CITIZENS HEALTH CARE WORKING GROUP

P-R-O-C-E-E-D-I-N-G-S

(1:15 p.m.)

MR. JOHNSON: We'd like to welcome you to our meeting here in Jackson, Mississippi. And we certainly want to thank you, Aaron Shirley, for your great hospitality and the great preparations.

The first item on our agenda calls for us to approve the transcript of the April meeting and the summary of the meeting. So I'm going to ask, although George and I haven?t discussed this, I'm going to ask you, George, do you have any introductory comments to the approval of these?

MR. GROB: The only comment that I would add is that I know that the documents were circulated for review and comments were incorporated. And we've received all the comments.

MR. JOHNSON: We received a couple. Not much in the way of comments, but it was an excellent draft.

MR. GROB: So anyway there was an opportunity and it was provided so --

MR. JOHNSON: So on this particular case, we probably need to formally approve them. And so may I ask for a motion to approve the transcript of the April meeting?

I heard a motion.

MS. MCLAUGHLIN: He moved. I'll second it.

MR. JOHNSON: It's been seconded.

Any discussion?

MS. STEHR: Yeah, I just want to make one caveat on the approval of the April meeting. We?ve sent it out to --

MR. GROB: This is the May summary actually.

MS. MCCLAUGHLIN: Oh, the May summary. But Randy said --

MR. GROB: No, we're talking about the April meeting right now.

MS. MCLAUGHLIN: The April meeting we sent the transcript out to Senators Wyden and Hatch to have them review their comments, and we haven't gotten word back from them, but pending that.

MR. JOHNSON: Subject to the Senators Wyden and Hatch regarding their comments.

Yes.

Any further discussion?

Thank you, Caroline.

MS. MCLAUGHLIN: So this is not the May one that we just got?

MR. JOHNSON: Right. April transcript, May summary. Because you actually last time approved the April summary already.

MS. HUGHES: So what are we approving now?

MR. JOHNSON: So what is in CD that some of us received is the April transcript.

MS. MCLAUGHLIN: So that most of us haven't looked at it yet, correct?

MR. JOHNSON: You may not have got -? we're talking about the April transcript.

MS. MCLAUGHLIN: Right.

MR. JOHNSON: And Andy sent out an opportunity for us to review this within the last seven to ten days.

MR. GROB: Yeah, I apologize. I was actually focusing on the May summary.

MS. MCLAUGHLIN: Right.

MR. GROB: But the transcript, some of you said you wanted it on CD.

MS. MCLAUGHLIN: Right.

MR. GROB: So you may not have looked at --

MS. MCLAUGHLIN: That's correct.

MR. GROB: -- the transcript electronically --

MS. MCLAUGHLIN: That's correct.

MR. GROB: -- that you received. So you may feel you're not ready to do this.

MS. MCLAUGHLIN: That's correct.

I think the problem is, Randy, is that several of us said we wanted it on a CD.

MR. JOHNSON: Right.

MS. MCLAUGHLIN: That was the preferred way. So we've been waiting for the CD.

MS. HUGHES: I also think that if you looked at it, you know it's about 600 pages long.

MS. MCLAUGHLIN: Right.

MS. HUGHES: And with all honesty I have read some of it, but I have had some personal stuff going on. I've been on family medical leave, and I haven't finished all 600 pages. So I don't know. I mean if you need to have it voted, I --

MR. GROB: No, we don't. We can --

MR. JOHNSON: Well, we have a motion on the floor and seconded. That's why we have the discussion on the vote.

MS. MCLAUGHLIN: We were confused. I thought we were talking about the summary. I beg your pardon. Because I did get back to you on the summary with some changes.

So Andy also thought it was the summary.

Frank, did you move based on full understanding?

MR. BAUMEISTER: I knew what he was talking about.

MS. MCLAUGHLIN: So you're the smart one.

MR. BAUMEISTER: I followed this.

MS. MCLAUGHLIN: You did. You were on top of things.

MR. JOHNSON: Am I hearing that you would like to postpone approval of the April transcript until a later meeting?

MS. MCLAUGHLIN: Well, I mean I think -- what is there to approve or disapprove, if some of the staffers can tell me? I mean what was on the transcript was on the transcript; is that correct?

MS. TAPLIN: The transcript was the transcript.

MS. MCLAUGHLIN: Right.

MS. TAPLIN: And there were -- Ken and I did a light edit of it and found a very, very few glitches.

MS. MCLAUGHLIN: Because it's just a recording of what --

MS. TAPLIN: It's a recording, and there were a few glitches when somebody's name didn't -- just was heard improperly. There's a lot of back and forth conversation and some people didn't -- we had that conversation about people and how they wanted to be heard.

And we can't change the content, but if you wanted to just sort clean up a little of the ums and ahs. I mean that's your option.

MS. MCLAUGHLIN: I know. Because the summary is where it's interpretive and --

MS. TAPLIN: Right, right. The transcript --

MS. MCLAUGHLIN: -- you have to make sure. The transcript itself I don't feel the need to read the 600 pages.

MR. GROB: If I could just comment. It's entirely up to you, but standard practice would be when transcripts are made that they are made available to the members so that you have an opportunity to read them.

MS. MCLAUGHLIN: Right.

MR. GROB: Many people focus on their own remarks.

MS. MCLAUGHLIN: Right.

MR. GROB: And there is generally light editing, as you say, which is again standard practice. So it would be a common practice to approve them. But they can, indeed, be approved at a later time when you've really had the opportunity to look at them.

And I do agree with the second thing you said. The interpretive summary, I think, is more critical.

MS. MCLAUGHLIN: Right.

MR. GROB: That's what people are going to look at. But the transcript does serve as a record of the meeting.

MS. TAPLIN: Right.

MR. ROCK: The only caveat I would add to that is the Federal Advisory Committee Act that we operate under ask that this be available publicly within 90 days, so that?s basically --

MS. TAPLIN: So that's where we're coming off.

MR. ROCK: The 11th of next month.

MS. TAPLIN: Right.

MR. ROCK: We have a month to get it out.

MR. GROB: The answer to the question is they ought to be approved. Let people have the opportunity to read them.

MS. TAPLIN: Right.

MR. GROB: And you can do that at any -- you know, as long as we meet that deadline.

THE REPORTER: I'm going to stop you.

MS. HUGHES: I move that since we just have --

THE REPORTER: Excuse me. My name is Steve Anderson. I'm the Court Reporter. I'm at a disadvantage. I know no one.

So when you speak to keep that from happening and not knowing who's speaking or the wrong person got something, please address yourself. Make sure the microphone -- you can hear yourself over the mike. That way we'll have a real good transcript. Okay?

MS. MCLAUGHLIN: Thank you.

THE REPORTER: Thank you.

MR. JOHNSON: Okay, we have a motion and second and some discussion.

Is there further discussion?

MS. MCLAUGHLIN: Now that I know what we've moved, I -- I don't even know how to turn it on.

THE REPORTER: It's on. Just identify yourself, please.

MS. MCLAUGHLIN: Catherine McLaughlin. I'm ready to vote now that I have a clear understanding of what we're voting on.

MR. JOHNSON: Any questions? Comments?

All in favor of approving the transcript as written, raise your right hand.

MS. MCLAUGHLIN: We don't have to have the friendly amendment --

MS. TAPLIN: Yeah, with the caveat.

MS. MCLAUGHLIN: Yes.

MR. JOHNSON: Correct.

All opposed.

The transcript for April is approved.

The next item that we have is a summary of the May meeting, and it's been delivered to us. And I'm wondering if you have had sufficient time to read it. And if you have not, we can postpone the approval until a later time.

But if you have had sufficient time to read it, then I would entertain a motion to accept the summary as written.

I have to admit that I have not had a chance to read this. So if you are like me and you'd like to read it, we can postpone a vote on this until tomorrow if you wish. Just briefly we can handle this or until the next meeting.

MS. MCLAUGHLIN: This is Catherine McLaughlin again. Andy, is this the one you sent us a little while ago and I sent you comments on so that I know now what I'm talking about?

But, no, this is the one that, as I said, I think we should have a chance to read. I did read it, and, again, I read what you said I said and sent you a few clarifications because you weren't sure.

But I think everyone should at least read what they said and sign off on it before we vote. That's my recommendation.

MR. JOHNSON: Any other input?

Well, I'm hearing silence to a recommendation that we postpone voting on this. And that would be my inclination too, unless you all differ with that. So why don't we postpone this?

So would be tomorrow sufficient time to review this?

We'll bring this up again before we close our meeting tomorrow for your --

The next item on the agenda calls for us to have a discussion about what we've heard in our May meetings. You may recall that we had hearings after hearings, and a lot of material was presented. We also had foundational briefings, and a lot of material was presented there.

And what the staff and I heard was that you might want to spend some time talking about some of the information that we shared in those meetings, those hearings.

So we'd like to take some time just to hear your input regarding that at this time in case there is material you would like to cover, talk about that was discussed in those May hearings and foundational briefings.

Open it up for any comments.

MS. MCLAUGHLIN: Well, I think one of the questions, Randy, was that several people after some of the presentations noted that they didn't always agree with things that we heard. And Richard is not here, and Mike is not here.

Several people said, "Gee, I'm not sure I think that is correct."

And in fact, Mike O'Grady afterwards said, "I was at CRS for years, and I don't think I ever heard those numbers."

And so I think that there was some desire on the part of some members of the Working Group for there to be time that we can have those kinds of exchanges among us. It's kind of too bad that a third aren't here and that several weeks have gone by. But I don't --

MR. JOHNSON: You're right. We did have some of those comments. And we were thinking this.

We asked the question: Do we challenge those who are providing information to us?

And initially I was a little bit ambivalent personally about that. But the more I thought of it, the more personally I thought, well, these are supposed experts. These are people who are coming in to share their information with us.

So if we feel uncomfortable or if we differ with what they're saying, maybe we ought to address that with them to have them explain more some of their rationale and some of their background.

So one alternative is to discuss it after they leave. But another alternative is to clarify what is it that we don't agree.

For example, if Frank were to make a statement regarding health care in Oregon, and I would have read something else and those statements are a difference, would it be helpful to get a clarification from Frank? Or why is it that he's saying what he is? What is the background of the other statements?

So we have -- that's a question, I think, that we should decide how we're going to respond that.

But there's the other issue of are there some things that we covered that you wanted to bring up as well for discussion by the Working Group. Some areas needing clarification, amplification, anything like that.

MS. MCLAUGHLIN: I'm looking at the transcript -- I mean at the summary, trying to remember.

MS. BAZOS: I know. I'm trying to remember too.

DR. SHIRLEY: Is the question -- Aaron Shirley -- when there might be some question about specific data or comments during an expert's presentation there would be room at some point to ask for clarification?

MR. JOHNSON: Aaron, I think there are two issues. One is the one that Catherine brought up. And that's a very valid point.

The other is, as I understood it -- and I'm looking for clarification from the rest of you as a Working Group. As I understood it, there were some who felt I've received a boatload of information. Those are my words, not yours. But the concept is I received a lot of information today and it would be just nice to have an opportunity where we as a Working -- for us as a Working Group to digest some of that together. And my recollection is that some of you here made some statements like that, as well.

MS. HUGHES: Therese Hughes. Randy, I agree with the comment, "getting a boatload of information." I think that I'm feeling at an absolute blank-out right now to discuss something that happened the 12th, 13th of May because -- well, for many reasons.

However, I would like to ask if it would be possible to have that opportunity to discuss it maybe after a speaker left which would mean that somebody would have to get back to the speaker if there were discrepancies in information given.

But I think I had a lot that I thought of at the last meeting concerning the information, but I don't have a clue where it is right now inside of my mind.

MR. JOHNSON: Where you differed with the speaker?

MS. HUGHES: Yes, where I differed with --

MR. JOHNSON: Or were you just looking for some clarification?

MS. HUGHES: Well, both, both. But I mean this is a bit --

MR. JOHNSON: It's so long ago.

MS. HUGHES: I'm mean maybe I'm just the only one. This is long ago for me. I mean I've lived several lifetimes between our last meeting. This is like really far away.

And so I just think that since that does happen to us, maybe if we could work it into the agenda after the hearings to do that, it could -- I wouldn't be non compos mentis.

MS. CONLAN: This is Montye Conlan. I just wanted to mention that there were a couple of issues that I brought up in questioning during the hearings. And then I found some supporting information to clarify that.

And I sent an e-mail to Catherine was it appropriate to bring it to this meeting. And she said to send it to Caroline, and so I did even though I didn't think it was really about state initiatives. And I was unclear how to handle that.

So perhaps we could have that session right after the hearing. But then if we had supporting documentation or information, there would be another time when we could gather that and bring it back to the group because I wanted -- sometimes I say things like, well, I've heard or I think. I always go back and try to research that because I don't think it's really good to bring secondhand hearsay.

And so when I had the opportunity, that's what I did. And I wanted to submit that. And I don't know what happened to it.

MS. TAPLIN: Our e-mail died for a week.

MS. HUGHES: Oh.

MS. MCLAUGHLIN: And this is a process issue, rather -- this is Catherine again ?- a process issue, Montye.

So I don't know if you want to talk about it later in the agenda, Randy.

But I guess the members of the Working Group should have very clear instructions of to whom do we send stuff. I mean, because I obviously misinterpreted and thought it was state and local initiative stuff and that Caroline was the person I knew who was dealing with that on the staff.

But maybe there is a point person that everybody should send things to, you know, potentially George, I don't know, who then will distribute it to the appropriate staffer. I don't know.

MR. JOHNSON: Well, let's ask George. You?ve been involved with other Commissions and Working Groups. How have other Working Groups handled the types of questions that are being brought up here and what are your thoughts?

MR. GROB: Well, there are two separate questions. One of them is how to handle the question when there is a possible disagreement here, a clarification when a speaker is speaking.

And then the second one is whether or not there are topics that people would like to talk about. I think we handle it separately.

Let me take the second one first. I think if the members can let us know particular topics that they would like to talk about, then what we could do is when we have the next meeting, we can gather up some information on that topic and put it on as a topic for discussion among the members.

That's what I heard the last time. There were several that said there was so much, and we would just like to talk about some of these things.

So a good way to do that is to come to a meeting when you know the topic will be discussed and where you'll receive some information about it. So I think that's what I would suggest for that.

You can just send that information directly to me. But I would also ask you to send that to Caroline. The reason is because Caroline will be kind of a repository of all information. And she can help you with it. And send it to the both of us. And then we'll bring that up in preparation for the next meeting. That's what I would suggest about that.

My sense of the discussion that I've heard or that's been said to me, I think, you know, there may be disagreement or questioning or whatever or need to discuss what a speaker said.

I think the people who are providing testimony are generally expecting there may be some of those kinds of reactions. I think it's not unusual. My experience is congressional testimony or town governments, when people who are experts come, it's not uncommon for the members of the panel to ask some questions and even challenging questions as a matter of fact.

That would be what I would think. But again I think that?s something that you can adopt your own rules and sensitivities -- but if you would ask me, I'd say open this --

MS. MCLAUGHLIN: I think that also, you know, you think about what you were saying about witnesses, etc., made me think of juries and trials and, yes, when the witness is up there, both attorneys get to challenge and ask follow-up questions and the judge. But then the jury deliberates afterwards.

It sounds to me that's where we're sort of going, that we do want to be able to ask challenging questions, back-up questions of the witness while he or she is there. But that we want to be like the jury and discuss it amongst ourselves afterwards and maybe asking for supplementary documents then.

And certainly those of us on the Report Committee have -- and we brought this up from the very first meeting, that we want to make sure that what is in our report has some external validity and that we don't want to put something up there and have a whole group of people say but, sorry, that number is not the right number. We can prove it. Or you forgot this whole set of experiments. Or you used research that people have found serious problems with.

And we have to make sure we have done due diligence. And I think that part of that is consistent with what we hear in hearings, too. That in some cases we as a group may want to say how do we want to handle that in our report?

Do we want to accept that, or do we think there may be countervailing research that suggests that what we heard is that person's opinion and it may even reflect their own personal experience, but may not hold up against further investigation?

And so that's more like the jury deliberations, if I've interpreted what you said, George.

And so I think for the report and then later when we do all these committee meetings, etc., that we have to be able to act like a jury in that sense and deliberate what we've heard before we decide what we want to put in our recommendation.

So I think both for the report as well as in the other processes down the road we do need this opportunity because evaluation and research can play an important role in helping us put the personal stories that we hear in context and may make us better able to then communicate what we've learned.

MR. GROB: Thank you for clarifying my statement with your remarks. In all the places where I've been, it's always been regarded as appropriate for Commission members, Council members to ask questions of the presenters. It's generally not regarded as productive to debate them.

MS. MCLAUGHLIN: Right.

MR. GROB: But to ask questions, yes, always. And even pointed questions. Then it seems to me that it could lead to discussion and you have two options. You can leave room for a discussion period at a future hearing, or any public meeting, just set aside a time for discussion, and that?s a common thing. Or as I said before, if you guys said, well, we'd like to hear more about that and further discussion at the next meeting, I think either one of those would work. Those are some suggestions.

MR. JOHNSON: So what I'm hearing in our discussion, I'd like to summarize and see if we're all on the same page. We will ask questions of the presenters when they are here, if we hear something that is questionable based on our experience. Obviously we will treat them with respect.

And what I'll try to do also as the Chair is provide you an opportunity toward the end of their discussion to ask questions of that nature.

But then we will also look for an opportunity from time to time just to have some further conversations among us as a Working Group.

And Catherine's term we'll be kind of acting as a jury is not too far off. We will be assessing what we hear, all sides of what we hear when we do a report and when we make recommendations and so forth.

Is that a consensus we can feel comfortable with? Deborah, are you feeling okay about that or?

MS. STEHR: Yeah, as long as it ?- this is Deb. Yeah I feel comfortable with that, except that the discussions, I think, have to happen fairly soon after we've heard the speakers. We can't wait until the following meeting a month or so later because it's too old.

MS. BAZOS: This is Dottie Bazos. I'd like then in our discussion period to not just talk about the facts that we've just heard. But I think we're growing in maturity as a group, and we need to have products developed. And I think we need to know each other better in a group.

I would like our discussions to be about the facts, but also taking those facts and putting them into the context of our mandate so that we could think about these facts in a more global sense as well. I mean we heard Medicaid, but I'd like to talk about Medicaid in relationship to Medicare, the VA, and other systems or in relationship to our mandate.

So if that could be addressed.

MR. JOHNSON: Well, thank you very much.

Any other comments on this subject?

Well, why don't we move then to an Executive Session. And this will be an off the record discussion. We have a number of staff people here, and George and I just briefly shared three sentences before the start. And at least my perspective in hearing your thoughts is it would be helpful for everybody to hear the following discussion, so we won't ask anybody to leave. But it will be an off the record, the public record, discussion as we talk about the Executive Report and committee meetings and so forth.

(Whereupon, this session went off the record.)