To help the continent, especially the subregion. A vacuum . Does it leave an opening for groups like al qaeda to come in . Guest there are lots of reasons for american you should. There are limits to what america can do. We are looking at the limits in the face now with the fiscal cliff, which we have delayed a little bit. We have to reckon with it. Within that context, we have to look at where our aid can have the most good affect. In mali, our loss to not permit us to deal with governments that come to power through extraconstitutional means. We have the case of the crew coup still pulling strings behind the scenes. It is a matter of military effectiveness. In order to win in northern mali, an outsider will have to engage in a counterinsurgency campaign. Taking the people in the north. Many have legitimate grievances for political marginalization and discrimination. That allowed the opening for al qaeda and the other islamic extremist to come in. They need a legitimate government to negotiate with. The entity they have there no one would negotiate with it because it is not legitimate. It is not supported by the majority of molly ends m alians. If you do not have a legitimate government, you are never going to be the insurgents. Thank you for coming in. That is all for washington journal. Senator sanders is talking about primary health and aging. We have a major crisis regarding primary health care access, which results in lower Quality Health care for our people and greater expenditures. Lower Quality Health care and we end up because of the crisis and primary Health Care Spending more than we should. Today, 57 Million People in the United States ban cannot see a. When they need to. Lack of access to a primary care provider is a National Problem. Those who are most impacted our people who are low income, minorities, seniors, and people who live in Rural Communities. As we have seen time and time again with dental care, Mental Health, and other healthcare issues, the groups that need healthcare the most are the least likely to receive it. The good news is 11 months from now we will be providing Health Insurance to dirty million more americans are the Affordable Care act. Dirty million more americans are the Affordable Care act. We do not know how we will provide primary health care to those americans who will now have Health Insurance. Let me rattle off some statistics that should be of concern to the congress and to all americans. Not widely known, approximately 45,000 people every single year die in the United States of america because they do not have Health Insurance and they do not get to a dr. In time. 45,000 americans. According to the Health Resources and service administration, we need 16,000 primary care practitioners to meet the need that exists today with a ratio of one provider to 2000 patients. Over 52,000 our merry care physicians will be needed by 2025 primary care physicians will be needed by 2025. Over half of patient visits are for primary care. Only 7 of the nations medical School Graduates now choose a primary care career. 7 . Nearly all of the growth in the number of doctors per capita over the last several decades has been due to a rise in the number of specialists between 1965 and 1992. The primary care physician to population ratio group to only 14 . The specialists population exploded by 120 . The average primary care physician in the United States is 47 years of age. 1 4 are near retirement. In 2012, it took about 45 days for new patients to see a family dr. Up from 29 days and 2010. If you can find a family provider, it takes longer than it should to see him or her. Only 29 of u. S. Primary care practices provide access to care on evenings, weekends, or holidays. That is compared to 95 of physicians in the united kingdom. Our culture is, do not get sick on saturday, sunday. Half of american emergency room patients would have gone to a primary care provider if they have been able to get an appointment at the time one was needed. We are wasting billions of dollars because people end up in the emergency room or nonemergent care because they cannot find a primary Health Care Position physician. Primary care is intended to be and should be the foundation of the u. S. Healthcare system. In 2008, americans made almost one billion Office Visits to the dr. 50 were to primary care doctors. According to patrol access to primary health care results in Better Health outcome, reducing health disparities, and lower spending by reducing emergency room but when you get people to the dr. When they showed, they do not get sicker than they otherwise would be at great cost. The problem we are discussing is a National Problem existing in 50 states and the country. It is even worse for particular geographic regions. The ratio of primary care doctors in urban areas is 100 per 100,000 people. Double the ratio in Rural Communities where it is 46 per 100,000. Urban communities have problems. Rural communities have greater problems. 65 of primary health care a National Shortage areas are in rural counties. My own state does better than the rest of the country in terms of primary Health Care Providers per 100,000. I cannot tell you and vermont, people have difficulty getting to the primary care provider they need. 20 of americans live in rural areas. 9 of fisher since physicians practice there. One of the differences between the u. S. Healthcare system and the Healthcare Systems of other highly developed countries, which could explain why we spend so much more than other countries around the world, is the ratio of primary care physicians to specialists. In the United States, roughly 70 of our practitioners are specialist. 30 are primary Health Care Providers. Around the world, that number is the opposite. About 70 of their practitioners are our merry healthcare providers. 30 are specialist. Can congress do to address this issue . What can congress do to address this issue . We must address the issue of primary care reimbursement rates. Specialists earn as much for their lifetime of practice as 2. 8 billion dollars more than primary care providers. If you are going into medicine, if you are a specialist, you can earn almost 3 million and a primary care practitioner. Radiologists and gastroenterologists have incomes of more than twice that of family physicians. The system for setting physician reimbursement in this country is determined i the 31 physicians who sit on the American Medical Association committee. The payment recommendations are accepted by the centers for medicare and medicaid services. Over 90 of the time. They are adopted by many private insurers and is dominated by specialists. Specialists sitting on the committee determine reimbursement rates. We have to look at that issue. The care has promoted the growth of residencies and specialty fields medicare has promoted the growth of residencies and specialty fields by providing 10 billion to Teaching Hospitals without requiring any emphasis on training primary care doctors. Unlike other nations, which provide significant Financial Support for medical school education, we do not do this in this country. The result is the median debt or medical students upon graduation is more than 160,000 and 1 3 of medical School Graduates leave school more than 250,000 in debt. What will you do . You will try to figure out how to make as much money as possible to deal with that debt. You will gravitate toward fields that pay higher incomes. If we are going to attract young people into primary health care , we must make that profession more financially attractive. We must address the issue of our reimbursement rates for med. In recent years, we have greatly expanded Community Health centers around the country. Community Health Centers provide good quality, costeffective healthcare. We need to do more than that. We need to make more progress. We need we have increased funding for the National HealthService Corps, which says to someone if you graduate Circle School and death, we will help you a trust that debt if you practice in underserved areas. It is working. We need to make more progress and that. Teaching Health Centers. Residents trained in Community Health centers or Rural Communities are more likely than those trained and other treasures more likely to serve n underserved areas. In underserved areas. We have to expand that concept. We have to take a look at the role of allied health providers, Nurse Practitioners, and others. How do we better utilize those people . We have a very serious problem. The lives of thousands of people depend upon what we do. I am very excited about the panelist we have at the hearing. I would like to hear from. Enator and se the senator joining you. Am back to be i would like to thank the witnesses for taking time out of their schedules to be with us. I would like to welcome Toni Decklever from cheyenne. I appreciate that you made the trip across the country to be here. It is a pleasure to welcome all of the witnesses to our hearing. The issue of improving access to primary Healthcare Services is 11 that is important to all of us but is especially significant given the obstacles people face in wyoming. Nearly the entire state is considered a front here or were rural county. 47 of the population is in a county with fewer than six residents per square mile. Approximately 200,000 residents live in Health Professional shortage areas with inadequate access to primary or dental care. There are accesses this requires creative solutions. One hospital is served by a physician that every time we lose that position, the hospital closes. The state has developed programs tailored to meet the needs of a frontier state where distance presents the biggest barrier to accessing a doctor. Recruiting Healthcare Professionals to live and work there is an ongoing challenge. The wyoming department of health operates its own Loan Repayment Program along with a physician recruitment grant program. These programs were to reduce the high cost of Health Professional graduate and training programs, which is often a deterrent to work in primary care or other lower income medical fields. The wyoming Health Resources network represent another approach to improving access and reducing primary Care Workforce shortages. This arrangement between the Major Medical and Health Professional societies, the university of wyoming and others maintains an extensive database of wyoming Healthcare Facilities and their need. Sharing information more effectively allows for better allocation of resources and man power and man power the fiscal climate limits our ability to spend money on the problem. The criteria that determines eligibility for federal funds to support Rural Health Programs are based on factors that make it difficult to prove the needs of the underserved. One provider per 3500 people in new york city is different from 3500 People Living in fremont. We need to think more creatively about how to use Technology Services to improve telemedicine capabilities. The advancement of more powerful Wireless Technology has potential to remotely link individuals across the country to deliver healthcare and more accessible settings. The have had access with that with some of the Veterans Outreach clinics where they used telemedicine extensively with Nurse Practitioners being in charge of handling the equipment and a dr. On the other end. I hope this hearing will make it clear that we need to the ground ways in which all americans can better access primary Care Services and ensure healthcare and fresh healthcare confessionals are Healthcare Professionals are where they are most needed. I want to thank the witnesses for their participation. I want to thank the chairman for his list of suggestions on things that need to be done. We have the capability to come up with solutions. Thank you. The senators will get five minutes. Senator warren was here first. I want to thank you for holding this hearing, mr. Chairman. I am very interested in the question about how we equalize access for all of our citizens and how we make the right investments to lower the overall cost of healthcare. The chairman said it best when he said what we are looking for is Better Outcomes at lower costs and that is the procuring or role the federal government can make it it makes the right upfront investments. I look forward to hearing from each of the panelist. I want to thank the Ranking Member. The comments about access and the reminder that it is different in a large city then it is in a rural area are comments that are well taken and one for us to remember. Also, they can have different consequences, even in massachusetts where we have very extensive Healthcare Services in some areas, but it still leaves us with part of the population in massachusetts with difficulties in accessing care. Sometimes distance is less the challenge, but cost can be a challenge and transportation. I appreciate the reminder of the diversity of issues that we face and making sure that all of our citizens have good access. Thank you, mr. Chairman. Senator baldwin. Thank you. I will not use the allotted time in its entirety. I will have to seek out to a tent another Committee Meeting in return for the q a. I appreciate your focus on this broad but critical issue that has so much relevance seen through the accreditation of the Affordable Care act. I represent a state that has urban concentrations as well as not as large spaces of rural areas but has the array of challenges that are the subject of this hearing. I appreciate the attention that will be focused on it. One of the things that i hope i will hear some collaboration on our side from issues of compensation plays in this is questions of lifestyle for primary care practitioners, things like the differences between the amount of time that somebody might be on call as a specialist versus a primary care physician. As we look at the larger payment reforms, how the flexibility and the practice of being able to spend the adequate time with a patient with multiple chronic conditions that is necessary versus seeing folks and 15 minute increments. What impact will those policy changes have on the number of primary care practitioners in this country . Thank you for focusing attention on this issue. I hope to return to hear more from the witnesses and ask my questions. Thank you very much. Senator franken. Thank you for this important hearing. We have 13 million more 30 billion more americans we hope if Medicaid Expansion is adopted by the states, leaving some people still uninsured. We read the testimonies last night. It is very clear that when you ensure the people, their healthcare outcomes are better. It costs us money when people are not in short. What we are doing it is so clear. Sometimes we hear, we have health care in this country. You can go to the emergency room. That is expensive. It does not mean you get treated after the emergency room and you get what you need to treat a chronic condition. All of your testimonies put a lie to that. I appreciate that. In minnesota, we do healthcare relative to the rest of the nation, extremely well. Hhs has rated as number one in highvalue care and outcomes divided by cost. We, like wisconsin, at a combination of urban centers and not miles and miles, but we but we have miles and miles. I look for to partnering on this. I admire the Ranking Members work on rural health, which is important in my state because there are people that are underserved. One of the things that the chairman talked about was the Student Loans. Graduating from medical school with a typical loan debt of 160 thousand dollars, sometimes more. 160,000, sometimes more. The tendency for doctors to say, how will i make this money . This is an issue you talk about in your testimony. And our country, we pay our country, ion we pay specialists more than primary care physicians and we do in other countries that do their healthcare less