By John Reichard, CQ HealthBeat Editor

 
March 23, 2009 -- Medicare demonstration programs to test better ways of treating the chronically ill don't point the way to a single best method, but other promising approaches do exist and should be pursued, panelists said at a Capitol Hill forum Monday sponsored by the seniors' lobby AARP.

Among the promising new models showcased at the forum is an approach called "guided care" in which a nurse-physician team begins with a detailed assessment of a patient's needs and a comprehensive plan of treatment. Using the resulting "care guide" and drawing on a "patient-friendly action plan" to involve the patient in managing his or her own condition, the nurse coordinates the various parties involved in care, monitors the patient and seeks to ensure that care continues as prescribed, particularly as the patient moves from the hospital to the home.

Similarly, a "transitional care" model developed by University of Pennsylvania gerontology professor Mary D. Naylor relies on planning by a registered nurse with gerontological expertise. The nurse tailors post-discharge care to each patient's situation, and provides follow-up care by phone and through home visits.

Among the lessons policy makers should draw from these approaches is the importance of following the patient through the hospital visit into other treatment settings and of in-person visits to monitor patients once they are discharged, said Susan Reinhard, director of AARP's Public Policy Institute.

Congressional aides at the forum agreed that Medicare demonstration programs offer no magic answer to the high costs and low quality that can result from the lack of coordination and monitoring characteristic of treatment of those with multiple chronic conditions.

Neera Tanden, representing the Obama administration, agreed, saying "we have limited experience with demos that are working." Tanden is a senior counselor at HHS on health overhaul issues. But Hill aides said that continued work to improve treatment could generate considerable savings and is a priority on both sides of the aisle.

Developed at the Johns Hopkins Bloomberg School of Public Health, the Guided Care Model appears to have reduced costs and boosted quality in a continuing study at eight primary care practices in the Baltimore-Washington, D.C. area.

"After the first eight months of the study, Guided Care patients experienced, on average, 24 percent fewer hospital days, 37 percent fewer skilled nursing facility days, 15 percent fewer emergency department visits and 29 percent fewer home health care episodes, as well as 9 percent more specialist visits," according to a Johns Hopkins fact sheet on the program. The summary said "these differences in utilization represent an estimated annual net savings." Patients involved rated the quality of care higher and doctors were more satisfied with communication with the patient and said they were better informed about the condition of the patient.

Use of the University of Pennsylvania transitional care model to treat congestive heart failure patients showed savings of $4,845 per patient after one year.

Mark Hayes, a GOP Senate Finance Committee health aide, said teamwork could be fostered through "accountable care organizations" that rely on a "shared-savings" model in which doctors and hospitals another providers who work together to deliver care more efficiently reap some of the financial rewards. Recently promoted at a Brookings Institution seminar by Dartmouth researcher Elliott Fisher and former Centers for Medicare and Medicaid Services Administrator Mark McClellan, the model shows promise, Hayes said.

Dan Elling, Republican staff director on the House Ways and Means Health Subcommittee, said better treatment of the chronically ill is a bipartisan priority. Elling said improved models should be designed to foster greater personal responsibility on the part of the patients, perhaps through incentives such as lower out-of-pocket premium costs for patients who manage their weight effectively.

Ashley Riddon, a legislative assistant to Sen. Blanche Lincoln, D-Ark., noted that legislation offered by her boss emphasizes a comprehensive geriatric assessment of the needs of chronically ill patents. She said that Medicare demos have shown that some design features of care do work, such as comprehensive geriatric assessments.

Mark Bayer, legislative director for Rep. Edward J. Markey, D-Mass., noted the importance of finding lower cost ways of treating people at home given the greater difficulties seniors have paying for assisted living because they can't raise enough money to enter those facilities by selling their homes in the slumping real estate market. Legislation offered by Markey and others in the last session of Congress would set up demonstration projects in 26 states to generate options to better coordinate care and keep the chronically ill in their homes and out of nursing homes as long as possible.

Chad Boult, the Johns Hopkins professor overseeing research to develop the Guided Care model, sounded a note of caution about changed payment systems, however. He said that the "shared savings" concept, for example, could in fact save money but also indicated that if not managed properly could lead to undertreatment.

By Rebecca Adams, CQ Staff

Community health service centers will get another $338 million in economic stimulus funding as part of the approximately $137 billion in total funds provided to the Department of Health and Human Services, the agency announced Friday.

The centers, which typically provide basic and preventive health care to people who are low-income or uninsured, received $155 million in stimulus funds earlier this month.

The funds will help centers provide care to people who are facing tough times during the economic downturn, said Health Resources and Services Administrator (HRSA) Mary Wakefield. "More Americans are losing their health insurance and turning to health centers for care," she said. "These grants will aid centers in their efforts to provide care to an increasing number of patients."

The grants are going to 1,128 federally qualified health center grantees who will use the funds over the next two years. Centers that received the grants had to explain in their applications how they will use the funds to expand their services. Examples include adding new physicians or other providers, expanding hours of operations or expanding services. The agency estimates that the funds will provide care to an additional 2.1 million patients over the next two years, including about one million uninsured people.

Health centers served more than 16 million patients in 2007, about 40 percent of whom had no health insurance.

By Rebecca Adams, CQ Staff Writer

March 24, 2009 -- The health insurance industry offered Tuesday to phase out the practice of charging people more for their coverage if they are sick. The proposal, sent in a letter to Senate committees working on comprehensive health care legislation, would apply only to the individual market that provides insurance for about five percent of people under 65 who have insurance and is contingent on lawmakers' willingness to impose a mandate requiring individuals to buy health insurance.

Health industry lobbyists said the move is a significant concession that could provide momentum for health care legislation this year.

The letter by America's Health Insurance Plans (AHIP) and the Blue Cross Blue Shield Association was presented during a hearing in the Senate Health, Education, Labor and Pensions Committee Tuesday. The insurers also said that they should still be able to charge more based on age, the geographic location of patients, family size and other factors.

The offer also is intended to stave off efforts among congressional Democrats in creating a public health insurance program that would compete with the private insurers and potentially pose a serious threat to their business.

The health insurance industry has already said it would be willing to cover everyone without excluding anyone for preexisting conditions. A health care expert said Tuesday's proposal did little to advance the debate because if every American was required to have coverage sold by the insurers, many observers already assumed that the industry would not charge unhealthier people more than healthy people. Adding more healthy people to the pool of people with insurance and spreading out the risks could compensate for the coverage of unhealthy people who have higher medical costs.

"There's no breakthrough here," said health policy consultant Bob Laszewski. "It doesn't move the ball forward at all. What's the big deal?"

He called the offer "an attempt at public relations more than a serious proposal" that is driven by the need to convince Democrats that the industry is willing to compromise and that there is no need to create a public coverage plan. "The industry needs to do all it can to look like good guys," he said.

A witness at Tuesday's hearing offered muted praise, saying it was a good first step but that the concessions should go farther and apply to more people. Len Nichols, director of the health policy program at the New America Foundation, said insurers should stop basing the cost of health insurance premiums on health status for everyone, not just for people in the individual market.

Karen Ignagni, president and CEO of AHIP, testified that the industry is willing to embrace tougher regulations and that health insurers believe that health overhaul legislation should happen this year.

"If we can get everybody in, we can change the system dramatically," she said. Spokesman Robert Zirkelbach noted that the letter marked the first time the industry has ever said that it could stop varying premiums based on patients' health conditions.

Health industry officials clarified that one of their primary underlying goals is to prevent Congress from creating a new public plan. They say that a large public program would undermine the private insurance that forms the core of the nation's health coverage system.

Ronald A. Williams, the chairman and CEO of insurer Aetna, Inc., had a straightforward answer when asked if a public plan can co-exist and compete fairly with private insurers.

"My opinion is no, it cannot," Williams said. He argued that a public plan would operate in a similar manner as Medicare, which he said does not negotiate but rather uses its leverage and size to set rates that providers must accept. Insurance industry officials say that providers charge private insurers more to compensate for the low rates paid by Medicare, Medicaid and other public health programs.

Janet Trautwein, executive vice president and CEO of the National Association of Health Underwriters, was equally adamant in opposing the plan before the committee. She said it was not possible for private plans and a new public program to compete on an equal playing field.

However, Karen Pollitz, professor of the Health Policy Institute at Georgetown University, expressed the opinions of many Democrats when she argued that public programs cover people that private insurers will not. "It's absolutely essential" to have a public plan, she said.

The letter was also sent to Senate Finance Committee Chairman Max Baucus, D-Mont. A Baucus aide said the chairman is pleased that the insurance industry realizes that business as usual is no longer acceptable. The aide said Baucus "recognizes that a public health insurance option raises concerns, but remains committed to the goal of making it workable."

By Paul M. Krawzak and David Clarke, CQ Staff

March 26, 2009 -- House Democrats approved a budget outline for fiscal 2010 late Wednesday that would advance President Obama's plans to remake the health care system and transform student aid programs.

The measure, adopted by the House Budget Committee in a 24–15 party line vote, includes reconciliation instructions to allow legislation implementing Obama's health and education policies to move later in the year without the threat of a Senate filibuster.

The Senate Budget Committee, which will finish marking up its resolution Thursday, does not include similar language—a discrepancy between the two chambers that will be resolved later this spring.

Although both plans largely hew to the priorities Obama laid out in February, they also scale back some of his spending and tax measures for fiscal 2010, with the House proposing $7 billion less in discretionary spending and the Senate trimming about $15 billion.

Before adopting the resolution, the House committee considered 28 amendments, defeating all but the final one, a proposal by ranking Republican Paul D. Ryan of Wisconsin. It added to the resolution a non-binding "sense of Congress" that "additional legislative action is needed to ensure that states have the necessary resources to collect all child support that is owed to families."

The other 27 amendments—all from Republicans—were defeated in mostly party line votes.

Several of the GOP amendments sought to prevent the administration from creating a cap-and-trade program to reduce carbon emissions, as Obama has proposed, or strike reconciliation instructions from the resolution.

Under an amendment by Cynthia M. Lummis, R-Wyo., a revenue-neutral fund for energy programs could not be used to impose a cap and trade policy. It was defeated 15–24.

The committee also rejected several amendments by Ryan. One would have barred the use of a health care reserve fund in the resolution to pay for creation of a government-controlled health insurance plan. The committee defeated it 14–23.

Ryan also tried to strike the reconciliation language from the measure, but his effort failed 14–22.

The issue of reconciliation has become a flash point in this year's budget debate. Senate Republicans view the use of the fast-track procedure as highly partisan because it would greatly diminish their ability to influence major pieces of legislation by taking the threat of a filibuster off the table. While reconciliation primarily affects the Senate, House leaders are pushing the idea because they have grown wary of their priorities being stalled or watered down in the Senate because Democrats lack the 60 votes to avoid filibusters.

"The Senate leadership on the Democratic side does not want its membership to vote on reconciliation in an open-floor battle in the budget," said Sen. Judd Gregg of New Hampshire, the ranking Republican on the Senate Budget panel. "They want to bring it back out of conference where it can be buried in a conference report and used as a vehicle to jam, jam the Senate on some very big substantive matters of public policy."

Democrats have been quick to point out that Republicans used the process in the past to move their priorities, including the 2001 and 2003 tax cuts (PL 107-16, PL 108-27) that added to the deficit.

Whether to include reconciliation provisions in the final budget resolution will almost certainly be the biggest issue for House and Senate negotiators when they hammer out a conference agreement next month.

Neither Senate Budget Chairman Kent Conrad, D-N.D., nor Senate Finance Chairman Max Baucus, D-Mont., wants reconciliation instructions on health care, because such a move would inflame partisan tensions and they believe the process should be used only for deficit reduction.

"I don't believe reconciliation was ever intended for this purpose," Conrad said.

But he and Baucus will be challenged hard on this point by House Democrats, and possibly the White House, who do not want to see a key part of the president's agenda stalled in the Senate.

Obama met with Senate Democrats for about 40 minutes in a Wednesday visit to Capitol Hill. Senate Majority Leader Harry Reid described the tone of the meeting as "comfortable." The president may meet with House Democrats on March 30.

Support for Reconciliation
Several Democratic members of the Senate Budget Committee expressed support Wednesday for using reconciliation.

Using reconciliation for education programs may be less problematic than for the health care changes, since the education proposals are more budget-related.

The president has proposed eliminating subsidies to private lenders that now participate in the Federal Family Education Loan program, making the government the originator of all federally backed student loans.

Rather than include reconciliation instructions, Conrad's budget simply sets up a "reserve fund" for both health care and education legislation. These provisions essentially leave it to the committees of jurisdiction to craft the legislation if they choose to, so long as it doesn't add to the deficit. The bills would then move through regular order, setting up the possibility of a filibuster.

But, as in the House's case, a budget resolution can set the stage for the reconciliation process by instructing specific committees to achieve a net change to the deficit, which can be accomplished through policies affecting tax and mandatory spending programs.

The authorizing committees can produce legislation to implement almost any policy, so long as it meets the deficit target laid out in the budget resolution. Republicans have noted that this means Democrats, despite their stated intentions, could use reconciliation for purposes other than health care and education policy, such as the president's proposal to use a "cap-and-trade" emissions program to combat climate change. For instance, the House Budget resolution instructs both the Energy and Commerce and Ways and Means committees to report legislation by Sept. 29 that would reduce the deficit by $1 billion over six years. These committees would write the health care legislation but could also deal with cap-and-trade.

Democrats have heralded their budgets as an attempt to invest in health care, education, energy and other domestic programs they believe will help the economy in both the short and long term.

But Republicans have bashed the proposals as tax-and-spend plans that would double the nation's deficit and involve the government too deeply in Americans' lives.

"There is a price to be paid for this kind of paternalism," Ryan said.

The amount of debt in Obama's budget has also been a concern for some moderate Democrats, and the Budget panels in both chambers had to trim some of Obama's spending and tax proposals in order to appease them. One area that was targeted was the discretionary funding accounts the Appropriations panels use to write their annual spending bills.

While the budget resolution never becomes law, it sets the parameters for considering tax and spending bills later in the year. One of the most important parts of the blueprint is that it sets the discretionary spending cap for the annual appropriations bills.

The House blueprint would provide $1.089 trillion in non-emergency discretionary spending in fiscal 2010, which would be slightly less than the $1.096 trillion requested by the president.

The Senate Budget version would allow about $1.08 trillion in non-emergency discretionary funding in fiscal 2010. Both the House and Senate match the president's request for defense spending, so trims would come from his domestic program requests.

Assuming the AMT
Both the House and Senate were able to show higher tax revenue figures than the administration by assuming that the alternative minimum tax (AMT) will hit more taxpayers in future years or that, if it doesn't, a comparable amount of taxes or spending cuts will be found elsewhere.

But this is a questionable move that critics deride as a gimmick. The administration championed its budget as being "honest," in part because it didn't assume additional revenue from the AMT, as Congress has never allowed this parallel tax system to hit more taxpayers each year, enacting a "patch" instead.

Because of these changes, the House and Senate plans show deficits falling faster and further than in the president's budget. The Congressional Budget Office projects the deficit for this fiscal year will total $1.7 trillion.

Under the House plan it would drop to $598.4 billion in fiscal 2014. The president's budget would lead to deficits of $672.3 billion in fiscal 2013 and $748.6 billion in fiscal 2014, according to CBO. The Senate resolution shows the deficit falling to $508 billion in fiscal 2014.

Both chambers plan to vote on their budget plans next week.

Senate leaders have expressed confidence they will have the 51 votes needed to adopt the plan. Twelve moderate senators wrote Conrad on March 24 stating they wanted to see deficits controlled but did not draw any lines in the sand about what needed to be done to win their votes.

On the House side, leaders appear to have mollified the concerns of the fiscally conservative, 51-member Blue Dog Coalition. They included a provision in the resolution that essentially states that some current policies, such as middle-class tax cuts, should not be extended if they are not offset, unless the House has already passed a bill that would put the pay-as-you-go deficit rule into law to cover future programs.

Since there is little chance that the extension of some existing popular tax provisions will be offset, Blue Dogs wanted assurances that a stricter pay-as-you-go system would be in place in the future.

"We simply cannot run trillion-dollar deficits forever," said Rep. Charlie Melancon, D-La., a Blue Dog leader.

House Republicans are attempting to pressure members of the group to vote against the budget because of the amount it would increase the debt.

"Do you really want all this government?" Ryan said to Blue Dog members at the House markup Wednesday. "You hold the cards. You have the votes that can make the difference on this. You can stop this."

Kathleen Hunter, Paul M. Krawzak and Chuck Conlon contributed to this story.

By David Clarke, CQ Staff

March 25, 2009 -- The House is taking a more aggressive approach than the Senate to implementing President Obama's proposals for overhauling the health care system and federal student aid programs.

The House Budget Committee was marking up a fiscal 2010 draft budget resolution Wednesday that includes reconciliation instructions to allow legislation implementing these policies to move later in the year.

The Senate Budget Committee, which was to begin a markup of its own budget resolution later in the day, does not intend to include similar provisions in its version.

The issue of reconciliation has become a flashpoint in this year's budget debate. Senate Republicans view the use of the fast-track procedure as highly partisan because it would greatly diminish their ability to influence major pieces of legislation by taking the threat of a filibuster off the table.

Whether to include reconciliation provisions in the final budget resolution will almost certainly be the biggest issue for House and Senate negotiators when they hammer out a conference agreement next month.

Both Senate Budget Committee Chairman Kent Conrad, D-N.D., and Senate Finance Chairman Max Baucus, D-Mont., do not want reconciliation instructions on health care, because it would inflame partisan tensions and they believe the process should only be used for deficit reduction.

"We want health care reform to be sustainable, and that means getting a significant number of Republicans on board," Baucus said. "If they are on board it is sustainable. Otherwise it's partisan, it's less sustainable, we're back in the soup again, we're fighting. Americans don't want that."

But Conrad and Baucus will be challenged hard on this point by House Democrats, and possibly the White House, who do not want to see a key part of the president's agenda die or be watered down because of objections from Senate Republicans who have the votes to filibuster a bill moved through the regular legislative process.

Obama was meeting with Democrats on Capitol Hill Wednesday to discuss the budget.

Using reconciliation for education programs may be less problematic since the administration's proposals on this front are more budget-related than a sweeping overhaul of the health care system.

The president has proposed eliminating subsidies to private lenders that now participate in the Federal Family Education Loan program, making the government the originator of all federally backed student loans. Obama wants to make Pell grants mandatory spending, which would remove them from the uncertainty of the annual appropriations process. He also wants to increase the maximum grant to $5,550 and index grants to account for inflation—all at a cost of $116.8 billion over the next 10 years.

Details Left to Other Committees
The budget resolution sets the stage for the reconciliation process by instructing specific committees to achieve a net change to the deficit, which can be achieved through policies affecting tax and mandatory spending programs. It instructs the committees to report legislation meeting these targets by a certain date. The authorizing committees can produce legislation implementing almost any policy so long as it meets the deficit target laid out in the budget resolution.

For instance the House Budget resolution instructs both the House Energy and Commerce and Ways and Means committees to report legislation by Sept. 29 that would reduce the deficit by $1 billion over six years. These committees would write the health care legislation.

The Education and Labor Committee is instructed to report a bill by Sept. 30 that also would reduce the deficit by $1 billion over six years for the purpose of making changes to education programs.

While the House budget notes that the reconciliation instructions are intended for health care and education legislation, they could be used to advance legislation addressing any issue under the committees' jurisdiction. The instruction does not specify what policies should be pursued—only that whatever is produced should meet the deficit target laid out in the budget resolution.

Altering Obama's Totals
The House Budget Committee resolution would provide less in spending and more in tax revenue than President Obama's proposed in effort to hold down rapidly rising deficits that worry Democratic moderates.

The House blueprint would provide $1.089 trillion in non-emergency discretionary spending in fiscal 2010, which would be slightly less than the $1.096 requested by the president. The Senate Budget version would allow about $1.08 trillion in non-emergency discretionary funding in fiscal 2010. Both the House and Senate match the president's request for defense spending, so trims would come from his domestic program requests.

The House budget also assumes that over five years its plan will raise $14.3 trillion in tax revenue, compared with $14.1 trillion in Obama's proposal. The House plan assumes that some revenue will be raised over that period by allowing the Alternative Minimum Tax to hit millions more households or, if not, that other tax increases or spending cuts will be enacted to make up for the shortfall.

Because of these changes the House plan shows deficits falling faster and further than in the president's budget. The Congressional Budget Office projects the deficit for this fiscal year will total $1.7 trillion. Under the House plan the deficit would drop to $585.5 billion in fiscal 2013 and then tick back up to $598.4 billion in fiscal 2014. The president's budget would lead to deficits of $672.3 billion in fiscal 2013 and $748.6 billion in fiscal 2014, according to projections by the Congressional Budget Office.

Overall the House budget would allow $3.55 trillion in outlays compared to $3.67 trillion under the president's plan.

House Budget Committee Chairman John M. Spratt Jr., D-S.C., said his budget protects the president's priorities while reducing the deficit faster in the face of a deep recession that has adversely affected the fiscal outlook.

Rep. Paul D. Ryan of Wisconsin, the ranking Republican on the panel, criticized the plan as mirroring much of Obama's proposal. He said it would involve the government too deeply in Americans' lives.

"There is a price to be paid for this kind of paternalism," Ryan said.

Meanwhile, White House Budget Director Peter R. Orszag pushed back against the idea that the budgets being drafted on Capitol Hill would differ greatly from the president's plans.

"The resolutions may not be identical twins to what the President submitted, but they are certainly brothers that look an awful lot alike," Orszag said.

In addition to trimming Both the president's discretionary spending requests, neither committee would make room to extend Obama's signature "Make Work Pay" payroll tax credit beyond its expiration in 2010. The credit was enacted as part of the $787 billion economic recovery and stimulus package enacted last month (PL 111-5).

Orszag argued that the since the payroll tax credit of $400 per individual and $800 per couple doesn't expire for almost two years, there is time to work that issue out with Congress.

He also said the budget allows the president's proposals on health care, climate change and education to go forward while meeting the president's goal of cutting the deficit in half by fiscal 2013.

By John Reichard, CQ HealthBeat Editor

March 24, 2009 -- House Energy and Commerce Committee Chairman Henry A. Waxman said Tuesday that a congressional overhaul of the health care system must not only provide for universal coverage but also for more primary care doctors and nurses to ensure that an insurance card actually gives the holder access to treatment.

"When our Committee takes up health reform, we will provide coverage for the uninsured," the California Democrat told a hearing by the Energy and Commerce Health Subcommittee. "However, I also want to make sure that our legislation addresses the barriers to access that insurance coverage by itself can't fix," he said.

Witnesses at the hearing suggested various approaches to improving access, ranging from sharply increasing the supply of primary care physicians and nurses, to strengthening Medicaid to addressing racial, ethnic and geographic disparities in access to care. GOP lawmakers stressed the need to increase the supply of doctors by revisions to the medical malpractice system they said have left certain parts of the country without access to specialists.

The need to strengthen the ranks of primary care physicians, viewed as essential to more cost-effective care because they can direct the overall treatment needs of a patient including better preventive care, was one of the biggest themes of the hearing. "Study after study has proven the importance of primary care," Subcommittee Chairman Frank Pallone, Jr., D-N.J., said in his opening statement. "Yet, two-thirds of the physician workforce practice as specialists and the number of young physicians entering primary care fields is declining."

"The United States is experiencing a primary care shortage the likes of which we have not seen," said Jeffrey P. Harris, president of the American College of Physicians. Lower pay is one of the biggest reasons, said Harris, who noted that the average primary care physician earns 55 percent of the average pay for other types of physician care. Harris called for "targeted annual increases" in the Medicare fee schedule payments for primary care physicians over a five-year period to make the field competitive with other physician specialties.

To make salaries competitive, "Medicare and all other payers would need to increase their payments to primary care physicians by 7.5 to 8 percent per year over a five-year period, above the baseline for all other specialties," Harris said in his prepared testimony. That would bring average earnings five years from now to 80 percent of those for other specialties. Annual increases of 12 to 13 percent per year would achieve 100 percent parity, Harris added.

Harris noted that increasing coverage would exacerbate shortages. He said that waiting times for a primary care appointment in Massachusetts, which is now inching closer to universal coverage, are now reportedly as long as 100 days.

George Washington University professor Fitzhugh Mullan testified that "hard work, low pay and 'lifestyle' expectations of medical graduates today have resulted in dramatic reductions in interest in primary care in U.S. medical graduates."

Specialists make up 63 percent of practitioners and primary care doctors 37 percent, he added. "This figure is markedly different than it was 50 years ago when 50 percent of America's physicians were generalists. In Canada today, by contrast, 51 percent of physicians are currently family physicians and general practitioners."

Mullan said the number of doctors overall in the United States is roughly what it should be but that geographic distribution is poor. In the United States some 800,000 doctors practice medicine, or 280 doctors per 100,000 people, more than in Canada, which has 210 per 100,000 and the United Kingdom, with 250 per 100,000. But "metropolitan areas have two to five times as many doctors as non-metropolitan areas" and "economically disadvantaged areas have significant physician access problems."

Title VII programs under the Public Health Service Act should be "reinvented and reinvigorated," he said, to create "incentives and educational pathways that will select and train students for primary care, rural health, diversity and social mission."

Mullan also suggested changes in Medicare's funding of graduate medical education. Modest changes could push Medicare "GME" more toward community-based care rather than hospital-based care, he suggested. Major reform would entail requiring teaching hospitals "to undertake community or regionally oriented analyses of physician workforce needs," he said.

Another witness, neurosurgeon James R. Bean, testifying on behalf of the American Association of Neurological Surgeons, said a health overhaul plan should address barriers in access to care created by flaws in the medical liability system. Bean noted that Democrats including President Obama, Hillary Rodham Clinton when she was a U.S. senator from New York and Senate Finance Committee Chairman Max Baucus of Montana have called for measures to counter the rising cost of malpractice insurance.

"In other words," Bean said in his prepared testimony, "those at the forefront of health reform understand that it will do little good to achieve universal coverage or even the most up-to-date health care IT, if the doctors who actually supply the care are being driven from the business, forced to retire early or shun potentially risky, life-saving procedures because of our broken medical liability system."

GOP lawmakers picked up on the liability issue. Rep. Joe L. Barton of Texas, the top Republican on the Energy and Commerce Committee, urged the subcommittee "to take a serious look at liability reform, as we move into the overall issue of health care reform." Barton asserted that a 2003 Texas law capping pain and suffering awards is bringing doctors back into the state, improving access to care by Texans "living in poor and medically underserved areas."

Michael Kitchell, president-elect of the Iowa Medical Society, described problems with access to care in rural areas. "Rural citizens make up over 20 percent of the nation's population, but only 9 percent of our nation's physicians reside in rural areas," he said. Rural doctors face lower pay and longer hours and vacancies for physicians go unfilled for years, he said. Recruiting won't improve until payment changes. "Physician shortages in rural areas are largely caused by Medicare payment policies that geographically penalize rural physicians," he said, adding that President Obama has urged "geographic equity" in payment. "I hope Congress will agree with President Obama: there should be geographic equity."

Brian D. Smedley of the Joint Center for Political and Economic Studies noted higher cancer death rates among African Americans and a higher prevalence of diabetes among American Indians and Alaska Natives, among many other racial and ethnic disparities in health status and in access to care. Smedley said that "no single policy—such as expanding access to health insurance—will fully address health care inequality. Health care disparities are complex and are rooted in many causal factors" that require changes not only in health care financing but also in health care systems and workforce development, he said.

Diane Rowland, executive vice president of the Kaiser Family Foundation, testified that Medicaid has improved access to health services among the most vulnerable Americans. "Drawing on Medicaid's experience and already substantial coverage of the low-income population offers an appropriate starting point for extending coverage to the low-income uninsured population through health reform," she said in prepared testimony.