinsured reported they are paying off medical debt over time. several provisions in the america's health choices at would reduce the number of people or under insured. the bill applies to the individual insurance marker with the regulated insurance exchange. the new market regulations would extend to all health plans. guaranteed issue and community rating would ensure that people could not be denied coverage, charged a higher price, or have a condition excluded because of a pre-existing condition. insurers carriers cannot impose annual lifetime limits on what they pay and would be prohibited from the use of recisions. the bill would establish a new minimum benefit standard which would ensure that families do not become bankrupt because of medical costs. that would encourage the use of time and services and prevent against catastrophic costs. medicare and medicaid substantially improved the situation. the cost sharing credit for significantly reduced out-of- pocket expenses for people with income under 350% of poverty. print costs would likely decline from current levels -- current cost would likely decline from current levels ar. reducing out of pocket costs will require national reforms and improved the overall performance of the health insurance. the house bill includes key provisions. these provisions will likely enhance the value obtained for health spending and set in motion reforms to slow the growth in health-care costs over time. thank you. >> thank you. mr. brock, your testimony, please. turn that light on and pull your microphone up a little bit. we look forward to your testimony. >> thank you. members, in 1992, a charity formed to provide free medical relief services overseas began receiving requests for service in the united states. that included dental procedures, i exams, free eyeglasses, and primary health. today, 64% of our work is in america. we run about 30 expeditions' per year and have completed 581. some 45,000 volunteers have delivered $40 million worth of free care and treatment to more than 64,000 animals. our most sought after services are dental and vision with over 55,000 patients served in the u.s. in each specialty. demographics revealed that 94% of the patients are adults. 83% are between the ages of 21- 64. that reflects the transition from childhood programs to the situation prior to receive medicare. 64% of visit emergency rooms. dentists and i doctors are unaffordable, leading to long lines of desperate americans at clinics for the greatest impediment to ram programs is regulation faced in 49 states to prevent practitioners from crossing state lines to provide free care even during declared emergencies, reciprocity between states is a complex matter that current legislation under the uniform practitioners act cannot adequately address. the sole exception is the volunteer health care services act of 10c. since 1995, a doctor can show up at a ram event in tennessee with license in hand, roll up their sleeves and get to work. no bureaucratic application process, no fees, and snow on necessary background investigations. in 1997, representative john duncan introduced a resolution to adopt a tennessee model. hcr 69 was referred to the department of commerce. it gained no ground nationwide. ram attracts thousands of uninsured and underinsured patients and recall -- that require large numbers of doctors. patient volume invariably exceed the numbers of local providers willing or available to volunteer for services. this gap can only be felt by reinforcing our teams with volunteers licensed in other states. there are more than 179,000 dentists in america and 800,000 positions that as a nationally standardized competency test and graduate from a nationally accredited school. many like to travel and will do so at their own expense to provide free care. some do in other countries because volunteering outside of the u.s. is easier than overcoming the bureaucratic hurdles to help the 47 million uninsured here in america. this demonstrates the need for all states to adopt the tennessee model as proposed in hcr 69. that need was recently emphasized in los angeles. in eight days, we treated 6344 patients free care exceeding $2.8 million. those numbers could have been doubled. we had 100 dental chairs and 20 lines of eye exam equipment. only recruit 25 california licensed dentists and five or six eye specialists. by comparison, in rural southwest virginia where laws were relaxed without impartial use,ram treated over 7000 patients in only 2.5 days. a patient number not attained in los angeles until the fourth day. thousands of uninsured california residents were turned away. ram patient surveys indicate that some carry some 46% carry no insurance. 18% are on medicare. dental and vision insurance is carried by less than 1%. self induced health issues wrought by the culture of poverty caused by fast-food, smoking, and lack of exercise are aggravated by the problem of access. patients do not have access to the doctors and the doctor can across state lines and have access to the patients and the doctor does not have reasonable access to protection from lawsuits. ram data proves that allowing doctors to cross straight lines dramatically increases service to the underserved. if the tennessee statute was enacted by all 50 states or possibly at the federal level under the interstate commerce precisions of the constitution, volunteers would respond en masse and treat uninsured americans at no cost the government or the taxpayer. thank you, mr. chairman. >> thank you mr. brock. we will open up for questions. >> thank you, mr. chairman. let me first extend my thanks to the commonwealth fund for the incredible work that has been done to advance our knowledge about this whole area of health care and health care reform. mr. brock, let me thank you for the remote area medical foundation. for me, what i would like to say is, it has highlighted and underscored a failure of the american health-care system. obviously, notice credit at all to you because you are providing -- you are filling a gap. what i take away from that is that you should not be doing this work in develop -- you should be doing this work in developing countries. we are the united states of america. i just feel ashamed when i see that people have to line up at 3:00 in the morning, even people that have some kind of insurance. my hope is that your organization will flourish and be able to serve people in truly remote areas around the world. your work should be not only applaud but supported. i wanted to talk to dr. collins about the issue of the health insurance market concentration. because of mergers and acquisitions by private health insurance companies, consumers in many parts of the country, most parts of the country, have few choices. i don't know if you have figure 25 that has a mapfh that showse country and the concentration of private health insurance companies in the state's. in eight states, you find two insurance companies control 80%- 100% of the market. in other states, they control 79% and the majority of states, those of that are shaded light blue, two insurance companies control more than half the market. as you said your written testimony, there are only three states in which the two biggest health insurance companies control less than half the market. is that right? what kind of a fact does this market concentration have on consumer premiums and out-of- pocket costs that american consumers face? >> what it means is that insurance companies, if they are facing concentrated provider markets with not a lot of competition and if they are not able to negotiate lower rates with providers because of the lack of market competition in the insurance market, they can simply pass those costs off to it is probably contributing to the rapid increase in premiums. we needed increasing competition in the insurance market to counteract that dynamic. >> how you see hr 3200 affecting competition in the insurance company and what affect would this happen underinsurance? >> that includes a public plan option. in these markets, there be a new option for people to choose from. it would mean that if the public plan was allowed to negotiate or to set provider payment rates, it would break up this dynamic that we are seeing where insurance companies just pass on their higher rates to consumers and employers and inject new price competition into the market, likely lowering premium costs for everyone and contributing to lower rates of growth overall health-care costs. it would also help spread innovation in payment reform, a delivery system reform, having the presence of the public option area it would introduce some needed price competition and innovation on the payment and delivery systems on the reform side. >> why don't more insurance companies try to enter these concentrated markets? what are the barriers, under our current system? >> many insurers are already contrasting with current provider networks. it is difficult for insurance companies to come in and get those providers into the network. that concentration in the market really does act as a barrier for other insurance companies coming into the market. >> thank you. thank you both. >> any further questions? mr. green for questions please? >> thank you mr. chairman. during our first panel, we heard from our witnesses about problems of transparency. we took some time to look at the policy that david null brought that he thought would protect and in a catastrophe. it did not protect them as expected. people should be responsible for repulses carefully but all too often, policies are confusing. dr. collins, do you see a widespread problem of boie in health insurance policies? are consumers generally well- informed about their health plans? >> the problem happens in individual markets where people are on their own in choosing plants. they are not often aware of what their plans cover. they may think that a life time grant of $100 million is a lot but it turns out it may not be enough. it is a pervasive problem. the minimum standard benefit of much increase transparency is needed in both of these markets, the house bill does that with a minimum standard benefit package. the new environment of transparency would be available through the exchange. >> in your view, what reforms would help ensure that consumers are informed better about their policies? >> i think there needs to be much more regulation of the individual market. there needs to be, as massachusetts has done, a way for people to look at what their policies have and know there is a minimum standards though there policies cannot fall below that standard, that there will be limits -- there will be limits on what their plans will pipe. they will know their deductibles. they will know what their plans will pay. having the kind of standardization for this market where people are on their own, is really important to counteract a lot of the experience we saw. >> there were hearings on transparencies and hospital bills. i put an amendment on h.r. 3200. most people do not think that bill had a partisan effort a lot of the language in that bill came out of both sides of the aisle. it is just we did not give me both on our committee on it. we did have the transparency amendment that would require hospitals to disclose the average prices for their common services. would this help with transparency and insurance policies if we did something like that on a national basis? >> i think having more transparency on hospital pricing side -- having both the federal government having those prices much more clear so that the cost is much closer to what prices are right down. -- right now. there is no transparency on what costs are for hospital procedures. people who are uninsured are often charged far more than what injured patients would be under negotiated contracts. having that transparency on price will be very useful to both the federal government and private insurers. >> mr. dingell, for questions. >> i would like to commend the panel for their very helpful testimony. i have no questions. >> i have a number of questions i would like to ask. mr. brock, you indicated that legislation was introduced to get doctors to, and volunteer their time. that was reduced t./ do you still face that's a problem today where a doctor cannotúib come to your operation and the volunteer time? >> this is the most difficult problem we face everywhere except in the state of tennessee. we have treated thousands and thousands of patients they're using predominantly practitioners from outside the state. what we do on a massive scale is we are dealing with thousands of people and requires hundreds and hundreds of doctors to do that. it is not possible in most cases to recruit enough local providers. >> when you mention wise county, va., you had to use doctors from virginia? >> no, tenn., to my knowledge is the only state that has this across the board, this open door policy. in virginia, there is an effort in that direction which is not -- which has not reached a point where it is very workable. we can bring in people for more no -- for no more than three days in virginia but it was a measure that was opposed by the dentists. the ones to bring in dentist, we had to have them jump through a number of hoops. the most dramatic case in point was last month, august in los angeles, where retreated 6344 patients but we had such an inadequate force of california license to doctors despite the fact that we petitioned to bring in volunteers from outside the state. we had 100 dental chairs set up. we had 20 lanes of eye exam equipment and the best we could do wawith 25 dentists and 25 optometrists and a dozen or so doctors. we have given at 1600 numbers. there that many people waiting on day one. we had to turn all of the wakes up a 700 that we could do with the limited force. had we be allowedkm to bring in people from anywhere in the country who would have been more than willing to come, we had some requests but we had to say they could not come because we are going to state that does not allow it. we could have treated 15,000 people instead of 6344. >> you also indicated that you conducted surveys to determine what portion of your patients had health insurance. what did to learn from this survey as to how people have health insurance but were still seeking free health care supplied by your fine organization? >> it is all across the board. there are about 42% that have insurance. of some type. this is not just treating people who are the unemployed and homeless we are getting people just like these wonderful folks in the first panel. these are people who have jobs. these are people who have reasonable incomes. they had issues that are not covered on their insurance policy. in many cases, it is a lack])o f dental coverage and a lack of vision coverage. they simply cannot afford or their deductible is too high. even though we may have 1000 people that make, any particular morning for treatment, and looking at the profile of these patients, you can see that they all have some pretty far- reaching medical problems, a large branches of them smok»j or were obese. they can take some of those problems to the emergency room when they run into a problem. they cannot take dentistry and it cannot take vision problems to the emergency room. in our neighborhood, every emergency room as a sign up that if you are here with a bad to very cannot see, see remote area of medical. virtually 100% of the patients that come to our clinic are there because they are in pain or they have vision problems. >> the 42% made no difference in urban or rural areas? >> it is similar across the board, yes. >> thank you for the remarkable work you and your volunteers do. we appreciate you being here. dr. collins, mr. brock said something interesting. he indicated that these are people who have insurance policies and you indicated that the most rapid growth of underinsured are people between $40,000.60000 dollars of income. -- $40,000 and $60,000 of income. you would not have any statistics because the economy took a nosedive of last year. i am sure the under insured and uninsured figures would be greater, would they not? >> that's right. it is also compounded by the fact that income growth has dropped between 2007 and 2008. health-care costs are rising at 6% per year. we know more employers are cutting back on their benefits. people have lost their jobs which means they are behind on the individual market or are uninsured. those numbers are have probably worsened. >> most of your numbers of the uninsured are basically people below 65? >> that's right. >> i think he said the same thing in your testimony that the adults uc are 21-64 and not 65 or older because that's because of medicare? >> yes, right, 83% are in the age group of 29-64. that is because after they passed that threshold into adulthood, they start letting these problems of dentistry care go by the boards so that is the age group will start to run into problems. >> you indicated the problems arise from a rapid rise in health-care costs and a reduction in household income. we have heard testimony from members saying that premiums have risen 131% in the last decade, more than three times the average family wage increase. what kinds of health care costs are families being expected to absorb that they were not five or 10 years ago? >> we know that many more people are paying from their income at a package. we are seeing rates among even middle income families that we were not seeing when we did the survey in 2001. those rates among middle on families are up for low income families were in 2001. it is release spreading out the income scale. >> we heard testimony today and the last battle mention that and we talked about it -- could you exploration more about health networks? we have a map of the states of most of the only have two or three dominant providers. they had to stay within their network. what does that mean? >> it is also related to what you are responsible for paying out of pocket. if your provider is a network, you are likely to face costs that will be lower than they would be if you go out of network. what happens when you go out of network is you may understand your insurance company pays a certain amount of the cost but not knowing as the policy that was on the screen showed, not knowing what the cost is. you might be left with a big bill because of that. this map really shows the massive concentration in the insurance industry right now and it has had a cost increasing on overall health care costs, certainly over premiums. there's a lack of competition. >> bluecross blueshield is our biggest carriers so if i go outside their network, i would have higher out of pocket expenses or may have to pay the full amount? >> right, they will have some providers that contract with the debtor in network. if you are out of network, depending on your policy, your costs would be covered by some percentage. what is hard to know is that even if they say they will cover a certain percent, it is hard to know what the total cost will be. they will often cover their share but you will not know what your margin of responsibility is on to you get your bill. >> i live on a border community and the upper peninsula and most of my medicare -- medical care is in wisconsin. i paid more of a pocket with my policy. i do not have the federal employees health benefit package. these are decisions that people are doing every day. if you only have two of your large providers and you're not one of the two, they are probably not offering you a good plan. when you're out of network,, that will cost even more money. you learn about the types of treatment for underinsured individuals. some other panels say the cost could be as much as $10,000. your survey showed the same thing. is that pretty common? >> it is common among people were uninsured or underinsured. people who are underinsured have rates of avoiding unnecessary care because of the cost at rates that are nearly as high as people without insurance coverage altogether. it is a very real problem that we see in our data. it is a problem that has increased over time. >> did your organization developing the data which would show that if i am sticking my doctor's appointment or not taking the screening tests, how much that is costing us? can you put a value on that? >> we ask about chronic health conditions and ask a group of patients in our survey who had heart disease or diabetes, whether they had ever skipped a prescription drug or tried to cut their bills and have been ordered to make their drugs last water. about 46% of people who had a chronic disease were underinsured said yes to that question. those are rates that are very high compared to the people who are uninsured. we estimate they stayed overnight in a hospital or gone to the emergency room. and we find out about 32% of underinsured patients said yes to that question. you can expect that people are skimping on their prescription drugs and are probably having more serious health conditions and there is a substantial amount of research that underscores this finding. >> we have that chart and it is interesting. i'm sure you see the same thing, mr. brock. they probably turn to you for more care. you said in the basic health plan bad dental and optical are probably not included. you can see people who need basic coverage coming to you who have some kind of insurance. is that true? >> yes, in fact large numbers are coming now that have insurance but it does not cover those two specific areas. we are getting people that are coming hundreds of miles and buying an airline ticket to come from florida to tennessee. we have had a request from a non-governmental organization in massachusetts wanting to bust people down from one of the richest race in the country to one of the poorest, tenn., so that we could fix their teeth and make him eyeglasses. this is becoming more common. this is even though we have not been seeing more patients. they are coming from further away. >> all the great worker organization does and you have some step with you today, how do you support your realization? is there grant funding or donations? >> our organization is largely supported by members of the public who sent in a $10.15 dollars donations. we have foundation support. up until early in 1998, the only people who knew what remote area medical was doing world war, the people who came to the clinics. -- the only people who knew what remote area medical was doing were the ppor. i wish we had corporate support but we do have some foundation support. we do not take any government money. in fact, we would never apply or want any money from the government. >> if we pass health care, it would be a good idea to put you out of business? >> 0 yes. it would be marvelous if we could concentrate on places like haiti and the dominican republic and india and africa which is what i formed an organization to do in the first place. >> did you imagine you'd be going to the united states? >> the sixth man to walk on the moon, astronaut edward mitchell asked me the same question several weeks ago where i grew up, we were 26 days on foot from the nearest doctor. this is in the upper amazon. >> he said i was on the moon and i was only three days from the nearest doctor. the people we are trading in the united states might as well be on the moon or might as well be someone else for the opportunity they have to receive care in this country. >> well said, well said. that includes all the questioning. i want to thank you for your patience. thank you for being here for your testimony. this will be dismissed. the committee rules provide that committee members can submit additional questions for the record. i am sure some members will commit some. i ask unanimous consent provided the committee can didact anything else privacy concerns. with no legs section, -- with no exception, the documents will be submitted. this meeting is adjourned. >> earlier this week, the senate finance committee approved their health care bill by a vote of 14-9. that made senator olympia snowe the only republican to support the bill. it will combine the bill with proposals from the senate health committee and input from the white house. you can follow all the work on health care online at/c- span.org health care. watch hearings and rallies, speeches, town halls or read the various bills, and leave your comments and reactions. visit c-span.org/healthcare. there are a pair of advertisements running in various states. >> for seniors, a doctor can mean everything. independence, hope, security, and medicare makes that possible. but every year, congress must make a temporary fix to the medicare payment plan so that seniors can keep their doctor and the care they depend on. we need a permanent solution to protect medicare and insure seniors get the security and stability they have earned. call your senators today. asked them to pass s 1776. >> partisan bickering, intentional lies, disorderly conduct -- the desperate tactics of those who oppose health care reform. the league of women voters believes that quality affordable health care should be available to all americans. call your senators today. tell them to stand up for the -- to the laws. the time for real health care reform is now. join us at lwv.org. you can watch ads like this at our healthcare hub, c-span.org /healthcare. this segment is 45 minutes. on your screen now is diane rowland, the executive vice president of the kaiser family foundation, executive director on medicaid and the uninsured. that is what we will talk about for the next 40 minutes or so, who are the uninsured in america? diane rowland, the 46 million figure of people that are uninsured, how did you derive that figure? guest: those numbers come from the u.s. census burke-bureau. they do an annual survey of americans and ask them about their health insurance status. those are government statistics that mantra every romany people are uninsured. host: the who are the uninsured? guest: they're all of us. they're working americans, most of them have moderate incomes and cannot afford health insurance because it has become so expensive. many of them work in areas that do not offer coverage. 80% come from working families that just cannot get their health insurance coverage through the workplace like those of us that have coverage. host: according to the charts at the kaiser family foundation has provided, characteristicsç of e uninsured -- we want to show this to our audience. of the uninsured, the 45.7 million uninsured workers, or people, they are one or more full-time workers in a family in 66% of the cases, correct? guest: right. >and host: and unemployed make p 19%. of the 66% employed full time, where are they working? to their employers not offer insurance? guest: many of them are working for small employers and small employers do not offer it often because it is expensive. it is harder for them to obtain a good deal on health insurance coverage the way the very large, say 1000 employee, might be able to do in the group market. many of them work for a low-wage job. the combination of an employee offering is hard for people because if they were get a small mom-and-pop store, for example, they're likely to be able to get insurance through their employer. if they -- they are unlikely to be able to get insurance through their employer. if they try to purchase it, it can be prohibitively expensive. you're looking at policies for a family of $13,000 per year and your a low-wage worker making $30,000 per year, you cannot afford it. the majority of large employers offer insurance. about 90%, say, over 250 employees. host: back to the uninsured when it comes to income, you have that 10% or 400% of their income, they have income of four and a% over the fogh -- a federal poverty level and that is 10% of the uninsured. 23% of uninsured people in the u.s. are at about 300 percent of the federal poverty level. 29% are at 100% of the federal probable and a 38% of unemployed workers are below the federal poverty level. what is the federal poverty level? guest: it is calculated based on family size. for a family of four, it is about $22,000 per year in total income. most of the individuals who are below the poverty level have incomes of below $22,000 for a family of four. which means that they are basically zocor that we consider them under the -- so poor that we consider them under the poverty level and eligible in some cases for assistance through medicaid, but mostly it is for children. we do not really provide adequate coverage. it is a myth that the poor are covered in the u.s. many of those float -- low- income people are going to be without a of insurance coverage. host: but not eligible for medicaid. of the 47 -- of the 45.7 uninsured americans, the majority are 30 to 54, working age, 19 to 29 years old, 30%, and 0 to 18, 18%. why is the majority in this working age group? guest: the group that is at highest risk of being uninsured are the young workers, and that is primarily because they are just starting out in their careers. many of them are going to work for the first time or are in jobs that are lower paying because they are just starting their careers. many of them are just coming out of school and they have been covered under their parents' policy and are no longer eligible for coverage through their parents and have gone to the workplace without other insurance. we're looking at a combination of low incomes and low offer rates. host: we have divided our lines a little different this morning between the injured and the uninsured. -- and the uninsured and the insured. the numbers are on your screen. here is another chart that is provided to us by the kaiser family foundation. let's do it by citizenship. again, totally uninsured, 45.7 million. u.s. natives, of that 45.7 million, 74% are u.s. natives. ç6% are naturalized u.s. citizens, and 20% are non-u.s. citizens. what does that mean by non-u.s. citizen? guest: that includes individuals who are here on visas with green cards who are working, but not yet citizens of the u.s. and they're also -- there are also some who are here illegally and they are included in that number. of the total 47 million uninsured, perhaps as many as 8 million of them are illegal immigrants, and therefore, excluded from the kind of coverage that we provide to citizens. host: you just drop #47 million -- threw out the #47 million. guest: it is between 45 million and 46 million of the elderly and if we include the elderly population, it gets a little bit higher. host: i thought coverage was mandatory at age 65. guest: there are some individuals who do not have the work orders are required to be eligible for the program, or you raise the immigration issue. some of the seniors of our immigrants have not got a connection there for the social security system and would not be melichar -- eligible for medicare. host: the uninsured overall is what percentage, including the elderly? guest: about 15% of the u.s. population is uninsured. host: and looking at the health care debates on capitol hill, with the decrease to under the various proposals? guest: most of the proposals are looking at providing a broader coverage through the medicaid program to the lowest income and then giving of -- others the option to go through an exchange to get some kind of broad and coverage. it looks like some of the bills will give cutting our insurance -- uninsured in half. we will still probably have those that are not legal residencts and the world the individuals that have not signed up for coverage in the early days. host: diane rowland is our guest, from the kaiser family foundation, the executive vice president. the kaiser family foundation is not an advocacy group and she will not take a position, but if you have a question about who are the uninsured, she is the person to ask. heather is an uninsured person in washington d.c., you are first of. caller: i have been watching c- span since i was 15 and this is the first time i have ever been on the air. i'm thrilled to be talking to you. i am in a group that is not mentioned very often in the debate, and that is people who are temporary employees. i have been temporary at my place for a year and out and temporary employment does not offer benefits. i am college educated. i am full time. i can get coverage through the city of your take-home income is less than $1,800 and mine is about $1,900. i have not seen anything in current polls -- proposals that would cover me. people like me that are not technically low-income, but i do not have coverage. guest: your situation is one that many people find they are working and not able to get coverage through their employer. what the legislation is trying to do is to make coverage broader and more available through employers, so in some of the legislative proposals employers would be required to offer coverage or pay a penalty into the exchange so you could get coverage there. basically, the legislation that congress is considering would try to give you a broader options for getting coverage and hope so that you would not be just above the line as you are right now for the coverage in d.c. host: new haven, conn., anthony on the injured line. -- insured line. caller: are you related to john rowland? guest: no, i am not, although i did grow up in connecticut. caller: i will be 68 this year. i have united healthcare and last year and this year, my premiums went up also with blue cross blue shield, the premiums are going up 30%. everyone talks about the illegal immigrants. how many of them are really injured by any -- insured by any big insurance like blue cross or whatever? also, diane, we're talking about $250 for the seniors and a lot of people called in saying i would not take it or it is not worth it. we just got $250 this spring and early summer. another $250, about what health. that is not borrowed money. that is coming out of social security. host: anthony, thank you for calling in this morning. diane rowland, to his first statement tomorrow their illegal immigrants who may have insurance coverage? guest: there are, in fact, if they are working for an employer and picking up coverage through the employer. some of the illegal immigrant population has merged into the working force and as such, they can buy coverage and probably to trigger employer. another host: charge from the kaiser family fund -- host: another charge from the kaiser family foundation. total of 300 million people who are covered by insurance. 52% of them are covered through employer sponsored insurance. the 15% are uninsured. medicaid or public assistance cover 13%. medicare covers about 14% of the population and then private non- group covers about 5%. what is private non-group? guest: that is the insurance that we think about as individually marketed insurance that people can purchase on their own. if you are not offered coverage through here in corera -- through your employer and you want to have coverage for yourself or your family, you can go through a broker to purchase individual insurance. it is that market that has some of the roles that are being debated today. they can exclude you for pre- existing conditions a a. they can cover you for one year i decided to have a lot of help experienced during that year they will not renew you. it is a small group, but the group in which people have the most trouble if they have health coverage -- health problems obtaining coverage. that is where the reforms would take place. host: the people that are uninsured, have you broken it down to see how many of them have just a catastrophic plan or full interest? guest: know that -- for full insurance? guest: we know that there is a range of coverage are there. most people have comprehensive coverage. some people who purchase in this individual market have their work policies with limited benefits. but we do not have the full measure of how many people just have catastrophic. we do know that as we begin to look at plans that have high deductibles, say $1,000, $2,000, $3,000, some of those can be classified as being under insurance because if you have a minimal income, you may not have the reserves to be able to pay those deductibles. we are moving toward having less comprehensive insurance and more out-of-pocket payment up-front that tend to be in some people's minds toward more catastrophic coverage than a a comprehensive coverage. -- host: on6v the uninsured lie from washington -- host: dawn on the uninsured live from washington. caller: i just wanted to let you know that i'm 47 years of age and a self-employed -- and i am self-employed. i employ maybe 45 people. about four years ago i have health insurance coverage and it started out around $1,800 a year, which i thought was very affordable. within about 4.5 years it went up to $9,000. i call of the insurance company and said, you know, i cannot really afford this because i'm only making about $32,000 per year. they said, well, we will help you out, thanks for calling. they lowered it down $3,000, but then i've got a $3,000 deductible and then i've got to pay 50%. they only cover 50% of the bill. it's got to the point where i thought, why am i paying out $5,000 and then another $3,000 out? it is $8,000. it is like, what i have been saving for the past 15 years, the insurance companies are going to wipe it out in four or five years and i would broker. -- will be broke. guest: you have hit on a very important point, there's a balance between lowering the premiums and lowering the kind of coverage at you get. sometimes when we lower the premium, we raise the deductible that you have toç pay before ay coverage kicks in. it is so high that it makes the value of the insurance policy only true if you have a very catastrophic illness. that is the tension in looking at health care reform, what are really going to say is health care coverage and how adequate will that be for people of modest incomes? you have also raised a critical point that the cost of insurance continues to escalate and it is getting more and more are of reach for individuals and part of what health reform also has to try to do is to make coverage more affordable for families. it cannot just be that everyone is required to have coverage. you have to be able to afford the coverage i you are getting. host: you also break down the contributions that an employee makes and that an employer makes. in 1999 on average, the premiums were about $5,791, about $5,800. the employee paid about 4200 of that. in 2009, the average employee paid about $3,500 in in premiums and the employee -- and the employer paid nearly $10,000 a year. why the increase? health care guest: cross have been -- guest: health care costs have been rising and therefore, workers' wages and when you get from inflation, as you just talked about in your previous segment, lags well behind worth the price of health insurance is going. we have a bigger and bigger disconnect between the ability to be able to afford coverage and the price of coverage. what you are showing here is that today, health insurance for an employer is about $14,000 per year, which is also about what a minimum wage worker makes. employers especially, as we talked about earlier, small employers have a hard choice. they can either hire another worker, or offer them health insurance coverage. host: would this be the cost for a corporation like ibm for tens of thousands of employees? guest: yes, this is a national average. we do a survey of 2000 companies across the country and look at the aspects of the cost sharing and some of the other aspects of the policy, but especially the cost of the average premium. when we look at that further, about one-quarter of the premium is usually the share that employers ask their employees to pay. some firms pay higher share and some a lower share. host: statistics from the kaiser family foundation. 45.7 million total uninsured in the u.s., about 15% of the total population. of that population, 46% are white. 32% are hispanic. @@@@@@@ @ @ @ @ @ @ @ @ @ @ @ @w them except to share a common founder. host: michigan, mario, on the injured line. injured line. caller: the insurance companies, the senators are a sleep over there. when the export of our jobs are, they were asleep then and now they are asleep at the insurance companies. they want us to pay money out of our pocket to go see the a doctor. we are poor already. there is no litmus test on the insurance companies to say, all the different names of entrances -- of insurances. they should be forced to put a total price on insurance. it is not truthful when you are drawing money out of your pocket. that is not insurance. you want to be able to pay for travel insurance and that we i have a comparison from one company to another company. they can lie about what they're really doing for the people. and they are still making money at our expense the the point is right there. host: any comment? guest: certainly, one of the challenges is how to make these policies more easy to compare and regulating the market. many of the changes we are looking at in regulating the insurance market is helping the consumers to know what they're looking at afd!when they get sick, to have the coverage available. one of the reasons we engage in this effort to provide coverage to the uninsured is that we know that the insurance makes a difference in terms of how use the health care system, how quickly you get to a doctor, and the goal for all americans is to help us live healthier and help us to be able to to excess health care when we need it early enough so that a disease like cancer it can be detected when it is still treatable and not go on treated -- and treated anduntreated. host: about 15% of the u.s. population are uninsured? the debt increased during this current recession? guest: it has clearly increased overtime. even we had a fairly good economy we did not see a great decrease in the number of uninsured. host: why? guest: because interest, as we have talked about, is so expensive that there is not as much of an offering. many employers that would have offered in the past do not always offer it. we have seen a decline in the availability of coverage through the workplace. what we're seeing in this recession is that as people lose their jobs, they lose their of insurance coverage. some of them can maintain their coverage through the cowger option, the ability to extend your employer coverage -- cobra an option, the ability to extend your employer coverage. but there is less availability of that anymore. many of the stories that we hear about people that never thought it would be uninsured, but now they are unemployed, have lost their jobs and are looking at options for coverage and there are not many out there. . . to provide at least some measure of protection for people over age 65. it now covers people with disability. host: thanks for holding on our uninsured line. caller: thanks for taking my call. i love this program. i watch it every day. i wanted to say that you were speaking about the covert plan -- the cobra plan. i became unemployed last year and can -- to continue the cobra plan i had to [unintelligible] i became eligible for unemployment, but there was no way for me to afford to keep the coverage. i applied for medicaid, which i was able to get for my kids and myself up until i received the unemployment, at which point i was [unintelligible] i guess i was trying to understand what exactly our priorities are. it feels like i should fall within the range of $330 a week. i am grateful that it exists, because it is keeping me in my home and helping to keep things turned on, but i certainly feel like i should qualify. i want to understand what are the proper guidelines for a family of three, one adult and two children? three, one adult, two children. guest: you have pointed out the gaps in the existing health care system. the cobra option requires you to pay the full share. when we talked about the individual having a contribution of about $3,500 against a total premium of 13,000 four hundred dollars, when you are on the cobra, you have to pay the full premium because your employer is no longer responsible for that. if you have lost your job in your are on unemployment, that is too much to pick up. the stimulus bill did provide a subsidy for those kroeber ocobra premiums. that does not really go as far as it needs to go to help people get over the hump. the medicaid program is a means tested program. you have to meet income guidelines, which vary across the state's. we have done in a lot in the past few years to provide broader coverage for children, which is why your children are on the program. we covered children in most states of to about 200% of the poverty level. however, the parents eligibility is much lower. the reason that your children are getting coverage and you are not eligible is because you have to be a lot poorer. that is one of the aspects that health reform is trying to protect. host: you also bring down the uninsured rates among the states. this chart shows greater than 18%. that is 17 states. they seem to be in the south and the west. 13% to 17% in the middle of the country. there are 10 states that have less than 13% uninsured rates. is there a regional reason for this? guest: but there are a number of reasons. the economy of a state of largely drives the uninsured rate. when you look at insurance -- when you look at the states in the northeast, their manufacturing base. they are union based. that has helped to contribute to a much more rigorous employer based coverage system then in rural states and states with large agricultural interest. and especially states with small employers, especially through the midwest. where states are poorer, they're less likely to have coverage. the low-income population is where most of the uninsured are. throughout the south, you see higher rates of poverty in those states. less adequate coverage through medicaid. caller: why are the insurance companies so dead set and danced -- so dead set against the public option, when most of the people you are describing cannot afford insurance in the private sector and how? it does not make a lot of sense. middle want to ensure them and they do not want the government to ensure them either. guest: this has been one of the controversial points in health care debate. public option would provide individuals who are going into the exchange and trying to get coverage to have a choice of either a private insurance plan or a plan that is more modeled on the medicare program. insurers say that will be an unfair competition, that they cannot compete with the public plan. many believe that having a public plan would give them an incentive to be better price and better in terms of the coverage they offer. i think that will remain one of the huge debates that we have as we go forward with health care reform. host: the majority of the uninsured are in working families. you state that over and over. why? guest: because the nature of our health care system today is based on whether you get coverage through your employer or not. the relationship between working and getting health insurance is one that we billed as the way in which to get health insurance coverage. we want to make a strong point that one of the places we need to strengthen is the employer relationships with individuals to get more coverage through the workplace, or you need to provide a broader alternative so that people who do not get coverage through the workplace can still get coverage. they are working. they're often temporary workers who do not have an option to get coverage through the workplace. we think it is important to stress that these are not families who do not want coverage. their families who cannot afford coverage. host: kff.org is the web site. florida on the uninsured line. caller: good morning. guest: good morning. caller: until they take the profit motive out of the health insurance companies, there will be this budding head between the private and public sector. someone made an observation on one of the show's earlier in the week. the people are going to reform the system. right now, we are not given a choice. if the choice is given to the people through a public option, the people will perform the system. guest: i think that choosing your health insurance plan and having lots of options available to you is something that is the goal of health care reform. you would like to be able to have a choice of a public plan. that's why it's so actively debated today. host: richard on the insurer's flyied line. caller: i was under kaiser for over 40 years. i did not know how good you were until the year 2000. my total family plan was $28 per month when i was working for the federal government. once i retired, then it jumped to $250. from then until now, i have become over 65. my wife i pay a higher price for my medication. i don't understand why kiser is not the model for how to do a health program for the entire country. i don't understand that. i will just listen to your comments. guest: let me remind you that we are the kaiser family foundation, not the kaiser health plan. it has been a model that can provide care at a lower cost and more comprehensive services than are available through the fee for service systems other plans offer. that is one of the issues that everyone will be looking at in health care reform. i am sure the health plan will be pleased how well you think they have done. host: 15% of the american population is uninsured. have you looked at how many of these are eligible for federal or state aid that did i get it? guest: we do look at that among the lower income population. most of the eligibility has been extended to children. we know that as children out there -- 8 million children are uninsured, as many as 5 million are probably already eligible for some kind of coverage but not getting it. part of that is that their families may not be aware that their income qualifies them for public assistance. in other cases, we know because the parents are eligible they are less likely to enroll their children. we think if we extended broader coverage to the entire family he would get more people to participate. some of it is just outreach. . some of it is just outreach. we need to do better outreach to tell people that there are options, especially for their children to get coverage. one of the issues in health care reform is that if we want everyone to have coverage, perhaps we need an individual mandate, a requirement that you get coverage. today, coverage is voluntary. in many cases, people do not know that they have to sign up for coverage. they find out when their child gets sick that the coverage is available in a sign up there. >host: i apologize to keep going back to this. i just want to figure out who these people are. about 46 billion uninsured americans. 8 million you estimate to be illegal immigrants. they would not qualify. that brings us to about 38 million. some of the plants say they will get us to 91% coverage or 94% coverage rather than the 15% uninsured that we currently have. who is left over? who are those 6% or 9% of folks who would not be covered by insurance under the proposals on capitol hill? guest: the proposals would require people to have health insurance coverage, but would also allow people to get an exemption. some of the individuals would be people who do not qualify for a subsidy, or for whom the subsidies that are offered are not adequate. health insurance is still on affordable. they are exempted. and the one group is the exempted group. the second group would be the individuals who are barred from coverage because of immigration status. in addition to that, you have some individuals who may elect not to get coverage and pay the penalty that is offered instead of the price of the insurance. that becomes very tricky in health reform. is the penalty substantial enough to provide an incentive for people to get coverage? it is important to get as many people covered as possible. we know that the broader the risk pool, the more affordable insurance premiums will be for everyone. we do not want a situation where ithose who have chronic illness sign up and those were healthy stay out. host: time for two more calls. steve on the uninsured line. caller: i am a laid-off union worker. i got laid off in the middle of 2008. a little bit before the spring. and i still had health insurance for a while. i was by the italia-- buying it. the cobra plan was $600 per month. host: justic to the health insurance. we're almost out of time. caller: the man said something about public option, which i do not oppose, but i was in south carolina this past summer, and i looked around for health insurance. i could get it almost $300 cheaper and south carolina. why canno't i get it in south carolina? guest: a lot of that depends on where you live. you are right. there are high-cost areas and low-cost areas. insurance premiums vary across the country depending on the costs of medical care, depending on what' they charge in terms of having people in the pool that are less expensive or more expensive. you are a higher cost state in ohio. your premiums will be higher because health-care costs are higher than in south carolina. one of the issues is -- should we be more national? should we have more of an average national rate so that you do not have a tremendous variation across the country? unfortunately, each state is different and medical care cost different amounts in different states right now. caller: i am a nurse at kaiser. i understand you are not part of the kaiser health care plan, but i work with managed care. i walked around on a broken pelvic for six months because i was not saying the right thing to my doctor to get an x-ray. i have watched children come in -- it takes weeks to get an appointment with their doctor. right now, if you want an appointment, it is a six-month wait. that is managed health care. if people who do not have jobs want a free ride, they need to understand is on the backs of people who work. guest: you point out that there are many gaps in our existing health-care system. one of the debates is do we have the best health-care system in the world? some say, yes, we do, when you can afford it. there are a lot of issues in how we improve the quality of care, not just the availability of health care insurance. you're speaking to the broadest challenges we face. host: all of this information we're showing you today is available at kff.org. characteristics of the uninsured in 2008. of the uninsured, one or more full-time workers is in 66% of the households. no workers in the 19% of the households. part-time workers in 14% of the households. everything we're talking about is under 65. we are presuming the elderly are insured by medicare. this is by citizenship. 45.7 million in thuninsured in e u.s. 74% are u.s. native. 6% are naturaliszed. guest: people year where students abroad as well as illegal population. host: which you estimate to be 8 million people. the entire u.s >> the senate finance committee approved their health care bill of a vote of 14-9 come up with olympia snowe the only republican to join democrats voting in favor. harry reid is leading efforts to combine that with proposals by the senate health committee. you can follow all work on healthcare online c-span.org /healthcare. watch speeches and town halls, and lead your comments and reactions c-span.org/healthcare. -- this is at c-span.org/ healthcare. president obama is traveling to texas today. he will join george h. w. bush to mark the 20th anniversary of his 1000 points of light speech in which he called for more volunteerism. watch their remarks live at 5:50 p.m. eastern on c-span. >> q &a" sunday night on c- span. now available on dvd, the original documentary, "the supreme court." learn about the role of the court and its traditions through interviews with all 11 current and retired supreme court justices. take a tour of the building, it includes a grand public spaces, and visit a private places only accessible to the justices and the staff. it is only $9.99 plus shipping and handling. get your copy today at c- span.org/store. stephen moore it's on the editorial board of the "wall street journal. host: he is an editorial board member on the "wall street journal." let's talk economic news. let's start with an article in your own paper. regulatory overhaul advances as derivatives bill clearest house. they are calling this a major step in advancing a broad regulatory overhaul pushed by the obama administration. guest: great to be with you again. i think almost everybody agrees we need over hall. i think there was a breakdown. -- we need overhaul. what worries me as a free-market conservative is a regulatory overreach. way, remember when we had the accounting scandals when enron went out of business, i think we overreacted and we passed the bill called sarbanes oxley which in my opinion has had negative attacks on business. so i do agree there are some very clear areas where we need better guidelines and regulations. i would start with new caps on the amount of debt and leverage that some of these banks and financial companies can take on. you had some of the companies like their stories that had $35 of debt the debt to every dollar of assets -- $35 of debt to every dollar of assets. but i worry about stifling our financial industry, which it been one of the leading industries in america and terms of job creation. host: what he'd think about the agency? it makes me a little nervous. let us look of the counterpart. consumer-products a decommissioned. that has a pretty spotty record -- consumer-products safety commission. that has a spotty record over consumer products. as an example there were these new lead statutes that congress passed that the consumer products safety commission is now enforcing, and it is basically taking all of these products that are perfectly safe off of the shelves of stores. it means literally hundreds of millions of dollars of inventory is being destroyed because of these regulations. so sometimes regulation can have a negative affect on consumers and businesses. host: there is another article on your paper this morning that deals with the fact -- kind of deals with the fact that kenmore isken lewis decided not to take money for 2009. assailing wall street's excess is as natural as shaking hands for lawmakers easy to pull out exports went executive pay taxes attention. when banking and investment powerhouses appear to be record bonuses less than a year after many were rescued by taxpayers, the reaction from the democratic majority in congress has been muted. guest: i am torn on this issue, too, peter. on the one hand i hate the idea of wall street paying out these big bonuses in * -- when shareholders have been losing money. there has been insensitivity on wall street's to, look, people are hurting. it is outrageous to many people that people on wal just as a matter of good public relations. i think is as objectionable as a shareholder, that when these companies are losing money, why are they paying these large bonuses? on the other hand, as a free- market person i hate the idea of government interfering and telling people what their pay should be. if a ceo of a company is performing and they are making money and creating jobs, i am for high pay for ceo's lebron james makes $40 million a year and we can pay ceo's that equivalent. the people who have to put a stop on the bonuses are not lawmakers or government regulators. it has to be boards of directors and the shareholders. host: did you write this morning's top editorial about the $250 -- [inaudible] guest: i did not, but i did write 11 month ago on this subject. i hope we don't get inundated with calls, but the idea of sending a $250 check to senior citizens is outrageous. seniors have benefited from the fact that inflation is very low. the reason they did not get a cost-of-living increase with social security is because there has been no inflation. somebody has to pay $250. i object to the idea of making young people pay for checks to senior citizens. i would love to get a $250 check from the government but i don't feel i deserve it. host: along with your phone calls, the numbers have been on the screen. for all others, allow 30 days between all of your calls. we will also be taking questions from high school students add henrico high school near richmond, virginia. they are on the c-span civic bus. our first question comes from someone from the ap government class. please go ahead. caller: i will be attending college soon. what type of employment opportunities will be available to me after i graduate? guest: what was this girl's name? host: vally. guest: i get that question asked every time i go on a college campus. at college campuses and a student asked that question, where of the job opportunities. here is what i will tell you and your classmates and all the people watching. when they ask me for career advice i simply say this -- do what you love. what ever you love to do and are good at, pursue that. that is what you will make money at doing and will be happy at doing. if you pursue your dreams, there is a good chance it will come true. the job market is very bad right now, but by the time you graduate hopefully there will be a much better job market. we have to keep taxes low and government spending under control and debt under control or else we will be -- host: where did you go to school? guest: illinois. i have not been back in years. champagne-urbana, illinois is not a place in the normal path but it is great to see these universities -- $200 million grant from a computer company and a rebuilt their entire computer engineering -- just to give an idea how things have changed, when i was at university of eleanor, computers were just coming into rigid they were not even laptop or personal computers. i remember we used to have, to do a computer program you had to have those cards all and order and if you had one card out of order -- it is amazing how things have changed. kids like her, you probably don't appreciate the fact that when we were in school there were no cellphone and there were no laptops and there were no ddb players and ipods. it is just amazing how this technological age has transformed america. host: never hills, florida. irene, republican. -- zephyr hills. caller: i am concerned about the $250 instead of the raise. my mother lives with me, and she is 79. i just resent the fact that they don't give this to the elderly, because they really need it, the 3% instead of the $250. guest: interesting question. i knew we would get calls on this because of this is an issue people care passionately about. the reason there was no cola was because labor department calculated the inflation rate was very close to zero. the reason we haven't is so paychecks can't stay up with inflation. last year's seniors got a pretty large: increase. i don't remember, 5% or 6%, because of rising energy costs. of course, your mother needs a raise. i need a raise. americans are financially pinched. no question did not just old people, everyone. we can't simply have the government sending out checks. somebody has to pay the bill. there is no free lunch. this is the problem of how we got into the debt crisis, $8 trillion to $10 children, the idea we can have the government send checks without somebody paying for -- $10 trillion beard host: another high-school student. caitlin, go ahead with your question caller: my dad is a car salesman. cash for clunkers affected my family. do you honestly believe it help the economy? host: before he answers -- what do you think? caller: my family, yes, because it got my dad to sell more cars but for everybody else i am not quite sure. guest: you are a very bright girl. i have been in washington for about 25 years. i would have to make the case that this was probably the dumbest program washington ever came up with. here is why. first, look at what happened to car sales in september when the program ended. they tanked. what happened was we paid people $3,000 to $4,000 to trade in their car to buy a new car. they would have bought a new car anyway. all they did was advance bought the cars they would have bought. that is problem number one. we did not help the auto industry at all because we just fast forward sales that would have occurred. the much bigger problem is we basically took 700,000 cars off the road that were perfectly functional. it would be the equivalent of us of burning down every third house in america and say we will create all of these jobs by having somebody build new houses. you don't destroy wealth to create wealth. that is why cash for clunkers program was a big waste of money. both last two questions tie into a big problem -- the crash of the dollar and the enormous debt. i view those right now as our biggest problem. our currency is collapsing and our debt is out of control and when people say we need all of these government programs -- folks, we are out of money in washington. host: does it matter if the u.s. dollar is no longer -- guest: that matters a lot. since the reagan-volker years in the 1980's. remember we have a really high inflation in the 1970's when the dollar was collapsing and we have 14% inflation and 20% mortgage rate and economy collapses. reagan comes in, paul volcker was fed chairman, we restore the value of the dollar. they said it very well, they will make the dollar as good as gold. for 25 years we had a sound, safe, stable currency. that is one of the things that led to the tremendous growth in the economy. we as americans benefit from the fact that foreigners all over the world want to hold gold. the dollarization is a big benefit. we pay a heavy price if the world moves to another currencies like the hero. and that is what the europeans and arabs and other countries are talking about because they don't have confidence in our currency because of the debt. host: alabama. caller: however you guys doing? one simple question about health care and our guests opinion. i listened to him on a lot of shows talking about health care in particular. i would like to -- for him to talk about the albatross, third- party administrators around the business and the workers and their administration of what they call health care. and the anti-trust legislation that does not allow them to act to be regulated by anyone. guest: i think this is honestly the hottest issue. i would say there are three things we can do that would dramatically improve our health care system and make costs lower for everyone and make insurance affordable to many of the people. by the way, none of these three things are in the health care bill being debated. number one, medical malpractice reform so we can sweat out $50 billion up to $100 billion of excess costs because of trial lawyers to exact a toll on our system. that is a no-brainer. number two, allow high deductible insurance policies. if you had an insurance policy with a $3,000 deductible, you could purchase that policy with premiums of only about $3,000 a year, one-third or one-fourth of what people are paying. this bill does not allow these policies that make insurance what really should be, which is to cover catastrophic cost. you get cancer or heart disease or have a terrible accident. those are the types of things you want health insurance to cover. third, allow people in a state like rhode island or maine or in california to buy insurance out of state. because then it gets to the point is dumb and was making -- there is not enough competition -- it gets to the point that that this gentlemen was making. host: do you think it is important to reduce the number of uninsured? guest: i do. we can do it through the kinds of things i just mentioned, lowering the cost of health insurance, but the other thing we need to do that i think is very important, if we as a nation decide let us reduce this number by have and let us get 20 million people insurance -- and we don't know if that number of people -- we can do that by simply providing them a subsidy, in other words, a payment where they can go out and buy insurance. we don't need to totally overhaul the entire system and screw up the system that for most americans worked pretty well so we provide insurance for the 20 million don't. remember, 80% of americans do have health insurance and the vast majority are pretty happy with the health care they get today. host: next is melody, and she is on the c-span civics bus. go ahead. >> as an art student, some of my college options are some of the most expensive in the nation. how do you think the economy and recession will affect my ability to earn a scholarship? guest: i have an 18-year-old son so i am going through what melody is going through as is -- as a parent, not the spirit of college tuition. i cannot believe. when i was at college and university of illinois, in state, i paid 1500 up to $2,000 a year for tuition. now they are 25,000, $40,000 a year. who can afford that? my feeling is that is the same problem we have with health care, we have sort of a third- party payer system where the tuition costs go out of control and instead of having cost- conscious students and families basically driving down the costs, costs go up because we have the government provided scholarships, grants, and so on. there is no reason we should be seen inflation intuition. when you think about it, universities are knowledge- based, they depend on technology, the cost of those things are falling. in a perfectly competitive world, in my opinion, melody, cost of tuition should be falling and not rising. i am glad you brought this up because of this is such a financial pinch to families with teenagers and young adults. host: next call, phoenix, arizona. caller: how are you doing? i don't know where to start. you continue to push supply-side economic theory that completely failed us over the last 30 years. i want everybody to know listening to the show especially in virginia that this man was wrong and never saw the collapse of the stock market that happened last year and a complete economic destruction, never saw it coming and at this point in time he is continuing to press the same load of garbage that has been pushed for the last 30 years. the statement you just made about college tuition, you need to look at that for the entire economy. for you and your ilk, your generation has an affordable lifestyle and could go to college and now it is all out of control. you think $3,000 deductible is a reasonable response for people who don't have health insurance? you want to have them have a $3,000 deductible, and you think it is affordable but he's a it is affordable but he's a $40,000 for colle guest: let me take on the issue of the financial crisis, because it is something everyone is concerned about. let me step back a minute. if you read our editorial pages, we were warning about a housing bubble before others' work. we were riding almost weekly about the crisis and fannie mae and freddie mac and saying this will explode if we don't do something. people like barney frank and chris dodd said we are fear madras, we should roll the dice on the housing market. -- said we are fear mongers. we were sounded alarm bells about the easy money policy of the fed which was a major contributor to the problem. i did not think we would see a complete well -- complete meltdown of the banking system. i don't know if there were too many people that did predict that. if we look at what happened the last time we had a financial crisis was in the late 1970's. the thing that recovered the economy and caused prosperity for the past 25 years was the reagan policies of lower taxes, getting inflation under control, getting government spending under control. those are policies we moved away from. i don't think they will move -- will work too well as we try to get out of this crisis. host: next up is from the -- next up is kamron. what is your question? caller: how do you foresee the economic situation affecting rising seniors and those who will start college already facing financial trouble due to the economic situation? guest: where do you plan on going to school? caller: old dominion university. guest: that is the number-one issue americans are concerned about, what kind of jobs will they have when they graduate? guest: related to this, i talked a lot of people lost their jobs and for deposit and deposit and finding a long time -- a hard time finding a job. the number one issue. a new poll out by fox news today that was very constructive, what it basically said is congress is dealing with all the wrong problems. health care is not the number one problems americans feel we should be addressing right now. 40% of respondents say the number one problem was jobs. i think another about 25% said debt. and i think the third issue had to do with overspending by washington. way down at no. 4 what health care, 13% to 14%. so, i think we should focus like a laser beam on job creation. we need to get taxes down, the debt down. and i think we need to get government spending under control. i believe if we did that -- the ones silver bullet ic for the stock market and the job market is if we had a steve forbes style 19% flat tax, we would have summoned a johnson this country, more jobs than workers. that is the silver bullet. everybody has to fight for a flat rate -- no double tax on capital gains, businesses, that will create jobs and prosperity. host: what does the term jobless recovery mean? guest: we are seeing growth. not a great growth. but probably third quarter gdp will come in probably around 3% or 3.5% with a big improvement over the negative numbers, good news. profits are up. you notice the stock market where we have a $10,000 dow. great news. profits are up. businesses are starting to come up with the problem is they are still not creating jobs. the way a lot of companies are becoming more profitable is that they are laying off workers, cutting costs. it is good in terms of making them more efficient but bad in terms of people who want jobs. we are not seeing the kind of business spending and hiring we would normally expect. we are a year and a half into this recession. this is an abnormally long and deep recession. host: stephen moore's most recent book is "the and the prosperity." -- "the end of prosperity." guest: not trickle-down economics. host: grand rapids. caller: i am calling about the social security thing. i worked until i was 81 years old. i worked in factories, i worked during world war ii in a factoring and i think we should not have to take this year. why don't they take a cut in washington? they don't know how they can make it -- i can tell them. you take half of what you were getting a budget back then. host: when did you retire? guest caller: i am 84. host: how is your health? caller: i was 80 years old when i quit working -- i had a knee replacement. guest: i want to salute this woman and she is part of what we call the greatest generation. they made incredible sacrifices to keep us safe from nazi germany and totalitarianism and applaud you, that you work or what were ii, to help the war effort. i knew we were going to get a lot of calls on this, peter. i warned you. i just simply think we should be sending out checks to people. everybody's income is being pinched right now. just about everybody. we cannot continue to send checks out to people because their financial situation is strained. we have to get the economy moving again by pro-economic growth policies in washington and those don't exist. the stimulus plan has not created jobs. cash for clunkers did not create jobs. we've got to move back to the policies that worked. if we do that i think we will see incomes rising. the other thing is, the good news about the economy in the last year as prices have not been rising for most things. i think we will see it come back a little bit. when it comes back -- and it is probe -- fair and appropriate that we provide seniors with a cost-of-living adjustment for higher prices. host: we have a twitter responding to cameron going to odu-- so there is some advice for parents. the next student is raven walker. caller: would be harder to pay off student debt? guest: i think the big problem for a lot of families is the debt. and it is brought the economy. we know what caused the economic crisis, a financial meltdown, ultimately too much consumer debt, too much in leveraging by businesses and to much bar wing, and too much over spending. this is one of the problems i have, by the way, with the so- called solution of this tunnel was built. which caused the problem by having too much debt and spending so we will have more debt and spending and that will get us out of the crisis? i think the best way to deal with this is when you get out of college, raven, if you could get a good, high-paying job, then you will be able to pay off the student loan in five or six or seven or eight years. if you don't have a job or working at a minimum wage job because there are no good typing jobs in this country, then it is going to be a very big financial burden for you to pay back that debt. this is why economic recovery is at the heart of a all of these problems, it really is. host: jackedtweets -- jack tweets. guest: i want to turn to a system where businesses are expanding, foreigners are investing in the united states because we of the lowest tax rates. i want to see american number one. i think the number one issue for our economy over the next 20 years to 50 years, especially the young people, is the issue of who is going to be the global economic superpower. is it going to be the united states or china? if it is going to be the u.s., and i felt confident, we have to get serious about fixing the problems and health care system, fixing education, medical system, and the litigation system. if we do that, we will be number one again. but the idea of a flat tax. imagine if we did not have any double tax -- capital gains, savings, business -- we would see an explosion of growth. we saw it happen when reagan cut taxes and the 1980's. host: georgina from washington. caller: help, gentleman. i wanted to ask about a couple of things. i don't know if you have firsthand knowledge about this, i keep getting offers saying you can get money in the government in grant to get a home or start a business or whatever, and they keep saying millions and millions of dollars available for that. in our current state of the economy doesn't make any sense? could something i thought be forestalled in a year or two to kind of prompt recovery and make up some of the deficit? host: i think she might be referring to the late-night infomercials, advertising here is the way -- guest: matthew lesko. we have almost $4 trillion budget right now, which is incredible when you think about it. there is a saying in washington that $1 trillion is the new billion did it really is true. when we first came to town we talked about the budget numbers and billions of dollars. did you ever think that we would talk about these in trillions? when you have the federal government giving out trillions of dollars. this is a million million dollars. a huge de lucia of money. -- a huge amount of money. he is right. the government is giving out stuff -- small business, if you want a mortgage, you can get all sorts of loans if you know the right buttons. this is the problem i have with washington right now. it treats money like it is monopoly money. this created the enormous national debt. host: out of the budget, how much of it is cost and how much is optional? guest: first of all, i don't think anything has really set. congress authorized the money, it can cancel it if it wants. the problem is everybody in washington kind of passes the buck and it keeps saying, these are uncontrollable costs or mandatory and we cannot cut them. we can cut these things. we can cut the cost of health care. we can cut the military, i think. i am for strong national defense but i think there is huge waste in the pentagon. if i were the economic czar of this country i would start by cutting every single agency of government by 15% across-the- board. households are cutting back. businesses plan for cutting back. why can't government save money? host: idaho, juppe, good morning. caller: i have been watching you for years and i see you push the war like billy crystal and espouse all the financial policies of the republicans and you are a financial editor for wall street journal. you have been one of the most dishonest journalists there has ever been because these are all the policies that took us down to the path to help. are you ever going to make amends to the people did for the vast amount of influence you have that over the united states? guest: i wish i had influence, peter. i guess it is a compliment to say i had influence. i have always been in favor of limited government. i have always been in favor of lower taxes. i have always been a favor of the trade and i have always been in favor of a sound currency. we talk in our book, "the end of prosperity" if we moved toward lower tax and bad debt under control and if we were to retain the soundness of our currency, there is no reason america cannot see incredible growth as we move more into this technological age. i happen to think right now the policies we have in place in washington are exactly the wrong thing to do. almost everything we have done in washington in response to the financial crisis, about a year anniversary sent the stock market collapsed, almost all the policies have failed. bailout, stimulus, cash for clunkers, federal reserve policy of buying up all of these toxic mortgages, i think it makes no sense because there is no such thing as a free lunch. if we bailout somebody, somebody has to pay for it and usually we are bailing out people who are bad actors and the people will play by the rules are the people will have to pay higher taxes to pay for this. host: 1 more student that has a question. maya thomas. >> i'm in a program that prepares people to go to teaching. how can teachers have a feature but shrinking government resources? host: teaches the discount and teachers have a future with disliking government resources -- guest: government resources have not been shrinking. but the growing like crazy. if you look at state and local and federal, the b it is true a lot of states and school districts are facing tough times because of the financial crisis. what i favor is we should pay good teachers of lot. i am in favor of paying a good teacher is top dollar because they are some of the most important workers, but i am also in favor of firing bad teachers and giving students choices of what schools they go to. we have locked ourselves into a monopoly school system that doesn't work well. we are in washington d.c. where we have some of the worst public schools in the country. we have to do something to liberate our schools and pay good teacher is a top-notch salary but get rid of the lousy teachers. all of this ideas have to go by the wayside. host: what do you want to teach? caller: i would like to teach third grade. i don't know what particular subject but third grade. guest: why third grade? . . guest: teaching is a great profession. i hope you do that. it sounds like you would be good at it and that you care a lot about kids. host: we want to thank the government teacher for coordinating our visit. we also want to thank comcast in richmond, virginia. caller: the gentleman, i would not believe anything. when george bush was seen there, he never created any jobs, he gave us two wars and we are having to pay for them. of course we are deep in debt. and this gentleman here was all for that, and of george bush had created jobs -- if george bush had graded jobs on the country was going good and not taken as to where we would be in a much better place. guest: well, i am in mixed opinions about his presence appeared on the one hand i think he does not get nearly enough credit as it deserves keeping america safe from terrorism which was the most important issue over the past 10 years unquestionably. our economy cannot function, our society cannot function if we have people willing up buildings and disrupting our society and making an unsafe. i give george bush allowed credit for that. but we were pretty critical @ "the wall street journal" editorial-page at a lot of the spending policies. i think his failure in terms of handling the economy was spending grew out of control. and the problem i have with barack obama's policies is he came in when bush as you quite correctly pointed out, he increased the debt to nearly half a trillion dollars and barack obama came in and borrow another trillion dollars on top of that. that and not make a lot of sense to me. but it is not true, by the way, we did not have job creation during bush's presidency. by about 2006 or to about seven we had unemployment rate down to below 5%, which is really good. the tragedy is we have doubled in the past 18 months. we have got to get jobs back. but i think the idea of having government spending and debt leading us out of the recession. host: your biggest worry about the economy? guest: right now i would say the debt has become just an enormous burden. i am not someone who normally things that is a terrible thing. it matters a lot, peter, what you spend money on. if you borrow, it matters a lot. in the 1980's when president reagan was in office, we borrowed a lot of money but what did we use it for? we used it to build up the military so we can win the cold war, which is one of the great investment of government resources of the past 50 years her -- we don't have a soviet in -- evil empire no longer, which is huge. and we use the debt to finance lower taxes so we can grow our economy. now we are using debt for is consumption. solar panels on libraries, which have absolutely almost zero return on the economy. i'm just aghast at how much we are borrowing and spending. we can't go on in this country or we will lose our status as the world's economic superpower. host: shreveport, louisiana, on the republican line. caller: good morning. i have seen mr. moore on bill maher's show on hbo and he is always taking to task. he is a very articulate speaker -- just like a republican -- so ingrained in that crazy philosophy and so tied to the hip with the conservative right, all these so-called christians, christian can be used by anyone, you know, the devil's workshop is always busy. guest: that is very true. interesting so many callers say i'm parroting the republican line because some of my republican friends and capitol hill have not been happy over the past couple of years because i have been set -- a sound critic of republican policy as well. all i'm trying to say is i believe we need to have a society where we create wealth, create a rising tide that lifts all boats, as john f. kennedy used to say, and we are not seeing that right now. what i want is a tax system that tries to make poor people rich. unfortunately we have a tax and government policy that tries to make rich people poor. that is not going to make america more prosperous place. i think we have to fundamentally look at how we are running our government. we have to say, can we do the things the government is supposed to do in about half the cost. i would say the answer is probably, yes. host: a statement by a twitterer. guest: you are so high tech. host: george bush barrault to give to the rich -- guest: welcome we are borrowing a lot of money but what is it going to? for example, the stimulus plan. observable failure. i would say the stimulus plan, the $800 billion stimulus is probably one of the greatest public policy flops in the last 50 years. where the jobs? we were promised by president obama and a democratic congress that if we pass this borrowing and debt bill we would have an unemployment rate of less than 8%. you remember that. now we have nearly 10% unemployment rate. we did not create 3 million jobs with the stimulus bill but we lost 3 million jobs. the policy is clearly a failure. we are not spending it wisely. a new report out today by the white house that shows the money is not even going to the states with the highest unemployment rates. that is inexcusable. we should be having policies and spending the money where it is needed most, and what is happening soso far is it is host: thank you for spending time with us and our viewers. >> the senate finance committee approved the health care bill this week by a vote of 14 to 9. snow was the only republican to join democrats voting in favor. senator harry reid is leading efforts to combine the bill with proposals from the senate health care committee with input from the white house. you can follow all the work on health care online. you can watch the hearings, rallies, speeches, and town halls. you can read the various bills and leave comments and reactions. >> president obama is traveling to college station, texas, today. at texas a&m, he will join george w. h. bush to mark the 20th anniversary of the thousand points of lights speech. you can watch the remarks live at 5:50 p.m. here on c-span. >> this weekend, eight years of secret meetings in the white house. the inside view of the american presidency from "clinton tapes." reporters will look at the invisible history of afghanistan. the latest book is called "descent into chaos. >> the chief technology officer of the united states on how the obama administration wants to use technology to improve transparency in government. that is on monday on c-span-2. >> the chairman of royal dutch will company on thursday endorsed a cap-and-trade system and urged greater emphasis on greater energy efficiency. jorma ollila is also the incoming chairman of the world business council. this is about 25 minutes. >> welcome to the national press club. i am president of the national press club. we're the world's leading professional organization for journalists. we are committed to the future of journalism by providing informative programming and journalism education and fostering the free press worldwide. for more information about the national press club, please visit our web site at www.press.org. i would like to welcome our speaker and our guests in the audience today. i would also like to welcome those who are watching us on c- span. we are looking forward to the speech today. afterwards, i will ask as many questions from the audience as time permits. please hold your applause during the speech so that we have time for as many questions as possible. for our broadcast audience, i would like to explain that if you hear applause, it may be from the guests and members of the public to attend our luncheons and not necessarily from the working press. [laughter] i would like to introduce the guests at the head table. the senior principal at grace and giuliani, lisa friedman, the deputy editor for "climate wire." the washington correspondent covering energy and climate for "nature" magazine. dennis welch, the executive vice-president of the environment, safety, health, and facilities, a guest of the speaker. the reporter for bloomberg. ambassador to the united states from finland. andrew schneider, this is the editor of blinker and the committee member that organized the event today. we also have the energy reporter for "clean skies television" and a member of the mpc board of governors. we also have the president of the world business council for sustainable development and a guest of the speaker. the press secretary and spokesman for the embassy of finland, and a member of the national press club. the associate editor of ki plinger editors. we also have the energy correspondent for reuters. [applause] as world leaders prepared to meet in copenhagen this december to address climate change and create a successor agreement to the kyoto protocol, deep divisions remain about how to fairly allocate the costs of cutting pollution. splits in the business community are more pronounced in recent months. major energy utilities have quit the u.s. chamber of commerce in disagreement over the climate change policy. duke energy has left the national association of manufacturers for the same reason. kyoto's exemptions given to larger emerging markets hurt his chances of the treaty in the u.s. congress. u.s. businesses fear those countries would gain a competitive advantage over u.s. firms that must meet emissions caps. china, india, and other emerging markets argue that economies in the u.s., europe, and japan have been fitted for more than a century of unfettered use of fossil fuels. these divisions not only complicate the passage of meaningful legislation here in the united states. they also threatened to deadlocked global efforts to combat the problem. finland is a leading component -- proponent to combat climate change. he began his career at citibank. mr. ollila joined nokia. while retaining his chairmanship of nokia, he was named the chair of royal dutch shell. he was the first non-produce -- non-british person to hold the office. asked about his commitment to addressing climate change at this year's international press institute world conference in helsinki, he said, "i may be the chairman of an oil company, but i am also a citizen and a human being." please join me in extending a warm welcome to jorma ollila. [applause] >> thank you for your kind words of introduction. good afternoon. it is a pleasure to be here today. i am most grateful to the national press club for making this opportunity happen. my goal here today is to leave you with three messages. first, the time for business as usual is over. we need big changes in industrial systems, business models, economic consumption, market rules, and government frameworks to tackle the huge challenges facing us all at once. business as usual just will not work anymore. second, business is part of the solution. i emphasize part of the solution. we have the technologies and the ability to innovate. we have capital and significant management knowledge and hustle. we lack a critical ingredient. constructive collaboration with governments and civil society. no man or business is an island in today's connected world. third, building the strategy into the rhythm of business will determine the difference between the winners and losers going forward. i believe that only the companies that develop products that address issues will be around for the long haul. i will come back to these three messages. i would like to elaborate on them and share with you a few points and examples from the companies that i am most familiar with as well as from the work being done at the world business council for and thi region for a sustainable environment. i am comfortable in front of you today wearing a few huts, drawing from my experience leading nokia for more than 20 years, my role as the chairman of royal dutch shell, and my most recently acquired hat, that of the chairman of the world business council. i come from finland. you might say that you need a number of hats, socks, gloves. i am doing this simply because i am enjoying it. this is the right kind of commitment that i need to take it this time. most of you are probably familiar with shell and nokia. the world business council for sustainable development is probably less familiar. the initials wbcsd partly roll off the tongue with ease. -- hardly role of the tongue with ease. let me introduce to you what this is all about. we are a business organization of about 200 companies. we have been around for about 15 years. we have companies from 35 different countries representing the opinions of 25 different sectors. we are establishing a stronger presence in the future in the u.s. we have historically always had a strong membership from the u.s. it is not only from the large companies, but also consumer companies. it is very broad representation. we have a global network of almost 60 partner organizations located throughout the developing world. what do we do? as a group of leading companies, we are committed to a sustainable development through economic progress, ecological balance, and social progress. our mission is to provide business leadership as a catalyst for change towards sustainable development and support the business license to operate, innovate, and grow in a world increasingly shaped by sustainable development issues. allow me to share some examples and bring these concepts to life. let me start with some facts. we face an expanding world in terms of population and our appetite for energy. the drain on natural resources east huge. the effect on business is profound. -- the drain on natural resources is huge. the effect on business is profound. the effect the three key messages i have already mentioned. the first fact is all about the underlying growth story. by 2050, the world is expected to have 50% more people. it will grow from 60 billion -- it will grow from more than 6 billion up to 9.7 billion in 2015. -- it will grow from more than 6 billion people up to 9.7 billion people in the year 2015. -- 2050. will have 50% more people. many of you will hopefully still be here. 80% of the population will live in what we now call developing countries. let me repeat that 85% of people on earth will live in developing countries in 2050. as 1/3 of the world's population lives on less than $2 per day and many suffer from malnutrition, have no access to health services, sanitation, electricity, safe drinking water, shelter, or transportation, the primary focus for these developing countries will be the alleviation of poverty and improving the quality of life for their populations. this is the first fact that we are all facing. the second fact is the growth story in the marketplace. these emerging economies represent the growth markets for the future. they already account for more than half of the world's gross domestic product. their economic weight will increase substantially over the coming years. by 2050, 75% of global gdp will have shifted to developing countries. last month, we saw an acknowledgment of this shift moving from a g-8 rolled to the g-20 world of tomorrows leading economies. the european union is the leading exporter of clean technologies with a global market share of 45%. the u.s. stimulus package as an important grain component. however, china is investing heavily in its domestic capacity to build economies of scale. this will be the platform for the next phase of their export growth. the third fact is the city growth story. currently, about 50% of the world's population lives in cities. people are becoming more urbanized. within four years, over 70% of us will live in cities. -- within 40 years, over 70% of us will live in cities in the developing world. in india, every minute, 30 indian citizens migrate from the countryside to the cities. this trend is expected to continue. in most developing countries, migration to urban centers is connected with changing aspirations and consumption patterns. that is reflected in additional demand for food, water, housing, and jobs. these people will also need access to energy to better their lives. these three trends present a great challenge and opportunity at the same time. it means an enormous growth in demand for infrastructure to provide energy, water, food, transport, and other services that a growing population will require. however, more people living in bigger cities with improved quality of life cannot be allowed to mean more greenhouse gas emissions. developing countries that of least contributed to the environmental degradation are suffering most from the consequences of climate change and water scarcity. they will continue to do so. there is no longer a choice between economic growth and environmental well-being. this move to a high-growth economy must be matched by a transition to a low carbon economy. how are going to make this transition? how will we tackle the challenges i have just identified? this conveniently brings me back to my first message. the time for business as usual is over. we need big changes in systems, mindsets, and governance. we are moving away from business as usual. depositions as better for addressing the challenges. -- that positions us better for addressing the challenges. we need a better price on carbon. i believe this to be one of the most cost-effective approaches in tackling climate change. carbon markets will enable incentives and funding to float toward the development of low carbon projects and the most promising solutions. all our carbon markets have started taking shape in many countries. we're on the brink of a much broader reshaping of our energy markets. a number of new cap-and-trade systems are coming closer to implementation around the world. unfortunately, challenges to remain. while the u.s. house passed a landmark climate change built this year, prospects for legislation in the senate are far from clear. as the world prepares for climate negotiations in copenhagen, we must seek american leadership backed by its own domestic actions on climate legislation. secondly, energy efficiency. what are we really waiting for? the actions and investments that make the most immediate impact beginning with energy efficiency. most of the technologies we need to dramatically reduce our energy use already exist. smart buildings and grids could reduce emissions by up to 15% by 2020. one of the biggest banks for the buck is the energy efficiency of buildings. buildings consumed 50% of the world's energy. even with existing technology, it is feasible to reduce energy use in buildings buy 50% -- by 50% by 2050. the ecological footprint is the third area. all businesses impact upon and are dependent upon ecosystems and the services they provide, like fresh water, food, fiber, and natural hazard protection. a recent u.n. study concluded that more than 60% of the world's ecosystems are degrading. this trend will continue with population growth and industrial development. within the organization, we're working in partnership with some of the world's leading ngos and think tanks. our aim is putting in place the tools that let companies do a better job of managing their impact. secondly, providing regulatory frameworks that leverage market forces for solutions. that show, our business culture is firmly grounded in thinking -- at shell, our business culture is firmly grounded in thinking outside the norm. shell's current scenarios are underscored by the three hard truths. they're similar to the 3 fax we just discussed. those are energy demand increasing, current energy supplies will struggle to meet demand. the age of easy oil is over. we need to find alternatives. historically, it has taken about 25 years for a new energy technology to gain a 1% market penetration. the time lags are huge. stress on the environment will continue to rise. climate change and energy security are in the news today. we cannot ignore the immense challenges of water and deforestation. 1/5 of worldwide emissions is from deforestation and the loss of biodiversity. that loss is potentially huge. these challenges require a new thinking, new tools, new approaches. business as usual is not an option. the next point i would like to come back to is business being part of the solution. i said earlier that the emphasis was on part of the solution. i believe that when business offers solutions to problems rather than excuses, people do listen. business is an innovation in june. -- business is an innovation junengine. we make money for shareholders, provide jobs for employees, buy and sell along the value chain, supporting other businesses in the communities in which we operate. but business cannot do it alone. we need to work in collaboration with governments and the civil society we operate in. the size, scale, and urgency of the challenges we face require new types of collaboration's and partnerships. business cannot succeed on its own. governments cannot be successful without input from the private sector. action is needed. there are two areas where i think constructed collaboration can go a long way towards solving the challenges we have laid out. the first example is around investment in technology. for the most part, this cannot be done as a solo player. delivery of new low carbon technologies by 2020 is beyond the financial and technical capacity of individual companies or businesses. -- of individual countries or businesses. it requires large-scale cooperation in key technologies. to harness the full capacity of information technology in reducing energy consumption and co2 emissions, we need to encourage more cooperation across industries. carbon capture and storage is an example of where a collaborative approach is crucial. new forms of public-private partnerships need to be defined where they work together to organize, fund, a screen, develop, and demonstrate selected technologies in a shorter timeframe. the second area ripe for new collaboration is the international negotiations on climate change. we often hear governments say that we need to talk to the private sector. but there are limited formal channels for discussion. the wbcsd has worked to change this. we have helped international negotiations for more than 10 years. we've contributed concrete options for governments to consider as they develop a new climate approach. the wbcsd submitted formal proposals to copenhagen, providing a business voice. alongside the member companies, we hold regular discussions with government regulators on things related to financing and reducing emissions from deforestation in developing countries. >> president obama is traveling to college station, texas, today. at texas a&m, he will join george w. h. bush to mark the 20th anniversary of the thousand points of light speech. watch the remarks at live -- watch the remarks live at 5:50 p.m. here on c-span. >> this week, the legacy of supreme court john -- supreme court justice john paul stevens. the panelists include the yale law school journalist in residence. also this weekend, prime minister's questions. gordon brown answers several questions dealing with afghanistan, veterans' care, and the economic situation in britain. watch that on sunday on c-span. >> on sunday, the co-author of "white you are wrong about the right." >> this is a house hearing on importing radioactive waste. committee members are considering amendments to the atomic energy act that would ban most imports of low-level radioactive materials. this event is one hour. >> the subcommittee on energy and the environment will come to order. there are many italian imports that i would welcome to u.s. soil. lasagna is great. ferrari, absolutely. let's not forget prada and armani. but italian nuclear waste makes me say, "mama mia." the act was drafted in response to the proposed importation of 20,000 tons of italian, low- level radioactive waste into the united states to be processed in tennessee and disposed of in utah. he was introduced by congressmen and members of the energy and commerce committee. this bipartisan bill would prevent the importation of low- level radioactive waste into this country. the state of utah along with the northwest compact said that they will not take the italian waste. today, a case is making its way through the courts to determine whether the states and the compacts have the right to say no to other countries 'radioactive waste. i have worked on these issues for many years. i was on the committee in 1980 when we established the system to deal with the issue o. in 1985 when i sub-chaired the committee, we passed the amendment to the act to consent to a number of contacts and to ensure that states without disposal sites would be able to access this critical facilities. let me state clearly that when we established the compact system, we did so to ensure that low-level waste in this country would be able to be safely disposed of in order to encourage new disposal facilities to be established, will allow the states to enter into compacts to dispose of their wastes regionally. we further granted them the authority to exclude waste from places outside of their respective compacts. the purpose of the system was to empower the states and not the compacts. but today, some argue that the compact's do not have the authority to say no to waste from other countries. to me, this position is incorrect. we did not intend for foreign waste to be allowed special privileges to be disposed of within the compacts, even against the wishes of the compacts and the states. the compact system is the result of a painstaking compromise. it has provided access for critical, low level radioactive waste disposal for almost three decades. today, i am very concerned that the system itself is under assault. i disagree with those who argue that this bill is anti-nuclear. this bill would actually preserve waste disposal capacity for domestic use. careful stewardship of our disposal capacity is more important than ever. in this context, it is important to examine the current state of low-level waste disposal in other countries. do other countries allow importation and disposal of waste from the united states? the answer is no. not germany, canada, switzerland, or italy. no other nuclear waste generating country allows low level waste importation for disposal. many countries with nuclear programs do not even have disposal facilities for their own low-level waste. that includes italy. if the u.s. remains the one country that allows for the disposal of foreign waste, then nothing stops the other countries from using us as their nuclear dumping ground. if we do not protect the low- level waste compact system, the u.s. waste sites could be turned into global waste dumps. we could be put in a position where many states are unwilling or unable to participate in these contacts at all. companies could have nowhere to go to dispose of their radioactive waste. that would not be a good development for the nuclear industry or for the nation. i would like to turn and recognize my good friend, the gentleman from michigan, mr. upton, for an opening statement. >> before i begin, i would like to put into the record two statements. i want to put in the nuclear agreements signed this month between the department of energy secretary chu and the italian minister for economic development. it seems to me that any movement on the bill we're looking at today it would violate the spirit of those agreements. i would like to submit the court ruling from the case. thank you for allowing that to be in the record. as a strong supporter of nuclear power, i hope the hearing today on importing low-level nuclear waste will lead to discussion of the larger issues of long-term storage of spent nuclear fuel or nuclear fuel recycling. the issue of waste disposal and that of new nuclear power plants directly related. directly from the written testimony, but " the regulatory authorities have informed the nrc that the material can safely go to energy solutions facilities in their respective states." the southeast compact solution expressed no objection. the nrc was provided with the views. also from the nrc, there appears to be ample disposal capacity for the foreseeable future, particularly at the energy solutions facility in utah. why are we debating the bill? the court has made a ruling. an appeals court is reviewing the case. energy solutions is voluntarily agreed to limit the disposal of foreign generated waste tomorrow -- to no more than 5% of its capacity or 10 years. this is just 4.3 acres on at 640 acre site. energy solutions has offered to make this a legally binding condition of its license. congress should not be interfering. we should have hearings on building new nuclear power plants, a cycling is spent fuel, and what happens now that the administration has scrapped yucca mountain. i have great respect for my friends on the other side who introduced the legislation. but i am concerned that will be used by the opponents of nuclear power to delay new plants from coming on line, causing further roadblocks to the safe disposal of spent fuel and low-level waste. the bill is a continuation of the attacks on the nuclear industry. the first attack was on the disposal of spent fuel at yucca. this bill is attacking the safe disposal of low-level waste. it is being used by those who would like to stop nuclear energy. nr hasc stated that the disposal of du is safe. if we cannot dispose of it, which cannot enrich uranium for fuel. if we do not have the fuel, we cannot generate electricity. the anti-nuclear attempts to stop nuclear energy by attacking waste instead of generation is the effort. despite what the proponents of the legislation may claim, this is not just about importing waste from italy. what happens to be identical waste safely being processed today? this is the camel's nose under the tent. that is shutting down all of our domestic processing capabilities. it will eventually mothball all of our nuclear power plants. waste is sent to that facility for processing and on to the facility in utah for safe disposal. we cannot compete on a global scale if the shutdown our domestic facilities. members of this subcommittee represent 18 different states that send waste to reprocessed and disposed of by energy solutions at their facilities. i have two nuclear power plants in my district, literally miles from my doorstep. they send their low-level nuclear waste across state lines for processing and disposal. these services are essential to the success of nuclear power. i know there are concerns about importing italian waste to the utah site and how it will impact the system. i do not believe it will. the compact system remains unaffected. the court has already and quickly ruled on the issue. i expect the appeals court will affirmed the ruling. we should let the process move forward. the judge's ruling in energy solutions vs northwest stated that the facility is not a regional disposal facility and not part of the northwest compact. two quotes are important. and of the 1980 act, northwest would have no authority to exclude waste from the facility. the sec " is that it is not a disposal facility as defined by the act. it is imperative that clean, safe nuclear power is at the forefront as we seek to solidify our energy supply and foster a new era of energy independence and reduced emissions. as applications for nearly 30 new nuclear plants are expected over the next couple of years, we're on our way to fulfilling our commitment to safe nuclear power. our environment will be better off for it and so will our national security. millions of households are powered by clean 0-emissions nuclear power. our nation's economy will be powered by nuclear as well. this is the right course. we will be better for it. i yield back. >> the chair recognizes the gentleman from utah. >> thinks you for holding this hearing. i have been working on this bipartisan legislation with my friends for the past few beers the subcommittee held a similar hearing last year. it was clear to those of us that attended the hearing that the policy for low-level radioactive waste in this country as created by the federal government in the legislation in 1980 and 1985 has some gaps. there are some questions. congress should look at the policy again. that is why we are here today. it is hard to see why the u.s. would ever want to import waste from other countries. simply put, we have very few locations in this country where the waste could go. given the fact that we are facing a future with an additional amount of nuclear power in this country, and i support the creation of new nuclear power plants, it seems to me that as nuclear power grows, we will want to preserve the u.s. capacity for low-level radioactive waste. some have said this is an anti- nuclear bill. nothing could be further from the truth. this is a pro-domestic nuclear power bill. i challenge anyone to show me in this legislation will will inhibit the development of domestic nuclear power. i want to get that on the record right away in the opening statement. as we said, the compact system that oversees the nuclear waste says that while the clive facility is authorized for takeaways outside the state, it also said it had never reviewed the issue of adopting access from outside countries to the facility in utah. as illustrated in the testimony from the rocky mountain compact, when the nrc applied for import from canada, it was listed as a leading to be processed at the bear creek facility. it was processed and then freeze it -- and then be designated as u.s. waste. -- and then read-designated as u.s. waste. those were pretty small amounts. now, we're talking about a large volume of nuclear wastes. you will hear some discussion about whether we have enough capacity in this country. you will hear reference to a gao study. they took it one day and then projected it out from there. it happened to be alone here. a professor trip all of us where we to date and then projected out. then he pointed out the other day that and we learned a good lesson. the gao made that first mba mistake. i hope we do not. i do not see a lot of other states lining up to take this waste. they decided to limit the storage capacity to 5%. at the same time in the testimony from the company today, they're suggesting they want to increase the license capacity. just two years ago, they said they would not apply for an application to increase the site. these voluntary commitments may not have a lot of meaning. i know my time has expired. i have an opening statement i would like to submit for the record. i look forward to hearing. >> perhaps you give me the name of the profs that we could send over to the congressional budget office -- perhaps you can give me the name of the professor the we could send over to the congressional budget office. i would request that the gentleman from tennessee who is co-sponsor of the legislation with mr. matheson, mr. gordon, be allowed to participate in the hearing and be recognized for making an opening statement. without objection, it is so ordered. the gentleman is recognized. >> thank you for having this hearing today. when a nuclear power waste policy act and the amendments were passed in the 1980's, the united states was facing a critical problem. where were we going to put low- level radioactive waste generated from our own power plants? reestablished the compact system under which the states and each compact would be responsible for establishing disposal sites and taking care of their own waste. as history clearly shows, a witness from the nrc testified last year that no one anticipated that other countries would try to dump their radioactive waste in the united states. the nrc stated that when it drafted legislation that allowed the importation, it did not anticipate "appreciable u.s. import or export traffic in low- level radioactive waste." that was true for more than a decade until energy solutions applied for a license in 2007 to import 20,000 tons of low level, re-elect of waste from italy for treatment in tennessee and disposal in utah. italy does not have a disposal site, nor has it been successful in obtaining public approval for a future site. italy is not the only country that does not have a waste site or enough capacity for its waste. britain is running out of room and looking for places to put its waste. germany, canada, belgium, switzerland, and denmark do not have sites either. if i were a public official in italy or britain, i would jump at the chance to send my waist to the united states and be rid of the responsibility. no one can claim that this is in the best interest of the united states to take on decades of responsibility for another country's nuclear waste. it also takes away the incentive for those countries to do the responsible thing by providing storage for their own waste. let me make it clear. this plan -- we should ask why the united states needs italy's waste. it has been safely stored on site for 20 years and can safely be stored for another 20 years or more. energy solutions overseas disposal sites. as it now stands, the nrc is powerless to prevent the foreign imports of waste even as our domestic waste dwindles. it is clear that only a legislative prohibition will stop the wholesale importation of waste into the united states. the act provides the prohibition while allowing the president to make exceptions if it is in the national interest. the united states is the only country in the world that allows imports and disposals of low- level radioactive waste from other countries. the fact is that we have limited space for this kind of waste. it should be reserved for domestic industries that generate it. that would include medical facilities and universities. 36 states have no other alternative but to ship their waste to utah. michigan, texas, and 34 other states have no other place. by banning the importation of radioactive waste for disposal, we also send the world the right message. if you are going to produce radioactive waste, you are going to have to build the necessary facilities to dispose of it. with all due respect to my friend from michigan, this is not an anti-nuclear waste bill. it is a pro-domestic nuclear industry bill. those two facilities near you in michigan, if the facility in utah runs at capacity, there will be no place for them to send their waste. thank you, mr. chairman. >> we will now turn to our witnesses. the first witness is the director of the office of international programs at the nuclear regulatory commission. this office provides overall coordination for the nrc's international activities. whenever you are ready, please begin. turn on your microphone. move it in a little bit closer. >> good morning. my office is responsible for reviewing import and export license applications and issuing licensing pursuant to regulations. my focus today will be on the regulatory framework for licensing the import of low- level radioactive waste. and like to thank you for the opportunity today to discuss our licensing process. we have provided prepared testimony for the record the describes the regulatory framework for licensing imports of low level, radioactive waste. i will highlight key elements of that testimony. nrc reduce applications against the criteria defined in its regulations. the nrc bases its licensing actions on the following three criteria. one, the proposed import will not be affecting comment security. it will not constitute an unreasonable risk to public health and safety. and inappropriate facility has agreed to accept the waste for management and disposal. the nrc has exclusive jurisdiction for granting or denying licenses for foreign radioactive waste. we determine whether to import a license -- we determine whether to issue an import license based on our evaluation. the evaluation is formed after consulting with the department of state, duplicable host state, and the applicable compact, and after consideration of public compacts. the nrc consults with the state regulatory officials for their views on the proposal and to ensure that the importation is in keeping with the regulations. the nrc consults with the compact commission to determine whether the compact will accept out of compact waste for disposal in a regional facility. to ensure that no radioactive waste is important into the united states and becomes orphaned waste, they will not grant a license unless it is clear from consultations of the waste will be accepted at applicable post agreement state and a low level compact. as requested by the subcommittee, i would like to turn to questions regarding disposal capacity in the united states. in the short term, the nrc has not identified any capacity issues at the utah facility. the agency as a regulator would have the authority to address future issues if their worre wee health or safety concerns.
focus on driving improvement for that very complex patient population and we're pleased with the progress we have been making. in a year from now i can give you a fuller report in terms of patient outcomes. the last of two areas i will mention,ing or gan donation and transplantation. we have pulled in the collaborative model to improve what we're doing on that front bringing together hospitals and organ procurement programs to boost donation rates and successes in procuring organs as well as increasing donation rates. two weeks ago i was in dallas to speak to about 400 hospitals and a related organizations. around a multi--year hrsa initiative that we have underway that is designed to improve donation rates. . nation s e multiple organ is being harvested from individual donors and to expand and improve clinical processes for recovering organs. the commitment obviously of the people and organizations in this practice collaboratives is extremely important. we have collectively with partnership far-reaching goals and i would say extremely important goals. the success of those processes are critically important because are critically important because even as we number of transplants over and above the last five or six years if you use 2003 as a base year up to 2008, in 2008 we saw the transplantation of over 3,000 more organs and 08 than we did in noeth risa the numbers have been coming up but frankly the need exceeds the numbers. so the individuals on the transplant list, the numbers are rising. we are not meeting the need that continues to outstrip our ability to supply organs so how we can improve the program is critical to saving people's lives so help their and ideas to help us in partnership with their colleagues would be a key area of focus for us. finally we also have a clinical patient's safety and clinical pharmacy services initiative. that is being operationalize through a collaborative to improve patients' safety by implementing critical pharmaceutical complicated medical problems for kooi of 110th teams involved in that collaboratives banning 40 states. those teams represent free anderton 50 organizations and we are planning on getting more this year as the second year becomes, gets underway. in conclusion, so that gives you a quick snapshot. in conclusion let me just say that with the sophistication of health information systems, with this administration's drive towards transparency of data and with the real openness to infighting partnerships, recognizing the only way we can execute our agenda at hrsa more efficiently and more productively and with high quality is in partnership with key organizations like the national quality forum. i want to and where i began which is to say that i appreciate the opportunity to acquaint you with some of what we are doing but also to i am convinced what we are doing is the tip of the iceberg. given the population that hers asserts, there is more we should do to help our grantees fishes jones, clinics, rural hospital said etc better serve the patients that we work with in collaboration to serve so that is the path we are charting at hrsa barcode is not just a maxes agency anymore. it is an access to high-quality health care. i welcome and valued the input you can provide this as we continue with this reenergize the agenda moving forward. thank you very much. [applause] >> mary has a couple of minutes for a couple of questions if anyone has any questions for her. >> or comments, or concerns. >> or comments. >> do you anticipate health care reform-- is that it? do you anticipate health care reform making any appreciable difference in the need for access that your agency addresses and it's so, have you thought about how you might we direct your resources if some might be freed up from that direction? >> what we are doing of course is working in collaboration with the hill providing technical assistance on anyplace where they are asking for and where some of our programs are reflected in the major pieces of legislation so we have been working hand in glove with them going forward. you see for example, you see across all the major bills references to help workforce and the title vii, tie late health professions programs, so we are working in collaboration and in some cases the potential uptick in need and other places sideways but all of this very much is you know a working. that is about as much as i can say is we are working collaboratively with them. if you look at those those who see a number, not necessarily all but a number of the programs i've talked about today reflected in those pieces of legislation in different ways. so i'm going to stop right there. you probably would have been able to give a better answer to your question. i know you are asking me specifically about the hrsa programs but that is about as much as i could say to you. there's a lot of information that is moving back and forth on the programs. anything else? >> talking about work-force training have you got a specific focus on professional workforce training on health information technology and measuring improvement? there is obviously been a lot of discussion we have had on the semielectric workforce across many of those dimensions. >> it is such a good point and we have some provisions in their workforce training programs that speak to technology but it is mostly about trying to help the academic institutions, in some cases grant funding for example the technology that students then can be exposed to even as they are moving through those academic programs. you saw some of that money coming through the recovery act, some additional dollars, through 09 / ten appropriation so you are seeing technology being trucked in on that side. we also have, with certain grants, that particular components brought in by, through the proposals that are submitted so it is not uncommon for us to be looking at training programs that have that as part of their priority to provide additional exposure to students. we are doing a major scrub right now on our health care workforce programs and while they have historically been thought of primarily as supply we are working with a lot of external groups to inform our thinking about competency, corp. poppins these as well as whether that may or may not fit within the statutory boundaries of the particular programs within seven and eight so looking at it, you see pieces of it here and there. we have got certain agendas we must me because it is in statute, but we are trying to push the boundaries of recognizing it is about ensuring not to stax's to workforce and what is the role that those programs could plan trying to drive the core competency agenda that would be appropriate in within the statutory scope. we are looking at that. >> as you may know the american association of informatics have got this program that they are trying to sponsor. did they get any visibility to your program or any of the legislation? >> i can't tell you, i could speak to how they are faring on the hill but i can tell you they are talking with folks inside her side, yes. i know that for a fact. [applause] thank you very much. >> i would like to invite glenn hackbarth and the panel, len nicholson chris koehler for next session. >> good afternoon. i am tom, senior vice president for strategic barken chipset the national quality forum. i am going to be moderating this last topic on our agenda today. replace the topic of payment last on the agenda and hopes that it would sustain your attention and it looks like that was successful. it to see everyone here. there are a couple of substitutions on your agenda that you have in front of you. first of all you will note that i am not ship, and so he was not able to be here. secondly we have elizabeth carpenter from the new american foundation who is here for her associate, len nichols. i am going to give a very brief overview of the topic and then introduce our keynote speaker, and glenn hackbarth, and then we will have a reactor panel from ms. carpentier and mr. koehler. payment has been identified by the national priorities partnership as a powerful driver for change. as policymakers are considering both financing and delivery reform, payments is an essential policy tool as we all know. so, we are going to be hearing about some of the innovative policy models from the chairman of the medicare payment advisory commission and from our reactor panel today. it is my distinct honor to introduce mr. hackbarth as sais ems the alum of four years. i followed his leadership of the commission and the commissioner's work very closely and it is very valuable to the congress into the administration. he has experience as a health care executive, government officials and policy analyst. he was chief executive officer of one of the founders of the harvard medical association, harvard vanguard medical associates, a multispecial group in boston that serves as an affiliate of harvard medical school. gis previously served as senior vice president of harvard community health plan and president of the health centers division as well as the washington council of intermountain health care. he has held various positions in the u.s. department of health and human services including deputy administrator of the health care financing commission , health care financing adminstration which obviously has given him very important background for his role as chairman of medpac. mr. hackbarth. >> thank you tom. did married leave, mary whitfield? i guess she did. i had the privilege to work with marrying in several capacities. she was a member of medpac and we also served on the commonwealth fund commissions on the high performance health system together and there's just nobody i know who has the energy and enthusiasm and commitment that she has for the work of hrsa so we are all very fortunate to have heard there. so, we got the coveted slot, the last group at the end of a long day, to talk about payment reform of all things. so, what i will do is try to keep it brief and allow elizabeth and chris and opportunity to join the scotian and hopefully u.s. will. in 20 minutes or less i will try to define what medpac's mission is in the area of payment reform and give you a few examples and then focus most of my time on the challenges of getting from here to there, which i think are important and sometimes overlooked. let me say a word about medpac. medpac is a nonpartisan advisory body created by the congress to excise the congress on medicare policy issues, payment policy, benefits, quality issues, you name it. our mission as we see it is to make recommendations both to the congress into the secretary of hhs that will help assure appropriate access to quality care for medicare beneficiaries. while simultaneously increasing efficiency in the delivery of those services so as to protect the taxpayers from undue financial burden. let me say a word about what we mean by efficiency and in some groups, when i say efficiency, that is interpreted to be synonymous with cutting costs. that is not how we use the term. we use the term efficiency to include both cost and quality so you can improve the efficiency by holding costs constant, improving quality or you can hold quality constant and reduce costs or some combination, but the important point is it@@@@@@r without the measures of quality and organizations who apply those measures to individual practitioners or to organizations that provide care. it will not surprise you that the medicare payment advisor commission thinks payment reform is really important. indeed, essential to improve the efficiency of health care system. the problems of the four service are well known. much of the discussion focuses on the incentive and fee-for- service to provide more complex and sophisticated services. that is all true. fee-for-service to do more and provide more complex sophisticated services. that is all true but from my vantage point, an even bigger problem that results from fee-for-service is fragmentation in the delivery of care. fee-for-service payment at least enables, it does not cause, care delivery to exist in silos in small units that make the task of integrated, coordinated care more difficult. but even more than that, it undermines the accountability for results and so that fragmentation is a key problem that we think payment reform needs to try to address. now, none of this is news and in particular it is not news to the health professionals that work in the system. physicians, nurses, pharmacists, physician assistants, of various sorts of technicians, managers, executives. they all realized this even better than people in the policy world. not in every case but in many, many cases, the people who live within the system feel trapped within it, trapped to do things that may not, if not in the best interest of the individual patient, certainly none the best interest of the broader system and the society it is supposed to serve. now, some people say in fact the u.s. doesn't have a system of care at all. it is a non-system and that is true but there are some forces that are pretty consistent, pretty constant in one of them is payments. obviously there are variations in payment policy between public and private payers but the prevalence and the power of fee-for-service incentives are still very strong. another more of less constant is professionalism. one of my activities is the board member for the foundation of the american board of internal medicine and one of our particular interest is in professionalism. the traditional notion of professionalism is the physician's responsibility is to the individual patient and to do what is right for the individual patient, which is understandable in good but it leaves out of the equation the cumulative impact of those decisions for the society. and, so we have professionalism that traditionally has been focused narrowly on the patient's to everything that has a positive risk benefit ratio for the patient without regard to the cumulative effect of those decisions on society. that is another powerful force in our system. and a last constant is the malpractice system, which reinforces in a way that traditional notion of professionalism and incentives of fee-for-service so the real constant forces that we have in this fragmented world are all driving us towards more, more, more. now let me turn to this specific topic of payment reform. when medpac talks about payment reform, our goal is to foster more integration and coordination of care, so west to improve accountability for results. most of which need to be measured not on a visit by visiting counter sort of basis or even a hospital admission but more on a broader ongoing episode of care basis and it is difficult to assess episodes when all of the actors the other touching a complex patients are independent of one another and not actively working with one another and certainly not assuming collective responsibility for the patient. so let me give a few examples of what we mean by payment reform. these are just a few and certainly they won't be new to you. these ideas are very widely discussed in the health reform debate and to varying degrees and in fact are incorporated in the bills. now working their way through congress. the first concept of payment reform is that we need to pay more for primary care, and we need to pay differently for primary care. not just fee-for-service. also some amount of per patient payments, lump-sum payments that will help support the infrastructure in primary-care practice that we think is conducive not to just quality but coordination and integration. a second example focuses on what happens to patients who are hospitalized, who of course are by definition vulnerable patient's. and, whatley have tried to do is make. payment proposals that will foster greater integration with the hospital state between physicians and hospitals but also in the immediate aftermath of the hospitalization between the hospital and physicians providing post hospital care and home health agencies in skilled nursing facilities and the like. and then a third area that we have addressed is the notion of creating accountable care organizations, which would be organizations that assume both the overall clinical and financial responsibility for a defined population of patients. win mcginty the discussion, i would be happy to delve into the details of any one of those areas but those are three major things-- teams that medpac is come back to repeatedly. what i want to do now in my last few minutes though its focus on the challenge, and let's assume the best case that congress passes legislation and these ideas are in it. how do we make them a reality? that is a very big task indeed and it is not going to be an easy task. i will just make a series of observations. one is that payment reform as we have defined it will probably need to be voluntary in the first instance. and the reason for that goes back to the fragmentation of care delivery. you can say well we are going to pay for aco's aco's did not exist everywhere. there notable examples that people point to, but those organizations are the exception in american health care and not the norms of we just have a payment policy that works for them, although we have not advance the cause very far at all so what we need to do is reach beyond them what that entails creating organizations, relationships that don't exist now and you want that effort to be led by people who are enthusiastic about it and welcome the challenge and the opportunity, not people who dread it and that in turn means it is probably going to have to be voluntary in the first instance. so, that leads to a second challenge. not only is voluntary payment reform slower than many of us would like, it can also result in the short run in cost increases as opposed to decreases, and that may seem counterintuitive. i can go into the reasons in the discussion, but that leads me to a next point, which is that our movement towards payment reform which is essential for the long term, needs to be complemented in the short run by continuing pressure on the fee-for-service system. and we need that pressure for two reasons. one is that pressure will provide the impetus for organizations to say there is that to be a better way, and i want out from under this oppressive system and i am willing to invest for example in becoming an aco or invest in being prepared to handle bundled payments of around hospital admissions. there needs to be some push behind that. in addition the pressure on fee-for-service payments frankly will also provide necessary short-term savings to help offset the short-term costs that i think maybe involved in the transition to a voluntary payment reform. the next observation is that-- again. i will use aco as an illustration. it is very easy to conjure up the idea of an aco but figuring out how to get the payment incentives just right is more complicated than it may seem at first blush. the most widely discussed payment model for aco's is based on the medicare group practice demonstration under which the participating organizations continue to be paid fee-for-service but a target for total cost is said and if the organization comes in with total cost less than the target while maintaining or improving quality they get to share in the gains. but the underlying payment is still fee-for-service. and you don't have to do the math for very long to begin to wonder whether the incentives are strong enough to induce the sort of change that we would all like to see. there are other models for doing aco's in the global capitation payments but they have their own issues, and one of the most important is it the go-to a global capitation model you probably need to have beneficiary choice. it needs to be in an roman model, which means that not all beneficiaries will unroll so the percentage of the organization's revenue affected by the new incentives might be relatively small. so, there are some very complex and tricky issues that need to be worked through which brings me to my next point. if we want to create the most powerful incentives as quickly as possible, i think it is unfortunate for us to focus on how to better harmonize the payment systems used by public and private pairs-- payers. to me this is one of the issues that the health care debate at least to this point has neglected. the power of the new incentive will be multiplied, amplified if it is not just medicaid but it it is 30 or 40% of the hospitals' revenues but it is all the private payers as well using the new payment methods. so, i think a concerted effort needs to be made to figure out how we can increase that harmonization not to just increase the power of the incentives but also we can do that there is the potential for us to reduce the administrative burden on providers if we are all paying the same way. next is the due payment reform come hhs will need a vast increase in resources. i won't dwell on that right now in the interest of time but a related point is that hhs and cms will also need much more political space than they have traditionally had to make controversial decisions. to its credit congress has recognized that. the legislation pending now, health reform, recognizes we can't continue to make medicare policy the way we have in the past and expect a dramatically different outcome, mainly an outcome that favors payment freeform so we looked at ways to get more discretion to the secretary, to do pilots and implement them if they are successful. to propose independent commissions. where that we'll end up i don't know but the important thing is the realization that we can't have the same policy process that we have had in the past and expect different results. last point is that@@@@@@@@@ v@ r i care about medicare. i would not have spent most of my career working on these issues for me, it highlights a vibrant medicare advantage program alongside traditional medicare. that pack -- medpac is often cited as being critical of medicare advantage. i think reductions of medicare payments is the right thing to do. it would not be corrected to conclude that we are against medicare advantage we think that private plans potentially can do things that traditional medicare will find hard even after payment reforms. a classic example is the ability to steer patients toward a high quality and efficient provider. it is difficult to imagine that medicare will act of the best interests of patients. that is a tool the private plans have potentially at their f thesal that ramifications of that. vince a tool the private plans have potentially at their disposal that traditional medicare does not. the problem with medicare advantage is not in the concept but in the execution, how congress that the benchmarked the dr the pricing system. that process has been wrong and has created in correct signals to private plans into medicare beneficiaries about what it is we value. and so with that, i have talked too long. i will turn it over to elizabeth and chris. thank you. [applause] >> thank you clan for your comments and for your strong leadership of the medicare payment advisory commission. we have to reactors today,-- the first as elizabeth carpenter who is the associate policy director for the health policy program at the new america foundation. her work focuses on health care initiatives, managing the health policy programs, congressional and media relations efforts. she peers. he in the media including news networks like fox news and cnbc and radio stations like abc news radio and wtop. before ng-- before joining she served as the campaign staff on that staff of senator lincoln chafee focusing on health care and education issues. ms. carpenter is a graduate of brown university and let me introduce our second reactor as well. he is chris koehler. he became risk's verse health care insurance commissioner in the 2005. the office of the health commissioner is responsible for health insurance consumer protection, the financial solvency of rhode island's domestic health insurers then fair treatment providers by insurers and directing health insurers for policies that improve the accessibility, affordability and quality of the state's health care system. after our reactors present we will have time for questions and discussion. >> thank you for that introduction and for having me here today. my name is elizabeth carpentier and imus says the policy director for the health policy program at the new america foundation. the new american foundation is a non-profit, non-partisan research institute with offices here in washington d.c. in sacramento, california. as i am sure you have noticed by now i have the pleasure today to stand in for len nichols and i am going to try to do my best to say what he would say but for those of you who may know when i am missing a southern accent and a beard which are often quite key to his presentation so i am going to do my best. the new american foundation was created to identify and develop new ideas that are capable of capturing the values of both republicans and democrats. one of the reasons that glenn's presentations is really so important and vital to this policy debate is that an embrace of these issues will really be essential to pass a health reform bill that earns the votes of both moderate democrats and some republicans. these members must be confident that reform is incentivizing higher-quality and more efficiency and in doing so begins to address our long term fiscal problems driven by health care cost growth. these payment models are really critical if we are going to achieve these goals. as glenn mentioned many of these ideas are already embraced in reform legislation. medical holds, the council care organizations, bundled payments, reduced readmissions as well as the sense that maybe the finance committee should not be making some of the day to day payment decisions sematic karen epic we will continue to see discussion and in fact improvement on this front going forward other seems to be a real appetite in congress to make some advances in this area, especially as we think about the intersection between the public and private sectors. but the other good the news really tearing this national health reform conversation is that health care readers-- leaders have submerged to support many of the ideas that glenn has just mentioned. at the america we facilitate a group called kelsey eo's for health reform which includes as a founding member dr. gary kaplan of virginia mason medical center who was an isenberg award winner here today so we are very proud of cat dr. kaplan. the ceo's ury willingness to change the way health care is delivered in the context of covering all. this summer they published a set of recommendations that included many of the ideas put forth today. the overarching theme in their white paper rally was that we must move away from fee-for-service payment in a way that encourages more coordinated in patient-centered care. we are very proud that they stated plain and simple that fee-for-service payment is unsustainable. they were also clear however that some of the changes that call on talk the battered not going to happen overnight. they may have been some places right away but some places certainly might need some more time. so as we strive towards highly integrated models of care and more advanced payment models like accountable care organizations we must also embraced transitional payment models like bundles and shared savings. one of the conversations that may not be as fully developed as it should be right now in the comprehensive reform conversation is, how do we make sure providers have the tools they need to deliver high-quality, he fishing care? this includes exchanging the practice of the evidence-based medicine for evidence-based regulation. dr patricia galbut who was one of our health ceo's and this c.e.o of denver health is particularly adamant about this point. she delivers some of the highest quality care in the country. a majority for patients are on medicaid or uninsured yet she is in the black every year. she tells us she has been evaluated by five, six or seven regulatory agencies for the same purposes and many more in total. these obligations cost providers time and money into not necessarily move us closer to the high quality efficient health system that we want. hell c.e.o's for health reform recommend a high-level task force to review and streamline existing regulatory bodies to form three regulatory bodies, focus on quality and safety, a financial oversight and education and training. in addition some of the laws that are governing our health system disincentivize providers to engage in the types of delivery and care that we know will improve patient care and reduce costs. hell co's for health reform recommended task force drew a chair by the secretary of hhs and the attorney general recommend general and statutory changes that would remove all barriers to high-quality, the vision and coordinated care. this should include a review of the current antitrust laws, the rules as well as medical malpractice reform. finally we should have a conversation as glenn mentioned, about how to reduce administrative costs especially as they relate to insure the ability. we hear time and time again that the fastest-growing expense for many providers especially hospitals is in the area of administrative stuff. health care should allow them to reach an agreement on unified billing procedures. this could include a debate about whether not to adopt medicare billing processes systemwide. one of the things we have really learned from hell ceo's and some of their colleagues is that if health reform gives providers a clear signal about where we need to go in the tymon tools to get there we can realize the high quality efficient system we all seek. current conversations in congress and in the stakeholder community tell us we can make great progress for many of the models dekle and out lines, especially if we pay a little more attention to some of the tools that providers need to enact some of these changes, so thanks for having me. [applause] >> so, i think my role is to give the perspective from the states, from the world of h1n1 and decimated state budgets and high unemployment, many of which you come from your sells wehr this payment reform is absolutely important when we are looking at rising medical costs, increasing numbers of uninsured, and what passes were some people want to burn this at both ends. as long as you can keep my health insurance costs down and we try to explain them that is kind of hard. i want to thank glendan medpac for the work for this opportunity and what has been a very good conference and also all of you who are working around the notion of standards development so that we can reduce some of the unnecessary variation that is out there. i am going to assume a common goal for this which all of us who were working on this are working to improve population health, which means improving quality and reducing costs and that requires delivery system changed and payment reform is an important tool. is not the only tool but it is an important tool for getting this delivery system change. so i will give the headlines at the beginning. three pawns lines and an obvious insight. the obvious insight is it is the finance this stupid and the free punchlines rfq wanted the payment reform from the state perspective unique multi-payer corporation to get this delivery system change. the second is that you need local leadership in some authority and the third is that we have to change the game with medicare so there is a pretty big overlap with glenn's message. the obvious inside is the finances stupak. providers don't want to change how they treat based on who is paying, so if you want to make the numbers work for the providers for them to do the kind of change we want you have to have enough money to make it work and no paper has enough money by themselves to make the required changes. you have to align the payment across the payers. it is pretty simple but you have to keep emphasizing this stuff. the first punchline, how did you get this multi-payer record nation to change its delivery system? in risk we started with an all payer patient home initiative. we had experience with the chronic care program. we have the kind of community care center changes that mary wakefield told us about mbf standards for what constitutes patient-centered medical homes and good chronic care measure. what we didn't have was a payment system so our docks would come out of these chronic care collaboratives, ready to change the world than they had a system. we can change that with an all payer project to pay providers differently if they do certain things to implement a patient-centered medical home and go through chronic care training and that is what we have been doing but we are able to do it in primary care first because it is cheap, because the evidence is there and because it is cheap there's not a whole money involved in it. they are so suffering it is easy to get primary docks to the table. you can only do if you make the numbers work across the pairs and we have our commercial payers and we have for medicative the table paying these stocks and a different way. who is missing? medicare and that it's the my third piece. the second punchline, to do this you need local leadership in some sort of state authority. the commercial payers did not come to the table willingly. that this mean that they were dragged to the table but they need to know these were going to be expectations to be passed on every but he, that there was going to be no differential of the edge to this and they needed to know they would be protected from antitrust considerations if they actually sat together and talk about how to do payment reform. state authorities can do that. if you look at the all payer medical home demonstrations that have traction across the country, vermont, north carolina, pennsylvania, north carolina and rhode island, they are all being led by some state authority, running into the barriers we talked about before. the second example that i have round using the state authority is, it's the health insurance commission is supposed to direct health plan policies that promote affordability, what does that mean? that sounds good in statued but what does it mean when you are working with the health plans? we ask the advisory council and what they came up with 44 standards working in risk. one, they had to increase the portion of their medical's been going to primary care by a percentage point a year. we spend 5%, 6% of dramatical on the commercial side of primary care. england is 25, spain is 28, kaiser is ten to 13 so we are going to get up to 11% over the next five years and that is a standard that is held on all health plans. it is a condition of getting their rates. the second standard is to continue the all payer manticle home demonstration. the third is to have coordinated incentives for amr adoption in promoting the health information exchange and the fourth is that when the time is right to participate in broader payment reform demonstrations within a state. none of those have been without some sort of a state convening facilitating role that can have consequences for the participants if they don't participate in it so i would say this quite voluntary the way glenn talks about it but it is collaborative and i want to know what it paradigm shift that is because what we are saying is the competitive contract model does not work to bring delivery system change so the challenge is can you extend that collaboration that we haven't terms of quality improvement in actually use it in some of these payment reform demos. look closely at massachusetts because that is the kind of work they are talking about. the third and final piece is this test it be in the game with medicare. we cannot have medicare is a monolith over on this side but also from medicare's stampler they can't support every payment demo that is out there. i have blah bin eight then of medpac's reports. most of the recommendations are there. they are sound and objective and maybe that is not a row for some medpac to define the parameters by which the stay base experiments can happen so you don't have everything going everywhere but you have a playbook that states and local folks can work off the. i think we have proven that states have the ability to do this kind of thing. we have started with primary care again trying from medpac's playbook. the challenge for the other parts of the system is going to be broader and i agree that in the short run this is not about saving money. we may have to eliminate the downside risk to get the provider to participate in this sort of thing in it absolutely requires the kind of private sector leadership to engage in these sorts of efforts to get the long-term returns we are looking for. thanks a lot. [applause] >> well the audience members who have questions are queuing up, i have an opening question for each of you. what is the most difficult challenge specifically related to performance measurement that needs to be addressed to unable performance based payment? any takers? >> i will try unless somebody else wants to try first. let me focus on a particular case, because the circumstances in dynamics of performance for different types of providers are so different. let's focus on physician performance assessment which in some ways is choosing one of the tougher cases, but a very important one. in fact one that is actively being debated as part of health reform. so, how is it that we go about assessing the performance? quality, patient satisfaction and cost of individual physicians or physicians practicing in very small groups, onesy, tuesday, three z. i think the answer to that is it is really hard to assess physician performance at that level. for a couple of reasons. one is, because of the high degree of specialization. i don't meaned specialization, orthopedics versus cardiology here. but the fact that physician practices even within the same specialty can draw a very different types of patients in terms of socioeconomic background or complicating conditions and the like, so the degree of specialization in physician practice because it can be relatively small units, is much higher than for hospitals are larger organizations. that puts extraordinary pressure on the risk adjustment tools to make sure that you are comparing apples-to-apples when you compare it to individual physicians. a second problem and related problem is small numbers. when you were dealing with physician practices, you are talking about small numbers of patients and just the statistical variation becomes more of a difficult factor to deal with in comparing practices. .. >> any changes to payment policy are being attacked. it hasn't -- it has inhibited our debate to have on this issue. before we get to that stuff, we have to refocus some of the debate on the facts at hand and less on some of the rhetoric. >> from a local perspective, i would say it is building a culture of trust to look at the data. when i look at our home demo, we left onto the care measures for the care we were doing. 8xwe got the doctors to produce data that measures themselves. then you have to convince them that it is ok to share and there will be no consequences from that. that only comes from a lot of time working together so you can create this local culture that we are trying to change something and it is ok to share what is out there. we're not done with it but you need all those things to fall in place. you need their standards and the trust. agreed on but then you need the trust to be able to share it. >> sir? >> advocate health partners in chicago. you mentioned and they're seems to be a lot of discussion about accountable care organizations and i think you mentioned that the examples cited certainly in the literature sort of tend to be multi specialty medical groups often within point physicians and we heard i think yesterday i think less than 15% of physicians in america belong to those groups and the population served by those are even less so the vast majority of the u.s. population is served by small independent practices. are you aware of any examples of other types of defective accountable care organizations other than a medical group that could be scalable? >> there are some others. in fact one of the organizations participating in the medicare group practice demo on which the idea is based in large part is hospital in connecticut, community hospital with a physician staff like a lot of community hospitals, a lot of small practices and no overarching organization. they had to create that. so there are some examples but the amount of effort required is orders of magnitude different. that is point number one. point number two ways the incentive issue is even more important, the power of the incentives. we could develop a payment system for intermountain health care meal clinic and figure out how to pay them different under medicare and do that tomorrow and they would be better off. medicare would be better off. because they have internal culture compensation systems that drive them in the right direction independent of medicare so we would be providing modest reinforcement for that. if you talk about a typical community hospital with a fragmented medical staff that doesn't exist and thus the weak incentives are even more problematic. frankly there are a lot of sub specialists who do very well under the status quo. it's not high under priorities to go into an aco to give up primary care, so it is a challenge. >> i am struck by the not participating federal intricacy the last discussion of the strategic vagueness of the accountable care organization. it's a lot of attraction because it is in the eye of the beholder and that is okay. i think that's actually kind of why is as a construct. i think a lot depends on what you can put together locally so i think that is -- and i know i'm sort of banging on the same drum but if you have local projects then maybe your best vehicle is the committee. you get everyone together and determine what the best vehicle is. if the payers are sort of aligned to say something has to change the new look for the local leadership emerges. then you run with it. if it emerges in the hospital then you run with it. it's not so much where you start as what you're pointing to at the end. >> glenn steele, the ceo of guice anger and a good friend tells me that i can make any idea sounds terrible. [laughter] she cautions me about being too much into the weeds, the details and i accept that as you surely have already figured out all i can really get into the intricacies of this stuff and come off sounding negative but in part i think that is our institutional role. there's lots of people promoting ideas and it's a good. i'm a believer in aco's. i come from a aco association so it is an important concept but i also think it's important for congress to be realistic about the challenges that they face and overselling ideas and in my book is never a good idea. >> it's not a question but just as we think about that, you need to think about what we have dismantled in the last ten or 15 years from a delivery system peace with rejection of managed care. the sins of the p.o. are being visited. fee-for-service medicine and this kind of disintegration that blind is talking about and it's been to take a long time to build the back and i think we love to figure out how to engage consumers in the process whether it is benefit design or some kind of financial responsibility because it can just be an inside job. consumers have to be aligned and participating in this. >> and a few moments, your calls and today's top stories live on guest"washington journa" and we will focus on people without medical insurance with a representative from the kaiser commission for the uninsured your comments on this year's governor's races in virginia and new jersey. we will be joined by steven more, "washington journal." "is next. . host: that will be the first topic we talk about on the "washington journal" as we go through the papers to see what else is in there, but this is how the "baltimore sun" placed its lead story. inside the "washington post" lawmakers back to under $50 checks, congressional leaders welcomed president obama this proposal to make $250 payments to social security recipients thursday as the government report confirmed there will be no automatic cost-of-living adjustment to the program. some policy experts argue that the action amounts to a politically motivated giveaway to seniors. and here is the "washington post" lead editorial this morning -- cash for seniors. çhere is "usa today" opening ld this morning -- pandering to assure security crowd sacrifices responsibility. and also in the "wall street journal" this morning, a lead editorial, cash for oldsters'. we want to hear from you, whether or not you support it. we especially want to hear from our seniors this morning, how will affect you and what you think about it. our first caller is from phoenix, ariz., beverley, a democrat. caller: good morning, peter. host: good morning, are you glad to be back in phoenix? caller: i'm glad to be here for thanksgiving. host: what you think about the 250 of project? caller: i am furious. i get $1,100 per month in social security. my real estate tax went up and the cost of groceries have gone up. and the one time thing, it is just awful. you need of -- you need cost-of- living when you are on a limited income. you cannot get out there and work. host: using the idea of a two and $50 check -- you think the idea of a $250 check would be good? caller: no, it stinks. host: you think it is not enough? caller: i want to know why congress took their cost-of- living twice this year. they get it automatically. they took care of themselves and us old-timers are here that make $11,000 per year, why is there cost-of-living more important to them than us old people are here? -- out here? i think you should have a show on host: thank you for calling in. jim in indiana, what you think about the $250 check for seniors? caller: i think is a good beginning, but not enough for the people. i can only speak for what i have seen with my own eyes and her of my own ears. i have been out of work for three years. i have not had a check for over 2 1/2 years. i will be 61 tomorrow. i want to wait another year to get a social security check. i am looking between now and then to get it increased to our have to be 65 to the additional shares security check by the way they've raped our social security system. people are only going to get a to under $50 check -- $250 check, what about all the people on food stamps? i am one of them. i am so upset. i got two honorable discharges from the marine corps three years in vietnam and i cannot buy a job. and all these illegal mexicans are working. it really upsets me. they're filling our jails up with to do -- with people or smoking dope. while congress is raping our country. host: long beach island, republican. caller: we are being duped by our government telling us that there is no inflation. there is no longer any such thing as a pound box of crackers. it is now 10 ounces or 9 ounces. there is no such thing as a 6 ounce can of tuna fish. it is now a 5 ounce can. there's no such thing as a jar containing 32 ounces of, for example, manas."tit is now 30 o. host: so? caller: the grocery manufacturers association is reducing the quantity and increasing the price. host: take it to the $250 proposed check for seniors. caller: it is absolutely inadequate. it is inadequate because they are saying there is no inflation and then they're going to try to give some kind of peace offering a $250 bridge over a 365 day year does not add up to peanuts. every product that you buy is being reduced in quality, even a candy bar. host: washington d.c., democrats like, what do you think about a $250 check for seniors? caller: i think is great. i think it will buy seniors more cat food for two more months. they really need more cat food. you should go to a website called a shadow steps and it will show you what the real inflation rate is and what the real unemployment rate is. this has been given -- getting progressively worse. i just finished my taxes and i was talking to my accountant and a -- i'm an investor and i found out that when you finfile taxes, will you get is, you make up numbers if you buy stocks. the government has no information about that. is your own good will to decide how much you are going to declare for paying those options. the government is causing to wondered billion dollars to four under billion dollars in revenue and our seniors can eat cat food. host: texas, what you think about $250 checks for seniors? caller: i think they manipulate. the gdp is ridiculous. when gasoline is up, it does not count. everything is ridiculous the way they handle this. host: are you on social security? caller: yes, and they want to give me $250 checked. i would rather have $20 per month so that if we ever have a cost-of-living adjustment, it will be taken in. i think is ridiculous that they want to do this. they're not taking in the things that seniors use. everything has increased. there is an increase on a of -- you buy your medication and the copaiba a plan i am on now is $40, up from $25. that is a pretty good increase. this is just a ridiculous peace offering. host: this is what we're talking about. this is in the "washington post" -- lawmakers beckham $250 checks -- lawmakers back $250 checks. we have a tweed, buying votes for health care, is that person's opinion. mississippi, go ahead. caller: i am against it. obama is to try to buy popular with the old people. host: are you on social security? caller: yes. i receive $500 per month. host: do you receive other income besides that? caller: no, my husband is retired and he is social security. host: and you do not see a cost of living increase the unnecessary? caller: i could use the money, but i do not want to lead to the deficit. i think obama is going down in the polls and he is trying to buy some popularity. host: landover, md., gloria, a democrat. caller: we are not worth more than $250? not only that, everything has gone up. i am for the cost of living increase, not 40 $250. -- not for the $250. what would $250 do if i cannot be my gas or electric bill? it is not enough. host: as you can imagine, a lot of articles on health care reform, health care proposals here in the paper, a couple of them. thisç is from the "philadelphia inquirer." this is in the "new york times" -- and this is in the "wall street journal" this morning. next call, grafton, vt., merely on the independent line. caller: i was calling about the increase. i do not mind getting it. i'm on social security. and i am a widow, so my total income for the month -- and that is all i have -- is 900 per month. -- $900 per month. it is just not enough. in vermont, our state takes pretty good care of its people and we are a very poor state. and hit hard with unemployment. so, taxes are not coming in. that makes up of -- vermont makes a lot of the things that the federal government should be doing, but it has been gutted from reagan on word back to hoover. when fdr started the program, he wanted it sos that the widows ad those on social security would have -- with live decently and not be mired in poverty. after reagan got a hold of it and changed it, it made it so that it was on a different house of copulation -- half of calculation in payments. our standard of living has gone down each year because inflation and cost of living has gone up some of tyre -- so much higher. i will take $250. i will take anything. but i also want our cost of living this year, which is not much, you know, it really needs to be -- they need to hype it up. if they're looking for the money, let them take it out of the defense budget. host: thank you for calling in this morning. allison, mclean, va., republican, hello. caller: i receive social security and dependency and indemnity compensation. i am strictly against thank you $250 -- strictly against the $250. if there is an increase in social security, the widows of the soldiers would get an increase --ç the two go hand in hand. i am against this $250 gift to reach individual -- to each individual. i feel the stock market is going of and perhaps a 1% increase next year would not hurt too much and it would be amortized over a long time frame. this $13 billion payout all at once i feel would be very hurtful to the economy. thank you for letting me talk. host: from the baltimore sun, supreme court justice is briefly hospitalized. next call, albuquerque, new mexico, susan, a democrat. caller: thank you for taking my call. i would like to say, yes, i agree with president obama that we need $250. it will get us through we're not going to get a cost-of-living increase. and i thank the president for thinking of us and thank you for taking my call. host: we have a tweet hear from texas. if you want to send in a tweet, our twitter address is cspanwj. next caller from a florida, good morning. caller: i am on social security and disability. i have a young child i'd take care of. i think i am relatively young, 37 years old. i really do not have a problem with that, because it is true, that in eight years there's not going to be a social security, then i can understand that because with the disability that i haven' i am not able to go bak to work. if they're going to do that, i would prefer them helping us maybe to get food stamps. i do not make very much money on disability and $250 is not much to live off for food with a child. but at least for the month, me and my child or able to read. -- are able to eat so, i will take it. in the long run, it is going to help and hopefully next year there can be an increase, the numeral the stability and social security, then i will take it. host: thank you for calling in this morning. sandy hook, conn., ruth, a democrat, what do you think about via $250 proposal for seniors? caller: good morning, it is so complicated. i would say because there is not a cost of living, go ahead and give it because there is such a divide in this country between the haves and have-nots. and the top echelon who have no idea what it was like to be the lower 10 -- 10% to 15 or 20%. let's talk about the fact that the social security has been robbed. all the money, you know, they will use it to pay bills. we do not ever really get to debating all of the issues that need to be debated. i would like to see congressman with term limits and not on the take and insurance companies -- i know i am traveling on the side issues. and we do not talk about the u.s. no longer being number one caring for its people, education, all of the issues, health care. europe has surpassed us. china is going to surpass us. india will surpass us eventually. host: writing checks willy- nilly, and -- çits per, paul, republican, wht you think about the proposed $250 for seniors? caller: i'm 69, would receive the money if it were allotted. i think it is a bad idea. it is possible that it is being used at this time to garner a little more room -- support for the seniors through a health care plan. the main reason i am opposed to it is because it just increases this enormous debt we're running out. if i had young kids, i would be frightened. this is way too much money we are spending. if you want to spend the money, do it to create jobs. we have millions of people out of work. the money could be much better spent for them than for us folks that are on limited incomes. host: in the "usa today" this morning -- and the mulrine joins us on the phone right now. -- ann de mulrine joins us on the phone right now. what is the status of the recount? i understand she is not any longer with us. we will go back to your phone calls on the proposed $250 checks for seniors. the savannah georgia, hello. caller: i would like to make for a full you -- i would like to make four points very quickly. i have been watching a lot of the commentators taking your calls. before your be cutting people off, make sure the person is doing the talking. a lot of the collins have great points. -- a lot of the callers have grade point. a lot of us can i get to our politicians and we get to them through you guys. that is the first point. the second point is, the $250 is a beautiful beginning. i used to do security. i'm a senior citizen and originally from chicago. i am out in georgia. they originally did a a a senior traveling plan -- they originally did a senior traveling plan. the money that they have been getting is not adequate, as many of the prior callers have been saying. it is not adequate, but every little bit helps. so, this is a beautiful beginning. another point that i would like to say is that if god, the creator of all, should seek it -- see fit to the allowance to be seniors, all of us should see the true -- see this through. the economy and health care, all of this is plain to if we should become seniors. i thank you for not cutting me off. host: ana will ring is with "u.s. news and world report -- ann a mulrine is with "u.s. news & world report." can you tell us what is happening? ok, we have tried that twice. maybe the third time is the charm. according to the afghan ambassador to the u.s. there was a recount, president karzai started with 54% of the vote. in the recount he got 47% of the vote. the rules are if you get less than 50% of the vote in the afghan election, then there is going to be another election. the ballots are being printed in london right now and they are being marked with an indelible part link -- purple ink. the real action in afghanistan will be in the first week of november it looks like at this point. that is an issue we will discuss later on in the "washington journal" over the next week or so. this is the front page of the "new york times" this morning. ãothis is their lead story. next call is san leandro, calif., lilly, democrat, what you think about a $250 check for seniors? caller: yes, i'm very happy to get evethe $250. what i do not understand is why people have not complained about the billions and billions of dollars we spent in iraq and are now spending and afghanistan. that is what people should be complaining about, not about this $250. if it is a broad, people must think very little of their fellow countrymen to say, well, $250 for a private. i would not even accept a bribe for $250. and that they be in mississippi who only gets $500 per month in social security, i really dupre that she is getting some other income because if i were to get just the small amount from social security, i would send it back to them. again, i thank you very much for taking my call. host: here is the front page of the "hill" newspaper this morning. the pentagon pays an average of foreign dollars to put a gallon of fuel into a combat vehicle or aircraft in afghanistan. wilmington, ohio, walley, republican, what you think about $250 for seniors? caller: good morning, peter. i am opposed to it and not only am i opposed to it, i do not intend to cash it. i just consider it an obvious pride for old timers because the polls indicate -- an obvious briza and for old timers' because the polls indicate seniors are upset about the medical scene. i could use $250, but i'm not going to accept it as a protest. i am 85 years old, a world war ii veteran and on not going to take any bribe from anybody, especially the government. where is that $250 coming from? it is coming from our children and our grandchildren. all it is is a transfer of wealth from one to another and god only knows what is going to happen to our grandchildren. thanks ever so much for accepting my opinion. host: what did you will for a living when you were working? caller: i owned my own business, peter. host: did you make money? caller: i started out with nothing and we built the business up. we severed all along the time the bill -- the business was building up, but we made it. host: what kind of business? caller:çó manufacturing graphic arts materials. host: thanks for calling in. jean drogin tweet in, not getting the cost-of-living raise this year means every year from now on you'll be one year behind where you should be making. this article in the "wall street journal" this morning -- ç this is, again, in the kob"wall street journal. what you think about the $250 check for seniors, michigan? caller: they are giving a multimillion-dollar some to very wealthy people, but yet, they're cutting our people's social security. doesn't anybody noticed this? iraq is the middle east gas station. afghanistan is where they are taking the heroin. they are bringing it back to the u.s. and dispersing it in america. every since we laid forth in afghanistan, the year when production has quadrupled. host: we will leave it there, thanks so much. one article before we turn to our guest. "house rejects the gop effort on detainees." this is from the "philadelphia inquirer." we have been hearing throughout the last year that there are 46 million uninsured americans who do not have health insurance. we are going to find out more about that from diane rowland from the kaiser foundation next. [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2009] >> q&a sunday, columnist and commentator s.e. cupp is the co- author of "why you are wrong about the right colli,." >> this sunday night on both tv, baran mcginty recounts the trial of the abolitionist john brown and how he says he transformed his treason trial into an indictment of slavery in america. >> now available on dvd, c- span's feature-length documentary, the supreme court, and to america's highest court. learn about the role of the court, its traditions and history through interviews with all 11 current and retired supreme court justices. take a tour of the building, including the grand public spaces like the great hall and chamber and was of the private places only accessible to the justices and the staff. the supreme court, home to america as highest court is only $9.95 plus shipping and handling. get your copy today at c- span.org/store. host: on your screen now is diane rowland, the executive vice president of the kaiser family foundation, executive director on medicaid and the uninsured. that is what we will talk about for the next 40 minutes or so, who are the uninsured in america? diane rowland, the 46 million figure of people that are uninsured, how did you derive that figure? guest: those numbers come from the u.s. census burke-bureau. they do an annual survey of americans and ask them about their health insurance status. those are government statistics that mantra every romany people are uninsured. host: the who are the uninsured? guest: they're all of us. they're working americans, most of them have moderate incomes and cannot afford health insurance because it has become so expensive. many of them work in areas that do not offer coverage. 80% come from working families that just cannot get their health insurance coverage through the workplace like those of us that have coverage. host: according to the charts at the kaiser family foundation has provided, characteristicsç of e uninsured -- we want to show this to our audience. of the uninsured, the 45.7 million uninsured workers, or people, they are one or more full-time workers in a family in 66% of the cases, correct? guest: right. >and host: and unemployed make p 19%. of the 66% employed full time, where are they working? to their employers not offer insurance? guest: many of them are working for small employers and small employers do not offer it often because it is expensive. it is harder for them to obtain a good deal on health insurance coverage the way the very large, say 1000 employee, might be able to do in the group market. many of them work for a low-wage job. the combination of an employee offering is hard for people because if they were get a small mom-and-pop store, for example, they're likely to be able to get insurance through their employer. if they -- they are unlikely to be able to get insurance through their employer. if they try to purchase it, it can be prohibitively expensive. you're looking at policies for a family of $13,000 per year and your a low-wage worker making $30,000 per year, you cannot afford it. the majority of large employers offer insurance. about 90%, say, over 250 employees. host: back to the uninsured when it comes to income, you have that 10% or 400% of their income, they have income of four and a% over the fogh -- a federal poverty level and that is 10% of the uninsured. 23% of uninsured people in the u.s. are at about 300 percent of the federal poverty level. 29% are at 100% of the federal probable and a 38% of unemployed workers are below the federal poverty level. what is the federal poverty level? guest: it is calculated based on family size. for a family of four, it is about $22,000 per year in total income. most of the individuals who are below the poverty level have incomes of below $22,000 for a family of four. which means that they are basically zocor that we consider them under the -- so poor that we consider them under the poverty level and eligible in some cases for assistance through medicaid, but mostly it is for children. we do not really provide adequate coverage. it is a myth that the poor are covered in the u.s. many of those float -- low- income people are going to be without a of insurance coverage. host: but not eligible for medicaid. of the 47 -- of the 45.7 uninsured americans, the majority are 30 to 54, working age, 19 to 29 years old, 30%, and 0 to 18, 18%. why is the majority in this working age group? guest: the group that is at highest risk of being uninsured are the young workers, and that is primarily because they are just starting out in their careers. many of them are going to work for the first time or are in jobs that are lower paying because they are just starting their careers. many of them are just coming out of school and they have been covered under their parents' policy and are no longer eligible for coverage through their parents and have gone to the workplace without other insurance. we're looking at a combination of low incomes and low offer rates. host: we have divided our lines a little different this morning between the injured and the uninsured. -- and the uninsured and the insured. the numbers are on your screen. here is another chart that is provided to us by the kaiser family foundation. let's do it by citizenship. again, totally uninsured, 45.7 million. u.s. natives, of that 45.7 million, 74% are u.s. natives. ç6% are naturalized u.s. citizens, and 20% are non-u.s. citizens. what does that mean by non-u.s. citizen? guest: that includes individuals who are here on visas with green cards who are working, but not yet citizens of the u.s. and they're also -- there are also some who are here illegally and they are included in that number. of the total 47 million uninsured, perhaps as many as 8 million of them are illegal immigrants, and therefore, excluded from the kind of coverage that we provide to citizens. host: you just drop #47 million -- threw out the #47 million. guest: it is between 45 million and 46 million of the elderly and if we include the elderly population, it gets a little bit higher. host: i thought coverage was mandatory at age 65. guest: there are some individuals who do not have the work orders are required to be eligible for the program, or you raise the immigration issue. some of the seniors of our immigrants have not got a connection there for the social security system and would not be melichar -- eligible for medicare. host: the uninsured overall is what percentage, including the elderly? guest: about 15% of the u.s. population is uninsured. host: and looking at the health care debates on capitol hill, with the decrease to under the various proposals? guest: most of the proposals are looking at providing a broader coverage through the medicaid program to the lowest income and then giving of -- others the option to go through an exchange to get some kind of broad and coverage. it looks like some of the bills will give cutting our insurance -- uninsured in half. we will still probably have those that are not legal residencts and the world the individuals that have not signed up for coverage in the early days. host: diane rowland is our guest, from the kaiser family foundation, the executive vice president. the kaiser family foundation is not an advocacy group and she will not take a position, but if you have a question about who are the uninsured, she is the person to ask. heather is an uninsured person in washington d.c., you are first of. caller: i have been watching c- span since i was 15 and this is the first time i have ever been on the air. i'm thrilled to be talking to you. i am in a group that is not mentioned very often in the debate, and that is people who are temporary employees. i have been temporary at my place for a year and out and temporary employment does not offer benefits. i am college educated. i am full time. i can get coverage through the city of your take-home income is less than $1,800 and mine is about $1,900. i have not seen anything in current polls -- proposals that would cover me. people like me that are not technically low-income, but i do not have coverage. guest: your situation is one that many people find they are working and not able to get coverage through their employer. what the legislation is trying to do is to make coverage broader and more available through employers, so in some of the legislative proposals employers would be required to offer coverage or pay a penalty into the exchange so you could get coverage there. basically, the legislation that congress is considering would try to give you a broader options for getting coverage and hope so that you would not be just above the line as you are right now for the coverage in d.c. host: new haven, conn., anthony on the injured line. -- insured line. caller: are you related to john rowland? guest: no, i am not, although i did grow up in connecticut. caller: i will be 68 this year. i have united healthcare and last year and this year, my premiums went up also with blue cross blue shield, the premiums are going up 30%. everyone talks about the illegal immigrants. how many of them are really injured by any -- insured by any big insurance like blue cross or whatever? also, diane, we're talking about $250 for the seniors and a lot of people called in saying i would not take it or it is not worth it. we just got $250 this spring and early summer. another $250, about what health. that is not borrowed money. that is coming out of social security. host: anthony, thank you for calling in this morning. diane rowland, to his first statement tomorrow their illegal immigrants who may have insurance coverage? guest: there are, in fact, if they are working for an employer and picking up coverage through the employer. some of the illegal immigrant population has merged into the working force and as such, they can buy coverage and probably to trigger employer. another host: charge from the kaiser family fund -- host: another charge from the kaiser family foundation. total of 300 million people who are covered by insurance. 52% of them are covered through employer sponsored insurance. the 15% are uninsured. medicaid or public assistance cover 13%. medicare covers about 14% of the population and then private non- group covers about 5%. what is private non-group? guest: that is the insurance that we think about as individually marketed insurance that people can purchase on their own. if you are not offered coverage through here in corera -- through your employer and you want to have coverage for yourself or your family, you can go through a broker to purchase individual insurance. it is that market that has some of the roles that are being debated today. they can exclude you for pre- existing conditions a a. they can cover you for one year i decided to have a lot of help experienced during that year they will not renew you. it is a small group, but the group in which people have the most trouble if they have health coverage -- health problems obtaining coverage. that is where the reforms would take place. host: the people that are uninsured, have you broken it down to see how many of them have just a catastrophic plan or full interest? guest: know that -- for full insurance? guest: we know that there is a range of coverage are there. most people have comprehensive coverage. some people who purchase in this individual market have their work policies with limited benefits. but we do not have the full measure of how many people just have catastrophic. we do know that as we begin to look at plans that have high deductibles, say $1,000, $2,000, $3,000, some of those can be classified as being under insurance because if you have a minimal income, you may not have the reserves to be able to pay those deductibles. we are moving toward having less comprehensive insurance and more out-of-pocket payment up-front that tend to be in some people's minds toward more catastrophic coverage than a a comprehensive coverage. -- host: on6v the uninsured lie from washington -- host: dawn on the uninsured live from washington. caller: i just wanted to let you know that i'm 47 years of age and a self-employed -- and i am self-employed. i employ maybe 45 people. about four years ago i have health insurance coverage and it started out around $1,800 a year, which i thought was very affordable. within about 4.5 years it went up to $9,000. i call of the insurance company and said, you know, i cannot really afford this because i'm only making about $32,000 per year. they said, well, we will help you out, thanks for calling. they lowered it down $3,000, but then i've got a $3,000 deductible and then i've got to pay 50%. they only cover 50% of the bill. it's got to the point where i thought, why am i paying out $5,000 and then another $3,000 out? it is $8,000. it is like, what i have been saving for the past 15 years, the insurance companies are going to wipe it out in four or five years and i would broker. -- will be broke. guest: you have hit on a very important point, there's a balance between lowering the premiums and lowering the kind of coverage at you get. sometimes when we lower the premium, we raise the deductible that you have toç pay before ay coverage kicks in. it is so high that it makes the value of the insurance policy only true if you have a very catastrophic illness. that is the tension in looking at health care reform, what are really going to say is health care coverage and how adequate will that be for people of modest incomes? you have also raised a critical point that the cost of insurance continues to escalate and it is getting more and more are of reach for individuals and part of what health reform also has to try to do is to make coverage more affordable for families. it cannot just be that everyone is required to have coverage. you have to be able to afford the coverage i you are getting. host: you also break down the contributions that an employee makes and that an employer makes. in 1999 on average, the premiums were about $5,791, about $5,800. the employee paid about 4200 of that. in 2009, the average employee paid about $3,500 in in premiums and the employee -- and the employer paid nearly $10,000 a year. why the increase? health care guest: cross have been -- guest: health care costs have been rising and therefore, workers' wages and when you get from inflation, as you just talked about in your previous segment, lags well behind worth the price of health insurance is going. we have a bigger and bigger disconnect between the ability to be able to afford coverage and the price of coverage. what you are showing here is that today, health insurance for an employer is about $14,000 per year, which is also about what a minimum wage worker makes. employers especially, as we talked about earlier, small employers have a hard choice. they can either hire another worker, or offer them health insurance coverage. host: would this be the cost for a corporation like ibm for tens of thousands of employees? guest: yes, this is a national average. we do a survey of 2000 companies across the country and look at the aspects of the cost sharing and some of the other aspects of the policy, but especially the cost of the average premium. when we look at that further, about one-quarter of the premium is usually the share that employers ask their employees to pay. some firms pay higher share and some a lower share. host: statistics from the kaiser family foundation. 45.7 million total uninsured in the u.s., about 15% of the total population. of that population, 46% are white. 32% are hispanic. 15% are black. and asian pacific/islander, 5%. we have a tweed here. guest: no, but kaiser family foundation was founded by henry j. kaiser, who also founded the kaiser permanente a health plan as well as kaiser industries, but we are not affiliated in any way with them except to share a common founder. host: michigan, mario, on the injured line. caller: the insurance companies, the senators are a sleep over there. when the export of our jobs are, they were asleep then and now they are asleep at the insurance companies. they want us to pay money out of our pocket to go see the a doctor. we are poor already. there is no litmus test on the insurance companies to say, all the different names of entrances -- of insurances. they should be forced to put a total price on insurance. it is not truthful when you are drawing money out of your pocket. that is not insurance. you want to be able to pay for travel insurance and that we i have a comparison from one company to another company. they can lie about what they're really doing for the people. and they are still making money at our expense the the point is right there. host: any comment? guest: certainly, one of the challenges is how to make these policies more easy to compare and regulating the market. many of the changes we are looking at in regulating the insurance market is helping the consumers to know what they're looking at afd!when they get sick, to have the coverage available. one of the reasons we engage in this effort to provide coverage to the uninsured is that we know that the insurance makes a difference in terms of how use the health care system, how quickly you get to a doctor, and the goal for all americans is to help us live healthier and help us to be able to to excess health care when we need it early enough so that a disease like cancer it can be detected when it is still treatable and not go on treated -- and treated anduntreated. host: about 15% of the u.s. population are uninsured? the debt increased during this current recession? guest: it has clearly increased overtime. even we had a fairly good economy we did not see a great decrease in the number of uninsured. host: why? guest: because interest, as we have talked about, is so expensive that there is not as much of an offering. many employers that would have offered in the past do not always offer it. we have seen a decline in the availability of coverage through the workplace. what we're seeing in this recession is that as people lose their jobs, they lose their of insurance coverage. some of them can maintain their coverage through the cowger option, the ability to extend your employer coverage -- cobra an option, the ability to extend your employer coverage. but there is less availability of that anymore. many of the stories that we hear about people that never thought it would be uninsured, but now they are unemployed, have lost their jobs and are looking at options for coverage and there are not many out there. . . caller: thank you for taking my call. i love this program. i watch it every day. you were speaking about the cobra plan. i became unemployed last year. to continue the cobra coverage, i had to produce a two hundred dollars at a point i was ouwitht employment. -- i had to produce $1,800. i applied for medicaid, which i was able to get for my kids and myself until i received the unemployment. at which point, i was too rich for medicaid. i'm trying to understand what exactly are the poverty guidelines? i feel like i should fall within the range. $330 a week. i'm grateful that i have it. it is keeping me in my home and helping to keep things turned on, but i certainly feel like i should qualify. i want to understand what the poverty guidelines are for a family of three, one adult, two children. guest: you have pointed out the gaps in the existing health care system. the cobra option requires you to pay the full share. when we talked about the individual having a contribution of about $3,500 against a total premium of 13,000 four hundred dollars, when you are on the cobra, you have to pay the full premium because your employer is no longer responsible for that. if you have lost your job in your are on unemployment, that is too much to pick up. the stimulus bill did provide a subsidy for those kroeber ocobra premiums. that does not really go as far as it needs to go to help people get over the hump. the medicaid program is a means tested program. you have to meet income guidelines, which vary across the state's. we have done in a lot in the past few years to provide broader coverage for children, which is why your children are on the program. we covered children in most states of to about 200% of the poverty level. however, the parents eligibility is much lower. the reason that your children are getting coverage and you are not eligible is because you have to be a lot poorer. that is one of the aspects that health reform is trying to protect. host: you also bring down the uninsured rates among the states. this chart shows greater than 18%. that is 17 states. they seem to be in the south and the west. 13% to 17% in the middle of the country. there are 10 states that have less than 13% uninsured rates. is there a regional reason for this? guest: but there are a number of reasons. the economy of a state of largely drives the uninsured rate. when you look at insurance -- when you look at the states in the northeast, their manufacturing base. they are union based. that has helped to contribute to a much more rigorous employer based coverage system then in rural states and states with large agricultural interest. and especially states with small employers, especially through the midwest. where states are poorer, they're less likely to have coverage. the low-income population is where most of the uninsured are. throughout the south, you see higher rates of poverty in those states. less adequate coverage through medicaid. caller: why are the insurance companies so dead set and danced -- so dead set against the public option, when most of the people you are describing cannot afford insurance in the private sector and how? it does not make a lot of sense. middle want to ensure them and they do not want the government to ensure them either. guest: this has been one of the controversial points in health care debate. public option would provide individuals who are going into the exchange and trying to get coverage to have a choice of either a private insurance plan or a plan that is more modeled on the medicare program. insurers say that will be an unfair competition, that they cannot compete with the public plan. many believe that having a public plan would give them an incentive to be better price and better in terms of the coverage they offer. i think that will remain one of the huge debates that we have as we go forward with health care reform. host: the majority of the uninsured are in working families. you state that over and over. why? guest: because the nature of our health care system today is based on whether you get coverage through your employer or not. the relationship between working and getting health insurance is one that we billed as the way in which to get health insurance coverage. we want to make a strong point that one of the places we need to strengthen is the employer relationships with individuals to get more coverage through the workplace, or you need to provide a broader alternative so that people who do not get coverage through the workplace can still get coverage. they are working. they're often temporary workers who do not have an option to get coverage through the workplace. we think it is important to stress that these are not families who do not want coverage. their families who cannot afford coverage. host: kff.org is the web site. florida on the uninsured line. caller: good morning. guest: good morning. caller: until they take the profit motive out of the health insurance companies, there will be this budding head between the private and public sector. someone made an observation on one of the show's earlier in the week. the people are going to reform the system. right now, we are not given a choice. if the choice is given to the people through a public option, the people will perform the system. guest: i think that choosing your health insurance plan and having lots of options available to you is something that is the goal of health care reform. you would like to be able to have a choice of a public plan. that's why it's so actively debated today. host: richard on the insurer's flyied line. caller: i was under kaiser for over 40 years. i did not know how good you were until the year 2000. my total family plan was $28 per month when i was working for the federal government. once i retired, then it jumped to $250. from then until now, i have become over 65. my wife is over 65. my insurance is over $800 a month. i get less service. i pay a higher copiague. i pay a higher price for my medication. i do not understand why kaiser is not the model for how to do a health program for the entire country. i simply do not understand that. i will hang up and listen to your comments. thank you. guest: we are the kaiser family foundation, not the kaiser health plan. the plan has been a model for many integrated health-care services. it can offer more comprehensive services. i think that is clearly one of the issues that everyone will be looking at in health care reform. i'm sure the health plan will be pleased to hear how well you think they have done. host: 15% of the american population is currently uninsured. have you looked at how many are eligible for federal or state aid that do not get it for one reason or another? guest: we do look at that, especially among the lower income population. most of that has been extended to children. we know that the children out there, 8 million children are uninsured. potentially as many as 5 million are probably already eligible for some kind of coverage but not getting it. part of that is of their families may not be aware that their income qualifies them for public assistance. in other cases, we know that because the parents are ineligible, they're less likely to enroll their children. we think if you extend the broader coverage to the whole family, you would get more people to participate. some of it is just outreach. we need to do better outreach to tell people that there are options, especially for their children to get coverage. one of the issues in health care reform is that if we want everyone to have coverage, perhaps we need an individual mandate, a requirement that you get coverage. today, coverage is voluntary. in many cases, people do not know that they have to sign up for coverage. they find out when their child gets sick that the coverage is available in a sign up there. >host: i apologize to keep going back to this. i just want to figure out who these people are. about 46 billion uninsured americans. 8 million you estimate to be illegal immigrants. they would not qualify. that brings us to about 38 million. some of the plants say they will get us to 91% coverage or 94% coverage rather than the 15% uninsured that we currently have. who is left over? who are those 6% or 9% of folks who would not be covered by insurance under the proposals on capitol hill? guest: the proposals would require people to have health insurance coverage, but would also allow people to get an exemption. some of the individuals would be people who do not qualify for a subsidy, or for whom the subsidies that are offered are not adequate. health insurance is still on affordable. they are exempted. and the one group is the exempted group. the second group would be the individuals who are barred from coverage because of immigration status. in addition to that, you have some individuals who may elect not to get coverage and pay the penalty that is offered instead of the price of the insurance. that becomes very tricky in health reform. is the penalty substantial enough to provide an incentive for people to get coverage? it is important to get as many people covered as possible. we know that the broader the risk pool, the more affordable insurance premiums will be for everyone. we do not want a situation where ithose who have chronic illness sign up and those were healthy stay out. host: time for two more calls. steve on the uninsured line. caller: i am a laid-off union worker. i got laid off in the middle of 2008. a little bit before the spring. and i still had health insurance for a while. i was by the italia-- buying it. the cobra plan was $600 per month. host: justic to the health insurance. we're almost out of time. caller: the man said something about public option, which i do not oppose, but i was in south carolina this past summer, and i looked around for health insurance. i could get it almost $300 cheaper and south carolina. why canno't i get it in south carolina? guest: a lot of that depends on where you live. you are right. there are high-cost areas and low-cost areas. insurance premiums vary across the country depending on the costs of medical care, depending on what' they charge in terms of having people in the pool that are less expensive or more expensive. you are a higher cost state in ohio. your premiums will be higher because health-care costs are higher than in south carolina. one of the issues is -- should we be more national? should we have more of an average national rate so that you do not have a tremendous variation across the country? unfortunately, each state is different and medical care cost different amounts in different states right now. caller: i am a nurse at kaiser. i understand you are not part of the kaiser health care plan, but i work with managed care. i walked around on a broken pelvic for six months because i was not saying the right thing to my doctor to get an x-ray. i have watched children come in -- it takes weeks to get an appointment with their doctor. right now, if you want an appointment, it is a six-month wait. that is managed health care. if people who do not have jobs want a free ride, they need to understand is on the backs of people who work. guest: you point out that there are many gaps in our existing health-care system. one of the debates is do we have the best health-care system in the world? some say, yes, we do, when you can afford it. there are a lot of issues in how we improve the quality of care, not just the availability of health care insurance. you're speaking to the broadest challenges we face. host: all of this information we're showing you today is available at kff.org. characteristics of the uninsured in 2008. of the uninsured, one or more full-time workers is in 66% of the households. no workers in the 19% of the households. part-time workers in 14% of the households. everything we're talking about is under 65. we are presuming the elderly are insured by medicare. this is by citizenship. 45.7 million in thuninsured in e u.s. 74% are u.s. native. 6% are naturaliszed. guest: people year where students abroad as well as illegal population. host: which you estimate to be 8 million people. the entire u.s. population, 15% uninsured. diane rowland, thank you for coming on. i hope you will come on again as we continue this debate. next, we'll talk about two tight governor's races in new jersey and virginia. >> after speaking last night in san francisco at a democratic fund raiser, pres. obama joins former president bush at a forum on volunteering at texas a&m university. the event honors the 20th anniversary of the president's volunteer service movement. president obama returns to washington later today. there is word this morning of more u.s. troop deaths in afghanistan. the military says four service members were killed in a bombing in the southern part of the country yesterday. an f-16 pilot and is missing. one jet landed safely at charleston air force base. the location of the other plane and pilot is unknown. the coast guard is currently conducting a search. those are some of the latest headlines on c-span radio. >> 2010 student cam contest is here. the top prize is $5,000. just create a five minute to eight minute video on one of the country's greatest drinks or challenge to the country is facing. it must incorporate c-span programming. winning entries will be shown on c-span. grab a camera and get started. go to studentscam.org. >> "washington journal" continues. host: two working reporters covering the new jersey elections. dunstan mcnichol is with bloomberg news. who is winning in new jersey? guest: that is a good question to the latest polls have hit a statistical dead heat. the last one had chris christie ahead by 1%. the margin of error is 2.8%. there are 18 days to go. each of the campaigns has an end zone strategy they're starting to work up now. like a lot of new jersey elections, this one will not be decided until each individual voter stance in a polling booth and figures out which name to put their finger on. no one has an enthusiastic following. it is mostly which one and i eventually going to put my finger on. host: governor jon corzine was elected four years ago with what percentage of the votes? guest: i do not know that number of hand. his republican candidate was a lot -- he had a lot less or starting power than his current opponent, chris christie. chris christie had a lot of recognition from a long career as the prosecutor in new jersey. he had a lot of high-profile political corruption cases in the course of this campaign alone, there have been two state senators convicted of crimes related to their office. there was a party official who is currently on trial for influence peddling. chris christie's role in the political corruption arena offered him a lot of name recognition. to say nothing of the economic dynamic, which is really working against any incumbent. new jersey, like the rest of the nation, has a basket full of problems. host: dunstan mcnichol, we have been showing a picture of three candidates. who is christopher daggett? what is his affect of the race? guest: he is a former environmental protection administration official. he was under republican gov. tom kane, who is still a popular figure in this state did his effect in the race this time is detrimental mostly to the republican candidate. this race has essentially become a fight over a vast pool of new jersey voters who could be called the anybody but jon corzine contingent. at the outset of the campaign, nothing on earth would make them vote for jon corzine because they did not feel he was successful in getting the state's finances and business circumstances in order. that has changed over the last couple of months. the reason it has changed is partly because of chris daggett. he gives that campaign a place to do that is not the republican candidate. they can say, i'm not going to vote for jon corzine, but i am going to vote for chris daggett. host: i want to interrupt you right here so we can get our numbers on the screen. we have divided our numbers a little bit differently. we will be talking about virginia and new jersey. virginia residents, we want to hear from you about your gubernatorial race. new jersey residents, and all others around the states who want to talk about these two gubernatorial races. also with us is rosalind helderman, "washington post" covering virginia politics. give us a quick snapshot of who is winning and what are the issues. >> it's a different story in virginia. the republican, bob macdo cdonnell had been ahead. right now, aiful had bob macdonalcdonnell ahead by 9. there has not been a lot changed. there is 19 days to go. a lot of things could happen. host: what are the issues? guest: transportation is a big issue. also very interesting have been federal issues. he has worked hard to introduce issues like the federal climate change bill and health care reform into the virginia race. he believes that one year after electing president obama, people of virginia are quite nervous with the direction president obama is taking the country. host: besides the economics of the state, are there any other issues in play? guest: the major issue is, has the incumbent accomplished what he set out to do. there's a profound level of disappointment across the state. some of which is the governor's doing. some is beyond his control. the national economy certainly collapsed. it collapsed just as hard, if not harder in new jersey. he takes the blame for that. four years ago, the state was already in fiscal issues. it had high debt. there were pension shortfalls. there was still the corruption issues. he came into office promising to address those things and make them better. there's no argument that can be made that they are better at this stage. host: here are a couple of the commercials that are playing right now. would you get away without points? chris christie did. chris christie threw his weight around as u.s. attorney and got away with it. chris christie, one set of rules for himself, and another for everybody else. >> jon corzine promised to cut property taxes. instead, he gave us the highest tax burden in the country. jon corzine, his negative ads cannot tied his failed record. >> i will cut spending and and the special-interest giveaways. i will cut taxes and restore property tax rebates. i will bring good jobs back to new jersey, not chase them to other states. i will make sure all of our children get the education they deserve. host: here are a couple that are showing in virginia. >> what kind of person writes a thesis calling working women detrimental to the family, and then lies about his opponent to cover up his own record. the post said he took office and began passing this social agenda. and that he voted to deny access to birth control. they said he opposed equal pay for women. no matter what his ads say, he cannot cover up his record. >> when you say i am not one to raise taxes, what did you mean? what did that mean? >> that meant in the general sense of the term, i'm not going to raise general fund taxes. i know we will need to raise money for transportation. >> so you will raise other taxes? i have no plan to raise general fund taxes. what kind of taxes? >> everything is on the table. >> is the gas tax in general fund tax? >> so it would not be covered under not raising taxes? >> i think i made myself clear, young lady. >host: how effective was that ad? guest: it appears to have been very effective in this campaign. what is featured the there is a moment after the two candidates debated last month. in the debate, the democrats have said that he would not raise taxes in this down economy. it was a little bit of a misspeak for him. it is not what he had said previously on that topic. he was trying to correct himself. he said he would sign some kind of tax increase to pay for road improvements and only road improvements. he has a habit of sometimes stammering through his words. he is not the smoothest speaker on the campaign trail. that ad has been aired again and again. there are several versions. some have been paid for by bob mcdonnell, some by the republican governors association. tax is a topic that has traditionally worked very well for republicans in virginia. host: who was the interesting when he said young lady? guest: he was addressing a reporter. the two of them have known each other for a long time to be called the reporter after words and apologized. she said she was not offended. it was a difficult moment for him, not just because he appeared frustrated. some people thought that comment was condescending to a woman. as you can see from the first advertisement, there's a big battle for women in this campaign. the democrat has accused the republican, bob mcdonnell, as unfriendly to working women. that was sort of undermining to the argument he had been making at that time. host: dunstan mcnichol, you have covered new jersey politics for a long time. where would you rank this race in terms of negativity? calguest: it is right at the bottom 10%. there's really no positive. it is pretty much 100% negative. host: trenton, new jersey, please go with your question. caller: governor jon corzine is being very unfair against free- speech. he is against the woman. he says the woman will not do any mammograms. the other thing that i do not agree is when he has the commercials, he makes fun of chris christie's weight. i do not think that is fair. guest: the first issue is a matter of chris christie's proposal that there be some mandate free insurance policies to make some insurance more affordable. that has developed into an issue where one of the state mandates requires that insurers provide coverage for mammograms. his suggestion of a mandate free policy got seized on by the jon corzine campaign. it has blown into a very consistent debate back and forth. the chris christie campaign insisted they would do nothing to do away with a mammogram coverage. it has become a real flash point in the campaign rhetoric. host: go ahead. guest: the second point was the jon corzine campaign overtly and suddenly has made a lot of issues of mr. chris christie's birth. they talk about him getting out of a few traffic tickets. they did not just say he used his influence. they said he threw his weight around. there are not many people who think that was by accident. host: the next call is on the virginia line from the suburbs of washington. springfield, virginia, go ahead. caller: bob mcdonnell is likely to win in virginia. he has shown himself to be the master of a triple play. he is running a positive campaign. to the extent anyone thinks bob mcdonnell's show negative, he is using deed's own words. third, he is running in the obama era. in northern virginia, we are much more like washington d.c. and maryland then the rest of the commonwealth. the fact is, obama is a great candidate to run against. host: rosalind helderman? guest: you are not alone in feeling that way. the post poll found that 60% felt as though democrat creigh deeds had run a largely negative campaign. bob mcdonnell 60% felt bob had run a positive campaign to the democrats would tell you that's partly because they are dramatically out spent in this campaign. bob mcdonnell can afford to be running negative ads, but balancing them out with a lot of positive ads. there's been a great cry even from democrats that creigh deeds run more positive ads. as for obama, that is also the case. bob mcdonnell has been very careful with how he has criticized obama. he has not gone in for some of the excess that could have alienated independents. he has talked very specifically about washington policies that creigh deeds has had problems responding to. at the same time, bob mcdonnell has praised obama at times to make sure this does not feel personal when president obama won the nobel peace prize. host: next call from new jersey, go ahead. caller: i supported lon again in the primary. i felt he had better ideas on reforming arbitration. with jon corzine, what do you think is going to be the effect of his personal fortune and the fact that all the state unions are behind him? also, how come the press did not report much about jon corzine when he was let go by goldman sachs? he walked away with i think $200 million. guest: jon corzine's departure from goldman sachs has been thoroughly explored early on and a lot more when he was running for u.s. senate and then for his first term as governor. that's pretty well plowed ground. the early. that he brought up about the republican candidate in the primary against chris christie, and tapped into the very conservative end of the republican party here in new jersey. is the dynamic that works against republicans on a statewide basis. in order to win the primary, they have to take positions that can at least placate the very conservative opponent of the party. that tends to compromise them in the general election. steve is an interesting character. the points he makes on the state debt and the state pension system hopelessly underfunded are very. accurate. -- are very accurate points. it will still play out, no matter who wins the governmenho: governor race we are talking about the virginia and new jersey gubernatorial races with two working reporters. dunstan mcnichol, how much money has been spent in new jersey? guest: the governor will end up spending around $30 million. most of that will be his own money. the republican candidate is limited. he is using the public finance. he is limited to $10.3 million. host: virginia, you are on. caller: good morning. i'm a first-time caller to thank you thank. -- thank you for your service. i see your unfair to the democratic party. when i say young lady -- you are criticizing creigh deeds because he called of the reporter young lady. what is he supposed to call her? you're all against this nomination of the democratic party, creigh deeds, because he had a problem speaking. we do not have to discriminate people when they have a problem speaking. that is very unfortunate. you never reports that a rich ladjohnson -- i forgot the first name. host: we asked rosalind helderman here to discuss the race. she was simply responding. she was in no way insulting or complimenting either of the candidates. his point about. mrs.. -- his point about mrs. johnson. guest: yes, a prominent businesswoman and democrat. over the summer, she crossed party lines and endorsed bob mcdonnell. some video emerged of her at a bob mcdonnell campaign event. she appears to be mocking creigh deeds and the way he speaks. she does it in a way that makes it appear as though she is making fun of people who stutter. creigh deeds does not actually stutter, but he does have a speaking style where he starts and stops his words. she quickly apologized after the video came out. bob mcdonnell says he has moved on. and he has. host: next call comes from buchanan county, virginia. william, please go ahead. caller: i am here and what you called the coal fields of virginia. due to cap and trade, you cannot explain to anybody in this area what cap and trade means. everybody thinks they'ir coal is not going to be mined. i have tried to explain that to the best of my knowledge. host: william, who are you going to vote for? caller: mr. creigh deeds. host: thank you. guest: this is actually an area that traditionally votes for democrats. they believmay be because of thn presence. last year, they went for john mccain, which was quite out of their normal voting pattern. will be interesting to see how that county goes in the selectioelection. virginia has some significant coal fields. coal mining remains a significant part of the economy. bob mcdonnell has said that creigh deeds would support the federal cap and trade bill. creigh deeds has endorsed the concept of addressing climate change in that way. he has said repeatedly that he opposes the bill that recently passed the house. he thinks of it will cost jobs. host: dunstan mcnichol, here is a tweet. guest: this is why i am not a campaign manager. that is a difficult challenge. the chris christie campaign strategy has been to go back to the first phase of the campaign. they have a tagline on most of their ads that is, "if you want to change trenton, start by changing the governor." that gets to a lot of the dissatisfaction with the current administration. he is back to talking about in general terms, i'm going to cut your taxes, i'm going to get your property tax rebates back. and i'm going to cut spending. for lack of specifics, i think people are frustrated with that approach. i think that is his strategy, to present his alternative, himself as the alternative, and not publicize pop chris daggett -- and not publicize chris daggett. host: here is a tweet for both of you. let's take this a step further. starting with rosalind helderman, is this a national election being held in virginia? guest: is both. every four years, you have this issue in virginia and new jersey. they're the only two elections in a country. they come after the presidential election. a lot of voters will vote based on local issues. across the country, they will be seen as a referendum on obama, especially if the democrats were to lose both races. host: dunstan mcnichol? guest: in new jersey, jon corzine wanted to be a national election like in 2008. he is bringing president obama up here to emphasize to the people who might consider drifting away from the democrats that you are drifting into the hands of a republican who is a george bush appointee. in new jersey, is in no way a referendum on obama. there are plenty of issues within the borders that have everybody concerned. the governor would like to be a referendum on republicans versus democrats. caller: i have listened to both of them talk. i live in new jersey. i know what the republicans have done. i know what the republicans say they will do. you cannot do a job in a short time that has been messed up years before you. jon corzine did a mess when he came into the state. obama, a mess when he went into the presidency. people think that you can come in and stop something. fifth third who thought the detective the fifth of property- tax rebate -- new jersey who was supposed to get a property tax rebate got a property tax rebate. faugall gives back to the state. host: dunstan mcnichol? callerguest: that is a message t jon corzine's campaign would like to cast far and wide over the state. we came into office and times were terrible and we did the best. host: "the new york times" poll this morning is approve/ disapprove for jon corzine. guest: he is probably happy it is under 50%. most of the other polls have his disapproval under 50%. yes, it seems like that should necessarily. . the feed -- yes, that is why it seems like it should necessarily spell defeat. you may not like the job i have done, but consider the job my opponent would do. host: his work on property taxes in new jersey, they say 17% approve of the way jon corzine has handled it. 72% disapproved. guest: there's no way that anyone likes what has happened with property taxes. if everybody votes with their faugh pocket books, the pocketbooks are being emptied very quickly. i have been here since 1993. i have yet to see a governor come up with a workable solution to get property taxes in line. caller: i am calling from chesapeake, virginia. this is the first time i have called in. i saw you were speaking about the virginia governor's race. i want to comment about it. i am undecided and in this race as to who i'm going to vote for. the reason is that i am an independent. i just saw an article in the paper where they were showing us the money that each of the campaigns have got to. bob mcdonnell have gotten a lot of support from big business and wealthy people. i am not sure if he is going to be a candidate for the main street people. i do not want to vote for someone who is going to go back into office and start implementing policy that will be the trickle-down theory. we need somebody who is going to get in there and fight for everyone, especially in this kind of economy. on creigh deeds side, i am undecided about him because he has not shown me anything. he is bashing bob mcdonnell, but he has not shown us -- especially in this area, trafficking is a huge issue. he has not said, "this is what i'm going to do." host: rosalind helderman? guest: she said a lot of things that a lot of people have said on both sides. bob mcdonnell had some comments over the summer praising some of the economic policies of george bush. he said the tax cuts of the early part of george bush's term lead to an economic expansion. a lot of people disagree with that and feel as though it was not what they're looking for. on the other hand, a lot of people feel that creigh deeds has not done enough to lay out his vision for the state host: come much money has been spent on this campaign? guest: the two campaigns together, $33 million. there are no limits on campaign donations in virginia. if you're interested in this race, you can write a $100,000 check and that is ok. bob mcdonnell has out raised creigh deeds. bob mcdonnell has had a money lead throughout. host: bob mcdonnell's connection to region university and his master's thesis on women in the work force. creigh deeds has made a lot of use of those freed has that hurt him? guest: bob mcdonnell went to law school and received a master's degree. it was then called christian broadcasting network. it was founded by pat robertson. pat robertson has been a long supporter of bob mcdonnell. bob mcdonnell has appeared on the 700 club. the post reported at the end of august that bob mcdonnell wrote a thesis for his master's degree in 1989. he was 34. it was a conservative action plan that argued that government should be about strengthening the family. he laid out how republicans could use government to strengthen the family. there were some controversial lines. the one that has gotten the most attention is that he wrote that women in the work force have been detrimental to family. a lot of working women have objected to that idea. creigh deeds has really hammered those topics in the campaign. ads over and. it appeared to be working for a while. some people believe creigh deeds over reached. host: next call from new jersey. caller: i am a first time caller. i am an independent. i do not like any of the candidates often. i seldom vote for a candidate. it is the lesser of evils. what i would like to see on the ballot is an actual option that says "none of the above" and have another election. guest: that is regrettably partly the jon corzine strategy. if you go into the campaign knowing that your favorability is pretty low, and your best option is to try to make the challenger also look distasteful. the ads that have come out against chris christie have had that effect, according to the various polls. the image questions about whether he is honest and trustworthy, whether you perceive him -- his favorability ratings. they have all declined under this advertising. it leaves the electorate with no candidate that they like. chris daggett is hoping to capitalize on that and presents himself as the breath of fresh air. and, i am a person who is not tied into old problems. i have a specific solution for property taxes. you may not like it because it involves raising the sales tax, but it is a solution that is on paper and you can look at it and argue about it. he is trying to tap into that sentiment and give people what he perceives as a positive option for. host: last call for our two guests. caller: thank you for c-span. i'm a long time the work. if we reelect jon corzine, heaven help us. the cost of living has gone down. people are losing jobs by tens of thousands. host: dunstan mcnichol, final comment? guest: that distills the challenge that jon corzine has. they're all very accessible. they can be reached when you need to reach them. there. in public all the time. host: dunstan mcnichol was part of the team that won the pulitzer prize in 2006. rosalind helderman, what kind of access do you have to the candidates? guest: the same. they're running very active campaigns. when you want to reach them, you can. host: thank you for being here to talk about the two governors here in the united states. coming up, we will take a look at the newspapers and have open phones. anything on your mind. fau. . the white house says the numbers show the administration is on track to save three and a half million jobs by the end of last year. " the wall street journal" reports the pay czar is acting -- asking the bank of america ceo to give back his salary and to forgo the rest of the salary for 2009. it this as earnings reports this morning show bank of america lost more than $2 billion in the third quarter. the losses are the result of many consumers not paying their bills. the company expects credit problems to continue in the near future. the united nations human rights council voted to refer a geyser war fraught -- war crimes report to the security council possibly setting up international prosecution of israelis and palestinians. israel and the united states called the report flawed and warned it could jeopardize the mideast peace prospects. more than 1400 palestinians and 1300 israelis were killed in last winter's conflict. there has been another attack in pakistan. this one in the northwest city did a trio of suicide attackers, including a female, struck a police station next to a mosque. 11 killed, 15 wounded. those are some of the latest headlines on c-span reappeared >> "washington journal" continues. >> about an hour left to go in " washington journal." you can see the numbers. if you have a public policy topic, now is your chance. stephen moore of "the wall street journal" editorial board will join us in about 20 minutes to take your calls and talk about some economic issues. don't forget, you can also twitter us, twitter.com/c- spanwj. c-spanwj is our twitter address. the front page of "the washington times" this morning. they had an interview with james jones, national security adviser. in an interview, the former marine general and nato commander acknowledged his views on afghanistan have soured in the three years since he left the military. he said security in afghanistan has deteriorated because of the u.s. failure to see the interaction of security, development, government, and rule of law. this is a quote -- i think it is becoming clear that the failure, the tendency to focus much on truth -- troop strength and not so much and other factors to develop a national afghan police, for example, which was on life-support for so many years, the development of the afghan national army, which has never drawn fast enough, those are things that as we develop a strategy released in march, we are clearly highlighted, and not everybody is turning full-scale attention to them. this interview is an "the washington times." if you would like to see the full article. if you -- this is from "the financial times." white house denies decision made on troops. it says barack obama has not made a decision yet on how many troops to send to afghanistan. in spite of afghan claims than an announcement of a large increase was likely. the first call up, west virginia. carl, republican. please go ahead. caller: what i would like to talk about is this thing with a rush limbaugh. you know, the way i see it, it is dangerous. it is censorship. it is trying to prevent a man -- i know he is a rich man, but it could happen to anyone. this political correctness thing, mr. zee or whatever his name is, who owns a portion of the new jersey nets, he comes out with all kinds of songs downgrading white people and all of this stuff and yet they can't let him on a sports franchise. political correctness in this country is getting dangerous. this whole thing is dangerous because what you people in the news media are doing by demonizing people, prevent them from making a living, it could happen to anybody, poor, rich, whatever. host: and if your interested in reading about the situation, "the wall street journal" editorializes about it today. they'd county, florida. caller: two things basically. we talked about the media and how you can really help wash limbaugh was basically a 15,000 or $60,000 a year employee in the sports -- $16,000 a year employee and a sports stadium. what happened is there was a need for this type of person to reach a certain type. when you look at slavery, there was a certain type person that was needed to be more or less the captain's or those in charge of the plays, who had no real heart basically was whipped and beaten because they had to serve and cater to the owners. so basically he was needed during the reagan era to help get in. and what was happening is you don't get the fairness when they reach the millions and billions. and secondly, the johnson woman, she could have been so much help along with rush because when you think of the kids that speak ebonics and you have the power with the video -- media, she could help comment on the race in virginia, which she had the opportunity, to help do the program at the station her husband owns -- host: let us leave it there. a lot on the table. long branch, the jersey. cathy on the independent line. caller: good morning, how are you? i'm fine, thank you. i am putting my vote for john corzine. i would not vote for chris christie anyway. i go to the gym every day. all of that being said. my taxes really have not gone up at all. a lot of that is local stop. people don't understand taxes are assessed locally in your town and its municipalities. all that being said, i watched the debate. i do like chris daggett but i will vote for john corzine because i know him. i heard chris christie said new jersey has the highest unemployment rate in the nation, false, and michigan does. i heard jennifer grant home, 10 minutes before -- it was a real -- jennifer granholme live state interstate had the highest unemployment rate. people need to call this man out for what he is. host: what do you do in new jersey? caller: i just volunteer with animals. i am wife. my husband works. host: does everybody in new jersey topped that fast? caller:no. i'm a county committee woman. it does not mean much. we don't get paid, so we are not on the take, that is how i put it, that is what i told the screener. i'm a county committee woman. because my congressman is frank browning. host: are you still with us? ok. thank you for calling in. new york. alex, republican, good morning. caller: i watched the thing last night. anita dunn awards for the white house, i guess she is one of the czar people. host: she is communications director. caller: in her words she said the two most top political philosophers she looks toward on a daily basis or to the most are now say tong and mother teresa. -- mao tse tung. i understand mother teresa. host: you heard that she reads mao? caller: the two political philosophers she likes to the most and looks to on a daily basis for input on policy is mao tse tung and mother teresa. host: youtube? caller: live on television, and i saw it today because i recorded it. she was speaking to high school students. she went on and on and quoted stop from him. that seems even worse than the stuff van jones -- i'm wondering if she is going to be next. host: all right. chicago, bob, democrat. hi. caller: how are you doing? i was going to talk about what this -- i was going to make another point but it is something so important that needs to be said. you know, the terrorists know of this country way more than americans. i watched a few talk shows and they ask americans who was the secretary of state during the bush administration and they could not say -- gates, condoleezza rice or rumsfeld. however, the terrorists know this country and the politics way more. so they realize how terrible bush was running this country. he was basically a terrorist himself. and they know obama in his heart really wants to help this country and move it in the right direction so they are more likely to attack us because they really hate america because he really wants to move this country ahead. and my last point -- and i so appreciate you allow me to say this on air -- is that until racism and is in this country, in no, i have no choice but to love jesse jackson and al sharpton. my father put american flag the -- on a black guy that taught me how to love america. the white person told me my car was on fire because my brakes were locked up when i was driving. i got to care about people. my last point -- obama, doing a wonderful job. host: the next call -- after a month to show you this article from "usa today." bill will expand home buyers' credit. lawmakers try to extend and expand and $8,000 federal tax credit for first-time homebuyers. the proposal would drop the requirement that the credit be available only to first-time buyers. just a tiny item in "usa today" this morning. tom in san diego. independent line. caller: a few comments and a few things. the last guy talking about racism. i'm white. but, you know, i might 30's and i had nothing to do with racism and it is getting old. we are getting tired of hearing about all the time. to the point that i really don't care. that is my honest opinion. i'm sick of it. the jobs that were created -- if i heard that right, 30,000 jobs were created to, from almost $1 trillion. that is what the government took from our future and spend it, if that is not a crime, i don't know what that is. it would be funny if it was not so sad. host: what do you do? caller: i am a chemist. there is no money coming into biotech anymore. it comes from venture capital. i suspect they are going to wait and see what happens. the president, when he was campaigning -- the lawmaking process. right now a handful of senators, all democratic, behind a door writing this bill that will cause either one trillion up to $2 trillion dollars. host: bob, republican. caller: good morning. it social security. when jimmy carter was in office he put down two bills, windfall elimination program and the government pension of said. and most teachers, firefighters, police, worked for governments, cities, and towns, they had taken half of the social security away from them all of these years. now they want to give $250 stimulus to the elderly point in social security. but the ones that are losing better than half the social security are not really getting anything out of this. i think it is time they looked into this. i feel it is a criminal act. host: well, i appreciate you calling in did regulatory overhaul advances as derivatives bill clears panel. this is from "the wall street journal." house financial-services committee approved a measure that will bring derivatives under the regulatory umbrella for the first time, a major step in advancing a broad regulatory overhaul push by the obama administration. we will talk with stephen moore about that in about 10 minutes or so. this is how "the financial times" played that bill that was passed yesterday at a house financial-services. agency put -- to protect consumer draws fire in house. the obama administration proposal to put a new consumer financial protection agency risks being watered down by lawmakers in congress after an intense lobbying effort by banks. the next call, shreveport, louisiana. leroy, democrat. caller: i was just calling to tell the nation that maybe they should kind of take things a little bit easier and not be so angry. the other day barack obama came up to louisiana and he went to new orleans. in the audience was governor body rigidbobby jindal -- gov. bobby jindal. the president to distance unpeople booed and the president -- the president told the people they're not to believe him. what i fear from all of these people calling in is that they refuse to see the humanity in everyone. i just wanted to share that with the nation. host: oregon. dale, on the air. caller: how are you doing? host: where are you? caller: central coast. i would like to weigh in on the $250 social security pavement -- payment. people called an earlier saying that it was a bribe. i see it more as hush money. i say that because when congress gets its cost-of-living adjustment next year, i think those of us who get the $250 payment are supposed to get the ticket for mouse shut. host: are you on social security? we will presume he is. when we talk with stephen moore with "the wall street journal," we will also speak to students at a high school near richmond, virginia. we will be talking with these kids on the c-span 6 bus and they will also ask questions. corpus christi, texas. well appeared caller: hello. host: how are you? caller: i'm fine. i am talking about the two runs and $50 social security amount. -- $250 social security amount. i am against doing that simply because $250 does not go that far. and our children will end up paying for it. i don't know what the total amount is. i didn't hear that. but i think it said something about $500 million soc -- 500 million recipients. host: no, no. that would not be -- that is larger than the population of the u.s.. one estimate in the paper was off $13 billion. caller: $13 billion that our children will end up paying off and i don't like it. host: are you on social security? caller: i and. host: can i ask, qvc and whether it is enough for you? caller: enough, yes. i think it is about $700 a month. host: do you have other income besides that? caller: yes. host: how long have you lived in corpus christi? caller: since 1974. host: coming up next, stephen moore of "the wall street journal." >> our lives even coverage today on c-span gets underway in just a few minutes, 9:30 a.m. eastern, house energy and commerce subcommittee hearing on radioactive waste on c-span3. then at 9:45 a.m., groups like rock the boat and a hip-hop caucus take part in discussion on democracy and the economic future. hosted by the policy and advocacy group demos. at 10:00 a.m. after " washington journal," u.s. policy options and afghanistan on the table at the brookings institute. it participants include a congresswoman from california. >> q&a sunday. columnist and commentator, call author of "why you are wrong about the right," the surprising truth about conservatives. sunday night on c-span. >> october 16 march is the one into the 16th anniversary of john brown's unsuccessful raid at harpers ferry. this sunday night on book tv, attorney brian magee recounts the trial and how he says brown transformed his treason trial to an indictment of slavery of america. >> "washington journal" continues. on the screen now is stephen moore, editorial board member of "the wall street journal" among other things, author being one of them. let us talk economic news. let us start with an article in your own paper. regulatory overhaul advances as derivatives bill clears not the house. -- clears the house. they are calling this major step in advancing broad regulatory overhaul pushed by the obama administration. >guest: first of all, great to be with you. i think everybody agrees we need an overhaul of the financial regulatory scheme. i think it was a breakdown in the regulatory process that contributed. what worries me as a free-market conservative is a regulatory overreach as we saw, by the way, remember when we had the accounting scandals when enron went out of business, i think we overreacted and we passed the bill called sarbanes oxley which in my opinion has had negative attacks on business. so i do agree there are some very clear areas where we need better guidelines and regulations. i would start with new caps on the amount of debt and leverage that some of these banks and financial companies can take on. you had some of the companies like their stories that had $35 of debt the debt to every dollar of assets -- $35 of debt to every dollar of assets. but i worry about stifling our financial industry, which it been one of the leading industries in america and terms of job creation. host: what he'd think about the agency? it makes me a little nervous. let us look of the counterpart. consumer-products a decommissioned. that has a pretty spotty record -- consumer-products safety commission. that has a spotty record over consumer products. as an example there were these new lead statutes that congress passed that the consumer products safety commission is now enforcing, and it is basically taking all of these products that are perfectly safe off of the shelves of stores. it means literally hundreds of millions of dollars of inventory is being destroyed because of these regulations. so sometimes regulation can have a negative affect on consumers and businesses. host: there is another article on your paper this morning that deals with the fact -- kind of deals with the fact that kenmore isken lewis decided not to take money for 2009. assailing wall street's excess is as natural as shaking hands for lawmakers easy to pull out exports went executive pay taxes attention. when banking and investment powerhouses appear to be record bonuses less than a year after many were rescued by taxpayers, the reaction from the democratic majority in congress has been muted. guest: i am torn on this issue, too, peter. on the one hand i hate the idea of wall street paying out these big bonuses in * -- when shareholders have been losing money. there has been insensitivity on wall street's to, look, people are hurting. it is outrageous to many people that people on wall street are walking away with these bonuses. i think it needs to be self- police, just as a matter of good public relationship -- relations. when these companies are losing money, why are they paying these large bonuses? i think that is what made people so angry. on the other hand, as a free market guy i hate the idea of government interfering and telling people what their patient be. look, peter, if a ceo of a company is performing and that company is making money and it is adding shareholder value and creating jobs, i am for high pay for ceo of's. live on james makes $40 million a year. with uncertain -- copperlebron james makes $40 million a year -- lebron james makes $40 million a year. it has to be board of directors for these companies and shareholders. those are the ones who are needed. host: did you write in this morning's top editorial about the $250? guest: i didn't but i have been following this story. i hope we don't get inundated with calls from seniors. but i think the idea of sending that check to senior citizens right now is just outrageous. the fact that seniors have benefited that inflation is low. the reason seniors did not get cost of living increase with social security is there has been no inflation. somebody has to pay for the $250. no free money. i object to the idea of making young people pay. i would love to get a $250 check from the government but i don't think i deserve it or senior -- social security recipients. host: allow 30 days between all of your calls. we will also take questions from high school students at a high school near richmond, virginia. they are on the c-span civics bus as we speak and our first question for stephen moore comes from a student in the ap government class. >> i will be attending college soon. what kind of employment opportunities will be available after i graduate? guest:boy, you know -- what is the girl's name again? host:valley. guest: every time i am at college campuses and a student asked that question, where of the job opportunities. here is what i will tell you and your classmates and all the people watching. when they ask me for career advice i simply say this -- do what you love. what ever you love to do and are good at, pursue that. that is what you will make money at doing and will be happy at doing. if you pursue your dreams, there is a good chance it will come true. the job market is very bad right now, but by the time you graduate hopefully there will be a much better job market. we have to keep taxes low and government spending under control and debt under control or else we will be -- host: where did you go to school? guest: illinois. i have not been back in years. champagne-urbana, illinois is not a place in the normal path but it is great to see these universities -- $200 million grant from a computer company and a rebuilt their entire computer engineering -- just to give an idea how things have changed, when i was at university of eleanor, computers were just coming into rigid they were not even laptop or personal computers. i remember we used to have, to do a computer program you had to have those cards all and order and if you had one card out of order -- it is amazing how things have changed. kids like her, you probably don't appreciate the fact that when we were in school there were no cellphone and there were no laptops and there were no ddb players and ipods. it is just amazing how this technological age has transformed america. host: never hills, florida. irene, republican. -- zephyr hills. caller: i am concerned about the $250 instead of the raise. my mother lives with me, and she is 79. i just resent the fact that they don't give this to the elderly, because they really need it, the 3% instead of the $250. guest: interesting question. i knew we would get calls on this because of this is an issue people care passionately about. the reason there was no cola was because labor department calculated the inflation rate was very close to zero. the reason we haven't is so paychecks can't stay up with inflation. last year's seniors got a pretty large: increase. i don't remember, 5% or 6%, because of rising energy costs. of course, your mother needs a raise. i need a raise. americans are financially pinched. no question did not just old people, everyone. we can't simply have the government sending out checks. somebody has to pay the bill. there is no free lunch. this is the problem of how we got into the debt crisis, $8 trillion to $10 children, the idea we can have the government send checks without somebody paying for -- $10 trillion beard host: another high-school student. caitlin, go ahead with your question caller: my dad is a car salesman. cash for clunkers affected my family. do you honestly believe it help the economy? host: before he answers -- what do you think? caller: my family, yes, because it got my dad to sell more cars but for everybody else i am not quite sure. guest: you are a very bright girl. i have been in washington for about 25 years. i would have to make the case that this was probably the dumbest program washington ever came up with. here is why. first, look at what happened to car sales in september when the program ended. they tanked. what happened was we paid people $3,000 to $4,000 to trade in their car to buy a new car. they would have bought a new car anyway. all they did was advance bought the cars they would have bought. that is problem number one. we did not help the auto industry at all because we just fast forward sales that would have occurred. the much bigger problem is we basically took 700,000 cars off the road that were perfectly functional. it would be the equivalent of us of burning down every third house in america and say we will create all of these jobs by having somebody build new houses. you don't destroy wealth to create wealth. that is why cash for clunkers program was a big waste of money. both last two questions tie into a big problem -- the crash of the dollar and the enormous debt. i view those right now as our biggest problem. our currency is collapsing and our debt is out of control and when people say we need all of these government programs -- folks, we are out of money in washington. host: does it matter if the u.s. dollar is no longer -- guest: that matters a lot. since the reagan-volker years in the 1980's. remember we have a really high inflation in the 1970's when the dollar was collapsing and we have 14% inflation and 20% mortgage rate and economy collapses. reagan comes in, paul volcker was fed chairman, we restore the value of the dollar. they said it very well, they will make the dollar as good as gold. for 25 years we had a sound, safe, stable currency. that is one of the things that led to the tremendous growth in the economy. we as americans benefit from the fact that foreigners all over the world want to hold gold. the dollarization is a big benefit. we pay a heavy price if the world moves to another currencies like the hero. and that is what the europeans and arabs and other countries are talking about because they don't have confidence in our currency because of the debt. host: alabama. caller: however you guys doing? one simple question about health care and our guests opinion. i listened to him on a lot of shows talking about health care in particular. i would like to -- for him to talk about the albatross, third- party administrators around the business and the workers and their administration of what they call health care. and the anti-trust legislation that does not allow them to act to be regulated by anyone. guest: i think this is honestly the hottest issue. i would say there are three things we can do that would dramatically improve our health care system and make costs lower for everyone and make insurance affordable to many of the people. by the way, none of these three things are in the health care bill being debated. number one, medical malpractice reform so we can sweat out $50 billion up to $100 billion of excess costs because of trial lawyers to exact a toll on our system. that is a no-brainer. number two, allow high deductible insurance policies. if you had an insurance policy with a $3,000 deductible, you could purchase that policy with premiums of only about $3,000 a year, one-third or one-fourth of what people are paying. this bill does not allow these policies that make insurance what really should be, which is to cover catastrophic cost. you get cancer or heart disease or have a terrible accident. those are the types of things you want health insurance to cover. third, allow people in a state like rhode island or maine or in california to buy insurance out of state. because then it gets to the point is dumb and was making -- there is not enough competition -- it gets to the point that that this gentlemen was making. host: do you think it is important to reduce the number of uninsured? guest: i do. we can do it through the kinds of things i just mentioned, lowering the cost of health insurance, but the other thing we need to do that i think is very important, if we as a nation decide let us reduce this number by have and let us get 20 million people insurance -- and we don't know if that number of people -- we can do that by simply providing them a subsidy, in other words, a payment where they can go out and buy insurance. we don't need to totally overhaul the entire system and screw up the system that for most americans worked pretty well so we provide insurance for the 20 million don't. remember, 80% of americans do have health insurance and the vast majority are pretty happy with the health care they get today. host: next is melody, and she is on the c-span civics bus. go ahead. >> as an art student, some of my college options are some of the most expensive in the nation. how do you think the economy and recession will affect my ability to earn a scholarship? guest: i have an 18-year-old son so i am going through what melody is going through as is -- as a parent, not the spirit of college tuition. i cannot believe. when i was at college and university of illinois, in state, i paid 1500 up to $2,000 a year for tuition. now they are 25,000, $40,000 a year. who can afford that? my feeling is that is the same problem we have with health care, we have sort of a third- party payer system where the tuition costs go out of control and instead of having cost- conscious students and families basically driving down the costs, costs go up because we have the government provided scholarships, grants, and so on. there is no reason we should be seen inflation intuition. when you think about it, universities are knowledge- based, they depend on technology, the cost of those things are falling. in a perfectly competitive world, in my opinion, melody, cost of tuition should be falling and not rising. i am glad you brought this up because of this is such a financial pinch to families with teenagers and young adults. host: next call, phoenix, arizona. caller: how are you doing? i don't know where to start. you continue to push supply-side economic theory that completely failed us over the last 30 years. i want everybody to know listening to the show especially in virginia that this man was wrong and never saw the collapse of the stock market that happened last year and a complete economic destruction, never saw it coming and at this point in time he is continuing to press the same load of garbage that has been pushed for the last 30 years. the statement you just made about college tuition, you need to look at that for the entire economy. for you and your ilk, your generation has an affordable lifestyle and could go to college and now it is all out of control. you think $3,000 deductible is a reasonable response for people who don't have health insurance? you want to have them have a $3,000 deductible, and you think it is affordable but he's a $40,000 for college is not affordable. where are you coming from? guest: let me take on the issue of the financial crisis because it is something everyone is so concerned about. i will plead guilty to the fact that i did not see -- let me step back a minute. if you read our editorial page, which i know you do, we were warning about a housing bubble for a long time before a lot of others. in fact, we were riding almost weekly about the crisis in fannie mae and freddie mac and saying this is going to explode in taxpayers laps. it was people like barney frank and chris dodd in congress who said, you are fear marketers -- fear mongers. i think it is a little unfair to say we did not see it was coming. we were sounding alarm bells. we were sounding along -- alarm bells about the easy money policy from the federal reserve which was a major contributor. i will confess i did not think we would see a complete meltdown of the banking system like we saw. i did not know too many people who did predict that. but, look, if you look at what happened last time we had a financial crisis and we have a meltdown, the late 1970's, and the thing that recovered to the economy and caused this great period of prosperity for the past 25 years the to the market tanked in 2008 was the reagan policies of lower taxes, getting inflation under control, getting government spending at least somewhat under control, those are policies we moved away from and i don't think they will work very well as we try to move out of this crisis. host: next up from the ap honors government class is cameron chichester. >> how do you see economic station -- situation affecting rising seniors and those graduating. host: where the plan on going to school? >> olbermann university. guest: -- >> old dominion university. guest: related to this, i talked a lot of people lost their jobs and for deposit and deposit and finding a long time -- a hard time finding a job. the number one issue. a new poll out by fox news today that was very constructive, what it basically said is congress is dealing with all the wrong problems. health care is not the number one problems americans feel we should be addressing right now. 40% of respondents say the number one problem was jobs. i think another about 25% said debt. and i think the third issue had to do with overspending by washington. way down at no. 4 what health care, 13% to 14%. so, i think we should focus like a laser beam on job creation. we need to get taxes down, the debt down. and i think we need to get government spending under control. i believe if we did that -- the ones silver bullet ic for the stock market and the job market is if we had a steve forbes style 19% flat tax, we would have summoned a johnson this country, more jobs than workers. that is the silver bullet. everybody has to fight for a flat rate -- no double tax on capital gains, businesses, that will create jobs and prosperity. host: what does the term jobless recovery mean? guest: we are seeing growth. not a great growth. but probably third quarter gdp will come in probably around 3% or 3.5% with a big improvement over the negative numbers, good news. profits are up. you notice the stock market where we have a $10,000 dow. great news. profits are up. businesses are starting to come up with the problem is they are still not creating jobs. the way a lot of companies are becoming more profitable is that they are laying off workers, cutting costs. it is good in terms of making them more efficient but bad in terms of people who want jobs. we are not seeing the kind of business spending and hiring we would normally expect. we are a year and a half into this recession. this is an abnormally long and deep recession. host: stephen moore's most recent book is "the and the prosperity." -- "the end of prosperity." guest: not trickle-down economics. host: grand rapids. caller: i am calling about the social security thing. i worked until i was 81 years old. i worked in factories, i worked during world war ii in a factoring and i think we should not have to take this year. why don't they take a cut in washington? they don't know how they can make it -- i can tell them. you take half of what you were getting a budget back then. host: when did you retire? guest caller: i am 84. host: how is your health? caller: i was 80 years old when i quit working -- i had a knee replacement. guest: i want to salute this woman and she is part of what we call the greatest generation. they made incredible sacrifices to keep us safe from nazi germany and totalitarianism and applaud you, that you work or what were ii, to help the war effort. i knew we were going to get a lot of calls on this, peter. i warned you. i just simply think we should be sending out checks to people. everybody's income is being pinched right now. just about everybody. we cannot continue to send checks out to people because their financial situation is strained. we have to get the economy moving again by pro-economic growth policies in washington and those don't exist. the stimulus plan has not created jobs. cash for clunkers did not create jobs. we've got to move back to the policies that worked. if we do that i think we will see incomes rising. the other thing is, the good news about the economy in the last year as prices have not been rising for most things. i think we will see it come back a little bit. when it comes back -- and it is probe -- fair and appropriate that we provide seniors with a cost-of-living adjustment for higher prices. host: we have a twitter responding to cameron going to odu-- so there is some advice for parents. the next student is raven walker. caller: would be harder to pay off student debt? guest: i think the big problem for a lot of families is the debt. and it is brought the economy. we know what caused the economic crisis, a financial meltdown, ultimately too much consumer debt, too much in leveraging by businesses and to much bar wing, and too much over spending. this is one of the problems i have, by the way, with the so- called solution of this tunnel was built. which caused the problem by having too much debt and spending so we will have more debt and spending and that will get us out of the crisis? i think the best way to deal with this is when you get out of college, raven, if you could get a good, high-paying job, then you will be able to pay off the student loan in five or six or seven or eight years. if you don't have a job or working at a minimum wage job because there are no good typing jobs in this country, then it is going to be a very big financial burden for you to pay back that debt. this is why economic recovery is at the heart of a all of these problems, it really is. host: jackedtweets -- jack tweets. guest: i want to turn to a system where businesses are expanding, foreigners are investing in the united states because we of the lowest tax rates. i want to see american number one. i think the number one issue for our economy over the next 20 years to 50 years, especially the young people, is the issue of who is going to be the global economic superpower. is it going to be the united states or china? if it is going to be the u.s., and i felt confident, we have to get serious about fixing the problems and health care system, fixing education, medical system, and the litigation system. if we do that, we will be number one again. but the idea of a flat tax. imagine if we did not have any double tax -- capital gains, savings, business -- we would see an explosion of growth. we saw it happen when reagan cut taxes and the 1980's. host: georgina from washington. caller: help, gentleman. i wanted to ask about a couple of things. i don't know if you have firsthand knowledge about this, i keep getting offers saying you can get money in the government in grant to get a home or start a business or whatever, and they keep saying millions and millions of dollars available for that. in our current state of the economy doesn't make any sense? could something i thought be forestalled in a year or two to kind of prompt recovery and make up some of the deficit? host: i think she might be referring to the late-night infomercials, advertising here is the way -- guest: matthew lesko. we have almost $4 trillion budget right now, which is incredible when you think about it. there is a saying in washington that $1 trillion is the new billion did it really is true. when we first came to town we talked about the budget numbers and billions of dollars. did you ever think that we would talk about these in trillions? when you have the federal government giving out trillions of dollars. this is a million million dollars. a huge de lucia of money. -- a huge amount of money. he is right. the government is giving out stuff -- small business, if you want a mortgage, you can get all sorts of loans if you know the right buttons. this is the problem i have with washington right now. it treats money like it is monopoly money. this created the enormous national debt. host: out of the budget, how much of it is cost and how much is optional? guest: first of all, i don't think anything has really set. congress authorized the money, it can cancel it if it wants. the problem is everybody in washington kind of passes the buck and it keeps saying, these are uncontrollable costs or mandatory and we cannot cut them. we can cut these things. we can cut the cost of health care. we can cut the military, i think. i am for strong national defense but i think there is huge waste in the pentagon. if i were the economic czar of this country i would start by cutting every single agency of government by 15% across-the- board. households are cutting back. businesses plan for cutting back. why can't government save money? host: idaho, juppe, good morning. caller: i have been watching you for years and i see you push the war like billy crystal and espouse all the financial policies of the republicans and you are a financial editor for wall street journal. you have been one of the most dishonest journalists there has ever been because these are all the policies that took us down to the path to help. are you ever going to make amends to the people did for the vast amount of influence you have that over the united states? guest: i wish i had influence, peter. i guess it is a compliment to say i had influence. i have always been in favor of limited government. i have always been in favor of lower taxes. i have always been a favor of the trade and i have always been in favor of a sound currency. we talk in our book, "the end of prosperity" if we moved toward lower tax and bad debt under control and if we were to retain the soundness of our currency, there is no reason america cannot see incredible growth as we move more into this technological age. i happen to think right now the policies we have in place in washington are exactly the wrong thing to do. almost everything we have done in washington in response to the financial crisis, about a year anniversary sent the stock market collapsed, almost all the policies have failed. bailout, stimulus, cash for clunkers, federal reserve policy of buying up all of these toxic mortgages, i think it makes no sense because there is no such thing as a free lunch. if we bailout somebody, somebody has to pay for it and usually we are bailing out people who are bad actors and the people will play by the rules are the people will have to pay higher taxes to pay for this. host: 1 more student that has a question. maya thomas. >> i'm in a program that prepares people to go to teaching. how can teachers have a feature but shrinking government resources? host: teaches the discount and teachers have a future with disliking government resources -- guest: government resources have not been shrinking. but the growing like crazy. if you look at state and local and federal, the budgets of governments have been literally doubling ever -- every eight years to 10 years. it is true that a lot of states and localities and school districts are facing tough times because of a financial crisis. what i favor in education is we should pay good teachers a lot. i am very much in favor of paying good teachers taught dollars because they are some of the most important workers in our economy. i also in favor of firing bad teachers. i am in favor of giving students across the country choices of what schools. i think we locked ourselves into a monopolistic school system that does not work very well. it is mediocre, at best. we are here in washington, d.c., where we have some of the worst public schools. we have to do something that liberates our schools, have all sorts of innovation. and pay teachers taught not salaries but get rid of lousy teachers. teacher tnure -- tenure at the above the wayside. host: what would you like to teach? >> i would like to teach a third grade. i do not know what particular subject, but third grade. host: why third grade? >> at that age i feel like i can deal with them and they are easiest to handle and to teach -- to help them. anything younger than that, it will be a little hard for me to have patience with them. but i think i can deal with third graders. host: -- guest: teaching is a good profession. it sounds like you will be good at it. host: i want to thank the high school, particularly the government teacher, for coordinating the visit and i would also like to thank comcast, a partner in richmond, virginia. bowie, maryland. caller: the gentleman, i would not believe anything. when george bush was seen there, he never created any jobs, he gave us two wars and we are having to pay for them. of course we are deep in debt. and this gentleman here was all for that, and of george bush had created jobs -- if george bush had graded jobs on the country was going good and not taken as to where we would be in a much better place. guest: well, i am in mixed opinions about his presence appeared on the one hand i think he does not get nearly enough credit as it deserves keeping america safe from terrorism which was the most important issue over the past 10 years unquestionably. our economy cannot function, our society cannot function if we have people willing up buildings and disrupting our society and making an unsafe. i give george bush allowed credit for that. but we were pretty critical @ "the wall street journal" editorial-page at a lot of the spending policies. i think his failure in terms of handling the economy was spending grew out of control. and the problem i have with barack obama's policies is he came in when bush as you quite correctly pointed out, he increased the debt to nearly half a trillion dollars and barack obama came in and borrow another trillion dollars on top of that. that and not make a lot of sense to me. but it is not true, by the way, we did not have job creation during bush's presidency. by about 2006 or to about seven we had unemployment rate down to below 5%, which is really good. the tragedy is we have doubled in the past 18 months. we have got to get jobs back. but i think the idea of having government spending and debt leading us out of the recession. host: your biggest worry about the economy? guest: right now i would say the debt has become just an enormous burden. i am not someone who normally things that is a terrible thing. it matters a lot, peter, what you spend money on. if you borrow, it matters a lot. in the 1980's when president reagan was in office, we borrowed a lot of money but what did we use it for? we used it to build up the military so we can win the cold war, which is one of the great investment of government resources of the past 50 years her -- we don't have a soviet in -- evil empire no longer, which is huge. and we use the debt to finance lower taxes so we can grow our economy. now we are using debt for is consumption. solar panels on libraries, which have absolutely almost zero return on the economy. i'm just aghast at how much we are borrowing and spending. we can't go on in this country or we will lose our status as the world's economic superpower. host: shreveport, louisiana, on the republican line. caller: good morning. i have seen mr. moore on bill maher's show on hbo and he is