Lowering Health Care Costs for All Americans: An Examination of the U.S. Provider Landscape

Subcommittee will come to order. The chair recognizes himself for a five-minute opening statement. Today we will discuss health care costs and patient access challenges by examining the health care provider landscape. This is the third hearing in the committee's health affordability series, following hearings with health insurance executives back in January and stakeholders from the prescription drug supply chain last month. The United States provider landscape includes a wide range of entities and organizations that deliver services to patients. Hospitals and large health care systems, hospitals and large health care systems provide acute and specialized care. However, we have also seen these entities expand into outpatient service delivery. Independent physician practices and group practices deliver much of the primary and outpatient services that patients rely on every day. Although they are not before us in this hearing, I also want to recognize the critical role that federally qualified health centers, rural health clinics, and community hospitals play in our health system, especially in our, in our most rural and underserved areas. It is no secret that across the country, patients are faced with fewer choices about where they can receive care as the provider market has consolidated dramatically. Hospitals are acquiring physician practices, systems are merging, and too often patients have little options among providers. In many cases, the states that see the most consolidation have the largest rural population, exacerbating access challenges, leaving communities strained and contributing to overall unaffordability. On top of vertical integration limiting the viability of independent practices, the so-called Affordable Care Act has enabled the landscape to become even more narrow. In fact, because of the Affordable Care Act, any existing physician-owned hospital built before 2010 is prohibited from growing beyond the size it was when the bill became law, forcing me to ask myself, how does that make sense? I don't think it does. As a result, many patients face limited provider options in their communities and may encounter higher prices with little insight into the cost of health services. At the same time, transparency in the health care provider system remains insufficient. Prices can vary widely for the same service depending on where care is delivered, and billing statements may include facility fees, multiple providers, negotiated rates, etc., that are difficult for patients and Congress to understand. Additionally, programs such as the 340B drug pricing program have become opaque, and a few hospitals have gone against the true intent of that good program. The 340B program was created with the intention of helping safety net providers care for low-income and vulnerable patients. However, as hospitals and large entities participate and expand affiliated contract pharmacies, visibility has become limited into how the program's generated discounts are used and whether those savings are reaching the patients that they were meant to reach. In many cases, the result of this system is that Americans are left navigating complex and often expensive medical bills, whether from a hospital or routine appointment, bills that they did not anticipate, cannot easily afford, and sometimes only learn about weeks or months after receiving care. When provider markets lack competition and transparency, prices can rise without patients having the information needed to make cost-conscious decisions. Today we will hear from different organizations that represent health care providers across a variety of settings so that we can look for ways to try and make delivering and receiving care more affordable. We have the American Hospital Association in front of us, who represents many types of hospitals and health care networks. We also will hear from the American Medical Society, who represents many physicians across the country. The American Academy of Family Physicians is here to give their perspective. We also have the Purchaser Business Group on Health before us to provide insights into the relationship between private employers and public purchasers. We also have a neurosurgeon from the University of California San Francisco to give the perspective of specialty doctors and the care that they provide to patients. Lastly, we have Barbara Merrill from the American Network of Community Options and Resources. These witnesses have unique insights into the factors that are currently leading to the high costs patients are facing when receiving care, and I am looking very much in favor of hearing all of this discussion. And with that, Madam Chair, excuse me, Madam Ranking Member, I yield back and maybe, maybe not. We'll see. Time will tell. I think we're going to be just fine. But that said, to my good friend, the ranking member, Ms. DeGette, I now yield her five minutes.

Thank you so much, Mr. Chairman. I'm so glad that my colleagues on the other side of the aisle have suddenly discovered that people want to be able to afford health care. Judging from their actions this last year, or maybe this last decade, one might think this is a completely foreign topic to them. In fact, in my opinion, the only people whose bottom line this majority seems to care about are the billionaires whose taxes they cut using funding that was supposed to go to health care coverage for working families and keeping aging adults in their homes and out of facilities. This is not hyperbole. This is exactly what H.R. 1, the big bad bill, did. It cut over a trillion dollars from Medicaid, which will make it even harder for sick kids, people with disabilities, and working-class Americans who are trying to get by. And by failing to extend the enhanced advanced premium tax credits for people who get insurance on the exchanges, people who are just starting out, people who work for small businesses, retired adults who aren't quite Medicare age, Republicans jacked up insurance costs for millions of Americans and cut insurance coverage for millions more. But it's not just the people who lost or will lose their insurance who are paying the price. In many communities across America, urban and rural, access to quality care is literally hanging by a thread. People who are uninsured don't just magically not need care, but they do tend to delay care, letting conditions get worse and then getting costlier health care, which they often can't pay for, leaving hospitals and taxpayers with the bill. And the hospitals who are here today know exactly what I'm talking about. Seventy-five percent of uninsured adults say that they skipped or postponed health care they needed in the last year because of cost. While uninsured patients may not be able to afford life-saving care, hospitals are the ones who are obligated morally and legally to provide it and then they have to shoulder the cost themselves. That uncompensated care is expected to increase by $443 billion nationwide in the next decade because of Medicaid cuts in the big bad bill, placing hospitals under incredible financial pressure, stress, and forcing many to reduce staff, eliminate certain services, or even close. And as many as 300 rural hospitals across the country may close their doors due to these pressures. I've talked a lot to the Colorado Hospital Association about this. This will increase wait times, make care less accessible, and raise the cost of health care for everyone regardless of your insured status. And it will also devastate the economies of those small communities where the hospitals are the lifeblood. So, what should we do now? First, as I've said before in this room, we need to restore the enhanced premium subsidies for health insurance. We need to rip out the health-caring provisions of H.R. 1, root and stem. That'll go a long way, but it's just a start. In my opinion, ultimately, the best way to achieve affordable, accessible care for every American is to build a single-payer system like Medicare for All. We need to guarantee that in the U.S., no matter who you are, no matter where you live, you have access to health care that's going to be there to prevent illness when you're well and get better when you're sick. We also need to recognize where factors outside our health care system impact health and address public health safety holistically as a whole-of-government and indeed a whole-of-society effort. The finest doctors and hospitals in the world can't replace healthy food and clean air. I'm not optimistic about tackling these important issues under this majority, but to my colleagues on the other side of the aisle, if you want to work on these issues in a bipartisan way, my door is always open. But we're not going to pass legislation, I call it, I call it fig leaf legislation, you've heard me say it before, we're not going to pass fig leaf legislation and say we passed this problem when my constituents continue to get sicker and sicker and be unable to afford their health care. We will continue to work on issues if we can in a bipartisan way that are going to improve health care quality and reduce health care and reduce costs and all are welcome to help us. I yield back.

Gentlelady yields back. I now recognize the esteemed chairman of the full committee, Mr. Guthrie.

Thank you. I appreciate, appreciate our witnesses for being here. Thank you, Mr. Chairman, for holding this hearing. And I want to talk about why we're here. One, people have to afford health care. That's absolutely true. And I disagree with my friend from Colorado that the answer to this is a single-payer system. Then you don't get, I don't think it, you can look at a system that delivers quality health care that has that system. I will also say that the expense in the health care system, the Affordable Care Act is still the law of the land. And so when we're dealing with the rising cost of health care, that's the law of the land. But let me tell you why we're, and I'll tell you why we're here. And I'm going to talk about my favorite constituent. She said I could use her information, it's my wife. So, so we've, we've been very blessed to have very healthy time until just, just recently. She had a, think about this, this is, this is why people are frustrated. This is what we're hearing from everybody. This is the system we have today. So my wife has a, was trying to pass a kidney stone, it got impacted, so we had to go to the hospital, have a kidney stone removed. Take her at 6:00 in the morning, leave at noon. And a couple days later, a few week, the days later we get a bill that says your stay at the hospital for less than six hours was $28,000. $28,000. It said your, your bill was $28,000, your health insurance paid $27,500 and you're paying $500. So we paid $500. We pay $1,500 a month for the insurance we have. People think that members of Congress get free insurance, we pay $1,500 a month for it, deductibles, copays. So think about that, $28,000 for six, and we had a good doctor, wonderful doctor, wonderful person, but we're trying to figure out why was it 20, we can't figure out why was $28,000. You can't figure it out. So then the second thing is, unfortunately, she slipped on the ice when we had our ice storm in Kentucky and pulled her shoulder out of socket and broke her, a part of her arm. Goes emergency room. A few days later, we get a call from a debt, a debt collector. Now, last time we got a loan for anything, the guy looked at us and said y'all have the highest credit score I've ever seen. Matter of fact, he goes I was one point behind her. I don't know why it wasn't the same because they're all tied together and she had bragging rights, she had a higher credit score than me by a point. So we pay our bills. We have the means to pay our bills. We pay the $1,500 and, and we want to, so we have the means and we have, we get called from a debt collector. Well, she went to the emergency room, my son-in-law took her because I was here, and he didn't have our insurance information. She couldn't give the insurance information. So it seems like the, the provider, who could have called us because they obviously knew who we were because they turned us into a debt collector, didn't, didn't even reach out. Fortunately, not many of my constituents can do this. I have the CEO's cell number. Gave him a phone call, he goes oh, they didn't have your insurance information. Well, my wife was like in, in excruciating pain. He goes well, let's, let's run it through and, and see what you can happen and then we'll just run it through insurance. So think about the system that people deal with. So yesterday, I had a prepared statement, but then I changed it because yesterday, we get this text from my wife sends me a text from Medicredit. I don't know who Medicredit is, but they're from Chicago and they send us a letter and first we thought it was a scam, it was so absurd. And we start looking online, and I don't know who Medicredit is, but if you start reading their comments online, you would think it's a scam company, but it seems like they're legitimate. And it says, and I'm reading, as of February 6, you owed $834.60. Between February 6 and today, you were charged zero interest, you were charged zero fees, you paid, your insurance paid, and you were credited for this amount, negative $1,947.40, so you now owe $2,782. So what we owe was $800, we didn't know we owe because we never got a bill. Now it's doubled, so it's tripled, three times what it originally was, and we never received a bill. So the providers turned us into a debt collector without ever informing us of the bill that we have. So I hate that this happened to my wife, I hate that my wife has been through this, but I'm glad that I've experienced it because I was committed to transparent competition in health care and I am telling you, I am committed not just to moving a bill, I'm committed to getting it done because a lot of people aren't in the position that I am in and have the opportunity to try to work through this with the CEO of the hospital to see why in the world we're, my wife's worried about her credit rating that she's taken great pride in, especially since she's one point higher than me. She's worried about, it's just absolutely frustrating that a six-hour procedure costs $28,000 and then you go to the emergency room and the provider makes no effort to try to run you down to say, all right, are you going to pay your, they knew who we were and so now we're dealing with a debt collector that if you read their comments, Medicredit, read about them online, they, a lot of people have had really bad experience with them. So we're going to deal with this, we're going to fix it, and I'll yield back.

Gentleman yields back. That's what Americans are facing across the board and all of us have a story. I now recognize the ranking member of the full committee, Mr. Pallone of New Jersey, for his five minutes for an opening statement.

Thank you, Mr. Chairman. Committee Republicans are holding yet another hearing that is purportedly about lowering health care costs for all Americans, and yet they continue to actively make the affordability crisis of their own making even worse. Republicans are hoping the American people will forget that last year they cut more than a trillion dollars from the Affordable Care Act, Medicaid, and Medicare with their big ugly bill so they could give giant tax breaks to billionaires who don't need them. And now, of course, when I'm home, my constituents are saying that these health care cuts are helping pay for an irresponsible war in Iran. And they, and they're right, and they say that instead of paying billions of dollars a day for an irresponsible war in Iran, we should have taken that money and used it to help people with their health care and give them the premium tax credits. And they're right about that too. These cuts that the Republicans are making mean that 15 million people are losing their health insurance and tens of millions more will saw their out-of-pocket costs skyrocket at the beginning of this year. And instead of doing something to help the situation, like unwinding the cuts or extending the ACA enhanced premium tax credits, Republicans are holding affordability hearings in an attempt to show that they care. Well, it's nothing but talk. As Americans watch the doctors' offices and hospitals in their community shut off critical services like labor and delivery or even closing their doors altogether, congressional Republicans are doing absolutely nothing to fix the problem. And worse yet, Republicans and the Trump administration are doubling down on the big ugly bill and making even more health care cuts. After Republicans refused to extend the ACA tax credits that would have made comprehensive health care more affordable for about 20 million low- and middle-income Americans, the Trump administration is now proposed new rules to increase costs even further by proposing to increase the amount that insurance companies charge people. The administration's proposed rule would raise deductibles for many families with ACA policies to $31,200. That's as much as 75 percent of household income for many of the people eligible to purchase this coverage. So now they have these huge deductibles in addition to the premium increases. And that means for the health care providers sitting in front of us today that uncompensated care is going to go up even more because Americans are simply not going to be able to afford insurance and will be forced instead to once again rely on emergency rooms for care. And Republicans are wanting to take us back to the days before the ACA. Sure, the chairman said the ACA is still out there, but if you can't buy the policy or you can't afford the deductible, you're going back to the days when there was no ACA, where Americans were skipping care that they need and instead come to health care providers sicker and more desperate, and it's going to leave millions of Americans buried in medical debt. That's the other thing. That will force even more providers to close their doors. And the Trump administration and Republicans are doubling down on Medicaid cuts at all, also. We heard this yesterday in the hearing. In their latest crusade, the Trump administration has acted to withhold and defer about 30 percent of all federal Medicaid funding to Minnesota, cutting funding for home- and community-based care that seniors and disabled people, including disabled children, rely on to live healthy lives in their communities instead of being institutionalized. Substance use disorder services will also be cut that help people recover. Support services for children with autism will also be cut. But this isn't just in Minnesota. Doctor Oz and Vice President Vance have made clear that they are on a state-by-state crusade to cut funding for services that seniors and people with disabilities rely on, and the committee Republicans are simply piling on, sending their own letters attacking Medicaid funding for similar services in 10 states. So I would ask, Mr. Chairman, unanimous consent to insert into the record letters from organizations representing seniors, people with disabilities, and people with substance use disorder who rely on these services, begging Republicans to stop this assault on their health care, if I could ask unanimous consent to include those records, those letters in the record, Mr. Chair.

Without objection.

Thank you. So ordered. And I have to say, I am tired of Republicans using this hearings as an attempt to show they care about health care affordability when they created this health care affordability crisis in the first place and are making it worse. You're not fooling the American people. They know Republicans are to blame for skyrocketing health care costs, millions losing their coverage, and hospitals closing their doors. You know, I have to say, I didn't even realize that a hospital in New Jersey could be a hospital and not deliver babies or provide pediatric care. But that's what's happening. If they're not closing, they're cutting back on essential services. And with that, I yield back the balance of my time, Mr. Chairman.

Gentleman yields back. We now conclude with member opening statements. The chair would like to remind members that pursuant to committee rules, all members' opening statements will be made a part of the record. We want to thank our witnesses for taking the time to testify before the subcommittee. Although it is not the practice of this subcommittee to swear in our witnesses, I would remind our witnesses that knowingly and willfully making materially false statements to the legislative branch is against the law under Title 18, Section 1001 of the United States Code. You will have the opportunity to give an opening statement followed by questions from members. Our witnesses today are Richard Pollack, President and CEO of the American Hospital Association; David Aizuss, Chair, Board of Trustees of the American Medical Association; Shawn Martin, Executive Vice President and CEO, American Academy of Family Physicians; Elizabeth Mitchell, President and CEO, Purchaser Business Group on Health; Anthony DiGiorgio, Neurosurgeon, University of California San Francisco Health; and Barbara Merrill, CEO, American Network of Community Options and Resources. Per committee custom, each witness will have the opportunity for a five-minute opening statement followed by a round of questions from members. The light on the timer in front of you will turn from green to yellow when you have one minute left. I now recognize Mr. Pollack for his five minutes to give an opening statement.

Chairman Griffith and Guthrie, Ranking Member DeGette and Pallone, and the members of the subcommittee, thank you for the opportunity to be here today. America's hospitals and the women and men who care for patients and families every day are truly the backbone of the nation's health care and one of the key elements of our national critical infrastructure. Think about the role that hospitals play. They are there in the very first moments of life, supporting newborns and families. They are there at the end of life, providing compassionate care when it's needed most. And they are there for patients in countless moments in between, caring for the injured, sick, and keeping people healthy. That blue and white H sign that we see on the side of the road is iconic because it represents hope, healing, and refuge. It says follow me because of the promise that skilled around-the-clock care is close by. That responsibility is enormous and it's part of what makes hospitals unique in our health system. And let me be clear, America's hospitals and health systems are deeply committed to providing high-quality, accessible, and affordable care. And across the country, hospitals are increasing efficiencies, adopting innovative technologies, and rethinking how they deliver care. Many are investing in preventive care and care coordination programs that help patients better manage chronic disease and avoid unnecessary hospital visits and stay healthier at home. These efforts improve outcomes and they help lower costs for patients, families, and the entire health system. Hospitals are also using new technologies to make care more affordable and more convenient. Telehealth, remote monitoring, and digital tools are helping patients access care in ways that fit their lives. Electronic health records and data-driven care models help clinicians catch problems earlier, avoid duplicative tests, and coordinate treatment more effectively. At the same time, science and technology are unlocking possibilities that were once unimaginable, and hospitals are where breakthroughs become real and we turn discovery into healing. But we also know there's more work to be done. As we talk about lowering costs and protecting access to care, it's important to understand the environment hospitals are operating in and the pressures they're facing. Now, hospitals are different than other parts of the health care system as they support a wide spectrum of services. Emergency care, inpatient care, surgery, diagnostics, all operating simultaneously. They have substantial fixed costs to maintain specialized services, high-cost equipment, and a fully staffed 24/7 environment that remains ready for anything, ranging from tornadoes to hurricanes to wildfires to floods to mass shootings to other large-scale emergencies, including the unthinkable. As a practical matter, hospitals are the public health system in many communities and society's ultimate safety net. We have seen time and time again that when America has a crisis, it turns to its hospitals. Hospitals today are balancing rising costs across the board, many of which are completely outside our control. They're treating sicker, more medically complex patients, and all of this is happening in a payment system that is increasingly misaligned with the realities of delivering care, particularly government reimbursement that is less than the cost of providing care. And I want to give a few examples. In 2025, hospital spending on medical supplies, equipment, and technology increased 10 percent, and that includes life-saving devices clinicians rely on every day, not to mention significant investments in cybersecurity. Hospital drug expenses rose more than 13 percent in 2025, driven by rising prices and the introduction of new high-cost therapies. About 60 percent of a hospital's expenses go to paying their talented workforce, and those costs are increasing 5.6 percent a year. Overall hospital expenses increased 7.5 percent last year, while hospital prices rose only 3.3 percent. And this is despite the fact that as a percentage of the GDP's total health spending, hospital services have remained relatively stable for decades. Hospitals, patients, and caregivers also face growing administrative burdens from large commercial insurers, delays, denials, and disruptions in care that add enormous cost and keep clinicians from caring for patients. And we can't ignore, we can't ignore what's ahead. Hospitals are preparing for reductions in federal Medicaid funding and changes to the health insurance marketplaces. This will further strain resources and increase the number of uninsured and underinsured patients. That means more families turning to already overburdened emergency departments for basic care as we become the family doctor to the uninsured. This results in clogged emergency departments and inevitably longer wait times, which impacts not just Medicaid patients and the uninsured, but everyone. In conclusion, in my written testimony, you'll see several specific solutions that can meaningfully improve value and affordability. And they focus on four areas: improving the health of individuals and communities, advancing value through care transformation, reducing regulatory barriers and administrative waste, and driving innovation. We look forward to working with you and all stakeholders to advance solutions, and thank you for the opportunity again, Mr. Chair.

Thank the gentleman for yielding back. Now recognize Dr. David Aizuss. Hope I said it right.

Pretty close.

Well, tell us how to say it so everybody else gets it right, even though I didn't.

So thank you, Chairman Griffith and Ranking Member DeGette, Chairman Guthrie, Ranking Member Pallone, and members of the subcommittee for having me here today. My name is David Aizuss. I'm a board-certified ophthalmologist with an independent ophthalmology practice in Encino and West Hills, California, and the chair of the Board of Trustees of the American Medical Association. Physicians want to care for all patients and ensure a healthy country. Congress can aid in this mission by recognizing that affordability is inseparable from access and promote policies that ensure consistent, reliable, and locally accessible physician care. Challenges surrounding patient access to physicians and healthcare affordability are multifaceted. They include market consolidation, inadequate physician payment, burdensome prior authorization rules, coverage instability, and physician workforce shortages. The consequences are severe. Independent physician practices are closing. Burnout remains high, and too many patients cannot find timely physician care in their communities. We are seeing a rapid transition away from independent physician practices and into higher cost settings. This drives up spending for both families and federal health programs. In my community, I am having difficulty finding primary care physicians willing to accept new Medicare patients. In fact, many physicians are charging patients an annual fee to enroll in their practices in order to keep their doors open. Congress can take several meaningful steps to shore up physician practices, stabilize patient access, and lower pressure costs across the system. First, Congress should prioritize Medicare physician payment reform. Stabilizing Medicare physician practice payment is one of the most direct ways that Congress can protect patient access to care and counter further consolidation in the healthcare market. Physician payment has declined by 33 percent when adjusted for inflation since 2001, while practice costs have continued to rise. The solution starts with preventing the 2.5 percent Medicare cut scheduled for the end of 2026. Even small cuts have significant consequences for patient access. In addition, Congress should reform Medicare's outdated budget neutrality requirements to stop the annual cuts. Next, Congress should establish a real inflation update tied to the Medicare Economic Index to reflect rising staffing, technology, and compliance costs. Moreover, Congress must reform MIPS to ensure that small, rural, and independent practices are protected from the steep 9 percent penalties and ensure physicians receive timely performance data. Second, Congress should reduce administrative and regulatory burdens that take physicians away from patient care. Physicians are wasting too much time dealing with paperwork rather than caring for patients. Prior authorization and complex federal reporting programs take time, add cost, and delay patient care. Congress should pass the Improving Seniors' Timely Access to Care Act and reform the Medicare MIPS quality reporting program. Third, Congress should promote competition and expand patient choice. Consolidation can negatively affect both cost and access, and Congress should ensure the viability of independent practices. In addition, we need to remove existing federal restrictions that prevent physicians from opening or expanding physician-owned hospitals. Congress should increase competition and patient access to care by passing legislation such as the Patient Access to Higher Quality Health Act. Fourth, Congress must address the growing physician workforce shortage, which is currently projected to hit 86,000 by 2036. Fifth, as changes to Medicaid move forward, Congress and the administration should focus on the implementation that protects eligible patients from falling through the cracks. The AMA is committed to helping ensure that eligible patients maintain health coverage and access to physician care. We encourage preserving coverage stability while also ensuring that physicians can sustainably participate in the program and care for our Medicaid patients. In addition, implementation should minimize barriers for patients. America's physicians are committed to their patients. We stand ready to work with you to build a system that keeps practices open, that patients are cared for, and costs are under control. Together we can get this right, and we must. Thank you, and I look forward to the committee's questions.

Thank you. And it's your turn, Mr. Martin, for your five minutes, sir.

Thank you so much, Congresswoman. Chairman Griffith, Ranking Member DeGette, Chairman Guthrie, and Ranking Member Pallone, and members of the subcommittee. Thank you for the opportunity to appear before you today on behalf of the American Academy of Family Physicians. The AAFP proudly represents over 124,000 family physicians providing comprehensive care for patients of all ages in over 95 percent of U.S. counties. Thank you for the opportunity to share thoughts on why healthcare has become more unaffordable and to offer ideas for how we might reverse these trends and help individuals achieve better physical, mental, and financial health. We as a population are unhealthy. Decades of policies have made primary care less accessible and affordable, and this has resulted in consequences: higher prevalence of chronic disease, declining vaccination rates, low utilization of prenatal services, and growing numbers of unmanaged behavioral and mental health issues, to name a few. Our system will spend trillions treating and managing chronic disease, yet we will invest comparatively little in prevention and primary care. And primary care is not affordable. An annual primary care for one year is often less than one visit to the emergency room or one day in a hospital. I suggest that the most effective way to lower healthcare costs for individuals and for our system as a whole is to improve the health of our population. And the best way to improve the health of our population is to strengthen primary care. Studies consistently show that primary care is the only area of healthcare that improves health outcomes while reducing costs on a per capita basis. And sadly, the number of Americans who have a usual source of primary care has decreased over the last decade. These trends are certainly a byproduct of consolidation, but also reflective of insurance design that has placed financial barriers between patients and primary care, particularly in the form of high deductibles and cost sharing. There have been meaningful bipartisan efforts to invest more resources in primary care over the past decade, including many by this committee. I would specifically acknowledge the important policies advanced by CMS this past year as part of the Medicare physician fee schedule. This type of leadership and these types of policies are consistent with our recommendations. Physicians are at their best when they are serving patients and communities and not the financial interest of an employment or investment partner. Over the past two decades, we've seen a dramatic shift in practice ownership. Today, nearly 75 percent of family physicians are employed by hospitals or other entities. Twenty years ago, that number was closer to 35 percent. This shift has occurred for several reasons. First, insufficient and unstable payment policies from all payers, including Medicare, have placed increasing economic pressure on physician practices. Independent practices often lack the market leverage needed to fairly negotiate payment rates with insurers. And the increasing burden associated with quality reporting, utilization management, and practice improvement have increased the cost of operating an independent practice. While private equity is often viewed unfavorably, I would suggest that many of the business tactics associated with private equity are not materially different from those employed by hospitals or care delivery systems owned by insurers. Each seeks control over diagnostic, treatment, and referral decisions within primary care in ways that serve the financial interests of the parent organization rather than always aligning with the interest of the patient. We are also concerned with the misaligned incentives within vertically integrated insurance organizations. Medical loss ratio requirements were designed to ensure that the most premium revenue is spent on medical care. However, as insurers have acquired physician practices, the lack of transparency has made it difficult to determine how much premium revenue is actually supporting patient care versus profits. I would offer six recommendations for your consideration. First, double the nation's financial investment in primary care and the primary care physician workforce. Two, reform our flawed Medicare physician payment system to more appropriately value the actual patient care done by physicians and not just the facilities in which they work. Three, establish regulatory frameworks that support independent physician-led models, specifically direct primary care. Four, create space for physicians to focus on patients by reducing the administrative complexity of the modern medical practice. Five, remove financial barriers to primary care. And six, promote proven evidence-based interventions, including vaccines, in our system. I will conclude with two thoughts. Healthcare consolidation has led to higher costs, decreased access to care, and universal frustration. And to truly reduce the cost of healthcare, we must invest in health, and health starts with primary care. Thank you for the opportunity to be here today, and I look forward to your questions.

Thank you, Mr. Martin. And now, Ms. Mitchell, you're recognized for your five minutes.

Thank you, Chairmen Guthrie and Griffith, Ranking Members Pallone and DeGette, and members of the committee. Sincere thanks for the opportunity to testify today and to share the experiences of large self-insured employers and public purchasers of healthcare as they seek to reduce healthcare costs, improve quality, and increase access and affordability for their employees. Over 180 million Americans receive health insurance coverage through their employer, and they rely on the commercial market to ensure that care is affordable and high quality. However, that is increasingly difficult. Soaring costs quickly turn a medical emergency into a financial disaster. Affordability for American workers is reaching a crisis point. My name is Elizabeth Mitchell. I run the Purchaser Business Group on Health. We are a nonprofit coalition of jumbo self-insured employers and public purchasers, collectively spending over $350 billion annually purchasing healthcare for about 25 million Americans. PBGH facilitates employer-led innovation in the commercial market, and for nearly 40 years, we have worked directly with purchasers and healthcare providers and practices to improve quality and affordability through active purchasing strategies and actions. Our members have implemented employer-led innovations that deliver real results, including joint HMO purchasing that reduced premiums by over 9 percent, advanced primary care initiatives that saved hundreds of millions of dollars and avoided tens of thousands of hospital admissions. And we have also done some of the nation's earliest centers of excellence programs that dramatically improved outcomes and cut cost. More recently, we have worked to combine price, quality, safety, and claims data to support value-based purchasing. In short, we know what it takes to deliver high-value care, and we appreciate this committee's leadership on affordability. However, while employers and purchasers are leading the way on innovation, policy intervention is necessary to address the anti-competitive business practices and restore a functional market. The healthcare industry has been largely unresponsive to the concerns of employers and patients, erecting barriers to access and affordability and stymying innovation. When this happens, American businesses, workers, and their families are the ones left holding the bill. And the committee should be crystal clear: self-insured employers and workers are paying these healthcare costs. Health plans simply administer payment with other people's money, keeping a large portion for themselves. But this is money coming out of businesses and wages. But there is good news: we know what works. Evidence-based strategies can improve care while lowering costs if they are scaled and supported. Based on our experience, we urge three priorities. First, ensure meaningful price and quality transparency so that purchasers and patients can make informed decisions. Second, redirect resources to underfunded high-value care, including primary care, maternity care, and mental health. And third, stop the anti-competitive business practices enabled by consolidation and strengthen policies like site-neutral payment and anti-competitive contracting reform that restore competition and accountability. Employers have demonstrated that they are prepared to confront the healthcare cost crisis, but they cannot do this work alone. By advancing these reforms, Congress can directly improve affordability and quality for more than half of the country through market-based solutions. Thank you for the opportunity to testify and for the committee's leadership on healthcare affordability. We look forward to working with Congress to advance transparency, competition, and market-based solutions that lower costs and improve care for American families.

Thank you, Ms. Mitchell. And now I'll recognize Dr. DiGiorgio for his five minutes.

Thank you, ma'am. Chairman Griffith, Vice Chair Harshbarger, Ranking Members DeGette and Pallone, members of the subcommittee, thank you for the opportunity to testify today. I am Anthony DiGiorgio. I'm a practicing neurosurgeon at the University of California, San Francisco, and the views I express here today do not necessarily represent those of UCSF. I clearly don't need to belabor the points about healthcare affordability. If we're serious about fixing this, we must look squarely at consolidation and the policy choices that have accelerated it. And I want to be clear: the answer is not weaker hospitals. We need strong hospitals for emergency care, trauma care, teaching, transplant services, and true safety net functions. I work in that world, and I believe in that mission. But we also need a strong independent physician sector. Independent physicians and physician-led facilities are one of the last practical checks on consolidation in American healthcare. They preserve patient choice, create local price competition, and maintain accountability through direct patient-physician relationships rather through distant corporate hierarchies. Yet over time, regulations have eroded the ability of independent doctors to maintain their practices. Just like any industry, this consolidation has led to significant price increases. Hospital acquisition of independent practices and vertical integration are associated with higher prices and higher Medicare spending, along with lower wages for nurses and other workers. And despite the usual promises, the evidence does not show that consolidation reliably improves quality. Congress must revisit policies that have restricted physician-led entry. Section 6001 of the Affordable Care Act essentially prohibited new physician-owned hospitals. This has removed one of the few physician-led entries that could have checked consolidation. However, there's ample evidence that physician-owned hospitals provide high-quality care. They're consistently ranked among the highest quality hospitals while improving access in underserved communities. That alone is enough to justify repealing Section 6001. Additionally, Stark Law acts as though every physician-led ownership arrangement is presumptively suspect. Independent physicians should be able to build lawful ancillary capacity, participate in joint ventures, and coordinate care without hiring a battalion of lawyers just to understand whether ordinary business planning is allowed. If policy makers are worried about weak utilization control in fee-for-service, a legitimate concern given the levels of fraud that are coming to light, an exception to Stark Law could be made within a managed care setting. Section 6001 and Stark create an untenable double standard. Corporate health systems are granted broad safe harbors that allow them to anti-competitively steer referrals within their system. Why should independent doctors be subjected to prohibitions on self-referrals when corporations are not? Additionally, CMS pays vastly different amounts for the exact same clinical service depending solely on the ownership structure of the building where the service is rendered. This structural flaw transforms healthcare delivery into a massive exercise in payment policy arbitrage. As an example, MedPAC showed that an echocardiogram is reimbursed 194 percent more in a hospital than in a free-standing office. An independent medical practice is often worth significantly more to a corporate hospital system than it is to the independent physician owner due to the site-of-service differential and the captured downstream referrals. For a truly independent practice, Medicare compliance is a substantial burden. For example, just to report CMS's mandatory quality metrics, outpatient physicians spend about two and a half hours weekly on reporting, and non-physician staff spend another 12 and a half hours. Additionally, Medicare's conditions of participation actively prohibit price transparency. Under current rules, physicians are not allowed to offer cash prices for Medicare beneficiaries. These prohibitions stifle the ability of physicians to innovate on payment design, creating transparent upfront pricing mechanisms that would empower patients. That all-or-nothing structure makes patient-centered payment innovation harder than it should be. Moving towards flexible private contracting and payment models is preferable to simply applying another fix to the physician fee schedule. But as long as Congress keeps physicians inside a prospective payment system, it should at least stop using that schedule in a way that destabilizes independent practice. The system effectively starves independent practices of revenue while burying them in paperwork, making selling to the hospital the only viable way out. Congress must also confront the distortions and abuses in the 340B drug pricing program. The availability of 340B discounts to hospital child sites but not independent practices creates yet another means of financial leverage for hospital systems to acquire clinics. Congress should use the power of the Medicaid matching percentage to incentivize competition in states. States that continue to protect incumbents through certificate of need laws, broad physician non-competes, and pro-consolidation state-directed payments or other barriers to physician-led entry should not receive the same federal matching treatment as states that permit real competition. We need a thriving independent physician sector. If Congress continues to kick the can down the road or rely only on band-aids, the U.S. health system will continue consolidating into a top-down market dominated by a handful of vertically and horizontally integrated monopolies, and the American patient will be the one paying the price. Thank you.

Thank you, sir. And now I'll recognize Ms. Merrill for her five minutes.

Thank you, Vice Chair Harshbarger. Yeah. Thank you, Vice Chair Harshbarger. I think it's not turned on yet. Is it green? Can you hear me now?

We can hear you fine.

Vice Chair Harshbarger, Ranking Member DeGette, members of the committee, it's an honor to be here. Thank you. I'm Barbara Merrill, CEO of ANCOR, a national association representing more than 2,500 private, mostly non-profit organizations that deliver life-enhancing, cost-effective home and community-based services to people with intellectual and developmental disabilities, or IDD. I want to spend my time today telling you about just one of those providers, DDRC. Since 1964, DDRC has supported Coloradans with disabilities in the Denver metro area through services like early intervention, residential support, and employment training. The impact of HCBS is evident to people like Susan Hartley, whose son Cameron was diagnosed with a rare seizure disorder at just six months old. Susan was a 22-year-old single mother when she was told her son would probably only live to the age of three and that she should consider institutionalizing him. She refused, and years later connected with her local community center board, which helped the family access therapy services and help get Cameron on the waiting list for Medicaid-funded HCBS. But the wait took years. "While I waited, life was so difficult," Susan told us. She pawned what she could, and she missed mortgage payments to cover Cameron's therapy and medical bills. Susan continued, "But when we finally got off the waitlist and received Medicaid, our lives changed dramatically for the better." HCBS enabled Susan to keep on working despite Cameron's need for round-the-clock care. As she put it, "I was actually able to focus on him and his therapy needs versus how I was going to pay for it while keeping a roof over our heads." Cameron passed away in 2017 from complications of his disability. But thanks to DDRC and HCBS, he lived to the age of 35, and he spent his entire life in a loving home. We hear stories like Susan's and Cameron's every single week. That's because home and community-based services make it possible for people with IDD to carry out daily activities of living, build skills, find and keep jobs. They also allow loved ones to remain in the workforce. These IDD services, which can only be accessed through Medicaid, accomplish all of this at an average cost of $70,000 a year per person, a fraction of the cost of the alternative, which is to support people in large state-run institutions at an annual cost of $395,000 a year. Despite these services being the preferred and the most cost-effective option, numerous barriers threaten their sustainability. For starters, these services are not mandatory, meaning states decide whether to offer them and to whom. Chronically insufficient reimbursement rates have for decades made it extremely difficult for providers to recruit and retain direct support professionals, workers who can earn more working in fast food and retail jobs. Together, these factors explain why there were more than 550,000 Americans with IDD on state waiting lists in 2025. Now new threats stand to make things worse. Last year, IDD service providers were told repeatedly that the Medicaid funding cuts included in HR 1 would preserve access for the most vulnerable and wouldn't impact disabled Americans. Yet when federal Medicaid dollars to states are limited through changes to provider taxes or state-directed payments, states often turn to cuts in optional services like HCBS. Numerous states this year are already proposing to cut directly from IDD services to overcome budget shortfalls. One state, Idaho, has even proposed eliminating HCBS services altogether. Given these barriers, we must ensure that every dollar that we spend reaches people in need. That's why ANCOR shares in the goal of ensuring that Medicaid is free from waste, fraud, and abuse. But such efforts must be precise and targeted. Cutting off funding from all providers of a given service serves to threaten the most vulnerable people and their families and runs counter to the goal of saving taxpayer dollars. In conclusion, discussions about healthcare affordability must recognize the crucial role of HCBS, investments that prevent people from needing costlier, more intensive care. Therefore, the best way to help to lower healthcare costs and improve outcomes for people with disabilities is to strengthen home and community-based services so that they can keep on supporting families like Susan and Cameron's, building a stronger America for everyone. Thank you.

Thank you, ma'am. We'll now begin questioning, and I'll ask members not to begin a new question to our witnesses as their five minutes expire and would encourage members to submit written questions for the record. I now recognize myself for five minutes. And I want to start with Dr. Aizuss, right? I want to ask you about an issue that directly affects physician supply, patient access, and healthcare costs. And you know, I'm a sponsor of the Fair Access in Residency Act in Congress, and I've been examining persistent discrimination against doctors of osteopathic medicine in federally funded residency programs. DOs and MDs hold equivalent licenses, yet nearly 75 percent of programs still require DO students to take the USMLE in addition to the COMLEX. And surveys show that DO students report bias in the residency match while nearly 30 percent of programs seldom or never interview DOs. The AMA itself has acknowledged this discrimination is a real concern, but despite years of discussion within the House of Medicine, the problem remains. Since Medicare spends over $20 billion a year and funds a majority of residency slots, barriers like this can restrict the physician workforce and ultimately affect patient access and affordability. So my question is, why hasn't the medical profession done more to solve the problem with such little progress, and why shouldn't Congress act to increase transparency in Medicare-funded residency programs to ensure DOs are treated fairly and that patients benefit from the full physician workforce, sir?

Thank you for the question. In the eyes of the American Medical Association, an MD and a DO is equivalent. There is no difference. Right. So I can't speak to any kind of discrimination that's occurring in academic centers for residencies, but there is no organized effort to discriminate between allopathic and osteopathic physicians. As I said, in our minds, they are equivalent. We have a member of the AMA Board of Trustees who is an osteopathic physician, and I would suggest that this is work that needs to be done in individual academic centers to ensure that they treat all applicants with equivalent credentials equally.

Well, if nearly 75 percent of programs still require them to take the USMLE in addition, you know, to the COMLEX, look, and if you've got 30 percent of those programs seldom or never interviewing those DOs, if you've acknowledged the problem, then you need to fix it. So that's just my suggestion, sir. Ms. Mitchell, there you are in the middle. The 340B drug discount program was intended to help vulnerable patients like the uninsured or the underinsured patients, but the nonpartisan Congressional Budget Office has found that hospitals can buy drugs at deep discounts while charging commercial insurers and patients much higher rates and keeping the spread. CBO also found that current 340B incentives are likely increasing federal spending, driving up costs through the use of higher-cost drugs, reduced insurer rebates, and more vertical integration. From the perspective of employers who finance a large share of private coverage, are these incentives raising costs for purchasers, and should Congress consider stronger transparency and guardrails to ensure the 340B is benefiting patients rather than inflating costs in the commercial market? Because myself and my colleague Buddy Carter have legislation about 340B.

Thank you for the question. The 340B program, as you know, was intended to support safety-net hospitals, but as you've also noted, it has expanded beyond its original intent, and we do believe it is driving up costs in the commercial market as well as for public payers. We fully support more transparency to get a better handle on what's happening and why and really identify strategies for savings.

Yes. Thank you, ma'am. Mr. Martin, from the perspective of family physicians, what are the steps should Congress consider to strengthen workforce capacity by better utilizing the providers already in the system?

Yeah, I think thank you for the question. One, we think there needs to continue to be decentralization of training opportunities, not that physicians should not be trained in hospitals, that is the most appropriate place for some physician specialties. For primary care and for other specialties, programs such as the Teaching Health Centers, supporting programs that allow for scholarship and loan repayment based upon rural training tracks and other opportunities have the potential and they have been successful in many parts of the country. I may, if I could, answer your DO question. We are we have almost 20,000 osteopathic physicians in our membership, we're one of the largest osteopathic organizations in the country, and I think that issue is largely specialty by specialty as a residency review committee set up their criteria for applications. I think there is wide variation. I don't think that discrimination is taking place across the GME platform.

Well, you need to talk to the good doctor beside of you and y'all get that fixed.

I think we agree. I think we agree.

Okay. I think my time is up, so I will recognize the ranking member, Ms. DeGette, for her five minutes.

Thank you so much. First of all, I want to welcome you, Dr. DiGiorgio, and tell you my daughter Raffaella is on faculty at UCSF in internal medicine, so maybe you can get to know her. Thanks to the HR 1, which is the Big Bad Bill, all of our states are being I call it Big Bad Bill because it alliterates, Frank. In Colorado, what that means is a 14 percent reduction in federal Medicaid funds, and that's money, as you heard in the testimony, goes for sick kids, keeping people with disabilities in their communities, and providing coverage for folks. And now they're trying to scramble to to how they can fund these already lean programs. So Ms. Merrill, I really want to thank you for sharing Susan and Cameron's story, two Coloradans that are really being impacted by this. And I'm sure you know and the rest of you know, lawmakers are really looking at cuts to caregiver services and programs to keep people in their homes and communities. Can you, Ms. Merrill, delineate some specific types of services that are getting cut in Colorado and elsewhere?

Absolutely, thank you. We're really worried about what's happening in Colorado, we're worried about what's happening...

Right, what specific types of services are being cut?

Let me share. Cuts that are already on the table are provider rate cuts to certain services, soft caps to services, reducing enrollment on the developmental disabilities waiver. But the legislature, we understand, and this is the information we got as as recently as last night, the legislature is also considering deep across-the-board cuts to provider rates.

Yeah. Okay, thank you. Madam Chair, I ask unanimous consent to put this April 16, 2025 study in Health Affairs about what sorts of services are first to go when budgets are cut in the record.

Without objection, so ordered.

Thank you. Now, I want to say that in my district, which is Denver, Colorado, nearly half of the patients at Denver Health are on Medicaid. According to a conservative estimate, 20,000 Denver Health patients will lose Medicaid as a result of HR 1, the Big Bad Bill. So I want to ask you, Mr. Pollack, people without insurance often go to the emergency room rather than getting care earlier and in cheaper settings. Is that correct?

Correct.

And it's not like those people suddenly don't need healthcare, it's like they can't afford to go so they just don't go. Is that right?

Yes, as I said earlier, we've become the family doctor to the uninsured.

And but the but but in fact, they're not coming for preventive services, so in fact they're sicker and that's more expensive. Is that correct?

Correct.

Now, in Colorado, the Colorado Hospital Association estimates that HR 1 might cause Colorado hospitals to close, and their spokesperson said it's existential for some. In the recent Senate report, they say six Colorado hospitals, mostly rural, are going to be threatened with closure. Would that surprise you that hospitals like this are feeling the threat of being closed because of this bill?

No, and we've been very vocal in expressing our concerns relative to the impact of the significant Medicaid cuts that are now coming down the pike. And so it's of enormous concerns, and CBO suggests seven and a half million people will lose coverage as a result of that and they all end up in the ED. We want to work to prevent people from getting there so they can get preventive care.

Right. And when the hospitals close, that has a repercussion throughout the community, especially when it's a rural and underserved community. Isn't that right?

That's correct.

Now, I'm also concerned, and you alluded to this, that when when people go into these emergency rooms in these hospitals, that actually all the costs for insurance go up for everybody. Is that correct?

Yeah, there is cost shifting as a result of government underpayment, not only in Medicaid, but in Medicare as well. But the real concern that we also have is that it will just clogged already overburdened EDs and there'll be longer wait times and that affects everyone.

Right, and worse health outcomes.

Certainly if people don't get the care on the front end that you could have prevented and then they end up at the ED, that's not good for the patient.

Great. Thank you. Thank you, Madam Chair. I yield back.

Gentlelady yields back, and I will recognize the chairman of the full committee, my friend Mr. Guthrie from Kentucky.

Thank you very thank you very much, and I kind of got started in my opening statement on some things I want to talk about, but first I know Ms. Merrill recognized in the one big beautiful bill we had the largest investment community-based services at $8 billion, over $8 billion. I know states have the choice to do what they want to do, we want to put federal incentives. The other thing that people are talking about was the way that states fund their sort portion of Medicaid and they do it in a way that puts most of the burden back on the federal taxpayer, and we want states to take responsibility like they committed to when they first went forward in this. And so we'll see what states' priorities are as we move forward in this. So Mr. Pollack, I talked about my wife's six-hour stay in the hospital being $28,000. I'm not sure the hospital received $28,000 nor do I think the insurance company probably paid $28,000, we're seeing it in and it just seems pervasive in the healthcare system. We just looked at rebate model on pharmaceuticals where there's a high, high list price, but that's not what's actually paid, and it just distorts the whole market. And are we not seeing similar effects where plans and providers have incentive to increase price regardless of what the service may actually cost?

Well, you know, when we talk about price and we talk about the bill that you referred to that was 27,000 or something...

28,000 for six hours.

Yeah, well that's a list price. We are price takers. We we don't have the we're not getting that. It's a negotiated rate that we get with the insurance companies, and for government payers, we get a rate. So none of that is the reality, and as you suggest, it was $500 at the end of the day. So that's the way the system is.

It was $500 for us. Right. But somebody paid more than $500 for that. Right. That's the problem, is the problem in the system when we're trying to get price transparency, you can't figure out what anything costs. And so and I'll go to to Ms. Mitchell on it, is that's I always thought that the way you're going to deal with this is because you know there's a choice. I mean, but they had great care, they were great facilities, both both of the instances I talked about, great great facilities, so we want that. So if if employers finally throw their hands up and say this is just beyond this is just crazy, so let and they they surrender, then we end up with a different system that one of my colleagues talked about this morning that I don't think would have the same great hospitals that we have. So I'm bragging on the care that she got, it's just the way that this this system works. And so to get, you know, an individual calling around and saying how much does this cost has an impact, but not like if if a big employer with a lot of covered lives do it. So I when I first got this this position, I started we really want to focus on this and you start talking to big employers, there was one instance I know there was a 700 percent markup on a pharmaceutical and it was an automotive supplier and my I know the automotive business, I said if if if an automotive supplier produced a product with a 700 percent markup that went into an assembly plant, they'd fire their buyer. But yet the human resources department, it turns out nobody knows what anything costs. And so you put together an organization, so I just want you to kind of talk about just how data's there, how trans how can employers even figure out what things cost, what's out of pocket, if they're they're just sending checks when they have no idea if it's really covering what they want to cover or not and and seem to be covering a lot of other people's costs as well when they do this. Could you just kind of explain what's going on in the employer market? I mean, Jamie Dimon said he wanted to fix it for his bank and couldn't, a very sophisticated financial organization couldn't get to what everything costs.

Well, thank you for the question, and it is a critical challenge right now in U.S. healthcare. Pricing is utterly irrational, and it is not related to quality, it is not related to safety, it's basically whatever a hospital can charge and get away with. That is one of the reasons Congress passed healthcare price transparency about five years ago. Unfortunately, we do not have adequate compliance from the hospitals to share their prices. So a basic step forward would be to require them to fully comply with the existing rules and make the price information totally available because to your point, you can't make an informed decision without information. So self-insured employers who bear 100 percent of the risk want to pay a fair price for high-quality care, as is their fiduciary responsibility. Without that information, though, they can't do it. It is still far too challenging to get basic...

Well, how do you get beyond, and we worked on this bipartisan actually. We had it in the bill last year, it ended up being just for pharmaceutical, it didn't really get into the, or PBM, didn't really get into the hospitals after it got out of the Senate. But how do you keep from having what you're, so if I'm an employer and somebody says you just paid, say you paid half, you paid $14,000 for a $28,000 service, and it wasn't really $28,000, how do the employers know what that is? I know I get 10 seconds, I'm sorry.

I will say we are now making that information, those prices available to our members. They are using it in...

What if the price is $28,000 they see and it's not the real price?

Well, that is a challenge, and they have to have full transparency into what goes into those prices and how it relates to quality and outcomes. It is much more difficult than it should be, but employers are and will continue to use that information as it's available.

Well, thank you. I appreciate it, and I hope we can work together on this, and I plan to. I yield back.

Gentleman yields back, and I now recognize the ranking member of the full committee, Mr. Pallone.

Thank you, Madam Chair. Again and again, we've heard what I consider false claims from the Republicans that their Medicaid cuts would not harm people with disabilities, and they argue they can cut nearly a trillion dollars from Medicaid in their big, big bad bill. But people with disabilities who rely on Medicaid for their health care nonetheless wouldn't get hurt, and it's not true. The reality is simple, you can't cut as much as 20 percent of federal Medicaid funding from a state's budget and expect that people's care won't be impacted. It's just not possible. I was at my governor's state of the budget address last week in Trenton, and she was talking about a $2 billion structural deficit, much of which is from the Medicaid cuts. So the reality is this is going to hurt people with disabilities. Now, Ms. Merrill, I want to hear from you and the providers you represent, you know, what's being played out for people with intellectual and developmental disabilities as these cuts begin to take hold, if you will.

Thank you for the question. I'd like to start by painting the picture of how incredibly fragile our community delivery system is to begin with.

I wanted to particularly focus, though, on the kinds of cuts that are hitting home and community-based care because, you know, we worked hard over the years to prevent people with disabilities from being institutionalized, and I'm afraid that that's going to be reversed now, if you will.

That's exactly what we're concerned about. And we saw that during the Great Recession when state budgets were under extreme constraint. During that time period, in every single state in the country and the territories, we saw really pretty deep cuts to home and community-based services because they're not mandatory, because they're optional. You know, we start out in a very, very fragile position because of stagnant, really insufficient reimbursement rates for decades. Our members, providers of services for people with disabilities who are also price takers, we do not set the prices. Our members, providers of services for people with intellectual and developmental disabilities, rely almost 100 percent on Medicaid. There's no opportunity to cost shift to commercial insurance, to Medicare, it is all 100 percent Medicaid.

But I don't want to cut you off, but I wanted to ask another question too. Does this mean that people are going to end up, you know, not being able to stay home and are going to have to be, we're going to see the reverse?

Absolutely. Absolutely. And that was the point of the story of Susan and Cameron. Already we have 552,000 people on waiting lists across the country. And that's before states have to start making really difficult decisions when they're going to have a whole lot less federal funding coming. So we're going to see waitlists get a lot bigger, we're going to see a whole lot more people winding up in emergency rooms at a cost of $3,200 a day. We're going to see what we're already seeing. I mean, that's really the point. The system is already super strained, and then one more thing is just going to make it worse.

Now, the other thing, we're talking about the Medicaid cuts, but the other thing we're seeing from this administration is direct attacks and cutting funding for services themselves, not just the Medicaid cuts, but just cutting funding for the services. So in Minnesota, for example, the Trump administration took action to cut off all federal funding for services, including some of the disability services your members provide. So just tell me a bit about the services that ANCOR providers deliver in Minnesota that the Trump administration has acted to withhold all funding for and what that means to cut off federal funding for this care. I know there's only a minute left, but whatever you can.

Well, let me just start by saying that fraudsters, there isn't an ANCOR member that isn't as horrified as every member of this committee is by fraudsters, by criminals, who divert money away from a system that really badly needs it. In Minnesota, as a result of actions that have not been targeted, they haven't been precise, providers of services for individualized home supports, you know, the types of services that allow people to stay at home, the cost-effective, you know, cost-saving services, those services were put on payment holds. And we're talking about a whole lot of small providers who don't have the wherewithal, don't have that financial capability to go for very long without being paid. And that's exactly the type of risk that is, type of service that is at risk, and that's why it's just really crucial that as we address fraud, that those efforts be super targeted, they be super precise.

Thank you. Thank you, Madam Chair. Oh, thank you, Mr. Chairman is back.

Thank you very much. Gentleman yields back, now recognize gentleman from Florida, Mr. Bilirakis, for his five minutes of questions.

Thank you, Mr. Chairman. I appreciate it. Thanks for holding this third hearing on affordability with regard to health care. While we focus on the topic of providers today, I'd first like to take the opportunity to recognize the important work of many providers in my great state of Florida. My district, like many of my colleagues here, has a blend of larger hospital systems, safety net providers like community health centers, and independent physicians. And each of these play a critical role in health care delivery. For example, BayCare opened the first and only behavioral health urgent care in Florida in New Port Richey, Florida, in early 2025. Just like a traditional urgent care, they are a no appointment needed resource for anyone in the community, whether they have insurance or not. Really incredible stuff. The success of this program has been remarkable, and yet many of the services are not reimbursed by the federal government. I also represent several independent medical practices and physicians who serve as the first line of defense for many patients in the office-based setting. Yet due to misaligned reimbursement in the physician fee schedule, independent practices are closing and consolidating, unfortunately. We must pursue balanced reimbursement policies to meet patients earlier in the health care system. I'm proud to lead efforts to realign reimbursement for office-based services. So my first question is for Dr. DiGiorgio. I know better, something's ringing in my ear, I apologize. Somebody's calling me. So your testimony discusses the loss of independent practices. In addition to reimbursement policies, can you elaborate further on the major factors driving this loss?

So I think the loss of independent practices have largely been due to multiple factors such as the site of service differential and the 340B program as being two major ones. The ban on physician-owned hospitals obviously is a barrier to entry in the hospital space for physicians, and then as well as Stark Law creating undue compliance burden for independent practices as well. So they're all contributing, and I think all need to be tackled equally.

Thank you. I appreciate that. Question to Mr. Martin. Your testimony highlights the importance of community health centers. Can you share more on the role of family physicians at CHCs? How do differing facility reimbursement rates impact provider participation and vertical integration in the physician marketplace?

Yeah, thank you for that question. So we're proud to partner with our community health center colleagues. About somewhere between 16 and 18 percent of family physicians work in a community health center. They are the prominent physician workforce along with their clinician colleagues in the community health centers. And we view the role of community health centers as becoming more important in, particularly rural communities, other underserved communities as the marketplace becomes, as the loss of independent practices we see community health centers filling a lot of that primary care need. So similar to what's already been said, we see a number of factors driving consolidation in primary care. I think the site differential payment certainly was an accelerant in many communities around the country, but the unpredictable nature of Medicare and Medicaid reimbursement certainly also has played an important role. And I do feel we saw the largest consolidation of family medicine around the HITECH Act, which is really more of an administrative complexity criteria where practices just simply couldn't afford the compliance associated with those regulatory requirements at that time. So it's a combination of things. But we do see physicians moving around, leaving rural communities and leaving other communities as consolidation happens, they go seek employment opportunities in other places.

Yeah, unfortunately. We have to do something about that and get the word out on how these centers or the quality of care is outstanding and they're accessible as well. So big fan of community health centers. All right, Mr. Chairman, I yield back. Thank you.

Gentleman yields back, now recognize gentleman from California, Dr. Ruiz, for his five minutes of questions.

Thank you, Mr. Chairman. Look, this is very rich. You know, the majority's called a hearing on the high cost of health care while flat out denying the elephant in the room. You know, this is a problem exacerbated by their making. I'm an emergency medicine physician, and what we do really well is to treat the acute crisis in the emergency department. And what we're doing right now is we're ignoring the gunshot wound and talking about the liver problems. We have to treat the patient. Our health care system is in a crisis right now. It's in a crisis because of the tariffs. It's in a crisis because of the one big beautiful bill, also known as the big ugly law. It's in a crisis because they adamantly refused to extend the Affordable Care Act tax credits. All of these things raise costs for the patient. A lot of us here discussed how to lower overall costs for programs, for institutions, but our focus always has to be how do we lower the out-of-pocket cost for patients. That's who you all work for. That's who I work for in the emergency department, are the patients. And so how are we going to do that when we have a the health care system has just sustained gunshot wounds to the chest and the abdomen with the one big beautiful bill that cut nearly $1 trillion out of Medicaid? When these guys voted against and intentionally did not extend the Affordable Care Act tax credit, that's going to raise premiums by $18,000 a year for some for many of my constituents. What happens when you do with those actions, you're going to have 15 million more people uninsured. That's going to be uncompensated care, sicker patients, not able to go to the primary care, not able to look at price transparency. They don't give a shit about consolidation right now when they're sick. They need health care now. And when they don't get it because they can't afford their health insurance or they just took it away because of the Medicaid cuts, they're going to go where, Mr. Pollack? The emergency department. That's going to be uncompensated care for you. Now, how which departments do hospitals have to cut in order to manage their care?

It obviously depends upon each individual hospital.

Which are the departments that are not the money makers in a hospital?

Generally, the low margin ones would be behavioral health.

One.

Obstetrics.

Labor and delivery, yep.

And infectious disease.

Infectious disease, what else?

Those are probably the main ones.

You know pediatrics is also one of those that are

Oh, I should have mentioned that.

You should have mentioned that, absolutely, because those are the departments that get cut from a hospital. So it doesn't give a nobody gives a rats ass whether they're on Medicaid or not. If you have Medicare, Medicaid, or private health insurance, if the hospitals don't provide those services, you're shit out of luck. You're out of luck. Okay, because you're not getting the care. They cut health care. In addition to that, when those hospitals cannot get cannot make the bills after you've eliminated those programs, what's next for a hospital, Mr. Pollack?

Well, some of them are threatened with closure.

Closure. So when there's closure, is there an emergency department?

No.

No, there's no emergency department, right? So when somebody has a stroke or somebody has a a heart attack and there's no emergency department, what does that do to the risk of permanent injury or death, Dr. Aizuss?

Rapidly, dramatically increases it.

So now suddenly people in our community, whether you have Medicaid, Medicare, private insurance, are going to be at risk for dying or permanent injury injury if they have a stroke or a heart attack. That's the crisis in the room because of the unaffordability caused by the one big beautiful bill known as the big ugly law. Now, how are you going to pay for this uncompensated care? You're going to renegotiate drug prices with the insurance companies, aren't you, Mr. Pollack? The hospitals will.

We're going to have to make a lot of changes.

You're going to have to make a lot of changes and renegotiate the pre the reimbursements with insurance companies, right?

Among other things.

Among those things. I asked seven CEOs in this room, they said yes, that's how they're going to cover the uncompensated care. So guess what they're going to do? They're going to raise premiums. They're going to raise premiums across the board for employers, for small businesses, for people with private health insurance. So suddenly everybody is paying more. That's the gunshot wounds to the body coming into our emergency department that we have to take care of. Let's stabilize this patient by reversing these damages, and then let's talk about consolidation, workforce problems, and full parity with MEI with other providers, tying physician reimbursements to MEI fully. Thank you.

Gentleman yields back. Now recognize the other gentleman from Florida, my good friend, Dr. Dunn.

Thank you very much, Chairman. And thank you to our witnesses today for for being here. I want to raise a bill I co-authored if I may, H.R. 4299, the Protecting Patient Access to Cancer and Complex Therapies Act. This bill addresses the negotiation provisions in the IRA, the Inflation Reduction Act, that relate to drugs often administered or infused in independent community settings. This setting of care is one that we have to work to protect as it provides critical points of access for patients across the country, delivering high quality of care in a cost-effective manner. Under the IRA provisions, negotiation is synonymous to a direct reimbursement cut to providers who are already facing significant financial pressures. Recent analysis by Avalere projects shows that on average, independent providers are going to face a 47 percent cut in their reimbursements. This is, you know, specifically a lot of Part B medicines. That makes stocking and administering these life-saving therapies a net loss. And, you know, forcing difficult financial decisions on on physicians in that situation. This bill provides a very simple technical fix, replacing direct provider reimbursement replacing the direct provider reimbursement cut with a back-end rebate by the manufacturers to CMS. And this will allow the system and the patients to still see the benefit of price reductions while removing the physician from the equation. Without that fix, though, the lack of reimbursement is sure to become another critical factor forcing consolidation again of care and more expensive and less patient-centric care. Dr. Aizuss, can you provide some perspective on what additional reimbursement cuts might mean for patients?

Well, the physicians in America are in a crisis in terms of reimbursement and payment. As you've heard, costs are rising dramatically, whether it's the cost of insurance, the cost of rent, the cost of employees, the cost of everything we do to maintain our practices as a business and keep them open. And the that crisis is what's accelerating further consolidation and independent practices to go out of business. So anything that will help prevent that from occurring is beneficial to the survival of independent

That was that was my experience in practice as well. Mr. Pollack, hospitals play a central role in providing care for complex and emergency cases. How are hospitals responding to this growing number of physician practices that are being acquired and consolidated for financial purposes?

Yes, you know, one of the things that's important to look at when you see this issue is that hospitals really are not the major drivers in acquiring physician practices. Over the last four years, the increase in hospital in physician practices has been acquisitions has been by private equity.

Yeah, I've noticed that. I've noticed that.

And second to that has been medical groups. Third to that is insurers, and we're the last six percent increase. Now, what's important to remember is that we recognize that physician employment is not the only model, and there are a lot of different ways to affiliate with our physician partners. But sometimes we are approached by physicians who want to be a part of a hospital system

I get that. You know, it's obviously they're just having trouble keeping their doors open and so they're

And the overhead costs associated with maintaining electronic medical records, cybersecurity, dealing with the insurers, and they want to be associated with

The compliance costs alone are staggering. Let me in my limited time, I want to turn back to Dr. Aizuss and say we were let's see, oh, physicians are frequently they cited administrative burdens, prior authorization, increase, you know, as drivers of burnout and increased costs. From the AMA's perspective, how much time and money are physicians spending on administrative tasks instead of patient care?

So physicians are spending a huge amount of time dealing with administrative tasks. In my own practice, I have two people full-time just dealing with prior authorization. So I always tell my patients now that when I write a prescription, I consider it a recommendation because I don't know what's going to be filled because we have to go through a prior authorization process frequently to get basic long-standing generic drugs approved so that I can treat my patients' glaucoma or whatever the problem may be.

It's absolute it's absolutely frustrating. And, you know, I want to close with saying I think that requiring prior authorization, whether on the part of an insurance company or whatever, is is the practice of medicine. And I I would invite them into the medical liability arena. You and I have to pay med mal insurance, so should they. With that, Mr. Chairman, I yield back.

Gentleman yields back. And now recognize the gentle lady from Michigan, Ms. Dingell, for her five minutes of questions.

Thank you, Mr. Chair, and thank you and Ranking Member DeGette for holding this important hearing. I know you keep hearing all of us say this, but on our side, but here it is a fact that the big, I will not call it beautiful, I can use a lot of other words but I'll behave and call it ugly bill that was passed and signed into law last year enacted drastic Medicaid cuts, jeopardizing access to essential care for millions, worsening health outcomes, increasing financial strain on providers, increasing the rates of disease, death, and uncompensated care. And then when we didn't extend the Affordable Care tax credits, more people got added to that. And the providers in front of us all know that. These cuts are impacting care for our most vulnerable communities, disabled people and older adults who rely on home and community-based services, which are Medicaid-funded essential support for those groups. They help older adults and people with disabilities with day-to-day activities such as bathing, dressing, managing medication, and participating in employment. And what's more important is it's cheaper, a lot cheaper than institutional. It roughly saves $44,000 per patient. Medicaid also sustains the care workforce and supports family caregivers. HCBS programs provide the majority of funding for direct care workers, 37 percent of whom also rely on Medicaid for their own health coverage. Three in 10 childcare workers rely on Medicaid for health coverage, and at least 13 percent of family caregivers, whose unpaid care contributed more than a trillion dollars to the economy, depend on Medicaid for coverage. Robust investment is essential to support those who rely on HCBS, the caregivers, and their families, and cuts to this funding will put care even farther out of reach than those that need it the most. So without this federal investment, states are trying to fill the gap left by federal cuts, and they're cutting their budgets to make up for the decrease in the federal support, they just can't do it. It's one of the first services that's being cut. So I'm going to ask Ms. Merrill some questions here. Can you tell us about why we see positive economic outputs from communities that invest in HCBS and what it means to communities when we have robust provider networks for community-based services?

I appreciate that question because the investment in HCBS is a major boost for state economies. A study that was done just last year in Missouri found that an investment of $1.6 billion from 2022 to 2024 contributed almost $6 billion. Your question was, how does that happen? And it happens because when people, when you invest in HCBS and people have jobs and they are supporting people with disabilities and their families, they're buying groceries. They're buying cars. They're saving to hopefully buy a house someday. It's just a crucial part of the economy. Providers are businesses, providers are spending money, providers are buying groceries. Providers are, you know, contributing to the economy in just a completely wholesale way. The combined federal-state spend for Medicaid is $67 billion. And that supports almost $170 billion in total. It's a significant impact.

Okay, I have two questions and you're going to have to go fast. Why is it problematic that community-based services are considered optional under Medicaid, which I don't think they should be because they save money, and what happens to people on the waiting lists for HCBS benefits when states also make the decision to restrict access or not to pay for it?

Well, let me just start by thanking you for your leadership, your championship in sponsoring...

I don't want to be thanked, I want results. What happens?

Well, yes, but your bill, the HCBS Access Act, would make HCBS mandatory. That would make an enormous difference.

Why?

Because we wouldn't have 552,000 people on waiting lists across this country.

And would it save money?

We save money because people aren't going into large expensive institutions. People aren't winding up in emergency rooms where the emergency rooms can't discharge them because they can't find a placement.

Thank you, Mr. Chairman. I have more for the record and I yield back.

Yes, ma'am, I appreciate that and the gentlelady yields back and now recognize the gentleman from Georgia, Mr. Carter, for his five minutes of questioning.

Thank you, Mr. Chairman, and thank all of you for being here. I want to preface my remarks by saying that I'm going to talk about the 340B program because I've got legislation that addresses what I think is a big, big problem and is going to evolve into an even bigger problem. But I do want to preface it by saying I support the 340B program and I get very irritated when I hear some of these companies say, oh, he wants to do away with the 340B program. That nothing could be further from the truth. What I want is for simply the 340B program to be what it was intended to be for. That's exactly what we're working for. You know, we've made a lot of progress in Congress on curbing waste, fraud, and abuse, but we've got other problems and one of them is the 340B program. That's why I've introduced the 340B ACCESS Act. And the intent of this legislation is to improve the program's long-term sustainability so that it can benefit those it was intended to benefit. The FQHCs, the rural hospitals, that's who it was intended for and ensuring the patient benefits from that. But today, that's far from the case. The 340B program grows more than 20 percent every year. More than 20 percent every year. 340B, as hospitals claim 340B discounts on any patient they have contact with as long as they pick up their prescription from a pharmacy that has a contract with the hospital. You know how many 340B contract pharmacies we have in the Orlando, Florida area? 5,000. 5,000 in Orlando alone. The 340B hospitals are looking to capitalize on the nation's top tourist hub. That's what's worse is that the program's increasing cost for the group it was meant to help. That and that's what I'm trying to get at. The increasing cost to the group that it was intended to help. Patients on average pay more for drugs at 340B hospitals while those same hospitals have failed to reinvest in staffing or charity care. Mr. Pollack, I want to start with you. Why can we not come together and align on a clear, on at least a clear patient definition to reduce the cost of the program and ensure that the patients benefit?

Well, you know, the patients benefit in so many different ways from the 340B program. A lot of those funds are used not only to provide discounts to patients but also for home health, behavioral health where it doesn't exist in those communities, substance and addiction programs. There are a lot of things that benefit the community.

All right, well, can you tell me why you're opposed to this reform that I'm offering here?

Well, we're willing to talk to you about it for sure, but...

You know the problem, what I struggle with is I get it. I know that the hospital, and I use hospitals in a general sense, okay, I know that the hospitals have become dependent on this. If we were to yank the rug underneath, it would be catastrophic. I get it. But the problem I have with this is that this is masking the cost of other things that I can't see. And if I can't see them, I can't help you with them. If you're masking the cost because of the profits that you're making on the 340B of other areas, then I can't help you. I want to help you. I know you're losing in other areas. So stop masking the cost of those areas with the 340B and let me see if I can help you. Perhaps there are rules and regulations that we can alter that would help you in those other areas.

We would be very willing to talk about how we can increase the transparency of how the program is used and how the funds are being distributed because you make a very important point and we appreciate your recognition of the importance of the program. But this program does serve as a cross-subsidy for the fact that we are grossly underpaid for a lot of other government programs.

Okay, I'm not questioning that. And I believe you. But if I can't see it, I can't help you. And this is the problem that I'm trying to explain to you and that's what we're trying to do. The 340B program was intended for the federally qualified healthcare centers, it was intended for rural hospitals, yet the urban hospitals and the large corporations have become so dependent on it, and I get it, that we're having trouble now, okay, and it's increasing cost for everyone.

Well, with all due respect, it also helps a lot of very inner-city urban hospitals.

I get it. I get it. But we've got to contain the cost. If it's growing at 20 percent every year, it's unsustainable. We all understand that. If you want to see time fly, try to get five minutes up here, you'll see time fly, okay. I'm down to 17 seconds, I'm sorry. I'm going to have to submit these questions for the record because I'm out of time, but look, I'm very passionate about this. I hope that you'll look at the 340B ACCESS Act and damn it, don't be telling people I'm opposed to it and I want to end the 340B program. That's not true. I want to make it better, better for those it was intended for. Mr. Chairman, I yield back.

Gentleman yields back, now recognize the gentlelady from California, Ms. Barragán.

Thank you. Ms. Merrill, do you know how much money was cut in H.R. 1, how much Medicaid cuts resulted from that?

My understanding is the total cut to provider taxes, state-directed payments, etc., totaled up to $1 trillion.

$1 trillion. Yeah, the number I have is about $900 billion, so rounding up. You know, my the chairman of this committee earlier said, let's see what the states' priorities are, but we've seen what President Trump and Republicans' priorities are. They've shown us that they're willing to cut almost a trillion dollars in Medicaid cuts. They couldn't find the money to keep that, yet they could find money to get involved in another forever war overseas, which is costing us an estimated $1 billion a day. And so it's a little rich to have this hearing and have nobody mention the cost of war versus the cost of also what it's costing the American people in healthcare in the Medicaid cuts. Now you brought up a number that I had not heard before, and I don't know if you could see this, but you said $70,000 to keep a person in in-home care versus $395,000. That's a huge difference. That's a pretty big savings. And I don't understand why when we get data like this, we don't have Congress making sure we're investing in programs like this to save money. And so it's really it's really frustrating to see that the Medicaid cuts are going to result in more people being on waitlists and less people getting access to care. My mother is in that program, she had to wait six months to get into it and we've seen the big difference. Mr. Pollack, I want to ask you, in 2021, Sutter Health, the largest hospital system in Northern California, settled a lawsuit for $575 million that alleged the hospital system used its market dominance to stifle competition and to drive up cost. Just yesterday, Sutter announced an acquisition that will create a 39-hospital system including across California, Minnesota, and Wisconsin. Should there be concerns that this California health nonprofit that was already large is doing this massive acquisition just five years after they settled a lawsuit over anti-competition practices?

Yeah, I don't know the details of the lawsuit that they settled, but this goes to the whole issue of systems and consolidation, and in this case, it's a consolidation that is in two different geographic areas of the country. And I would point out that when we come together as systems, we are often providing a lifeline to rural hospitals that are in great jeopardy.

So you don't see this as a concern at all?

No, I think that there's great value...

Okay, that's good. I just want I need to make sure I go to other folks. Ms. Mitchell, I want to talk to you. In your testimony, you highlight yet another case against Sutter Health in which Sutter withheld access to maternity care unless employers contracted with their entire system. Sutter settled out of court but returned over 500 million to employers and unions, which you say suggest significant overcharging by Sutter. From the employer's perspective, how can hospital consolidation allow this type of overcharging?

Thank you, and we were actually catalysts in bringing this suit that you referred to where anti-competitive practices like anti-tiering, anti-steering actually drove up costs. The example that I cited was to access some of the maternity services, employers were required to buy the entire system even if they didn't have employees in those areas. So it is highly problematic for these hospital systems to first of all consolidate and then participate in these anti-competitive contracting approaches. We are very concerned about this latest expansion. We believe that that will likely contribute to additional cost increases, and all of the data, all the evidence shows that consolidation drives up prices between 3 and 60 percent with absolutely no benefit to quality or access. So I think it's very important to address consolidation as an affordability crisis.

Great, thank you. Dr. Aizuss, consolidation raises the price of care because it creates less competition. What steps should Congress take to prevent consolidation?

Well, I think the most important thing Congress can do to prevent consolidation is ensure that we have adequate Medicare reimbursement to independent physician practices that would allow them to stay open. As you know, the Medicare fee schedule impacts not only Medicaid but also private insurance reimbursement. So in an era where physicians are struggling to keep their offices open because of financial pressures, updating the Medicare fee schedule consistent with an inflationary update on an annual basis, which all the other providers receive, would be of a tremendous benefit in ensuring less consolidation.

Thank you, I yield back.

Gentlelady yields back, now recognize the gentleman from Pennsylvania, Dr. Joyce, for his five minutes of questioning.

Thank you for yielding, Mr. Chairman. According to CMS data from 2024 on total healthcare expenditures, spending has reached a new high of over $5 trillion. Notably in this report, hospital costs, which now make up for 30 percent of that $5 trillion, are the steepest rising costs being paid for by the American patient today. There are several forces at work that drive these costs higher. One of the biggest is, as many of you have mentioned, hospital consolidation. In response to the consolidation in healthcare medical markets, RFI HHS issued a report concluding that consolidation of healthcare providers has led to higher prices, reduced access, and lower quality of care. Because of the differences in Medicare fee schedules, hospital reimbursement has gone up while the reimbursement for independent physicians and providers has gone down when adjusting for inflation by 33 percent since 2001, and patients continue to pay that price again each and every day. When a hospital acquires a physician practice, patients are exposed to higher copays, they're exposed to prices that are increased for the exact same services simply because the ownership and the name on the door has changed. But there are other hidden charges that will occur as well. Mr. Martin, do large hospital systems implement restrictions on their employee physicians and their physicians regarding their referral patterns? Does that affect the bottom line?

Thank you for that question. It is our understanding that yes, many health systems will impose either direct or indirect requirements on their employed physicians.

Do you think that affects the bottom line?

I think it does affect the bottom line.

Dr. DiGiorgio, have you seen instances where this occurs as well as when a doctor is reprimanded for a referral for an out-of-network referral, and even if it is in the best interest of patient care?

Yeah, I have plenty of colleagues who work for large health systems and have told me that they have faced this, where it may be things like losing a parking spot or not getting a bonus if they allow what is commonly referred to as leakage outside the system. There's even that term is used for it if physicians in the system let referrals go outside of the healthcare system.

As doctor to doctor, I don't like that term leakage. I think that doctors have a responsibility to provide the best care for their patients, and I think that should be unencumbered by where that patient is referred.

I agree.

Dr. Aizuss and Mr. Martin, this is a yes or no. Is increasing the Medicare physician fee schedule by tying it to the rate of medical inflation a necessary first step to stop consolidation? Dr. Aizuss.

Yes.

Mr. Martin.

Yes.

With my remaining time left, I'm going to turn to you, Dr. DiGiorgio. Beyond an initial down payment for the Medicare physician fee schedule reforms, must we in Congress work to lower costs and increase competition? I have long advocated for the repeal on the ban of physician-owned hospitals. But can you explain how that and other steps are necessary in a minute and a half?

I can give it a shot. So physician-owned hospitals work because the same physician who sees the patient every day is also the one making operational decisions. So physician-owned hospitals have a tremendous record of providing high-quality care at lower costs than non-physician-owned hospitals. I have a colleague who owns a spine hospital that runs it with about one-third of the amount of staff that a similarly sized non-physician-owned hospital runs.

Is the quality of care the same?

No, it's better. And his patients prefer that hospital. They have a net promoter score of 93, where similar-sized hospitals have a net promoter score in the mid-teens. So the patients prefer these hospitals. These hospitals provide wonderful care because again, the physician who sees the patient is the one making the operational decisions. Personally, when I go in in the middle of the night to do a decompressive craniectomy at 2:00 AM, there's no administrator that knows how to do that surgery. There's no administrator that knows what is needed to make that happen efficiently and putting the patient first. Only the physicians have that knowledge. So physician-owned hospitals align the interests and the incentives in the patient's best interest.

Are you aware of where and who owned the first physician-owned hospital in the United States?

I was not expecting to get pimped on that today, so no, I don't.

I wouldn't use that verb. Is anyone aware of that? Dr. Aizuss, do you know where the first physician-owned hospital was in the United States?

I don't know.

It was owned by Benjamin Rush, a physician who signed the Declaration of Independence. It is owned and was owned by a physician in the city of Philadelphia, Pennsylvania. It is a precedent that should be maintained. With that, Mr. Chairman, I yield the remainder of my time.

Gentleman yields back. We could go into a long lecture on Dr. Rush, who also was big about being in person to cast his vote on the Declaration.

I would welcome that at another hearing.

Another time. And I recognize the gentleman from Texas, Mr. Veasey, for his five minutes of questioning.

Mr. Chairman, thank you very much. As my colleagues have made clear, we will all feel the impacts of Republicans stealing $1 trillion out of the American healthcare system. But on the topic of provider landscape in this country, I want to be very clear about how these cuts are going to devastate the physician workforce, which is already in crisis. Dr. Aizuss, would you agree that the United States is currently facing a physician shortage, and what does that mean?

So we definitely are facing a physician shortage. As I mentioned in my opening comments, we're expecting a shortage of 86,000 within 10 years. And we are already facing that shortage. And what it means right now is it makes it much more difficult for patients who need care to get appointments, simple as that. When my spouse needed to be evaluated by a neurologist, it was a six-month wait. And that's being well-connected in the community. So if that's happening to me, it's happening to my patients as well.

Yeah, absolutely. Yeah, people already have to wait a lot longer, travel further, pay more for care, if they can get it at all. And instead of fixing the problem, last year's big ugly bill made it worse in very two specific ways. First, it makes it harder to become a doctor. Today, the average cost of one year of medical school in the U.S. is about $60,000. On the high end, it will cost you well over $100,000 per year, per year. When all is said and done, going to medical school can set you back a half of million dollars. But the big ugly bill capped the amount that a medical student can borrow from the federal government at about $50,000 a year. Does that math sound about right to you? And the reason why I'm asking is that we are asking kids across this country from low and middle-class backgrounds who dream of becoming a doctor one day. That's something that any school, public or private, become a doctor, it's like a big deal. But we're telling kids who dream of becoming a doctor one day to come up with at least $40,000 or turn to predatory loans if they want to help their community. I think that's devastating. Dr. Aizuss, will a $50,000 annual cap on federal student loans severely limit who will be able to go to medical school or worsen the physician shortage?

I think it's the belief of the American Medical Association that a cap like that will limit opportunities for individuals to attend medical school and will impact the variety of individuals who might choose to become physicians, which will impact the care that we render in our own communities.

Yeah, absolutely. Thank you. Now the big ugly bill doesn't stop at making medical school more affordable. It also makes it harder for physicians to stay and practice. And as a reminder, my Republican colleagues ripped about $880 million out of Medicaid. And states do not have a magic pot of money or rainy day funds to replace trillions of dollars. Instead, states are now being forced to make very hard decisions, and that will include reducing the amount they pay providers. Mr. Martin, on average, what does Medicaid pay physicians compared to Medicare or private insurance?

Thank you for that question. In Medicaid for primary care, it's about 60 percent in Medicaid versus of Medicare, and commercial rates are one and a half to two times that.

Yeah, so it sounds like Medicaid pays about 20 to 30 cents per dollar that a private insurance pays physicians, and that's already a very huge disparity. Now states will have to pay physicians even less. So Mr. Martin, how would even lower Medicaid reimbursement rates worsen America's physician shortage?

Well, in primary care, it's a great concern because primary care tends to have a higher Medicaid panel than many other physician specialties in their community. So lower payment rates, lower coverage rates, separating people from coverage in the Medicaid program is going to create issues for family physicians in many communities and, you know, quite honestly, it's going to result in less prevention care, less vaccination, less cancer screenings, and ultimately more upstream costs as patients have disease progression and go to higher cost care sites.

Yeah, no, thank you very much. And as you can see, this physician shortage crisis is only going to get worse under these Republican policies. It worries me. You know, we think about tech workers and the shortage that we've had in that space. We think about ag workers. We may have to start looking for some way how we're going to do more visas to bring more doctors over because capping rates and these Medicaid reimbursement rates, they're not going to help us recruit or maintain more doctors in our system. Thank you, Mr. Chairman.

Gentleman yields back. Now recognize the gentlelady from Iowa, Dr. Miller-Meeks.

Thank you, Mr. Chairman, and I want to thank our witnesses for testifying before the subcommittee today. Today's hearing is critically important because every policy discussion are real patients. Employers trying to provide health insurance, families trying to afford care, seniors managing chronic conditions, and providers working to keep their doors open in increasingly complex systems. Over the past decade or so, we've seen significant consolidation across the healthcare system, especially after the passage of the Affordable Care Act and particularly among hospitals and large health systems. At the same time, Medicare physician reimbursement has declined by over 30 percent in inflation-adjusted dollars since 2001. If we continue on the current path, we're not just cutting payments, we are cutting access. In rural Iowa, we don't have an excess of providers. When one closes, patients have to drive hours for care. A 2 to 3 percent cut in Washington can mean the difference between staying open and shutting down in a small town. Dr. Aizuss, as both board-certified ophthalmologist who practiced outside of large health systems and in rural areas, we've experienced how many small rural and independent practices struggle to participate in value-based care models. Can you tell me are there payment models that would be more accessible without disadvantaging independent providers who are often the ones in small towns?

So as a fellow ophthalmologist, I can tell you that we don't really understand what value-based care models are for ophthalmology, unfortunately. There are not a lot of opportunities for ophthalmologists to participate in a value-based care model. In reality, as you know, ophthalmology in particular is episodic care. People come in annually for an examination. If they have more significant disease such as glaucoma or diabetic eye disease, we may see them every three to four to six months.

Let me ask that you mentioned episodic care. Are there procedures that could and once were done in a physician's office that would be less costly to the patient and to the healthcare system overall than are now done in hospital outpatient departments?

Well, absolutely. I mean, as we see consolidation taking place and physician practices being acquired or physicians working for the hospitals, if you go in for an eye examination at a large system in my area, the cost is double what it costs when you come into my own office.

Mrs. Mitchell, can you speak to the impact of hospitals acquiring physician practices and entering into employment arrangements that may exceed fair market value or be commercially unreasonable, and how Congress should address these practices to protect affordability and competition?

Yes, our members want to pay more for independent physicians because we know that it leads to better referrals based on quality, it leads to lower costs, and the distortion of pricing in hospitals is highly problematic. When you look at site-neutral payments, we could save billions of dollars by just charging the same price from a hospital-owned facility to a non-hospital facility. I mean, a Band-Aid is a Band-Aid, a CT scan is a CT scan, and yet they are upcharged because they can. We would like to have those fair prices.

Thank you. Dr. DiGiorgio, my apologies, you and I both strongly agree that Section 6001 of the Affordable Care Act and Stark Law create an untenable double standard. As you say, why should independent doctors be subjected to prohibitions on self-referrals when corporations aren't? How have these policies changed provider behavior to incentivize vertical consolidation and higher costs?

Right, the compliance burden alone for Stark Law is immense. I have a colleague who's a spine surgeon, he just wanted to purchase his own MRI machine, he hired three lawyers and got five different opinions on whether or not he was violating Stark Law. So just the compliance cost on Stark are immense. And then of course, with the site of service differential by banning physicians from owning hospitals, we cannot participate in those facility fees. We are shut off from the facility fees. Even ambulatory surgery centers, which are almost identical to hospitals, charge significantly less and do not get the hospital outpatient department facility fees. Many neurosurgical procedures can be done in ASCs much cheaper than in hospitals, but we are not allowed to participate in owning those hospitals.

Thank you. And Mr. Pollack, the declining fee schedule conversion factor and rising hospital base rates are not an accident but a result of policy choices made by Congress in MACRA of 2015. For the record, I'm going to submit these questions for the record to have you answer them. The primary base hospital rate payment for inpatient services has increased by 30 percent since 2016. The outpatient service base rate has increased by 26 percent since 2016. Meanwhile, the physician base payment rate has declined over the same time. Shouldn't we have Medicare Economic Index and inflation adjustment for physicians? It's high time that we do to ensure we have access. With that, Mr. Chair, I yield back.

Gentlelady yields back and I now recognize the gentleman from Ohio, Mr. Landsman, for his five minutes of questioning.

Thank you, Mr. Chair and the ranking member for the hearing and for all of you for being here. We appreciate it. I want to focus on the healthcare crisis and get the thoughts of a couple of you. Mr. Pollack, you represent hospitals. Mr. Martin, family physician. So I'm going to ask both of you some questions to get at if you believe we're in the middle of a healthcare crisis, and if so, what is at the heart of it? If you had to pick one or two things, this isn't a gotcha question, I'm legitimately curious as folks who are representing providers. What is, would you describe this as a healthcare crisis that we're in, yes or no, and then what is driving that, one or two things? Mr. Pollack first. Sorry, the mic.

That's an easy question to say yes on a yes or no question. Between government on the payment, rising number of uninsured, access problems for behavioral health, workforce shortages, supply chains that are broken, and our investments that we need to do in cybersecurity, there are multiple dimensions to the issue. So your question as to how do we get at some of this, this hearing is about affordability. And we are supportive of looking at new arrangements to better coordinate care, different versions of value-based payment is the right direction to go in. When you consider that one percent of the people...

Mr. Pollack, I hate to interrupt, that was super helpful. I just want to get Mr. Martin and then I'll come back.

I've got a great number for you. Okay, sorry, finish. One percent of the people consume 21 percent of the spend. Five percent over half. If we can focus on those people that are really sick with chronic conditions, we can make progress.

Glad you said that, thank you. Mr. Martin.

I will be brief. Yes, we are in a healthcare crisis. It is first driven by the fact that we are becoming more unhealthy as a population. We have separated people from primary care, the opportunity to pursue health, that results in higher cost care at higher cost settings. Number two, we have layered payment policies on top of each other that have accelerated consolidation in ways that I think were unpredictable, but they are severely damaging.

I agree. I appreciate the answers and agree based on my conversations with hospitals and physicians and folks close to the ground that it is a combination of several things. You mentioned, Mr. Pollack, a couple, and Mr. Martin, you I think reiterated some of those, one being there is the underpayment issues, which we could address. I mean, we could immediately as United States Congress increase at least the Medicare, Medicaid reimbursement rates, the way in which we pay physicians. We could do that immediately and I would support that. I think that would make a huge difference. You also talk about the coverage issue, and that is part of the issue with more and more people being unhealthy. If they don't have coverage, they're more likely to be unhealthy. The ACA subsidies, it did not help. The fact that this Congress did not extend the ACA subsidies made it harder for you all, correct, or maybe let me ask in a less leading way. Mr. Martin, what's the impact you're seeing?

Well, I would go back to my opening statement. Separating people either procedurally or financially from an opportunity to seek and receive healthcare, particularly primary care, will result in them being less healthy for a variety of reasons and will result in upstream costs. So the credits or whether it be Medicaid eligibility, those procedural and financial barriers have health consequences.

Thank you. Mr. Pollack.

Well, according to CBO, 4.2 million people will lose insurance as a result.

It's a staggering number. Can you, I've got a minute left, on the Medicaid cuts because you take a trillion dollars out of the system, which is what we're seeing with the Medicaid cuts. A trillion dollars in Medicaid cuts, Mr. Pollack, what are the hospitals, how are they reacting?

Well, they're putting together scenarios to determine how best to adjust to that with the hope that perhaps we can get some of that reconsidered.

What does adjust mean?

Adjust means how do you maintain the highest quality service in the services you can provide?

Will they cut services?

And what services do you simply have to not provide or rely on other parts of the system to do it? That's where systems come in, by the way.

Mr. Martin.

Labor and delivery units are going to close, prenatal and postpartum care is going to decline, vulnerable populations in vulnerable geographies are going to have harder time accessing care, primary care is going to become less available and less affordable for those individuals.

By the way, that is a nightmare situation. I mean, what you just painted is a nightmare scenario. Unfortunately, that's all my time. Thank you and I yield back.

Gentleman yields back and I now recognize the gentlelady from Florida, Mrs. Cammack, for her five minutes of questioning.

All right. The real purpose in her poster is to make sure you don't have to see the ugly face of the chairman, I'm just saying. [Laughter.] Thank you for your graciousness, Mr. Chairman. [Laughter.] And thank you to our witnesses for appearing before us today. Throughout this affordability series, we have examined the drivers of what patients ultimately pay. And today's focus on the provider landscape is really a cornerstone of the discussion, so I'm excited to be having it today. But as we all know, families across the country are paying more for healthcare, whether it is higher out-of-pocket costs, higher premiums, and ultimately they're seeing fewer and fewer choices of where they can receive care and when they can receive care. Now, a major trend that we're seeing is consolidation across hospitals and physician practices, and we're hearing that integration improves coordination and expands access, but for so many patients and so many of my constituents, they're seeing the opposite. It's not what that feels like. It feels like they're getting worse outcomes as consolidation increases. In market after market, consolidation is followed by fewer independent providers, less competition, and fewer real options. And in some cases, patients are paying more for the exact same service simply because of where it is delivered. Now, Congress has taken steps to improve transparency, but transparency alone does not create competition. In highly consolidated markets, it can just as easily become a tool to raise prices as lower them. Now, at the end of the day, patients don't really care which part of the system is responsible, they just know that they're paying more, getting fewer choices, and that the system continues to be broke. Now, as we hear from witnesses, I think it's important that we separate theory from reality and we focus on what patients are actually experiencing. So I'm going to start with you, Mr. Pollack. In our last hearing, we heard that vertical and horizontal integration improves care coordination and expands access. But in market after market, as I just said, consolidation is immediately followed by higher pricing and fewer independent providers. So I'm going to ask you directly, how is consolidation supposed to lower prices for patients when the evidence consistently shows that prices go up after hospitals merge or acquire physician practices?

I know some people may say that, but for the research that we've done, we've actually seen operating costs reduced as a result of systems coming together by minus 3.3 percent, and we've actually seen revenue decrease per adjusted admission. Now, the issue, Congresswoman, is that doesn't always get passed on to the patient because there's an insurer in between that sets the rates. We've also seen, by the way, quality improve according to articles in the Journal of American Medicine, where we have seen a reduction in readmissions and a reduction in mortality measures as a result of systems coming together. And again, as I said earlier, systems are a lifeline for hospitals that may not survive on their own, especially in rural areas.

I think that the data points to a completely opposite scenario than what you just painted, but I'm going to direct to Dr. Do I have to do it with the Italian hand gesture too?

That does help, yes, absolutely.

How do you say it?

DiGiorgio.

What you said. Would you like to respond to that?

Yeah, there's some studies that show that the volume of services and the intensity of services do go up with acquisition of private physician practices. I believe the latest number I read was about 14 percent increase in Medicare spending alone with acquisition of independent practices. And your chart there, it should be pointed out that while hospitals are 31 percent of that spending, about 75 percent of the physician and clinic spending is actually owned by the hospital and a significant amount of the retail prescription drug spending is also going to the hospital, largely through their 340B program. So hospitals actually take up a lot more of that chart than is let on.

We were trying to be nice with the chart. But I think that that is very important for folks back home watching what you just said to get clarity in this. Now, I know my time is running out, so I'm going to jump to you, Ms. Mitchell. Employers supported price transparency so patients and purchasers could compare prices and make informed decisions. But in highly consolidated markets where one or two systems dominate, have you seen cases where transparency simply allows dominant systems to see competitors' pricing and adjust their prices upward?

We are concerned about that. We think transparency is absolutely necessary but insufficient. It takes the large purchasers to actually use that information to negotiate better rates. That is extremely challenging in consolidated regions. I will also say all of the evidence we have shows that consolidation only drives up prices without any corresponding improvement in care. And it's interesting that they say that operating costs go down because that just means that there may be more savings at the hospital, but that is certainly not being passed on to anyone paying a bill.

Yeah, so just to put a button on it with the last 10 seconds that I have. As consolidation increases, access goes down, prices that the consumer pays go up, and even though they say that they're saving money in their system, that's really going towards their profits. And so I think in the end, it's just a broken system that continues to perpetuate, correct?

I would agree. And if they are generating savings, they should come to patients and purchasers.

100 percent agree with that. I yield back.

Gentlelady yields back and now recognize the gentleman of Louisiana, Mr. Carter, for his five minutes of questioning.

Thank you, Mr. Chairman, ranking member, for holding this hearing. And thank you to all of our witnesses for joining us here today. Under the failed leadership of Secretary Kennedy and the Trump administration, we've seen some of the largest cuts to Medicaid in history. ACA premiums have skyrocketed for families and small business owners. The dangerous misinformation on vaccines have grown rapidly. As a father of two sons, I empathize with the healthcare providers navigating this difficult landscape of misinformation and the parents, especially first-time parents, looking for evidence-based guidelines and recommendations to protect their children from preventable diseases and to keep them safe and healthy. Dr. Aizuss, given Monday's court decision to halt Secretary Kennedy's and the ACIP's damaging childhood vaccine schedule changes, parents and providers alike will be relying on trusted medical societies like the American Medical Association and the American Academy of Pediatrics to provide them with reliable information. How will the recently announced collaboration between AMA and Vaccine Integrity Project help parents make informed evidence-based decisions and how will it help clinicians communicate the safety and efficacy of vaccines?

Thank you for that question. As you know, physicians need evidence-based vaccine guidelines that they can trust and that they can use to confidently advise our patients. And that's why the AMA is working with the Vaccine Integrity Project so we will be able to restore a transparent evidence-based process for vaccine recommendations. In particular, we will be doing a review, a structured review, to assess vaccine safety and effectiveness for the upcoming 2026 to 2027 respiratory virus flu season and others. And we'll be convening other medical organizations as well as public health and healthcare organizations to develop a comprehensive set of guidelines for vaccine use. I recently encountered one of my own patients who has a newborn and was telling me that she was afraid to go to her mommy and me classes because she was uncertain whether the other children in the mommy and me class would be vaccinated.

And along that line, I don't want to cut you off, I got a little bit of time. Is it safe to assume that the public has lost confidence in CDC and HHS in these policies?

I think it's clear that the public needs an independent organization like the AMA and the...

But would you also agree that having the collaboration between the organizations that I've mentioned and you mentioned are critical to restore that confidence?

Yes.

I'd like to enter to the record, Mr. Chair, three articles by unanimous consent that speak to these issues. The New York Times, talking points about vaccines, pediatricians navigate the sea of misinformation. CNN, hospitals fighting measles confront a challenge few doctors have seen it before. And the Washington Post, Judge halts RFK Jr.'s vaccine overhaul citing a flawed process.

What we'll do is we'll take a look at those real quick and then probably do it at the end, but I don't see any objection. I assume they're all timely.

They are very timely. Thank you.

Okay, then I expect they will be, but we'll have our team take a look at them if you can pass them to us.

I trust your judgment, sir. Thank you.

There you go. Thank you.

Dr. Aizuss, can you share the challenges your members are facing with the current climate of vaccine misinformation and fear?

Well, I think as I indicated, patients are confused. So anything that will help allay that confusion is of benefit. So they need to trust their physicians and they need to trust that physicians will be using science and appropriate measures to advise them and ensure that they understand what vaccines are needed and when.

Is it not also true that we are still fighting new diseases, new needs for vaccines? We don't need to revisit those that we've conquered like measles, isn't that correct?

Correct.

How bad is the measles epidemic that we see in our country as a result of a removal or a stepping away from the efficacy of vaccinations?

Well, as you know, we're having measles popping up all over the country. Most recently, we had nearly 1,000 cases in South Carolina.

Is that directly attributed to the fact that people are moving away from vaccines?

Patients who don't get vaccinated are going to get the measles if they're exposed to it, yes.

And it's been proven to be effective.

Yes.

I yield back.

Gentleman yields back. Now recognize the gentleman from Oregon, Mr. Bentz, for his five minutes of questioning.

Thank you, Mr. Chairman. And thank the panel for being here. I'm from Oregon and I've traveled around my district, which is large, 70,000 square miles, and I've gone to, along with my staff, about 31 different hospitals and healthcare facilities. I ask them when I get there because they're all concerned, they're all having difficulty with the cost of everything, what we could do to help drive down costs. And so the prompt answer is always staffing. It's almost always nurses. And so my staff found a study by McKinsey and Company 2023 where it says that we have a projected nursing shortage of between 200,000 and 450,000 nurses. So I'll just start, I'm not sure who to start with. Mr. Martin, does that sound right? Is this a surprise to you?

It is not a surprise to me. There are healthcare shortages in physicians and nurses and med techs and lab techs. It's well-documented that there's a healthcare professional clinician shortage across the country.

Okay, so what do we do about it? What's the solution? Give me, we need between 200 and 450,000 nurses. What's the solution? By the way, members of my family are nurses. Members of my family going to nursing school. It's a long and necessary process. So are you talking about immigration or what are we talking about to solve this problem in the near future?

I will be humble here and tell you I'm not an expert on the nursing shortage. I obviously the workplace environment, compensation rates, quality of work and the importance of the work they do and you know drives professional satisfaction in all healthcare careers.

So let me just mention that the going rate for a nurse in Oregon is 120,000, a traveling nurse it's 220,000. So I'm not sure that what people are being paid is the problem. It appears that we don't have people that want to do it. Dr. DiGiorgio, what's your opinion?

I think a lot of it comes from the consolidation. The same things that we see in the physician workforce are mirrored in our nursing colleagues. So number one issue is with consolidation and with a lot of the regulation is we see a deprofessionalization of the workforce, both on the physician and the nurse side. If you've been in a hospital, the nurse is no longer predominantly at the bedside, she's stuck to the computer, right? And this is happening with our physicians as well is that we are turning our professional workforce basically into data entry clerks because of the large amount of regulation. And then with consolidation, we see the same thing on the physician side, but there's a reduction in pay. There was one study that showed about a 7 percent reduction in nursing pay when large systems consolidate. So systems consolidate, they cut out the pay because there's no longer now they're an monopoly buyer of nurse labor and physician labor and then they deprofessionalize.

If I may interrupt you. Is artificial intelligence going to be the solution? We hear about it all the time that now it's all solved, all this paperwork's going to melt away because of AI, is that correct?

I'm very hopeful about artificial intelligence. I was also I think people were hopeful about computers. The problem is we overregulated the electronic health record so instead of them becoming helpful, they became an impediment to care. I hope we don't make those same mistakes with AI.

And so who's taking care of this? Who's making sure those mistakes don't happen? Because the truth of it is, it almost seems as though the shortage gives people an excuse to raise prices. Is that the truth?

I agree.

And we've heard that in other conversations with various groups. And by the way, the remarks about larger systems resulting in a higher quality care at less cost, I have to beg to differ, at least in previous conversations that appeared that there was a focus on those types of things while ignoring the amount of money being made on the float by delaying care. And so I asked that question of United Healthcare when they were here. It was discouraging to hear how many billions of dollars are being made on the float, I must say, and that appears to be something we should be focusing upon. As long as I'm with you, Dr. DiGiorgio, in the minute I have left. You're a practicing neurosurgeon in a big healthcare system. You've done a lot of academic research in healthcare affordability. Where does the physician fit in this shortage space? And we heard earlier a focus on residencies. What can we do here in Congress to spring loose this huge herd of doctors waiting behind the barrier of not having enough residency slots?

Well, the training pipeline is one area and I think we should certainly support more training, but on the back end as well. If we empower physician ownership and independent physicians, we'll keep more physicians practicing longer. Right now too many physicians are looking for the first exit out of clinical practice because we have diminished the practice of medicine so much and we've reduced independent physician autonomy.

And your solution there, you think we should ban the consolidation? What's your solution to the problem you just described?

So I think addressing a lot of the issues that are driving consolidation such as the ban of physician-owned hospitals, Stark Law, the site of service differential, 340B, certificate of need laws. All of those could help empower physicians to open their own independent practices and with that investment and buy-in into their communities, practice for longer and help alleviate the workforce shortages.

Thank you. Yield back.

Gentleman yields back. Now recognize the gentlelady from Texas, Ms. Fletcher, for her five minutes of questioning.

Thank you, Mr. Chairman. And thank you to our witnesses. House Republicans have once again brought us here to discuss health care affordability, an important topic for people across the country and certainly at home in my district. But this hearing is really looking to shift the blame from this Congress and this administration for the health care affordability crisis that we're experiencing. And certainly there are a lot of important drivers, but as many of my colleagues have already said today, we cannot have any discussion about health care affordability without acknowledging that over the last year, this Congress has voted time and again, and it is Republicans in this Congress who have cast vote after vote to increase health care costs in the so-called one big beautiful bill that cut Medicaid and in turn, because the cuts were so big, cut Medicare too, and by failing to extend the Affordable Care Act's enhanced premium tax credits. For an administration that says it wants to make America healthy again, its actions demonstrate the opposite. And my home state of Texas already has the highest uninsured rate in the country, and because of this Congress's actions over the last year at the urging of the Trump administration, that number's estimated to go up, not down. Now, I have the privilege of representing so many people who work at the Texas Medical Center, the largest medical complex in the world, and I also get to work with incredible people in our community who are working at federally qualified health clinics and other locations providing incredible care. And I'm so grateful to hear from all of them frequently about the many issues that they face in trying to care for their patients, including the strain that increased uninsured rates will add to the whole health care system. I mean, it's really an ecosystem. And so when we talk about cuts here and changes there, it affects everything else. And we know that these changes to the health care system and these increased burdens are forcing hospitals and providers to cut services and reduce staff. And we're only a few months into 2026, we've already started to see drastic losses. The Bureau of Labor Statistics reported in February 28,000 people lost their health care jobs nationwide, including some in my district. So we've covered a lot of issues here today, but there are other things happening in our hospitals that are also impacting access to care and to the health of our communities that we in Congress cannot continue to ignore. In fact, they arise not from the main topics that we have covered today, but from other policy decisions in Washington, including the Trump administration's immigration policies. We just heard about the nursing shortage. President Trump instituted a new $100,000 fee for H-1B visas, which are the visas that many health care workers rely on. This policy's going to make it harder, not easier, to get a robust health care workforce. But I want to focus with the time that I have left on another. The Trump administration has ended a long-standing policy that prevented immigration enforcement actions in sensitive areas, including hospitals. And since this new rule has been implemented, health care professionals have reported an influx of immigration enforcement agents in hospitals and that the presence of these agents roaming the hospitals has left many people scared to go there. And recently, federal health officials agreed to give immigration enforcement officials access to a Medicaid database that includes enrollees' addresses and citizenship status. And despite a court challenge, the courts are allowing this policy to move forward, and that is creating fear in our immigrant communities. And in cities like mine where one in four people were born in a foreign country, in districts like mine where that number is one in three, this has a huge impact on people's ability to access health care. And this includes legal immigrants who are getting swept up in this mess of immigration enforcement that this administration is pursuing. And so I'm stating the obvious here, but if people are too afraid to go to the hospital because of immigration policies like these, they will not go, or they will delay going until they absolutely have to when their conditions are worse and in sometimes when it's too late. And so, you know, we saw that during the COVID-19 pandemic, we saw the disastrous impacts when patients delay access to care. And so I trust that all of you would agree that delayed care often results in increased costs of care as well. And I want to ask questions, but I've only got seven seconds left, so I'm going to ask them for the record. But what I want to know is from each of you hearing about what happens when a patient is forced to delay care for themselves and what are the impacts on the overall health in our communities when we're delaying access to care for patients. Mr. Chairman, thank you for letting me go a second over my time, and I yield back.

Gentlelady yields back. Now recognize the gentleman from Ohio, Mr. Rulli, for his five minutes of questioning.

Thank you, Mr. Chairman. This question goes to Ms. Mitchell. How are we doing now? Thank you, Mr. Chairman. This question goes to Ms. Mitchell. The Department of Justice is suing OhioHealth over anti-competitive practices, alleging their use of all-or-nothing contracts are leveraging their market power to force plan sponsors to include all OhioHealth hospitals in the network at the expense of affordability. This led to Ohioans paying more for benefits with no increase in quality of care. So my question is almost a two-part question. Ms. Mitchell, is there something that your members are seeing today that is impact by this OhioHealth maneuver? Should employees pay more because a hospital system has a monopoly on power or are there alternative paths that we could choose?

Well, I can't speak to that specific case, but we see that regularly across the country. When hospitals consolidate and you want access to any member of that system, it is harder to do that at a fair price when they are consolidated and there have not been benefits in terms of better quality or access.

So there's no example you could see in the country that would prove opposite of that?

Not that I can think of.

Well, thank you so much, Ms. Mitchell. With that, Chairman, I yield my time.

Gentleman yields back. Now recognize the gentlelady from Indiana, Ms. Houchin, for her five minutes of questioning.

Thank you, Mr. Chair. Before I get into my questions, I do want to make some clarifications. The Democrats have made some accusations that we're trying to shift blame on the cost of health care because we've cut spending in Medicaid and Medicare. But Medicaid spending has increased and is expected to grow from it grew 8.6 percent in fiscal year 25, expected to grow in spending 7.9 percent in 2026. Medicare spending is projected to accelerate to 5.4 percent growth in spending annually through 2030. So it is simply incorrect to state that House Republicans are cutting spending even if we are spending less. Medicare and Medicaid spending is still increasing. Thank you to the witnesses for being here. Health care costs are a top financial concern for American families. I won't deny that. One in three Americans are cutting back on daily spending to cover medical bills. Families are delaying major milestones such as buying homes or having children because of rising premiums. We do not have a functioning health care system currently. That has been driven in large part by the institution of Obamacare and principles that took the doctor and patient relationship and put in a great deal of middlemen. I consistently hear the same issues from providers in Indiana. They're being squeezed from multiple directions simultaneously. Payment rates for Medicare have fallen roughly 33 percent in real terms since 2001 while practice costs are climbing. Administrative burdens consume resources that should be going to patient care, and the consolidation of market power in both the payer and provider markets is eliminating the independent practices that historically kept costs competitive and care personal. This is the third hearing we've had on affordability. I think it may be the most consequential because the provider landscape is where these issues meet real patients. Dr. Aizuss, in your testimony, you note that practice costs rose roughly 63 percent over the same period that Medicare physician payments declined by roughly 33 percent, putting an increasing strain on independent practices and threatening patients' access to care, particularly in rural parts of the country. From your perspective, how is this sustained gap affecting patients' ability to access timely quality care? What specific actions should Congress take to stabilize physician practices and prevent further disruptions?

Thank you. So as I've noted, the decrease in real payment for Medicare services is accelerating independent physician to close their offices or to sell their practices to private equity or to be employed by large systems. So, you know, the access is definitely impacted by that. People in their own communities can't access the private practice physician when they want to, and wait times are increasing significantly. And the biggest solution, as I keep emphasizing, is having a having Medicare payment reform tied to the medical economic index with automatic inflationary updates just like the other providers are receiving.

When was the last time that independent practices received an update for inflation?

We haven't received an update for inflation since I've been in practice.

And how long has that been, sir?

Almost 40 years.

Would you favor tiering a system based on provider areas that may be in a desert or a rural part of the country where independent practices might have a slightly different reimbursement rate than other systems to help keep them afloat?

Well, I think it's not unreasonable to offer incentives for physicians to open offices in primary care deserts, for example, or in OB-GYN deserts. I think that's a creative approach. But I think the bottom line is all physician practices are substantially hurting at this point in time, and we need to do something to correct that in the form of an inflationary update.

Thank you. In the remaining time I have, I want to shift gears a little bit, continuing with you, Dr. Aizuss. The American Medical Association recently came out in with a new statement on transgender surgeries for minors with gender dysphoria, now deferring that and recommending deferring treatment for that to adulthood. Can you comment on why the change or the clarification was made from the association?

So I want to be very clear that the policy of the American Medical Association is that individuals with gender-affirming disorders should be have access to the appropriate care.

I'm just specifically asking about minors.

In surgery in minors, our belief is that it should generally be deferred until adulthood, but we respect the physician-patient-family relationship in determining that, and we respect the fact that various medical societies that are experts in this care will be providing the appropriate input in when those sorts of surgeries should be performed. And I want to also emphasize the number of such surgeries taking place in this country is remarkably little. It ranges from some people saying 85 in one year to 220 out of a population of 300 million.

Respectfully, sir, I always comment that it doesn't matter if it's 85 or 200 or one to the families that are impacted by that if and to the individuals that have endured that as minors who have regretted that decision as adults. Thank you, Mr. Chairman, I yield back.

Gentlelady yields back. Now recognize the gentlelady of Massachusetts, Ms. Trahan, for her five minutes of questioning.

Well, thank you, Mr. Chairman, and thank you to our witnesses for being here today. Republicans claim that their signature legislation isn't taking health care away from people, but for me, the numbers just simply don't add up. States are being forced to grapple with a series of new federal policies all at once. Right? We've got new Medicaid eligibility requirements, mandated paperwork requirements, six-month redeterminations, limits on provider taxes and state-directed payments, the expiration of enhanced ACA premium tax credits, reduced NIH funding, changes to H-1B visas, and I could actually keep going. These changes put enormous pressure on state health care systems and they force states into impossible choices: reducing services, cutting provider rates, restricting eligibility for coverage. In Massachusetts, officials estimate the bill could cost the state $3.5 billion annually in federal health funding and leave up to 300,000 of our residents without coverage. Now, as all of you know, when people lose coverage, they don't disappear from our health care system. They still get sick, they still get injured, and they still show up in emergency rooms and safety net hospitals, an issue that's projected to increase demand on the Massachusetts health safety net by an estimated $550 million by fiscal year 2028. States are projecting billions in lost health federal health funding and significant increases in uncompensated care. My colleague Rep. Ruiz highlighted this clearly, but it bears repeating that these cuts will directly drive up costs and make it harder for people to access their care. So Mr. Pollack, when hospitals are forced to absorb those costs, what kind of service reductions or closures do we typically see in communities across the country?

I would highlight... I would highlight the word communities because we're a very diverse country and every community is different and every situation is very different. So there's no question that this is going to cause great stress. There's no question that there are going to be clogged emergency rooms as we are the family doctor to the uninsured, and there will need to be some changes in terms of the array of services that are provided. Now, I know there's been a lot of criticism of systems in this discussion here today, but systems are able to better organize the delivery of care so that certain services may be provided in one entity and others could not provide it but still provide it in the same location. So there's real value to systems that we really haven't talked about. But we're very concerned about the impact, and we're very concerned about the impact on people because if they delay the care, it's care denied because they don't have the coverage.

Yet we're seeing maternity wards close. That's not a hypothetical for Massachusetts. And when you can't get that care and that service close to home, it's pretty problematic for a woman carrying her child. And it's bad enough when hospitals are forced to close these services or maternity wards, behavioral health units, you name it. But as you mentioned, when uncompensated care rises, hospitals still have to cover the costs, and that means higher prices for everyone else, particularly people with private insurance. So can you explain how increases in uncompensated care ultimately affect the prices that hospitals charge commercial insurers and what that means for people with private coverage?

You know, we have been very open to the fact that between regular chronic government underpayment for Medicare and Medicaid combined with an increase in the amount of charity care that is going to be provided, there's a cost shift. And that affects the private sector because we have to stay whole to provide 24/7 coverage for all of the things that we do. And as a result of those government underpayments, there is a cost shift there, and that's part of the reason you see costs rising on the private side.

And we're seeing that with premiums. Mr. Martin, beyond premiums, where else do costs of rising uncompensated care show up for patients or families? Seeing that in higher copays and prices for common services?

Yes, I mean, actually the high-deductible health plans, we're seeing more cost-sharing requirements on patients, which is creating offsets of them delaying or not pursuing health care, which accelerates disease states and ultimately they end up in a hospital, a higher cost care setting.

I appreciate. I don't have time for my final list of questions. I'll absolutely submit them for the record, but I appreciate you being here and talking plainly about what we're seeing in hospital systems and the impact on its patients. Thank you.

Gentlelady yields back. Now recognizes gentleman from New York, Mr. Langworthy, for his five minutes of questioning.

Thank you very much, Mr. Chairman. Today's hearing comes at a time when health care costs continue to climb, yet too many patients still have no clear sense of what their care will cost until after they receive the care. We know that hospitals and insurers and others across the system all play a role in what patients ultimately pay, with hospital and provider services now making up more than half of the total health care expenditures in this country. Now, despite that, in most parts of the economy, people can compare prices before making an ultimate decision, and in health care, that's often not the case. Patients move forward without knowing what they will owe or how prices compare across providers offering the same service. If patients are expected to make informed decisions, they need clear and consistent information before care is delivered. And without that visibility, it becomes much harder to understand what is driving cost across our health care system and where those costs ultimately will fall. And with that, Mr. Pollack, I understand that the AHA has expressed support for implementing advanced explanation of benefits and his work with stakeholders to develop a mock claim approach to make that process workable. Can you explain how that approach would help ensure that patients receive accurate cost estimates before receiving care and how you and your system are working with your insurer counterparts to make sure that that information is consistent, reliable, and accurate for patients?

We think that that approach is really something that has promise and commend you for your support and leadership in this regard because it'll give patients accurate information on the front end in terms of what they can expect in advance of their care. And I think that's what most patients really want to see. And as you said, we're working with stakeholders and we want to work with CMS and you all to move in this direction. I will say that we are deeply committed to providing patients with the information, the transparency that they need relative to the cost of care. There's we're all there on that. But I would also share with you all that we are in a very confused state, and that's why this advanced EOB has promise. You know, we've had the hospital transparency rule, then we had the health insurer transparency rule, then we had the No Surprise Act, and right now it's kind of a jumble of different things as to where you get that. And that's why that approach is real important. Last point I could make, I'd like to make, please, is that it's also important, transparency's really important for shoppable services, but 60, I just saw a number over 50 percent of hospital admissions come through the ED. The ACEP, the Emergency Physicians Society, say it's up to 70 percent. I don't know that you can shop around for those particular things, but regardless, we need to do better and your suggestion is a way to do it.

We need transparency across the entire system, and we can't get our arms around the entirety of our health care spend in this country until we truly understand where the dollars are going. Staying on transparency, Mrs. Mitchell, in your expert opinion, how usable is hospital price transparency data?

It is increasingly usable. Unfortunately, we don't have good compliance. Estimates are at most 69 percent of hospitals are fully compliant. So we need more transparent information. But once that information is available, self-insured employers can and are using it to identify who are the higher value providers in their community or where can they maybe revisit some of the pricing when it is compared to other benchmarks. It is incredibly important for them to actually be fiduciaries and know if and when they are paying a fair price.

Mrs. Mitchell, does PBGH support broader implementation of an advanced explanation of benefits, and how effective do you think it would be in improving price transparency for patients?

We think patients and employers are absolutely entitled to full transparency upfront. It is it is simply unworkable when a patient goes in and comes out with a $100,000 bill. It is not responsible of the system to burden patients with that type of cost. And we we need to give patients and purchasers the information they need to make good decisions.

Improving price transparency in health care is critical to empowering patients and helping them understand what they have to pay before they receive the care. And, you know, certainly emergency departments, there's there's certain things that it's tough to, you know, guess what you're going to pay after you're getting procedures in a car accident, but there are many predictable parts of our health care system that we can do that, and patients should be able to see the cost of care upfront, understand where their money's going, and make informed decisions before receiving treatment. Right now, too many prices are still hidden. We need better visibility across the health care system so that we can clearly see where the costs are coming from and who's ultimately bearing them. And by bringing these costs into the open, we can create a more competitive system that works better for patients. I appreciate all the witnesses for being here with us here today, and I yield back, Mr. Chairman.

Gentleman yields back. Just so that we can get the state of play so that the witnesses will know where we're at, appreciate your time. I have not yet gone. I'm going to recognize myself and then Mr. James. We may have somebody else that walks in that I'm unaware of, but I think those will be the last two, but you never know. Somebody could of the from the committee could walk in any second. So I will now recognize myself for five minutes. I raised it in my opening statement, Dr. DiGiorgio has raised it, Dr. Joyce has raised it, I think Miller-Meeks at least touched on it, and that is that the Affordable Care Act placed a ban on physician-owned hospitals. So for the whole panel, we'll make it easy, just raise your hand if you support the ban on physician-owned hospitals. So if you raise your hand, you're against physician-owned hospitals. Okay. And and let the record reflect that that Mr. Pollack was the only hand that went up. I understand that means some of you may be ambivalent. I'm not trying to put you on record, I just want to know where to go with my questioning. And and I would say that it's it's interesting because certain hospitals already receive special designations like our critical access hospitals. Critical access hospitals must be rural, they do have to be nonprofit and located more than 35 miles from another hospital. Mr. Pollack, you support the critical access hospitals, do you not? So this is where the question comes in because in order to accommodate widespread Stark Law concerns, I tweaked the physician-owned hospital bill. It's now called the Physician Led and Rural Access to Quality Health Care Act to allow for physician ownership for of rural hospitals more than 35 miles from a main patient campus or critical access hospital in order to mirror the critical access because I represent a lot of areas where they want hospitals. We just filled that need just a few months ago in Patrick County, Virginia. A new hospital opened up, and interestingly, while it had a corporate identity, it's run by doctors. It's got a corporate identity, but it's it's pretty darn close to a physician-owned hospital, and this hospital had been closed for a number of years because none of the systems that you've referenced wanted to get involved, and this group has figured out a way to make rural health care in underserved areas a reality. Are you opposed to that form of physician-owned hospital as well?

We're not opposed to creating access points for care in rural areas for sure. The issue with physician-owned hospitals different from critical access hospitals is they're not full-service hospitals. A lot of them don't have emergency rooms, they don't take Medicaid, they don't care for the indigent, they're not open 24/7, they take the easier well-insured cases and call 911 when something goes bad and ask us to come to the rescue.

Okay. So what you're saying is if we created a model where they were open 24/7 and they had an emergency room, you'd be okay with a physician-owned hospital.

If I can add a couple of other things.

Yeah, yeah, yeah.

No, no, seriously. The readmission...

I want to give... because time runs fast as you heard Buddy Carter say, time flies when you're sitting up here and five minutes goes by quick. Dr. DiGiorgio.

Yes, sir.

Your comments on that.

I think all the behaviors that he's describing can also be attributed to non-physician-owned hospitals. There's nothing special about a physician-owned hospital that prevents it from having an ER. In fact, there are plenty of physician-owned hospitals that do have ERs. There's plenty of physician-owned hospitals that have L&D units and that are open 24/7. There's plenty of physician-owned hospitals that are super-specialized focused factories that do nothing but orthopedic procedures. All of these physician-owned hospitals expand access to care and drive down prices. Talk about price transparency, physician-owned hospitals are leading edge on price transparency because they have to compete and they have to show the people who come to their hospitals that they are competing on both price and quality.

I appreciate that because I do think that long-term and historically in a large rural district like I represent, it's larger than nine states by landmass. Historically, when you look at the histories of the various hospitals, even if they're not physician-owned today, they may have started out, most of them did start out as a physician-owned hospital. All right. Switching gears, I'm going back to you, Mr. Pollack. In our hearing with health insurance executives, I raised the question or the issues that there have been negotiations for health insurance rates in my district in Virginia and Ms. Harshbarger's district in Tennessee, and I wanted to know if the insurance companies, how they reimburse larger systems versus smaller systems, and they just came back with a generic, oh, everything's a little bit different. Do you see that? Because I get the impression that the larger systems get a better deal. What are your thoughts?

It's uneven. I don't think it's a yes or no type of thing. I think one of the things you have to appreciate is that the insurance companies that these systems negotiate with are very, very large entities. And they are very concentrated. And when you negotiate a system with a UnitedHealthcare, which is a $330 billion conglomerate that has immense...

My time is running out. What you're saying is it's hard to negotiate when you don't have as much competition and when you have big entities taking over the entire market and then dictating what happens. Is that what I'm hearing?

And that's on the insurance side. We are price takers from them.

Yeah. And it could be applied also to hospitals in certain circumstances. That ends up my time. I'll probably have some more questions for the record. I greatly appreciate all of you being here today. And I will now recognize the gentleman from Michigan, Mr. James, for his five minutes of questioning.

Thank you, Mr. Chairman. So grateful for you having this hearing and to our guests for being here. Let's be clear about this hearing today. Health care in America is not just expensive, it's deliberately opaque. Patients don't know what health care costs are until the bills show up. Employers don't know what they're paying until premiums go up. And taxpayers are left holding the bag in a system that too often rewards consolidation over competition and secrecy over accountability. We've heard today that consolidation is driving prices higher without improving quality. In fact, hospital-dominated markets can raise prices significantly, sometimes by double digits, while limiting patient choice. We also know the rules that were supposed to fix the system are not followed. Nearly half of all hospitals are still not complying with federal price transparency requirements. That's unacceptable. When prices are hidden, patients lose power. When patients lose power, prices go up. And when costs go up, families in Michigan and across the country are forced to make impossible choices between care and groceries, between prescriptions and rent. This is exactly why I introduced the Patients Deserve Price Tags Act. It's simple. If you're charging patients, you should be transparent with patients. Post the real price. Post the rates. Make it accessible, accurate, and enforceable. Because transparency is not a partisan issue. It's a fairness issue. It's a competition issue. And most importantly, it's a patient issue. We don't fix affordability without fixing accountability. And we don't get accountability without transparency. So, Ms. Mitchell, you represent employers covering 21 million Americans and spending more than $350 billion on health care annually. So let me ask you directly. If employers and patients cannot see real prices up front, is it even possible to have a functioning health care market?

It is not. We are 100 percent supportive of transparency. As a fiduciary, we are obliged to only pay fair prices. You can't do that without the information.

Wonderful. And when prices are hidden or incomplete, who benefits more, the patient or the system charging the price?

Clearly the system.

Thank you. Ms. Mitchell, you also highlighted even large employers struggle to access usable pricing data and face barriers created by the system itself. At the same time, we know that federal transparency rules exist, but compliance is inconsistent at best and enforcement is weak. If Congress were to require complete, accurate, and regularly updated price disclosures in uniform format, would that materially improve employers' ability to lower costs?

Absolutely, and we will use that information as it's available.

Outstanding. Ms. Mitchell, final questions. If every patient and employer had access to actual negotiated prices, cash prices, and comparable data before receiving care, would that increase competition and drive down costs system-wide?

Absolutely. We need both competition and accountability. So much of the price distortion is just unexplainable in terms of the service provided. We need to be able to know where to go for the highest quality, most fairly priced service, and transparency enables that.

Outstanding. And finally, is it fair to say that the more complete and enforceable the transparency requirements are, the more effective they will be at lowering costs for American families?

Absolutely. Apparently the industry thinks they're optional because they've had five years to comply and they are still not complying. So I think enforcement is at this point warranted.

That is unacceptable and we should hold them accountable. Mr. Chairman, with that, I would yield the remainder of my time to the chairman.

I appreciate that. That was a question I hadn't had time to get to. So Ms. Mitchell, I've long supported the transparency because I think it brings about certain disruptors into the system when they can see the transparency prices, they figure out ways that they can make money by making the system better, lowering the cost for everybody. And one of those is to allow with the transparency is to allow companies to come into the market to operate without a traditional network in the health insurance field, allowing members to see the licensed, any licensed provider including non-network or out-of-network doctors without penalties and allowing patients to shop around for the best prices. Would you agree that disruptors like that are a benefit long-term to the system?

I think everyone benefits if you can identify and go to the highest quality, most fairly priced provider, regardless of network.

And you can't figure that out if you don't know what the prices are.

You can't. And then to make it worse, a lot of these anti-competitive practices make it hard to exclude them once you have identified them. So it is a compounded problem of lack of transparency and consolidation.

I greatly appreciate it and I yield back the remainder of Mr. James's time. And with that, that concludes all the questions. I don't see anyone else here wishing to ask questions. I ask unanimous consent to insert in the record the documents included on the staff hearing document list, including Mr. Carter's request earlier for three documents that he, three articles that he wanted included. Without objection, so ordered. I would like to thank all of our witnesses again for being here. Members will have additional questions. You heard several of them say so, I know I will, a number of people will have additional written questions for you after the hearing. I remind members they have 10 business days to submit those questions for the record and ask the witnesses to respond to the questions promptly. Members should submit their written questions by the close of business on Wednesday, April 1st. That does not mean the questions will be foolish, they will be wise, but nonetheless, Wednesday, April 1st. Without objection, subcommittee is adjourned. Thank you, witnesses.