[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]





                THE PRESIDENT'S FISCAL YEAR 2009 BUDGET

=======================================================================

                                HEARING

                               before the

                      COMMITTEE ON WAYS AND MEANS
                     U.S. HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             SECOND SESSION

                               __________

                           FEBRUARY 13, 2008

                               __________

                           Serial No. 110-69

                               __________

         Printed for the use of the Committee on Ways and Means










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                      COMMITTEE ON WAYS AND MEANS

                 CHARLES B. RANGEL, New York, Chairman

FORTNEY PETE STARK, California       JIM MCCRERY, Louisiana
SANDER M. LEVIN, Michigan            WALLY HERGER, California
JIM MCDERMOTT, Washington            DAVE CAMP, Michigan
JOHN LEWIS, Georgia                  JIM RAMSTAD, Minnesota
RICHARD E. NEAL, Massachusetts       SAM JOHNSON, Texas
MICHAEL R. MCNULTY, New York         PHIL ENGLISH, Pennsylvania
JOHN S. TANNER, Tennessee            JERRY WELLER, Illinois
XAVIER BECERRA, California           KENNY C. HULSHOF, Missouri
LLOYD DOGGETT, Texas                 RON LEWIS, Kentucky
EARL POMEROY, North Dakota           KEVIN BRADY, Texas
STEPHANIE TUBBS JONES, Ohio          THOMAS M. REYNOLDS, New York
MIKE THOMPSON, California            PAUL RYAN, Wisconsin
JOHN B. LARSON, Connecticut          ERIC CANTOR, Virginia
RAHM EMANUEL, Illinois               JOHN LINDER, Georgia
EARL BLUMENAUER, Oregon              DEVIN NUNES, California
RON KIND, Wisconsin                  PAT TIBERI, Ohio
BILL PASCRELL, JR., New Jersey       JON PORTER, Nevada
SHELLEY BERKLEY, Nevada
JOSEPH CROWLEY, New York
CHRIS VAN HOLLEN, Maryland
KENDRICK MEEK, Florida
ALLYSON Y. SCHWARTZ, Pennsylvania
ARTUR DAVIS, Alabama

             Janice Mays, Chief Counsel and Staff Director

                  Brett Loper, Minority Staff Director

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                            C O N T E N T S

                               __________

                                                                   Page

Advisory of February 6, 2008, announcing the hearing.............     2

                                WITNESS

The Honorable Michael O. Leavitt, Secretary of Health and Human 
  Services, U.S. Department of Health and Human Services.........     7

                       SUBMISSIONS FOR THE RECORD

Puerto Rico Hospital Association, Statement......................    55
The Senior Citizens League, Statement............................    55

 
                THE PRESIDENT'S FISCAL YEAR 2009 BUDGET

                              ----------                              


                      WEDNESDAY, FEBRUARY 13, 2008

                     U.S. House of Representatives,
                               Committee on Ways and Means,
                                                    Washington, DC.

    The Committee met, pursuant to notice, at 2:03 p.m., in 
room 1100, Longworth House Office Building, Hon. Charles B. 
Rangel (Chairman of the Committee), presiding.
    [The advisory announcing the hearing follows:]

ADVISORY

FROM THE 
COMMITTEE
 ON WAYS 
AND 
MEANS

                                                CONTACT: (202) 225-1721
FOR IMMEDIATE RELEASE
February 06, 2008
FC-20

               Chairman Rangel Announces a Hearing on the

              President's Fiscal Year 2009 Budget for the

              U.S. Department of Health and Human Services

    House Ways and Means Committee Chairman Charles B. Rangel today 
announced the Committee will hold a hearing on President Bush's budget 
proposals for fiscal year 2009 for the U.S. Department of Health and 
Human Services. The hearing will take place on Wednesday, February 13, 
2008, in the main Committee hearing room, 1100 Longworth House Office 
Building, beginning at 2:00 p.m.
      
    In view of the limited time available to hear witnesses, oral 
testimony at this hearing will be limited to the invited witness, the 
Honorable Michael Leavitt, Secretary, U.S. Department of Health and 
Human Services. However, any individual or organization not scheduled 
for an oral appearance may submit a written statement for consideration 
by the Committee and for inclusion in the printed record of the 
hearing.
      

FOCUS OF THE HEARING:

      
    On February 4, 2008, President George W. Bush submitted his fiscal 
year 2009 budget to Congress. The budget will detail his tax, spending 
and policy proposals for the coming year, including his proposed budget 
for the Department of Health and Human Services. Many of the 
Department's programs--such as Medicare, efforts to assist those who 
lack health insurance, and Temporary Assistance for Needy Families and 
other income security efforts--are within the Committee's jurisdiction.
      
    In announcing the hearing, Chairman Rangel said, ``The President's 
budget calls for unprecedented deep cuts to traditional Medicare. We 
should be working together to strengthen Medicare for future 
generations, not undermining it,'' Chairman Rangel said in announcing 
this hearing. ``Among the various proposed reductions in funding for 
low-income programs, President Bush's budget calls for the complete 
elimination of the Social Services Block Grant in 2010. Furthermore, 
this budget changes the tax code in ways that would erode health 
security and raise taxes for millions of American families. I hope 
Secretary Leavitt is willing to have an honest conversation about how 
best Congress and the Administration can work together to protect 
taxpayer interests and help all individuals and families get the social 
services and health care they need.''
      

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    Mr. STARK. We will commence our hearing on President Bush's 
fiscal 2009 budget. We are honored to have the Honorable 
Michael O. Leavitt, the Secretary of Health and Human Services 
for the U.S. Department of Health Human Services, to present to 
us today.
    Mr. Secretary, Chairman Rangel is at the White House for 
the signing of the economic stimulus legislation. It is my 
honor to welcome you to the Committee. Having read your 
testimony, I don't know where to start.
    Rarely have I seen an official document filled with so much 
misleading rhetoric and so few thoughtful suggestions. It is 
nothing short of disingenuous to claim concern about Medicare's 
future after what this Administration has done to the program.
    The unfunded obligations that you cite were driven 
substantially higher by excessive corporate welfare provided to 
the insurance companies through both Medicare Advantage and 
Part D. While bashing the government, whom you and I are paid 
to work for, you say essentially that Medicare is a bad system 
and needs to be changed.
    You decry price-setting, but offer no better way to control 
costs and ensure coverage. You suggest we rely on the private 
sector, but conveniently fail to point out that that system 
costs taxpayers far more than traditional Medicare, and we have 
no data to know what we are buying. The private sector, at 
least in Medicare, is neither transparent nor efficient.
    You assert that government is making coverage decisions, 
but that is not quite true. In Medicare, physicians tend to 
drive medical care, and the program itself has relatively few 
coverage restrictions. Regardless, any of us who went through 
the Patients Bill of Rights debate can tell you that on the 
rare occasions when Medicare does make decisions, they are 
considerably more transparent and generous to patients than the 
arbitrary decisions too often made by private plans, whose 
priorities are profits and not patients.
    Your budget takes a meat ax to a program that, together 
with Social Security, has substantially improved the health and 
financial security of American retirees. I predict it will be 
rejected by both parties.
    Before I turn to Dr. McDermott, there is one thing on which 
we agree. With respect to Medicare, you wrote, ``We need a 
change in philosophy, not just a change in the budget.'' I 
couldn't agree more.
    Fortunately, we have only a few months left of this 
Administration, and then there will be a change. We need a 
President who is committed to protecting and improving, not 
dismantling, Medicare. That will be the real change from 
President Bush's desire to privatize a program that only exists 
because the private sector wouldn't take care of senior 
citizens in the first place.
    Dr. McDermott, do you have an opening statement?
    Dr. MCDERMOTT. Thank you, Mr. Chairman.
    Secretary Leavitt, we had the pleasure of having the 
Secretary of the Treasury up here the other day, and I said 
that it reminded me of when Colin Powell went up to the United 
Nations General Assembly to sell the war. It is a heavy task 
that you have. I couldn't help thinking, as I read over this 
document, that Yogi Berra was right when he said, deja vu all 
over again.
    We have seen this budget before a number of times, and you 
have been asked, among a growing list of people, to come up 
here and try and defend, I think, what is indefensible. It is 
because of your prior background that it is particularly 
troublesome to have you up here.
    We have heard it before, but let me focus on one particular 
plan, and that is the plan to completely eliminate the social 
services block grant. Now, maybe younger Members don't 
understand how this works. But when Republicans get in charge, 
they always want to lump things together into block grants 
because it would be more efficient, and it will force 
efficiencies, and all this kind of stuff.
    What they are really doing is lumping them together so they 
can chop them off little by little by little until they are 
gone. This budget that you put in front of us is a perfect 
example of why the social services block grant was a bad idea 
when it was put forward in the first place, because it funds 
today welfare services for 2.8 million abused and neglected 
children. It funds child care for 4\1/2\ million American 
children of working parents. It provides services to 1.3 
million Americans with disabilities.
    Now, to wipe that out is to simply drill a hole in the 
bottom of the lifeboat of an awful lot of people in this 
society. You knew it when you were governor because when you 
were Governor Leavitt in Utah, you once said, in your own 
words, ``Vital human services for our most vulnerable citizens 
are provided by the social services block grant.''
    Now, you were right back then. That is why it is hard to 
have you up here today completely doing a reversal for the 
President. I understand you are sent up here to do this, and I 
really--I respect your doing it. But it has got to feel a 
little uneasy doing it because you know.
    The President wants the Congress to eliminate a program, 
but is really hiding it under the shell of the old rhetoric 
that we have heard again and again, your claim that we really 
aren't--in the documents--you really aren't cutting services to 
millions of children or seniors and families because other 
programs can do the job.
    Now, really? Where are they getting the extra money for 
these programs? I don't see any programs that got any extra 
money, practically speaking, in the President's budget. Poverty 
is rising in the country, and the country may be headed into a 
recession, and all this budget says to our nation's most 
vulnerable families is, tough luck.
    The social services block grant, in my view, is a lifeboat, 
and it is nothing more than that. You are out really to drill a 
hole in the bottom of it, leaving those folks at the greatest 
risk possible with states in recession, struggling to some way 
to come up with the money to fill the hole that you drill in 
the bottom of the boat with this kind of thing.
    The National Governors Conference ought to be up here all 
over this place, whether they are Republicans or Democrats. 
Their ability to deal with child care and abused kids and all 
these things will take a serious shot from this kind of a 
budget.
    It is really not compassionate conservatism. We heard that 
eight years ago. But there is very little evidence that I can 
see that this is anything but mean-spirited conservatism.
    Fortunately for the people, I guess, Congress will shortly 
dump this in the waste bin. We go through this process of 
listening to you, and we will write our own improved version 
and fix some of the problems.
    I yield back the balance of my time, Mr. Chairman.
    Mr. STARK. Mr. Camp, would you add your kind comments to 
welcome----
    Mr. CAMP. Well, thank you. I think they will be kinder than 
the ones we have heard so far.
    Thank you, Mr. Chairman, and welcome, Secretary Leavitt. I 
want to commend you and thank you for your service to this 
country, and also to commend you for your efforts to draw 
public attention to the looming crisis facing the Medicare 
program.
    Medicare costs continue to soar, and the premiums 
beneficiaries pay for Part B have more than doubled since the 
year 2000. Doctors face impending payment cuts that are likely 
to drive many of them away from treating Medicare 
beneficiaries, and the hospital insurance trust fund will be 
exhausted in just 11 years.
    Given these many challenges, I would have preferred the 
Administration propose fundamental reforms that are needed to 
preserve Medicare. The 183 billion in payment reductions 
proposed by the President may help to alleviate the short-term 
financing issues, but I am concerned that they may not do 
enough to secure the long-term stability of this important 
program.
    The President's proposals continue to rely on the same 
pricing system that has helped create many of the fundamental 
challenges now facing Medicare. Even if Congress were to 
immediately enact all of the President's Medicare proposals, we 
would still have payment systems that underpay many providers, 
create perverse incentives to provide more and not better care, 
and distort the entire health care marketplace, as you and I 
have discussed in numerous meetings over the past year.
    I think with this final budget, bolder ideas about how to 
transfer Medicare could have been put forward. I will say also 
that the Majority should not have wasted a full year of 
inaction on this pressing issue. We did not hold a single full 
Committee hearing on Medicare or Social Security, for that 
matter, both of which we addressed in the last Congress. So, we 
are wasting valuable time on this important issue.
    This should have been an opportunity to discuss proposals 
like premium support for all Medicare beneficiaries, tying 
hospital payments to the value they provide, and providing more 
effective care to high cost Medicare beneficiaries. They are 
less than 20 percent of the Medicare population, but account 
for up to 80 percent of Medicare's total spending.
    I hope, Mr. Secretary, that we can work with you in the 
time that we have left together to develop these ideas in 
anticipation of the looming national debate about health care. 
Mr. Chairman, I trust that you would be eager to join us in 
that effort.
    I also want to thank the Secretary for his continuing 
efforts to encourage debate on how to expand private health 
insurance coverage, including the tax reform proposal that 
would insure up to 8 million more Americans. Our current health 
insurance system subsidizes employer-provided insurance and 
discriminates against workers solely upon the basis of where 
they work. Given the mobility in today's job market, not losing 
insurance just because you change jobs would be an improvement 
for all Americans.
    I believe that any reforms we enact need to give 
individuals more control over their health care choices. We 
have seen in the new Medicare drug benefit, where beneficiaries 
have the right to choose among competing plans, Part D plans 
have been able to slow the rate of drug cost increases, and the 
costs of the program are now 40 percent below their original 
estimates, as you point out in your testimony.
    The current health care system mandates that we take what 
we get, whether we need it or want it. Personal choices in the 
health care marketplace can lead to better consumer decisions 
regarding preventive care and help to reduce the rapid growth 
in national spending on health care.
    Thank you, Mr. Chairman, and I yield back the balance of my 
time.
    Mr. STARK. I would like now to recognize the gentleman from 
Illinois, the Ranking Member of the Income Security and Family 
Support Subcommittee.
    Mr. WELLER. Thank you, Mr. Chairman. Mr. Secretary, 
welcome. Good to have you before the Committee, and appreciate 
the time you are giving us today.
    I note the President's budget involving Income Security 
Subcommittee programs recognizes the fact that simply spending 
more money on welfare and related programs is not the same as 
actually solving problems. So, this budget proposes ways for 
states to use current funds more flexibly to prevent problems 
like child abuse from occurring rather than simply treating the 
consequences of such abuse after it happens.
    That follows the successful model of the 1996 welfare 
reforms, which increased work and earnings while at the same 
time reducing poverty and welfare dependence. These are 
precisely the sort of positive reforms this Committee should be 
reviewing because they promise better services and support for 
American families in need.
    This hearing also provides an opportunity to review 
progress implementing welfare provisions in the Deficit 
Reduction Act of 2005, which extended and strengthened the pro-
work policies included in the 1996 welfare reform law. As 
recent HHS data shows, welfare dependence is falling faster in 
the wake of that legislation, which is what Congress intended, 
to help more parents go to work and to support themselves.
    So, Mr. Secretary, we welcome you before this Committee. We 
look forward to reviewing these and other important issues.
    Mr. Chairman, I yield back the balance of my time.
    Mr. STARK. Figure out these buttons here. Thank you, Mr. 
Weller.
    Mr. Secretary, I am sure now in whatever manner you would 
like--we have your written testimony. It will appear in the 
record in its entirety. I am sure that in your verbal 
testimony, you are going to redeem yourself marvelously. Please 
proceed.

  STATEMENT OF THE HONORABLE MICHAEL O. LEAVITT, SECRETARY OF 
HEALTH AND HUMAN SERVICES, U.S. DEPARTMENT OF HEALTH AND HUMAN 
                            SERVICES

    Secretary LEAVITT. Thank you, Mr. Chairman. May I thank you 
for that cheery greeting, and also recognize that though we 
have different philosophies, I have always enjoyed our 
interactions. I have great respect for your intellect and your 
experience and the sense of public service that you bring.
    I am here today to represent the President's budget. You 
will shortly begin to lay your hand to budget-writing, and I 
recognize that some of the decisions we have made may be 
different than the ones that you have. My job today is simply 
to do my best to describe why the President made the decisions 
that he has made.
    I do desire to start with Medicare. It makes up 56 percent 
of the budget that I am representing today. It is also a very 
important program, and I do want to be clear with you and the 
American people that I care deeply about this. I care enough 
about it that I hope that your budget will be viewed as a clear 
warning. Medicare on its current course is not sustainable, and 
it is such an important part of the lives of so many of our 
citizens.
    In 2007, the Medicare trustees' reported that the Hospital 
Insurance Trust Fund will be exhausted by 2019--that is 11 
years from now--and that Medicare represents now a $34.2 
trillion unfunded liability in our obligation for the Federal 
budget over the next 75 years.
    I view this to be a very serious problem. I want to 
acknowledge the fact that American sensitivity to entitlement 
warnings has become somewhat numbed by what is a repeated cycle 
of alarms and inaction. Those types of warnings have become an 
almost seasonal occurrence, like the cherry blossoms blooming 
every April. It is part of life's natural rhythm now. We hear 
the warnings, but we don't actually stop to think about what 
they mean or how important they are.
    This budget, however, warns, I hope, in a different way. It 
illuminates with specificity the very difficult decisions that 
policymakers, no matter what party they are in, will face if we 
don't begin to reform and to change our philosophy. We can keep 
our national commitment, and must keep the national commitment 
we have to those who are beneficiaries of this program. But we 
do need to begin changing the way we manage the program.
    Currently, Medicare's fee-for-service program, as you 
pointed out, is a centrally planned, government regulated 
system. I would characterize it as a price-setting system. 
Price-setting systems allow regulators to decide the 
priorities. Government decides in many cases the treatments 
that are provided and how much will be paid. We make decisions, 
a few thousand of them at CMS, that have a great impact on 
individual decisions in the medical life of many patients, 
millions.
    Government tries to determine the value of those decisions 
based on procedures. It is a system that I think does not 
produce the right outcomes. Price-setting systems inevitably 
subsidize the wrong things. We overprice other things. A well-
informed consumer, allowed to make decisions through an 
efficient, transparent market, in my judgment would make 
decisions that are more precise, and they would make decisions 
that are more wise.
    One need look no further than the experience we have had 
with Medicare's prescription drug benefit, where government 
organized a market and then let consumers decide what drug 
plans work best for them. We are now entering the third year of 
that program. We see enrollment continuing to rise. We see 
beneficiaries highly satisfied. We see costs of beneficiaries 
and taxpayers consistently lower than originally projected.
    Just last week, we announced that compared to the original 
Medicare Modernization Act of 2009 (MMA) projections, that 
Medicare's cost on the benefit will be reduced by $243.7 
billion over the next 10 years. Beneficiaries have also saved. 
The most recent estimate shows that beneficiaries will pay, for 
a standard Part D coverage, at about $25. That is nearly 40 
percent lower than we originally projected back in 2003.
    There are lots of factors that led to lower costs. But 
competition has clearly been a big part of that. The plans have 
achieved greater efficiency than they expected. The retail 
prices have been negotiated better, manufacturers' rebates, et 
cetera. The program is working.
    Now, I want to be clear that we prepared this budget with 
three major things in mind. One was long-term sustainability of 
Medicare because we do view it as so important. The second is 
affordability of premiums for beneficiaries. The third was to 
balance the budget.
    Now, my time is up, and I don't want to go beyond that. You 
have my formal statement. I will get a chance, I am sure, to 
comment on various parts of it. But Mr. Chairman, I do want to 
reflect on the fact that I care greatly about Medicare, and I 
want it to be around for every generation subsequent to this 
one. I look forward to a conversation as to how we can best 
accomplish that.
    As you know, a person who is 54 years of age today in 11 
years may not have the same stability that one does today. In 
October we are going to start selling bonds at the Treasury 
Department--to fund this deficit. We need to focus on it.
    My time is up, and I will now look to your questions.
    [The prepared statement of Secretary Leavitt follows:]



    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]



    Mr. STARK. Thank you. We can come back to a lot of the 
subjects that you have touched on. I suspect our principal 
difference--I happen to think that we are the only country in 
the world that doesn't set prices for the delivery of medical 
care. We are the highest cost, and only clock out at about 17th 
or 18th in outcomes, so that we don't have much to brag about 
there.
    I just don't think that people shop or are able to shop for 
medical care the way they would shop for a Chevrolet or a 
Toyota or a new pair of shoes. There are those who think they 
can, but my guess is that that is beyond the competency of most 
pedestrians, and particularly beyond the competency of those 
who are in pain or in agony and need emergency care. They are 
in no position to shop. So, I tend to discount that.
    But the private plans, as I am sure you are aware, the 
Medicare Advantage plans, cost the government a lot more than 
traditional Medicare. Do you know how much more, on average?
    Secretary LEAVITT. I am aware that there are rates in 
certain areas--it varies by area--that are higher.
    Mr. STARK. Thirteen to 20 percent higher. We have heard 
that the private plans will eventually cost less than the fee-
for-service and yield savings. Why didn't you take advantage of 
these projected savings from Medicare Advantage in your budget?
    Secretary LEAVITT. I can only reflect the fact that the 
actuaries were not prepared to score it, like they are not 
prepared to score a lot of things that I believe will 
ultimately occur in a market-driven system.
    Mr. STARK. The chief actuary testified, didn't he, 
actually, before our Committee that there are never any savings 
under Medicare Advantage under the current law, and really no 
efficiencies in the system? Isn't that the situation?
    Secretary LEAVITT. I believe there are changes that we can 
make to Medicare Advantage that would in fact hasten that. One 
example would be beginning to change the breadth of the 
competitive band. Right now it is county-by-county, and I don't 
think that is a good system. We ought to change it to where we 
have broader ranges of competition, and if we do----
    Mr. STARK. Be glad to see what the actuaries have to say 
about that.
    Secretary LEAVITT. I think it would be clear.
    Mr. STARK. When you testified before the Senate Finance 
Committee, you stated that the plans cannot be subsidized 
indefinitely, and the subsidy was established so that a 
nationwide system could be developed. I think that is your 
testimony.
    Any idea what kind of a timeframe you see on that, that we 
could end the subsidy for the Medicare Advantage plans?
    Secretary LEAVITT. Well, the actuaries--not the actuaries 
on the policy. I would like to see immediate changes made on 
the range of competition that we have so we can open up like we 
did Part D. I am confident that if we were to change the system 
from focusing on a county-by-county basis and allow even for 
the bidding of those costs to be done on a state-by-state 
basis, that we would begin to see substantially more rigorous 
competition, and we would begin to see prices fall. I believe 
they would ultimately fall in the fairly near term below the 
level of other regular Medicare fee-for-service.
    Mr. STARK. Well, we look forward to any plans that you 
might put forward that the actuaries or others would suggest to 
us would save plans. My feeling is, and I really don't meant to 
lay this dead cat at your doorstep because I am not sure it was 
your idea, but I have said often and I don't know as I would 
get much disagreement, whether it starts back from Newt 
Gingrich or Ronald Reagan or wherever, that my feeling is that 
in privatizing, like encouraging people into Medicare 
Advantage, we could then pay a flat annual fee and get rid of 
our entitlement responsibilities and turn Medicare--I think 
this is the Republican plan--into a voucher program.
    Then each senior would get a couple of thousand bucks, and 
they would go shop for whatever is in the market, which I think 
would end up putting us back into the pre-1965 era where there 
wouldn't be much available to them, although I am sure that 
your philosophy would be that, no, there would be a lot of 
plans open to them.
    I don't want to put that to the test. You haven't convinced 
me yet. But would you agree with me that it is the 
Administration's long-range intent to try and, if privatize 
isn't the right word, do away with the entitlement features of 
Medicare?
    Secretary LEAVITT. I think we would like to see Medicare 
Advantage look a lot more like Part D does. In Part D, we used 
the government to organize an efficient market, and we 
obviously made it available to every Medicare recipient. We 
gave people a choice. They could choose the plan that fits them 
best, and as I pointed out, we have not only seen dramatic 
reductions in the cost, we have seen people happy with it and 
we have seen enrollment go up. There is a----
    Mr. STARK. Don't you think we could get those costs even 
down lower if we allowed you to negotiate prices?
    Secretary LEAVITT. I don't believe government is an 
efficient--as good a negotiator of prices on an apples-to-
apples basis. I don't.
    Mr. STARK. Mr. Secretary, I think you would have PhRMA 
quaking in their boots if we were going to let you go out and 
negotiate with their clients. I have a great--boy, oh boy. I 
would want to bet on the side of how far you would reduce those 
prices.
    I think Mr. Camp would agree. He is a hell of a negotiator, 
isn't he? I will let Mr. Camp go after him now. Thank you, Mr. 
Secretary.
    Mr. CAMP. Well, thank you. Thank you, Mr. Chairman. You 
know, this discussion on Medicare Advantage, there was a study 
released last month by the Kaiser Family Foundation that found 
Medicare beneficiaries with the highest annual out-of-pocket 
costs in traditional Medicare could save thousands of dollars 
each year if they enrolled in Medicare Advantage.
    For example, the study said that the sickest beneficiaries 
spend at least $6,353 in traditional Medicare, but those same 
beneficiaries would have spent only $2,160 in a coordinated 
care Medicare Advantage plan, for a savings of nearly $4,200. 
So, there are advantages, certainly, that we are seeing 
recorded in private sector studies that may not be reflected in 
actuaries.
    But my question is: Since the majority has voted to cut 160 
billion from Medicare Advantage, what would have happened to 
the 9 million beneficiaries currently enrolled in those plans 
if those efforts had succeeded?
    Secretary LEAVITT. Well, you make the point, and a good 
one, that people like this. They like it a lot because they get 
better benefits. They have an opportunity to choose a 
physician. They don't have as difficult a time getting a 
physician. It is having a terrific impact among particularly 
low income and minority communities. People like Medicare 
Advantage and would be, I think, upset if it were to be removed 
from them.
    I do want to make clear that I believe there are things we 
could do to enhance the competitiveness of Medicare Advantage, 
and we ought to because it is such an important part of the 
future of Medicare.
    Mr. CAMP. I appreciate those Committees. I said as well in 
my opening statement that I think we need to look at the 
successes of programs like Part D and try to find a way to 
inject a similar structure into traditional Medicare.
    You had mentioned a range of competition. Are there any 
other thoughts or details you wanted to mention about this type 
of reform?
    Secretary LEAVITT. Well, I do want to make clear that when 
government negotiates, what government does is it begins to 
control the choices that consumers or patients make. If the 
government were negotiating the drug prices, for example, you 
would also have to give the Secretary the control of the 
formulary. I would have to make a decision on what drugs people 
could take.
    I think consumers make better choices on what drugs they 
are going to take between them and their doctor than they do 
the Secretary of Health deciding and limiting their choices. 
So, there is a very clear give and take, and I believe 
consumers make better decisions than government.
    Mr. CAMP. I know you have also been working on ways to make 
health care more accessible through the establishment of a new 
standard deduction, but also through your Affordable Choices. 
Can you describe for the Committee how the current tax system 
discriminates against workers without employer coverage?
    Secretary LEAVITT. I think this is uniformly accepted by 
Republicans and Democrats, that the current code is blatantly 
discriminatory between those who buy insurance through their 
employer and those who buy outside the system. If a person 
outside the employment system were buying insurance through an 
employer-sponsored plan, they have to pay their taxes before 
they pay their insurance. It means that the biggest subsidy we 
give any person in America in the tax code is denied them.
    As I work with states, who are working feverishly to try to 
give access to their citizens, this is the one problem they 
can't solve. If we could solve this for them by equalizing and 
taking the inequity out, there would be many states who would 
rapidly begin to assure that their markets were organized in a 
way that consumers could choose from low-cost plans that are 
available to them. If they can't afford it, then we could help 
them further. That is what the Affordable Choices would be.
    Mr. CAMP. Wouldn't those choices among low cost plans 
provide more help to lower income workers?
    Secretary LEAVITT. It would provide not only more help, it 
would give them more choices. They would be able to make 
decisions for themselves. We would be able to meet what I 
believe is our national goal, which is every American having 
insurance.
    Mr. CAMP. How many currently uninsured would receive 
coverage under a proposal like the President's, which we have 
been discussing?
    Secretary LEAVITT. Various estimates range, based on 
exactly how the law was written, but there are estimates that 
would have as many as 20 million people able to buy insurance 
who are currently not buying insurance.
    Mr. CAMP. All right. Thank you, Mr. Secretary. Thank you, 
Mr. Chairman.
    Mr. STARK. If I could just use up the last 30 seconds of 
your time.
    We had this discussion last time, but I am sure you are 
both aware that under this deduction, automatic deduction of 
$7,500, which I gather is the same plan we had last year, that 
lower income workers would lose about 30 percent of their 
Social Security benefits as a result of their salaries being 
lowered by the deduction.
    There was some talk with Secretary Paulson about fixing 
that, but I think it is important to notice that in addition to 
what else this might do, it would cut the Social Security 
benefits of the lower income workers.
    The other comment that I wanted to add is that of the 34 
trillion, which is a good calculation for dynamic scoring, but 
if we just did not cut the inheritance tax, we could cut half 
of that.
    In other words, if you take the inheritance tax that is due 
to be eliminated--hopefully not--if it is not eliminated, we 
would pick up about 15 trillion in 75 years. If we did away 
with the whole Bush tax cut, we would have 100 trillion extra 
money in 75 years that would more than three times cover the 
unfunded obligations that you are talking about in Medicare.
    Secretary LEAVITT. Well, raising taxes is always an option. 
It is not one we support, but it is always an option.
    Mr. STARK. Just postponing the cut for 75 years.
    Mr. Levin, would you like to inquire?
    Mr. LEVIN. Welcome, Mr. Secretary.
    As I read the budget, there is an assumption that Social 
Security would be changed to provide for private accounts. Is 
that correct?
    Secretary LEAVITT. Actually, that is not part of the budget 
I am presenting today. Social Security is not in my portfolio.
    Mr. LEVIN. So, you are not sure about that?
    Secretary LEAVITT. Well, it is not part of what I am 
proposing today in this budget.
    Mr. LEVIN. Is the Administration proposing it?
    Secretary LEAVITT. Well, you would have to speak with those 
who have responsibility for it. I am not here to defend that 
proposal or to support it either way.
    Mr. LEVIN. You know, under the tenure of this 
Administration, the poverty rate among children has gone up. In 
real dollar terms, NIH funding has been going down, in real 
dollar terms. I think that is part of the appalling feel of 
your testimony.
    Dr. McDermott, Mr. McDermott, also talks about your 
suggestion to eliminate the social services block grant. I 
don't know what you replace it with. We are talking about 
kids--child welfare services, day care. I just find this 
appalling.
    Let me ask you: You talk about basic philosophy, and you 
repeated it. Consumers make better decisions than government. 
On page 2, you say, ``If consumers were allowed to make these 
decisions through an efficient and transparent market, their 
decisions would be far more precise and wise.''
    What that essentially says is that over time, you would 
suggest the replacement of the present Medicare structure. Is 
that correct?
    Secretary LEAVITT. What I would propose is that we find 
ways to improve the management of the system. I believe one way 
to do that would be to provide consumers with information about 
the cost and quality of their care, and that if they have that 
information, they will make very good choices. Because 
consumers want high quality and they want low costs.
    Mr. LEVIN. Okay. But----
    Secretary LEAVITT. One way to do that would be through 
Medicare Advantage.
    Mr. LEVIN. So, essentially, your hope is that overt I mean, 
the present Medicare structure, the basic structure, would be 
replaced with private insurance?
    Secretary LEAVITT. No. I think Medicare is a very important 
part of the social fabric of our country. I believe it would be 
better if Part A and B worked more like Part D.
    Mr. LEVIN. That is private insurance.
    Secretary LEAVITT. No. It is a government program.
    Mr. LEVIN. Yes. But it is through----
    Secretary LEAVITT [continuing]. That was organized by 
government to give people an opportunity----
    Mr. LEVIN. It is a private insurance program.
    Secretary LEAVITT. It is a program that is provided by 
private insurance companies, but it is a government-funded 
program and it is a government-provided program.
    Mr. LEVIN. It is government-funded, but it is operated by 
private insurance. So, you essentially would replace the 
present system.
    Secretary LEAVITT. I would like consumers to have the 
choice of being able to have a Medicare Advantage-like program.
    Mr. LEVIN. Let me just say to you, I think one of the most 
mistaken statements that can be made is to talk about health 
care across the board and, ``If consumers were allowed to make 
these decisions through an efficient and transparent market, 
their decisions would be far more precise and wise.''
    Because you talk about 20 percent using 80 percent of the 
resources. These are people who have serious illnesses, by and 
large. Essentially, you are sitting here and telling people 
with the serious illnesses that consume most of these dollars 
for senior citizens that the decisions would be better made by 
them, that they would be far more precise and wise.
    All I can suggest to you is that you go out into the 
countryside you have, and go back and try that. My hope is that 
this budget, this health budget, will be put up for a vote on 
the floor of the House, and everybody have to vote yes or no on 
what has been proposed by you and the President.
    I am going to make that recommendation, and see where 
people are with these massive changes, with these massive cuts, 
and let you defend----
    Mr. CAMP. Would the gentleman yield?
    Mr. LEVIN. Yes.
    Mr. CAMP. I would be glad to put that up as long as it was 
also tie-barred with a vote to repeat Medicare Part D. We will 
see where the votes comes down on that as well.
    Mr. LEVIN. No, no. I don't want tie-bar----
    Mr. CAMP. What the Secretary is saying----
    Mr. LEVIN. I will take back my time. Mr. Camp, we will 
decide what is tied to what because we are going to want you to 
vote yes or no on what has been proposed by this Administration 
and the Secretary, whom we respect personally, has come here to 
defend.
    It will be interesting to see how many of you will vote for 
these changes. I hope that day will come. The reason I finish 
with this is I think it will help project this issue even 
further into a reasonable, responsible dialogue in the 2008 
election.
    Secretary LEAVITT. Mr. Chairman, could I respond?
    Mr. STARK. Go right ahead, Mr. Secretary.
    Secretary LEAVITT. Thank you. I would like to reflect the 
fact that at least I believe we could agree--I would hope we 
could agree--that the trajectory right now that Medicare is on 
is a dangerous one financially, and that we have to solve this 
problem for future generations--and we may have differences of 
opinion on how to do that. But I hope we could agree that this 
problem needs to be resolved.
    I take no pleasure in being able to be the one who, in the 
context of a budget, makes decisions on what is basically a 
spreadsheet pro forma as to how I would rank the things that 
are the most important or least important. Some person with 
this system will ultimately have to make those decisions.
    Mr. LEVIN. Let me just say, I agree with you something has 
to be done. Your medicine is worse than the illness. I agree 
there is a problem.
    Secretary LEAVITT. Well, I think there is a better 
solution, and the solution would be to begin to change the 
system, where people have access to information about the cost 
and the quality of----
    Mr. LEVIN. I am all in favor of information.
    Secretary LEAVITT. I think we could agree on----
    Mr. LEVIN. Not destruction of the program.
    Mr. STARK. Mr. Herger, would you like to inquire?
    Mr. HERGER. Yes. Thank you very much, Mr. Chairman.
    Mr. Secretary, I want to thank you for coming before us, 
for being courageous, for recognizing a program that has 
incredible challenges to it, and being willing to go out beyond 
just a government control, which means well. But wherever we 
have total government control in any program any place in the 
world, well-meaning people, we just don't get the results. We 
get shortages. We get a lack of the care. We just don't get the 
results that we deserve here in this country and that people 
deserve any place.
    I hear a number of concerns from my friends on the other 
side of the aisle that the Administration's budget would hurt 
Medicare. My fear is what will happen to Medicare if we don't 
take action soon to slow its growth? As you have mentioned, the 
unfunded liabilities of the Medicare program are estimated at 
$34.2 trillion. Now, that is a huge number, and it comes out to 
over $110,000 for every man, woman, and child in America.
    I am concerned that if we continue to ignore this problem, 
it won't be long before Medicare disappears altogether. I am 
grateful that the Administration is responding to this crisis, 
and yet even this far-reaching budget proposal eliminates only 
one-third of Medicare's total unfunded liabilities.
    Mr. Secretary, in your judgment, what needs to be done to 
get Medicare back on a solid financial footing?
    Secretary LEAVITT. Well, thank you. I will answer your 
question. I would like to make the point that the reductions in 
growth that we are proposing will allow Medicare to continue to 
grow at 5 percent a year. Currently, it is growing at roughly 
7.2 percent. So, we are simply slowing the rate of growth. We 
are not cutting anything. We are slowing the rate of growth. 
Now, I know Washington-speak. Everybody wants to argue about 
that as a cut. But the reality is, 5 percent a year over the 
next 5 years, more will be spent.
    My view is that anyone, whether it is Mike Leavitt, George 
Bush, or any person who has to solve this problem, will 
ultimately have to do one of three things. They will either 
have to make hard cuts, or they will have to raise taxes, or 
they will have to find a way to begin allowing the system to be 
managed in a different way.
    I believe the best way to manage it is to give people 
information about the cost and the quality of their services, 
and then let them choose. Let them make choices, not 
necessarily between care and no care, but choices between who 
provides the best quality at the best price.
    Now, to do that, we are going to have to change not just 
Medicare but our health care system. It will require us to do, 
in my judgment, four things.
    Electronic medical records need to be pervasive in our 
system to drive more efficiency. We have got to have better 
quality measures so our people know whether what they are 
getting is quality or not. We need to have price measures so 
that people know the price and they know the quality, and they 
are able to take the cost and the quality and make judgments. 
We know, from Part D, that if you give people good information 
and give them a choice, they will make choices that will drive 
quality up and the costs down.
    So, this is not about leaving Medicare. It is about finding 
ways to improve Medicare so it is sustainable. A person who is 
54 years of age today, when they turn 65, won't have a Medicare 
trust fund they can call on. We are this year selling bonds 
that are in the trust fund of Medicare Part A, and by the time 
we get 11 years out, they are gone and we will no longer be 
able to do that.
    We are going to have to do one of two things: employ one of 
the tax-increasing methods that the Chairman has referred to; 
or we could do it with payroll tax, the way it is currently 
done; or we have got to change the system in a very thoughtful 
way. I believe now is the time to do that. I do not support the 
idea that we simply do this with tax increases.
    Mr. HERGER. Well, thank you. Mr. Chairman, I don't, either. 
I don't believe--I mean, at the rate we are going, we could 
not--at the rate this program is going, we could not raise our 
taxes enough in the long-term to be able to pay for all these 
entitlements that we have. We have to make the system work 
better and more efficiently. I want to commend you and the 
Administration for having the courage to move forward to 
attempt to do that. Thank you.
    Secretary LEAVITT. Thank you.
    Mr. STARK. Dr. McDermott, would you like to inquire?
    Dr. MCDERMOTT. Mr. Chairman, thank you. Listening to Mr. 
Herger, I am very, very, very depressed. He has said that it is 
just not possible to solve this. I don't know, maybe the Finns 
and the Swedes and the Norwegians and the Germans and the 
Italians and the Dutch are smarter than we are.
    Mr. STARK. The Irish?
    Dr. MCDERMOTT. I guess that is what he was really saying. 
Americans--even the Irish have a national health plan. We can't 
fund ours. Somehow, they do. I guess they must be magicians, or 
else Americans, in Mr. Herger's view, are without the 
creativity and the ability to design a system that would work.
    I find that very depressing. But I was reading my 
testimony--or your testimony and my questioning of you last 
year. My God, it is deja vu all over again. I said almost the 
same things last year. But last year, your answers were that 
the governors--that the problem was--because I said, well, you 
said, I was writing that when I was Chairman of the governors 
association.
    I had that conversation with the governors, and I pointed 
out to them that there are categorical grants that every year 
they are using. It is not the most efficient way to deal with 
the states. You said, well, but they were in much better 
financial shape than when I wrote the letter. So, from the time 
you were governor to the time you got to be Secretary, things 
went uphill. So, you said, make some cuts.
    Where are you today? How are the states doing today?
    Secretary LEAVITT. Well, none of us are doing as well as we 
were two years ago, and we need----
    Dr. MCDERMOTT. So, you cut the budget. You say----
    Secretary LEAVITT. I had to----
    Dr. MCDERMOTT [continuing]. States are in terrible shape in 
taking care of abused kids and child care and handicap, and you 
say, they are in worse shape but we are going to cut the money 
from the Federal Government. That is your answer to the states' 
problems.
    Secretary LEAVITT. My answer is, we need to balance the 
budget by 2012, and we have to make hard choices. Within those 
are a number of programs that we can't----
    Dr. MCDERMOTT. You think we could close one of the 800 
bases that the military has? We have the largest military 
budget in the history of the world. We have more spent on 
military than the whole rest of the world combined. All we do 
is keep cutting the social programs.
    The abused kids, they don't count. The kids--we want the 
mothers to work and we want child care and we want the schools 
to perform well, but we don't want to have decent child care. 
We don't want to pay for it. We are going to cut all that.
    You are saying to the mayors and to the governors and the 
county executives all through this country: We don't care about 
the kids. We are going to keep piling it up over here, and as 
long as it is national security or the defense budget, it is a 
sacred cow. We can't touch it.
    Secretary LEAVITT. I am sure you appreciate I don't have 
any defense depots in my budget. However, I do have a 
responsibility to bear my share of balancing the budget by 
2012.
    Dr. MCDERMOTT. You mean what the President----
    Secretary LEAVITT. So, I had to go through and make 
decisions based on a whole series of what I think are 
redeemable, good programs to say, here are the ones that I 
think should be the highest priorities. That is what I have 
done. You may see it differently.
    Dr. MCDERMOTT. But you are a good soldier. In that sense, 
you are a good soldier. The President says, Sergeant Leavitt, 
go out there and take that hill. You say, yes, sir. Here you 
are up on this hill. You are taking the hill.
    Now, when you tell me that you are just slowing the 
growth--it is increasing 5 percent--but you are cutting a third 
of a trillion dollars out of the budget, the actuaries say that 
that money is for growing population and inflation. So, you are 
saying to them, look, cooks in my unit. We have one bag of rice 
here for food. I know that they have given us 100 more troops 
to eat. But you guys are going to have to eat that one bag of 
rice because I don't have the money to get you a second bag.
    That is the solution of this Administration. It is the old 
story everybody knows from the fair about the guy who bought 
the horse. Feed it a bucket of oats, it will do fine. So, they 
fed it a bucket of oats. Well, the farmer said, gee, maybe I 
could get away with two-thirds of a bucket. So, the horse still 
pulled the wagon, so he fed it two-thirds. Then one day he fed 
it a third of the bucket. One day the horse died.
    The problem with what you are proposing with cutting a 
third of a trillion dollars out of Medicare is you are trying 
to get the horse to die. You are trying to starve it to death. 
It is very clear what this Administration's plan has been from 
the start.
    I yield back the balance of my time.
    Mr. STARK. The distinguished gentleman from Texas, Mr. 
Johnson, like to inquire?
    Mr. JOHNSON. Please. Thank you, sir.
    I hate to hear all this talk of socialism and trying to be 
like some other countries that we know about. I will tell you, 
it doesn't work in those other countries. You guys ought to 
know that.
    The President achieved some savings in his budget by tying 
beneficiaries' premiums----
    Mr. PASCRELL. Mr. Chairman? Mr. Chairman, excuse me. I take 
exception to being--my comrades up here--I hope you don't take 
exception to the word ``comrade''--being called socialists, Mr. 
Chairman.
    Mr. STARK. Well, some of us----
    Mr. LEVIN. I think that is absolutely out of order.
    Mr. STARK. There are some of us who may get pretty close to 
that. So, let's not go down that road right now.
    [Laughter.]
    Mr. Johnson and I have come to an agreement on this. I am 
sure Sam will bail me out as we go along. Thank you.
    Secretary LEAVITT. That is one of the most rewarding 
expressions of candor I have ever heard, Mr. Chairman.
    Mr. JOHNSON. No. He and I do agree on a lot of things, 
believe it or not.
    As I was saying, the President achieved some savings in his 
budget by tying beneficiaries' premiums for the Part D benefit 
to the beneficiary's ability to pay the premium. I agree that 
people like Ross Perot and Warren Buffett probably don't need 
the same help from the government to pay their health care 
bills as low income seniors.
    I think maybe we ought to do away with the requirement to 
require people to enroll in Medicare just because they are 65 
years old. Why hasn't the Administration allowed seniors the 
choice to opt out of Medicare Part A? Wouldn't that be a way to 
save some money?
    Secretary LEAVITT. I don't know the answer to that. I think 
there is a general view that Medicare is a commitment we have 
made to seniors. The issue that we are talking about here is: 
What is the American system? Someone is going to have to make 
hard decisions. Should it be the government, should it be 
insurance companies, or should it be consumers who are armed 
with good information about cost and quality?
    This is not a criticism I have simply of Medicare. This is 
a criticism I have about our system generally. In fact, I think 
you could argue in many ways we don't have a system. What we 
have is a large sector that needs a better sense of 
organization. The best organization would be giving consumers 
access to information about cost and quality, and allowing them 
to make decisions in an organized market.
    With respect to Medicare and that decision, I don't know 
the answer to that.
    Mr. JOHNSON. You are going to be made to get on Medicare 
when you get to be 65. Are you going to like it? I will tell 
you, I don't.
    Secretary LEAVITT. I just had a birthday, and I am getting 
close.
    Mr. JOHNSON. I would like to know if the Administration is 
prepared to send to Congress a proposal that addresses all 
these larger problems within the Medicare program. You probably 
realize that there was a 45 percent budget trigger. Are you 
going to send us something that takes that into consideration?
    Secretary LEAVITT. Yes, Mr. Johnson. As you point out, the 
Medicare Modernization Act requires the trustees, of which I am 
one, to give notice if the budget is 45 percent or more from 
general revenue. We have met that trigger twice, the warning 
has been provided, and the Administration will be responding to 
that warning within the time limit allowed. We will be 
providing a proposal.
    Mr. JOHNSON. Is that going to happen pretty quickly?
    Secretary LEAVITT. We have until the 21st of February, and 
I have it on good authority we will do it before then.
    Mr. JOHNSON. Well, you are on the board. You ought to be 
pretty good authority.
    Secretary LEAVITT. Well, I think I am the authority on this 
one.
    Mr. JOHNSON. I want to thank you for pushing the lessons of 
Part D. I think you are correct, totally correct, in that 
viewpoint. It distresses me that our nation can't stay on a 
businesslike proposal for Medicare, just like it does for a lot 
of other things. I thank you for your comments and thank you 
for being here today.
    I yield back the balance of my time.
    Mr. STARK. The gentleman from Georgia, Mr. Lewis, would you 
like to inquire?
    Mr. LEWIS OF GEORGIA. Thank you very much, Mr. Chairman. 
Welcome, Mr. Secretary.
    Mr. Secretary, let me just ask you a question first off. In 
your discussion and your meetings with the President and the 
OMB director, did you ever raise any question against some of 
these unbelievable cuts?
    Secretary LEAVITT. You know, Congressman, there are lots 
of----
    Mr. LEWIS OF GEORGIA. You are free to----
    Secretary LEAVITT. There are lots of areas that I proposed 
more than what is reflected in this budget. But that is the way 
budgets are developed. We all come back with the things that we 
would both need, aspire for, and hope for. Then we whittle it 
down from there. This is the budget that the President----
    Mr. LEWIS OF GEORGIA. Mr. Secretary, I must tell you, I 
shouldn't be surprised but I am surprised that the Medicare 
budget will destroy the Medicare program. $556 billion in 
Medicare cuts will destroy Medicare. We wouldn't know Medicare. 
Are you telling me that you didn't argue against cutting 
Medicare by $556 billion?
    Secretary LEAVITT. Well, let me again reflect the fact that 
Medicare will continue to grow at more than 5 percent over the 
course of the next 5 years.
    Mr. LEWIS OF GEORGIA. You are cutting hospitals. You are 
cutting the most vulnerable section of our society. Some of 
these hospitals are going to be forced to close. What is going 
to happen to the sick, the poor, the disabled, the most 
vulnerable people in our society? Are they going to fend for 
themselves? Are you suggesting that we should just end Medicare 
and just give everybody a check?
    That is what you were suggesting that may take place, Mr. 
Stark. Is that the road we want to go down?
    Secretary LEAVITT. Clearly not.
    Mr. LEWIS OF GEORGIA. Are we in the boat together? Are we 
all in the same boat?
    Secretary LEAVITT. We are. We have a commitment that we 
have to meet.
    Mr. LEWIS OF GEORGIA. Well, shouldn't we look out for each 
other?
    Secretary LEAVITT. Absolutely.
    Mr. LEWIS OF GEORGIA. Well, I don't think this budget is a 
reflection of that.
    Secretary LEAVITT. Well, this budget is a reflection of a 
concern we also ought to share, and that is that in 11 years, 
it goes broke. We have to do something to fix it.
    Mr. LEWIS OF GEORGIA. Are you trying to end Medicare?
    Secretary LEAVITT. No. I want it to survive----
    Mr. LEWIS OF GEORGIA. Is this the goal? Is this the plan? 
Is this part of the timetable, that this Administration wants 
to end Medicare as we know it?
    Secretary LEAVITT. Well, the same question could be asked 
about those who refuse to do anything to change it. Because we 
are going to run out of money, Mr. Lewis, in 11 years, and if 
we don't start now to begin to reshape the system in a way that 
it can be sustainable, the accusations that you render would 
become, by their nature, true. We want that not to happen. We 
want this to be sustainable----
    Mr. LEWIS OF GEORGIA. My colleague----
    Secretary LEAVITT [continuing]. Available to help people 
who are poor.
    Mr. LEWIS OF GEORGIA. Mr. Secretary, my colleague here, Dr. 
McDermott, is a learned scholar. He is a doctor. He knows all 
about the area of medicine. He is suggesting maybe we should 
consider closing some of our bases. We don't cut the defense 
budget.
    Someone who is in charge of these programs, you don't tell 
me that you cannot stand up and argue with the President, argue 
with Mr. Nussle, and say, this is not the road we should go 
down?
    Secretary LEAVITT. I advocate forcefully the views that I 
have in the budget process. The President and Mr. Nussle 
obviously make decisions that begin to make allocations. Once 
those allocations are made, then we do our best to shape the 
budget in a way that will provide the best and maximum amount 
of good.
    I believe Medicare is a very important part of the social 
fabric of this country. I believe that we have made a 
commitment that if a person is elderly, if they are disabled, 
if they are poor, or if they are in some other way in need, we 
need to help them. We need to make certain that those programs 
are sustainable over a lengthy period of time.
    Right now this program is not. I might add, neither is 
Medicaid. Unless we change it, we will have difficult problems. 
The solutions will be so harsh, I worry that people won't fix 
it. I want to fix it now while we can.
    There is a point in the life of every problem when it is 
big enough you can see it and small enough you can still solve 
it. We are getting darn close to the point that this one is 
unsolvable. We need to act now.
    Mr. LEWIS OF GEORGIA. Mr. Secretary, I must tell you that I 
am deeply troubled, and I fear for the American people, for our 
sick, the disabled, our children today. I think we can do 
better. I think this budget is not a budget of compassion. I 
think it is mean-spirited.
    Thank you. Thank you, Mr. Chairman.
    Mr. STARK. Mr. Weller, would you like to inquire, sir?
    Mr. WELLER. Thank you, Mr. Chairman.
    Mr. Secretary, I always enjoy listening to my good friends 
on the other side of the aisle. My good friend Mr. McDermott 
made reference to increases in child care funding. I would note 
for a historical fact that in the 2005 Deficit Reduction Act, 
which went into effect in 2006, that it contained the last ever 
increase in child care funding.
    In fact, we had a vote on increasing child care funding by 
$1 billion, and unfortunately, I noted, even though it went 
into effect, it was passed on a party line vote. Mr. McDermott 
and his Democratic colleagues on the other side of the aisle 
voted against, the last time we ever had a vote on the floor, 
to increase funding for child care. I just want to note that 
for the record.
    You know, in 1996 the welfare reform legislation--which was 
passed by a Republican Congress and signed into law by a 
Democratic President; it is lauded for an act of 
bipartisanship--proved a tremendous amount of success. I would 
note that it was 12 years ago that that was passed, and of 
course, the impending doom of the Medicare trust fund is 11 
years. Right? So, that is actually a shorter period of time. 
So, it shows we do need to act to find ways to do a better job 
with the resources we have available.
    That is the point I would like to focus on, Mr. Secretary. 
As welfare reform showed, you don't show compassion by how much 
money you spend. It is how well you spend those dollars to get 
the results that help people.
    I am interested, Mr. Secretary, if you can outline for us 
how the President's budget spends the resources we have in a 
smarter way, more efficiently, helping the people who need 
help. If you can walk us through those initiatives, Mr. 
Secretary.
    Secretary LEAVITT. Well, you mentioned child welfare. The 
flexibility that would be provided under the child welfare 
option that we have in the President's budget would improve 
child protective services. It would allow the states to receive 
their Federal foster care funds in a fixed and flexible stream 
instead of waiting to receive the funds only after they have 
removed a child from the family.
    Under the option, states would receive these funds to spend 
on child welfare activities as they choose. We would encourage 
them to invest these dollars in evidence-based proven 
prevention activities. That is one example.
    Mr. WELLER. Why is prevention important when it comes to 
child care?
    Secretary LEAVITT. Well, it is the same as health care. If 
we spend all of our time treating the patient after they are 
sick, it is very expensive and there is a lot of human 
suffering. If we prevent, there is less cost and we avoid a lot 
of human suffering and long-term costs. I think all of us know 
that preventing is the answer and not just picking up after it 
has occurred.
    Mr. WELLER. What I see as one of the problems we have often 
in Washington is there is a Washington knows best attitude, 
telling states how they should administer programs. This 
budget, I know, from what I have seen, really emphasizes 
flexibility.
    You have been a governor. Can you explain, from the 
perspective of having been a governor, how flexibility can 
actually help us make sure those dollars are spent in a better, 
more effective way in helping people?
    Secretary LEAVITT. Well, I think two programs, one you 
spoke of, welfare reform, when we went to the TANF system. We 
gave states essentially a set of expectations and allowed them 
to design programs that would in fact solve the problem. They 
have, and it has dramatically reduced the amount we spend, the 
number of people on it, and people view it as a milestone in 
the delivery of human services.
    I think another is Part D Medicare, where the states 
weren't involved in that, but we provided flexibility.
    Another good example with the states is the SCHIP program. 
Many of the states have managed their SCHIP program in a way 
that has provided for dramatically more children to be on the 
program than if they just used the regular Medicaid system that 
is prescribed or would be prescribed by the Federal Government.
    Mr. WELLER. Well, thank you, Mr. Secretary. I see I have 
run out of time.
    Thank you, Mr. Chairman, for the opportunity to question.
    Mr. STARK. Any time, Mr. Weller.
    Mr. Becerra, would you like to inquire?
    Mr. BECERRA. Thank you, Mr. Chairman. Mr. Secretary, thank 
you very much for being with us. Good to see you again.
    Let me try to focus my questions a bit. I would like to 
chat with you a bit about the cuts and how they seem to be 
focused in certain areas. First, it seems that you--well, first 
let me ask: You signed off on this budget before it got to the 
White House for clearance with the Office of Management and 
Budget for submittal to Congress?
    Secretary LEAVITT. We go through a budget process where my 
various operating divisions submit budgets to me. Acting with 
guidance from the White House, we develop our recommendations. 
They go down to the White House. They make suggestions and 
decisions. We then go back and appeal.
    Mr. BECERRA. So, this Medicare budget within the 
President's overall budget, you concur with?
    Secretary LEAVITT. I concur clearly that we have to do 
something to solve this problem.
    Mr. BECERRA. No, Mr. Secretary. My question is----
    Secretary LEAVITT. Now, let me finish. Let me finish.
    Mr. BECERRA. This budget that has been presented--well, let 
me be more specific. Do you agree with all of the different 
cuts to Medicare that are in this Bush budget that is presented 
to Congress?
    Secretary LEAVITT. First, there are no cuts. There is a 
reduction in the growth rate. We will see Medicare grow by 5 
percent.
    Mr. BECERRA. So, let's call it reduction in the growth 
rate. Do you agree with all the cuts to the growth rate in 
Medicare that are in this budget?
    Secretary LEAVITT. If you are asking if I believe that 
there is a better way to do this, I do. But it is not available 
to us in the government price-setting world we live in.
    Mr. BECERRA. Now, Mr. Secretary, I understand all that and 
I don't--what I am trying to do is get as specific as I can. I 
understand that there are qualifications to anything. Forgive 
me if I try to have you be as specific as possible.
    I am trying to identify whether there are any--I call them 
cuts; you may call them a reduction in growth rate--but if 
there are any cuts that you disagree with in this budget.
    Secretary LEAVITT. This is the President's budget. I am 
here to defend his budget. Are there those that I would have 
done slightly different? Of course. But he is the President, 
and----
    Mr. BECERRA. Are there any that you can identify for us?
    Secretary LEAVITT. Well, I am here to defend the 
President's budget, and I feel good about defending it. I will 
tell you, and I want to reemphasize----
    Mr. BECERRA. Now, Mr. Secretary, let me move on.
    Secretary LEAVITT [continuing]. This is a blunt instrument. 
There is no way you can do this with precision in the system we 
have. That is the problem I have with the system. When I said 
to Mr. Stark, I would like to see the system change, I would 
like to see a system that isn't--where we don't create a budget 
with such blunt instruments. Somebody someday is going to have 
to deal with this.
    Mr. BECERRA. Fair enough.
    Secretary LEAVITT. You may not like mine, but someday 
somebody is going to have to make these decisions.
    Mr. BECERRA. That is fair enough. I appreciate what you are 
trying to point out, is that we do have an issue that must be 
addressed that is a long-term issue that, if we don't address 
sooner than later, becomes very big later on down the line. I 
don't think anyone disagrees with you there.
    It is just that a number of us believe that this budget 
doesn't do anything to improve the situation by making a lot of 
seniors face some pretty devastating cuts. You may call them 
reductions in growth rate, but to a senior who has to pay more 
this year for that medication that may be lifesaving than he or 
she did last year, not getting an increase in that Medicare 
payment for that physician prescribing that medication or for 
the medicine itself amounts to a cut, which that person now has 
to come out of pocket to pay or somehow has to figure out what 
to do, either that or not get the medicine.
    So, what we may call here as technocrats a reduction in the 
growth rate is, to most living and breathing human beings who 
receive Medicare benefits, a cut.
    With regard to hospitals, it seems like this budget--and I 
will say this budget; I won't say you, Mr. Secretary--this 
budget punishes hospitals more than any other provider of 
medical services to our senior population. In particular, I am 
shocked at the level of precision of the hit that goes to 
children's hospitals, in this case, children's hospitals 
through the graduate medical education payment that they get.
    I know in California we have about 25, 27 children's 
hospitals. I know that there are several throughout the nation, 
tens of children's hospitals, who do yeoman's work. Many times 
these families don't have the money that it takes to provide 
the lifesaving services that they receive for their children. 
In many cases, the children have miraculous recoveries.
    But the millions of dollars that you take out of the hides 
of these children's hospitals, I don't see where they make it 
up. You don't provide anywhere in the budget where they would 
make it up. I hope you will take a look at that.
    Also what disturbs me is the teaching hospitals. The 
hospitals that are willing to educate the next generation of 
medical leaders are going to get hit dramatically in this 
budget. You almost force them to go away from teaching and into 
more of a profit-making mode by just taking patients through a 
mill process.
    Because they can't make money when they are trying to 
educate the next class of doctors and providers if they are not 
getting reimbursed for that, and we know that most of these 
teaching hospitals actually provide health care to a lot of 
poor and indigent--I mean, indigent and minority populations.
    So, since my time is expired, I will leave it at this and 
say, Mr. Secretary, I hope that you will counsel the White 
House and really urge upon them that we reexamine some of these 
proposals for reductions in growth because I think those 
reductions in growth are going to devastate, through their 
cuts, a lot of very dignified seniors who thought they had 
worked a long time for their Medicare benefits, and now find 
that the government is leaving them behind.
    So, I thank you for your time.
    Secretary LEAVITT. Congressman, can I just respond that I 
acknowledge that there are a number of places here where you 
might make decisions that are different than what the 
Administration has. However, whoever it is that ultimately has 
to deal with this problem will have to make similar decisions.
    What I am here to argue is that the time for us to just 
argue about what price-setting measure we are going to use or 
not use, how much we are going to increase this or that, is not 
as good a system as we could create if we began to modernize 
health care as well as Medicare and give information to people 
where they can make decisions that will allow the invisible 
hand of the consumer to begin to drive priorities.
    It will ultimately get to it. I fully acknowledge how 
difficult many of these things are. It is the reason I said I 
hope this is a very clear warning that somebody has to make 
these decisions. Right now we are not making them.
    Mr. STARK. Mr. Brady, would you like to inquire?
    Mr. BRADY. Thank you, Mr. Chairman.
    Mr. Secretary, two questions, one about Medicare fraud, the 
second about IVIG. It seems like every week we open up the 
newspaper and see some major fraud case--medical devices, 
scooters, physicians who don't exist, patients who weren't 
treated, and on and on.
    Do you have any estimates or studies that quantify just how 
much we lose to Medicare fraud each year?
    Secretary LEAVITT. Studies have been made, and those are 
available. I would be happy to provide them to you 
independently. I don't have them on the top of my head. I will 
tell you this: I have personally been involved in operations we 
have had to find and to remedy this.
    One of the big disappointments to me of the 2008 budget, 
frankly, was the $300-some-odd million that was in the budget 
for anti-fraud was taken out. We get a 13 to 15 times return on 
those dollars. I hope that the current budget will not make 
that mistake. This is money that we need in order to keep 
people from defrauding seniors.
    Mr. BRADY. So, Congress--are you saying Congress cut the 
funding for anti-fraud?
    Secretary LEAVITT. It was in the budget and then was 
removed at the last minute for reasons I don't fully 
understand. But it has hurt our capacity to stop fraud.
    Mr. BRADY. Well that doesn't make sense because it seems 
like the fraud is significant. They are just ripping off our 
seniors when they do that. We don't have enough money to go 
around----
    Secretary LEAVITT. Every dollar we put into this, we get 13 
to 15 back, and it gives the system more integrity. We need to 
focus more money on this.
    Mr. BRADY. I hope this Committee leads the way in providing 
you the resources you need.
    Second question. I raised this last year. We have talked to 
your office and agency frequently about this. The issue of IVIG 
deals with the treatment for those without an immune system in 
their bodies. The reductions we have had here in the past year 
have made it almost impossible for these patients.
    There are not a lot of them, 10,000 or so, if I recall, who 
now are being almost forced to go into the hospital to receive 
treatment, which for someone without an immune system, the 
worst place in the world to be is a hospital setting.
    I know that we have introduced legislation and worked with 
your office to treat this, much like Medicare has treated the 
hemophilia clotting factor, where you recognize it as a unique 
biologic product that requires a modified Part B reimbursement 
policy.
    Mr. Secretary, would you and your colleagues at CMS be 
willing to work with me and other Members of this Committee to 
finally address the issues surrounding IVIG? I understand the 
need to try to get the best bang for our buck. But this 
actually, I think, is an awfully bad move. I don't want to see 
it be made even worse going forward.
    Secretary LEAVITT. The answer is yes. I am aware of the 
problem. In fact, we have recently developed an inter-agency 
workgroup to be able to work with FDA and CMS and others. So, 
the answer is yes.
    But could I point out that this is a great example of the 
difference between Part B and Part D? We don't have this 
dilemma in Part D because consumers and doctors are making 
decisions about this. We have it in Part B because we are 
having to have a government price-setting decision. There are 
differences of opinion that are going to be playing out here.
    We will work this problem out, but it is a very good 
example. We don't have this kind of dispute in Part D. We do in 
Part B.
    Mr. BRADY. Well, I will take you up on your offer because 
just for these people, it has been very frustrating. There has 
been good bipartisan support on this Committee to modify the 
reimbursement. We have worked with the Senate on it. There 
seems to be agreement that the cost of it is very small, but 
the importance to those patients is huge.
    So, I would like to see--and the sooner the better, 
obviously, for all of them. So, thank you, Mr. Secretary.
    Secretary LEAVITT. Thank you, Mr. Brady.
    Mr. BRADY. I yield back, Chairman.
    Mr. STARK. I just wanted to respond again to my good friend 
from Texas that I would like to join with him to help and see 
whether we could get some kind of a solution to it. It is very 
expensive. Individual doses are $5-, $6,000. But for people who 
need it, it is very important.
    Mr. BRADY. Thank you, Chairman.
    Mr. STARK. I would be glad to work with you.
    Mr. BRADY. The good news is I think we just got a recent 
score on the modification, and it is very small. But thank you.
    Mr. STARK. Mr. Doggett, would you like to inquire?
    Mr. DOGGETT. Thank you, Mr. Chairman. Thank you, Mr. 
Secretary.
    Mr. Secretary, as you are most familiar, this Committee and 
the House approved significant improvements to Medicare last 
year in the CHAMP Act which were paid for by reducing by $50 
billion over 5 years the subsidy to private insurance carriers 
in the so-called Medicare Advantage program.
    You and the Administration opposed paying for it in that 
manner, and when the Senate, considering our legislation, 
proposed an amount to come out of the private insurance company 
subsidy that was less than that $50 billion, the Administration 
threatened to veto it if there was a substantial amount taken 
from the private insurance company subsidy.
    Does that remain the position of the Administration today?
    Secretary LEAVITT. The Administration is a big supporter of 
Medicare Advantage. I have indicated earlier that I personally 
believe that there are things we can do to improve its----
    Mr. DOGGETT. Yes, sir. I am going to ask you about that. 
All I need to know now is: Your position hasn't changed, has 
it?
    Secretary LEAVITT. We believe Medicare Advantage is an 
important component of Medicare, that people like it, and we 
are not----
    Mr. DOGGETT. You don't want money taken from it in order to 
improve traditional Medicare?
    Secretary LEAVITT. We believe that it is an important part 
and needs to continue. We believe that it is important that it 
is nationwide, and that the system that was established was 
done so to make----
    Mr. DOGGETT. I will accept that as a yes. You are aware 
also that as you discussed with Chairman Stark, that the 
subsidy amounts to about a thousand dollars per beneficiary 
this year, according to everybody who has looked at it. It is a 
significant subsidy for each beneficiary, more expensive than 
under traditional Medicare to be in the Medicare Advantage 
program. Right? That is not----
    Secretary LEAVITT. I am sure that we would agree that 80 
percent of those go to the beneficiary.
    Mr. DOGGETT. That is not a new subsidy. In fact, as I look 
back through the proceedings of this Committee going all the 
way back to 2004, when my colleague Max Sandlin from Texas 
asked the actuary if there was any verifiable savings to be had 
at any point in these plans, and he said no.
    That hasn't changed through 2004, 2005, 2006, 2007, 2008. 
We are up through this ideological experiment of relying on 
privatizing Medicare. It costs us a thousand dollars a 
beneficiary, per person, last year. Neither you nor anyone in 
this Administration can point to any objective, verifiable 
savings that have come from that.
    Secretary LEAVITT. I earlier today pointed out the fact 
that I believe if we were to expand the bands of competition, 
we would----
    Mr. DOGGETT. All right. I want to talk to you about that. 
But the answer is no. You can't show us any verifiable savings. 
You think that maybe if you change the plan, you could get 
those savings. Right?
    Secretary LEAVITT. I think it is an important part. 
Medicare Advantage is an important part. People like it. We 
need to expand it because it in fact gives people choices.
    Mr. DOGGETT. So, I will take your non-answer as an 
indication you have no savings. You think the plan should be 
changed. Where is your legislation to change the plan?
    Secretary LEAVITT. I believe it is very clear that the----
    Mr. DOGGETT. I am sorry. Where is it? Do you have it with 
you today?
    Secretary LEAVITT. I do not.
    Mr. DOGGETT. Which one of the Republican Members of this 
Committee has authored legislation to change Medicare 
Advantage?
    Secretary LEAVITT. Mr. Doggett, I am not sure I----
    Mr. DOGGETT. In the fashion that you recommend?
    Secretary LEAVITT. Well, we are having a discussion today 
about the philosophy, not the specific legislation.
    Mr. DOGGETT. Well, we are having a discussion after 8 
years, almost, of this Administration in which we have 
subsidized and had an incredible amount of waste in subsidizing 
private insurance, an ideological experiment. We have no 
verification that it saves the taxpayer a dime.
    You tell us, well, maybe we can't prove it saved anything, 
but I got an idea that if we change it a little this way or a 
little that way, we could start having the savings that make up 
for these billions of dollars that have been wasted. Neither 
you nor anyone in the Administration or any of our colleagues 
on the Republican side has that legislation after 7 or 8 years. 
So, I don't find it very substantive.
    Let me ask you about another example of the waste that this 
Administration has tolerated. You have been boasting if we 
would just be a little bit more like Part D, things would be 
wonderful. Well, I refer you to the Inspector General's report 
from your Department about how Part D has worked.
    They point out that Medicare only overpaid the Part D 
private insurance companies $4.4 billion for the year 2006. 
That is a little bit of change, $4.4 billion, and that it took 
Medicare under its procedures 9 months to even figure it out.
    Is that an example of what you think is a good treatment of 
the taxpayers' money in managing Part D with these private 
insurance carriers?
    Secretary LEAVITT. Both of those procedures were 
contemplated in the law and were done in accordance with what 
we expected----
    Mr. DOGGETT. According to the law that you recommended and 
that this Republican Congress before us approved over our 
objection in the middle of the night. Yes, sir, it is.
    Secretary LEAVITT. A law that----
    Mr. DOGGETT. As a result of that, we get private insurance 
companies getting $4.4 billion, and 9 months before Medicare 
even figures it out. How much interest have you gotten back 
from them on that $4.4 billion that they got for 9 months, plus 
whatever time it took you after you figured it out to get it 
back?
    Secretary LEAVITT. Congressman, this is a program that 86 
percent of the people who have it like it. This is a program 
that 40 percent----
    Mr. DOGGETT. It is a program that the taxpayers----
    Secretary LEAVITT. Excuse me. This is a program----
    Mr. DOGGETT. $4.4 billion. Not a penny of interest have you 
gotten back from it.
    I asked last June and again in October--we have submitted 
it in writing; we have asked it orally--to tell us what 
happened to the $100 million that you wasted in paying private 
insurance companies for retroactive coverage for low income 
beneficiaries that they were never told about until too late to 
take any advantage of it.
    I still don't have an answer. The Subcommittee doesn't have 
an answer to its written questions. Do you think before you 
come to testify before the Budget Committee this week or next, 
when I get a chance to ask you about this again, that you could 
please bring us those answers that have been due since last 
summer?
    Secretary LEAVITT. That seems like it would be a smart 
thing to do.
    Mr. DOGGETT. Thank you.
    Mr. STARK. Mr. Pomeroy, would you like to inquire?
    Mr. POMEROY. Mr. Secretary, I want to ask you not just 
about the budget; I want to ask you about some rules that have 
been promulgated by HHS. I know it is a budget hearing, but we 
don't get you up here often, so it is a chance to do that.
    The rule I want to ask you about was proposed on August 31, 
2007. It would exclude from Medicaid or SCHIP matching grants 
any payments under state plans that use school personnel to 
help enroll children that might be eligible for either SCHIP or 
Medicaid.
    I just want to talk conceptually with you about this. I 
don't know if you mean to be mean-spirited or if this is kind 
of just inadvertent, an inadvertent consequence of a badly 
conceived rule. First let's see whether we have some values 
agreements.
    I believe that you would believe that enrollment of those 
eligible, enrollment of children eligible for Medicaid coverage 
or SCHIP coverage, is a positive feature as states work these 
programs. Is that correct?
    Secretary LEAVITT. They clearly are.
    Mr. POMEROY. Clearly. I believe that you would think that 
the school was a pretty good place to do that. There was a 
specific report, in fact, put out in 2000, the last 
Administration: HHS, U.S. Department of Agriculture, and the 
Department of Education, that pointed out that schools are 
where the children are and represent the ``single best link'' 
for identifying and enrolling eligible low income children in 
health coverage.
    Do you agree that the schools are a very good place to 
identify and enroll children?
    Secretary LEAVITT. Clearly they manifest themselves, and 
that that is one of the sources.
    Mr. POMEROY. You know, the success of these programs is 
evident in your hometown, Salt Lake City, or the town you 
previously lived in. I don't know if that is where you were 
born and raised or not. But the Granite School District there, 
just as an example, reaches out to children to identify and 
assist those who qualify for Medicaid or SCHIP. They have got 
two full-time and two part-time people involved in this, and 
each year they submit about a thousand apps for Medicaid, and 
about 77 percent are enrolled, which is a very favorable 
enrollment rate.
    Now, under your plan, you would eliminate funding for those 
school personnel working through the Granite School District. 
Now, what would be the rationale for taking a step like that?
    Secretary LEAVITT. The dilemma we have faced with Medicaid 
in many ways is that lots of places don't get the budget they 
need for many purposes. I am not specifically aware of what you 
are referencing. But I can tell you what we are eliminating, 
and it is the non-medical--I mean, there are school districts, 
Congressman, that buy school buses with Medicaid dollars.
    Mr. POMEROY. I mean, I think that is appalling. That has 
got nothing to do with enrolling people in Medicaid or SCHIP.
    Secretary LEAVITT. Well, that's right. That is what we are 
trying to----
    Mr. POMEROY. The Department, without objection from this 
Committee, put forward a rule in 2003 to address that.
    Secretary LEAVITT. Our effort in dealing with these 
targeted case management rules is to be able to assure that we 
are paying for medically necessary things and eliminating what 
we believe to be misuses. There is nothing mean about this. We 
are looking to find a way to preserve the dollars----
    Mr. POMEROY. Maybe you don't have this information. I 
actually would appreciate it, if you don't have it, get me 
information. If the 2003 rule fell short of preventing abuses, 
where did it fall short? Because what you have now done is 
something quite different.
    You have prohibited any Federal funds to be used on school 
personnel. You do allow Federal funds to be used for contract 
personnel. So, let's say Halliburton today is in the business 
of some kind of school outreach activity. I don't know whether 
they do this or not. But you would happily pay the Halliburton-
type contractor, but not the school district, including, for 
example, the Granite School District personnel who have been so 
successful in Salt Lake City in getting poor children enrolled 
for the coverage they need.
    So, I believe this has been an extremely ill-advised thing 
the Department has advanced. Congress has put a moratorium on 
it as they reauthorized SCHIP. But it is only a temporary one, 
and it to me would appear to be something the Department 
continues to move forward.
    Secretary LEAVITT. Congressman, I want you to know--I am 
not able to respond to the granularity of what you are talking 
about. But I do have some knowledge of both what happens on the 
ground and what we are trying to accomplish.
    There is a robust industry of consultants who will use 
every possible means of being able to find ambiguities in the 
law and to parse them so that various entities that are not 
medical providers, that are not part of the medical system, can 
tap into Medicaid funding. It distracts from our original 
mission and purpose. I would be happy to respond with more 
specific information.
    Mr. POMEROY. I would respond to you that there are also 
special education teachers that are dealing with children in 
schools today with developmental disabilities, some of them 
medically related. Some of those children are from families 
that don't have coverage, and they can't get access to doctors 
because their families can't afford it.
    You would prevent this school teacher from bringing this 
family----
    Secretary LEAVITT. No. I would not prevent that school 
teacher. What I would prevent them from doing is paying for the 
teacher.
    Mr. POMEROY. You would prevent any compensation to that 
school district for----
    Secretary LEAVITT. No.
    Mr. POMEROY. Yes, you would. Yes, you absolutely would.
    Secretary LEAVITT. We are not doing that. No, we are not. 
Congressman----
    Mr. POMEROY. You would prevent the payment to that school 
district for any assistance in helping that special education 
teacher get the epileptic child that needs the medication that 
they can't afford because the family doesn't have coverage--you 
would prevent that by rule.
    Secretary LEAVITT. Congressman, you are pointing your 
finger at me and ascribing motives that are simply not true.
    Mr. POMEROY. Well, and I don't care about your motive.
    Secretary LEAVITT. No. Let me----
    Mr. POMEROY. It is the fact, Mr. Secretary.
    Secretary LEAVITT. It is not the fact.
    Mr. POMEROY. Read your August 31, 2007 rule. This drives us 
to distraction. You are not a bad man. I have enjoyed knowing 
you over the years. But the evil effect of impacting a school 
district like Granite District in Salt Lake City from helping 
kids that get coverage that need it, to me that is just an evil 
impact.
    Secretary LEAVITT. Do you find it----
    Mr. POMEROY. I don't know if it is intended. I don't know 
what. But I do know that it is extremely bad policy, and this 
Administration should be ashamed of it. They wrote it, and they 
would have 
had it impacted today except for the action of Congress in stopp
ing it.
    Secretary LEAVITT. Our time is up. But I will simply say 
that our purpose is to do nothing but to use wisely the money 
we have, and that there are districts that abuse the privilege 
in a way that I don't believe you would feel good about, 
either.
    Mr. STARK. Mr. Ryan. Would you like to inquire?
    Mr. RYAN. Thank you, comrade.
    [Laughter.]
    Mr. Secretary, good to have you here with us again. I had 
some questions on the trigger and transparency. But I have just 
been enjoying this conversation.
    I just look at the fact that the Medicare Part D bill, law, 
is coming in about 40 percent under estimates. It is about 40 
percent less expensive than we projected it to be. When is the 
last time Congress passed a program that came in 40 percent 
under budget? It is because of competition.
    You take a look at the Medicaid program, which is not a 
competitive program, and you have got stories in the Wall 
Street Journal just a couple days ago where you have one 
company overcharging Medicaid by $650 million. So, to suggest 
that only government-run programs that have government 
monopolies are saving all this money, it just doesn't jive with 
the facts.
    So, I think there is another side of the story from what we 
have been hearing here, and that choice and competition in the 
hands of the consumer and among providers actually is proving 
to work.
    Let me ask you two questions, first trigger, then 
transparency. Give us your assessment on the Medicare 45 
percent trigger. When and if do you expect the Administration 
to respond, and do you care to comment on some suggestions that 
we might act on in order to conform with the trigger law?
    Secretary LEAVITT. First of all, we believe that responding 
to that trigger is an important discipline that should be 
followed not only by this Administration but future 
Administrations. This is a serious problem, and it needs to be 
responded to.
    Second, we will respond, and we will respond within the 
timeframe allotted in the law, which is 15 days after the 
President has submitted his budget.
    Third, you will see a series of proposals that will, in 
fact, not just deal with reducing the growth rate in a scorable 
way, but will also begin to focus on ways we can change the 
system, not just of Medicare but of health care: basic things 
dealing with electronic medical records and the efficiencies 
that can come from that; basic things like measuring quality so 
that people know what they are getting and have an idea of 
whether it is good or not; and third, things like cost, so they 
can actually see the cost and the quality; and providing 
incentives, not just for consumers but also for the payors and 
for the plans and for everyone, so that they have a motivation 
to drive quality up and cost down.
    Again, we believe fundamentally that consumers, armed with 
information, make better decisions than the government makes 
for them. I think there is a long history to demonstrate that 
that is true. Part D is just one good example.
    Mr. RYAN. So, it sounds like we are on the same page. I 
hope we do systematic changes that, as responding to the 
trigger, we do it in such a way that it actually helps the 
long-term sustainability of Medicare, that it is not simply a 
price control plan like we did in 1997, where Congress ends up 
giving all of it back. I hope we do things that are actually 
systematic, structural, and put us on the right glide path 
toward making Medicare more sustainable and enhancing its long-
term solvency.
    Transparency: Give us your take on where the next stage of 
the transparency movement is. I can just tell you, in 
Milwaukee, for example, the price of a bypass surgery ranges 
from $47,000 to $120,000. The price of an MRI in Milwaukee 
ranges from $600 to $5,000. The price of rotator cuff surgery, 
$4,700 to about $15,000. You know, on and on and on. About a 
300 percent price disparity among all different kinds of 
payors, just in the metro Milwaukee market. No one knows this. 
It took us a couple years just to get that information.
    What is the best way to proceed forward in a lasting way to 
have real transparency, and therefore real competition, based 
on price and quality?
    Secretary LEAVITT. Congressman, I have laid out what I 
believe are the four cornerstones of such a system.
    Mr. RYAN. I apologize if you are repeating yourself. I have 
been in and out of this hearing.
    Secretary LEAVITT. Well, it needs to be repeated many 
times. Electronic medical records. Quality measures that people 
can agree upon that are developed by the medical community. 
Price grouping so that people know what they are paying for. 
Then motivations and incentives so that people have a reason to 
care what the costs are and have information about the quality.
    Given that kind of information, as we have seen in every 
other part of our economy, including health care, given that 
kind of information, people make those decisions. Today 
Medicare makes a series of decisions, a couple thousand of 
them, that make those decisions for everyone.
    We don't always make the right decision. Oftentimes we are 
subsidizing pieces of the health care system that we ought not 
to. Sometimes we are underpaying things that ought to be 
encouraged. We are not always able to find those. The market 
will.
    Mr. RYAN. So, where prices are visible----
    Ms. SCHWARTZ. Excuse me. Would Mr. Ryan yield? I appreciate 
very much the dialogue that you are having. But isn't it 
correct that you actually cut the funding for comparative 
effectiveness research, when in fact we have agreed that that 
would be helpful; that you did not include an e-prescribing 
proposal, which many of us in a bipartisan way actually want to 
see done?
    Mr. RYAN. The quick answer is I have one more follow-up.
    Ms. SCHWARTZ. Because I think you might agree on that, and 
it would be great to see it actually included in the budget.
    Secretary LEAVITT. No. I am a big supporter of e-
prescribing. It is time to do it. It is time to say it has to 
be done.
    Ms. SCHWARTZ. Well, maybe we can get that done.
    Mr. RYAN. All right. Well, I see my time is expired.
    Ms. SCHWARTZ. But it would have been good to have it be in 
the budget to start with.
    Secretary LEAVITT. I would have liked to have had it done 
in the SGR fix. I would like to see it happen in June. So, you 
can't do it soon enough for me.
    Ms. SCHWARTZ. Sorry.
    Mr. RYAN. That is all right. No problem.
    Ms. SCHWARTZ. But I thought if we had a moment of 
bipartisan agreement, let's see if we can't make it happen. It 
is not in the budget now. Thank you.
    Mr. RYAN. I yield my time on a bipartisan basis.
    Mr. STARK. I am going to recognize Mr. Pascrell and Ms. 
Berkley, who were here ahead. But I am going to ask if you 
would--we have got 15 minutes till five votes. With the folks 
that are here, I hope that we could finish up.
    Mr. PASCRELL. Mr. Chairman?
    Mr. STARK. We have got 12 minutes. I recognize the 
distinguished gentleman from New Jersey for 3 minutes.
    Mr. PASCRELL. Three minutes? Mr. Secretary, thank you for 
your service. Twenty-five states are about to declare deficits 
in their budgeting. There will be more coming down the line. I 
want to remind you of a statement that you made in 1999, when 
you were the governor of Utah. You sent a letter to the 
Congress of the United States, and this is what you said in 
that letter.
    ``Reductions in the funding for social services block 
grants will result in cuts to vital human services for our most 
vulnerable citizens.'' This President, in his proposal, is 
nothing more--is cutting more than $1.7 billion annually in the 
services that are most needed.
    If you were in a governor's position, which you were, and 
you did a very good job when you were the governor of Utah, you 
would have a different attitude in supporting this budget 
before us.
    I want to get into a very specific area which affects New 
Jersey particularly, and that is the area of teaching 
hospitals. I think that this borders on criminal. The proposal 
before us will damage our ability to train a generation of new 
doctors at a time when the nation is facing a shortage of 
doctors. This is exactly the opposite direction which we need 
to move.
    In fact, today I, along with my colleague and fellow 
Committee Member Congressman Ron Lewis, introduced legislation 
that will bring equity to a deficient Medicare compensation 
formula for direct graduate medical education currently used to 
reimburse teaching hospitals.
    More than 600 American hospitals are being reimbursed by 
Medicare at an inadequate level for their work in training 
America's doctors of tomorrow. These costs bear little if any 
relationship to the actual costs of operating the training 
program in the 21st century. I was going to give you anecdotal 
evidence; I think you know the evidence.
    In New Jersey alone, our teaching hospitals have lost close 
to $7 million. When you combine a broken DGME payment system 
with the draconian indirect medical education cuts that you are 
proposing contained in this budget, I am extremely concerned 
that these unsustainable losses will threaten the future of 
this nation's health care infrastructure.
    Under these circumstances, at a time when we need more 
doctors, not less, how are teaching hospitals to fulfill their 
mission, Mr. Secretary?
    Secretary LEAVITT. First let me acknowledge the 1999 
letter. I have had it read to me enough times now, I could 
probably quote it.
    But I would like to acknowledge that there is one 
fundamental difference between 1999 and now. We had a balanced 
Federal budget then. We don't now. Obviously, a lot of 
circumstances are different.
    Mr. PASCRELL. I am very aware we had a balanced budget 
then.
    Secretary LEAVITT. I am sure you are.
    Mr. PASCRELL. Yes. Very aware.
    Secretary LEAVITT. I just point out the difference.
    With respect to the teaching hospitals, I know and you know 
how vital it is to have vital teaching hospitals. I will tell 
you I think the system of the way we finance it is 
``skiwampus.'' It ought to be spread over a much greater part. 
The Federal Government does a substantial part of it. We ought 
to spread the base.
    Mr. PASCRELL. But there is nothing in this proposal, in 
this budget, that addresses that issue. You have had 300 
hospitals close in the last decade.
    Mr. STARK. We will get to that, Mr. Pascrell.
    Now we are going to get to Ms. Berkley, who is going to be 
recognized for 3 minutes.
    Ms. BERKLEY. Thank you very much for coming. I wish we had 
a little more time. I know that you have family that lives in 
my congressional district.
    Secretary LEAVITT. I do, yes.
    Ms. BERKLEY. I met with them very recently. So, let me tell 
you about the community that they are living in right now. I am 
going to restrict my comments to SCHIP, Medicare, and Medicaid. 
We have a serious health care crisis in the state of Nevada. I 
think this budget is going to exacerbate the problem. Let me 
tell you why.
    I have got the fastest growing senior population in the 
United States. I have got doctors that are calling me, not in a 
threatening way, but telling me that they will keep the 
Medicare patients that they have, but they can no longer accept 
new ones. Right now they are losing money.
    If what is in this budget, with the fee schedule, the 
physicians fee schedule--if we don't restore the money, they 
are going to take a considerable hit. Short of me going to 
medical school and learning how to treat my senior citizens, 
there is not going to be any health care for them. That is 
going to be disastrous. That is number one.
    Number two, SCHIP. There are 70,000 kids that are eligible 
for SCHIP under the current regulations and income levels. We 
only can service, with the money we get now, 29,000. Without 
increasing the SCHIP program, I have got approximately 40,000, 
41,000 kids that are eligible as we speak that aren't getting 
the health care that they should be getting from us, from this 
incredibly wealthy country.
    Third, Medicaid. Medicaid is in crisis in the state of 
Nevada. With serious budget shortfalls on the state level, the 
fact that we are moving to a 50 percent rather than a 52 
percent match with Federal dollars is going to have devastating 
consequences to the poor people in my state that rely on 
Medicaid for health care.
    What can you do to help me to care for the people that I 
represent? Yes, we are going to need to make some long-term 
changes to Medicare so it will continue. But I am also talking 
uninsured. A third of the people that I represent are 
uninsured.
    I have got SCHIP issues, with 40,000 eligible kids not 
getting it. Medicaid is in crisis because there is no money now 
and there is going to be less later if this budget goes 
through. Medicare, I have got seniors that are dying for a lack 
of health care because I have got a doctor shortage.
    So, what do I do? What do you do to help me do my job?
    Secretary LEAVITT. In the 17 seconds we have left, let me 
just deal with SCHIP. You have probably seen in the President's 
budget that he has proposed just under $20 billion. That would 
fund those who are eligible for SCHIP and all those that the 
states have indicated to us they expect to be needed. So, that 
is one thing.
    Ms. BERKLEY. Excuse me one minute. Let me tell you, I spoke 
to our administrator of SCHIP, not of my party, who told me she 
is capping at 30,000. We have 70,000 kids that are eligible 
right now. She is going to cap it. We have got 29; she is 
capping at 30. I have got 40,000 kids that aren't going to get 
health care.
    Secretary LEAVITT. I am guessing if the President's budget 
passed, she would change that view.
    Mr. STARK. We have just a few minutes. I wanted to 
recognize Mr. Nunes for a unanimous consent request, to be 
followed by Mr. Porter, who I will recognize for 3 minutes.
    Mr. NUNES. Thank you, Mr. Chair. Due to the time 
constraints, I have a statement that I would like to submit for 
the record.
    Mr. STARK. Without objection, it will be included in the 
record and sent to the Secretary.
    Mr. NUNES. Thank you.
    [The prepared statement of Mr. Nunes follows:]
    [The statement was not received in time for publication.]
    Mr. STARK. Mr. Porter, you have 3 minutes to conclude our 
hearing.
    Mr. PORTER. Thank you.
    Mr. STARK. I will thank you now. We are going to go off for 
a vote. At the conclusion of Mr. Porter's inquiry, Mr. 
Secretary----
    Secretary LEAVITT. Thank you for being here.
    Mr. STARK [continuing]. Our thanks to you for your patience 
and courtesies. We will be seeing more of you over the next few 
months.
    Secretary LEAVITT. Thank you.
    Mr. STARK. Mr. Porter.
    Mr. PORTER. Thank you, Mr. Chairman. I appreciate the 
opportunity. Mr. Secretary, I will be very brief.
    There was a plan just a few months back that would have cut 
benefits to 9 million beneficiaries in Medicare under the 
Medicare Advantage program. It was a $160 billion cut. Forty 
thousand seniors in my district would have lost or reduced 
their benefits, I believe, in the largest cut in Medicare 
benefits in the history of the country.
    Again, that was a few months ago. I realize that we are 
fortunate in Nevada that the plan did not pass because it would 
have impacted over 100,000 seniors in Nevada. What would the 9 
million beneficiaries in Medicare have done had the Democrats' 
plan of cutting $160 billion from Medicare--what would they 
have done, these 9 million beneficiaries?
    Secretary LEAVITT. Well, those 9 million made a change to 
Medicare Advantage because it was better for them, and in most 
cases they got better benefits. They could find a doctor more 
easily. There were particular areas where there were low income 
populations as well as minority communities that just love 
Medicare Advantage.
    Mr. PORTER. Mr. Secretary, I had hundreds of calls from 
seniors, dozens of letters from seniors, that had trouble 
paying their bills, meeting their rent, putting food on their 
table. This Congress considered cutting off their benefits. I 
personally think it is appalling.
    But I know we are here today to talk about a future budget. 
But looking back, that would have had a major impact on Nevada 
families. I appreciate what you are doing. Thank you.
    Secretary LEAVITT. Thank you.
    Mr. STARK. Thank you all for your patience and your 
courtesy and your cooperation. Thank you, Mr. Secretary.
    Secretary LEAVITT. Thank you.
    Mr. STARK. The hearing is adjourned.
    [Whereupon, at 3:49 p.m., the hearing was adjourned.]
    [Questions for the Record follow:]

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    [Responses to Questions for the Record follow:]

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    [Submissions for the Record follow:]
             Statement of Puerto Rico Hospital Association
    Today, we want to respectfully express our concerns with the 
President's fiscal year 2009 budget proposal. We feel the proposed 
legislation lacks sound solutions to the problems and challenges we are 
facing. Further, we have serious concerns with the impact this proposed 
budget will have on the quality of health care services provided by 
hospitals, not just in Puerto Rico, but in the U.S. mainland. It is 
very difficult to envision how this proposal will put us in a better 
position to discharge our responsibility to provide the quality health 
care needed by individuals and families.
    The Puerto Rico Hospital Association (PRHA) is a private not-for-
profit association representing over 90 percent of all private and 
public hospitals in Puerto Rico as well as other institutions or 
entities interested in the field of health. PRHA was founded in 1942 
with the purpose and mission of maintaining excellent health care 
standards in our industry for the benefit of our community.
    Our organization has actively lobbied the U.S. Congress for the 
past two decades, highlighting the Island's unequal treatment in major 
Federal health care entitlement programs such as Medicare, Medicaid and 
SCHIP. This severe lack of funding impacts the Island's health care 
industry as a whole. Puerto Rico loses anywhere from 1.5 to 2 billion 
in health care funds every year because of the Island's discriminatory 
treatment in these vital programs.
    Specifically, under the PPS, hospitals in Puerto Rico are 
reimbursed under a special formula consisting of 75% of the national 
share and 25% of the local rate share (compared to the 100% national 
average for hospitals located in the 50 states). This unequal treatment 
to hospitals on the Island has been maintained despite the fact that 
the U.S. citizens of Puerto Rico pay the same Medicare payroll taxes 
and deductibles as their fellow citizens in the 50 states. Also, Puerto 
Rico hospitals are required to comply with the same Medicare standards 
of participation as hospitals on the mainland.
    Furthermore, hospitals in the 50 states receive reimbursement 
adjustments under the Medicare Disproportionate Share (DSH) program for 
providing essential health care to a disproportionately large number of 
low-income patients. Because the U.S. citizens of Puerto Rico are not 
entitled to SSI benefits, current Federal law results in the inaccurate 
conclusion that hospitals on the Island do not treat any low-income 
Medicare beneficiaries. As a matter of fact, nearly 50% of Medicare 
beneficiaries in Puerto Rico are Medicaid eligible--compared with only 
12% in the 50 states.
    It is quite unfortunate that the President's budget fails to 
address any of the aforementioned discrepancies, which are forcing 
thousands of senior citizens on the Island to move to the U.S. mainland 
in search of better quality and more accessible health care. It is our 
sincere hope that we can all work together as a nation to craft 
legislation that will benefit the country as a whole without leaving 
the 4 million U.S. citizens of Puerto Rico out of the equation.

                                 
                Statement of The Senior Citizens League
    On behalf of the approximately 1.2 million members of The Senior 
Citizens League (TSCL), a proud affiliate of The Retired Enlisted 
Association (TREA), thank you for the opportunity to submit a statement 
regarding the President's Fiscal Year (FY) 2009 Budget for the U.S. 
Department of Health and Human Services (HHS). TSCL consists of active 
senior citizens, many of whom are low income, concerned about the 
protection of their Social Security, Medicare, and veteran or military 
retiree benefits.
    In 2003, legislation that overhauled Medicare included a provision 
that requires the President to propose changes to Medicare in the event 
that the entitlement was going to draw more than 45 percent of its 
funding from the government's general revenue instead of the Medicare 
Trust Fund. This finding occurred in 2006 and 2007, and in the 
President's proposed budget for fiscal year (FY) 2009, Medicare 
spending is reduced by $12.2 billion in FY 2009 and by $178 billion 
over five years. It is not clear at this time if there will be 
additional proposals.
    While TSCL fully understands the need to address the looming 
Medicare Trust Fund exhaustion, we are concerned that it may come at 
the expense of Medicare beneficiaries, many of whom are already 
financially strapped due to high premiums and an inadequate cost of 
living adjustment (COLA) to their Social Security benefits. Since 2000, 
Social Security benefits have increased 22%, and Part B premiums have 
increased 111%.
    The 2009 Budget includes several legislative proposals that the 
Administration believes could strengthen the longevity of the Medicare 
entitlement program, if signed into law. The proposals would: 
``encourage provider competition, efficiency, and high-quality care; 
rationalize payment policies; increase beneficiary responsibility for 
health care costs, improve Medicare's fiscal sustainability, and 
improve program integrity.'' \1\
---------------------------------------------------------------------------
    \1\ www.hhs.gov/budget/09budget/2009BudgetInBrief.pdf, p. 53-54.
---------------------------------------------------------------------------
Encourage Provider Competition, Efficiency, and High-Quality Care
    TSCL agrees that reform is needed when it comes to provider 
reimbursement, especially in the case of physicians providing 
outstanding care to Medicare beneficiaries. In recent years, premiums 
have been announced prior to increases in physician reimbursements, 
meaning that actual program costs are higher than originally estimated. 
Although temporary fixes have been issued, TSCL is concerned that with 
the ``trigger,'' proposals could eventually lead to a substantial jump 
in Part B premiums to offset the rising cost of quality health care.
    Last year, the Medicare Trustees estimated that Medicare Part B and 
Part D premiums, deductibles, and coinsurance costs were taking one-
third of the average Social Security benefit. Skyrocketing premiums, 
accompanied with a COLA that does not take adequately into account 
health care expenses are making it difficult for many seniors, 
especially those relying solely on their Social Security benefits, to 
get by. We should note, however, that TSCL and its members were 
pleasantly surprised with a Part B premium increase of $2.90 per month 
in 2008 for the majority of seniors.
Increase Beneficiary Responsibility
    Increasing beneficiary responsibility on the surface may sound like 
a good idea to some. TSCL is concerned about the proposal to eliminate 
the annual indexing of income thresholds for Medicare Part B premiums, 
especially if Part D becomes subject to the same income thresholds.
    We fear that halting the annual index for income related premiums 
will lead to more and more middle-income seniors paying higher rates. 
Although some advocates consider it to be fair for those with higher 
incomes, we fear that low- and middle-income seniors will be the ones 
to suffer and eventually end up paying higher premiums as the threshold 
is lowered to make up for future funding shortcomings. Further, it 
seems unjust to have a group of beneficiaries paying more for the same 
care and coverage. As the snowball grows, more seniors could look 
outside of Medicare plans for quality health care insurance at a lower 
cost.
    TSCL also questions how private entities will be able to implement 
income indexing accurately. With the involvement of private companies, 
the Internal Revenue Service, and the Social Security Administration, 
the automatic deduction of premiums from monthly benefits could become 
more costly and onerous. It seems that the only way means testing could 
work for Medicare Part D is to consider eliminating private insurance 
companies from the equation, leaving Medicare to coordinate Part D as 
it does Part B.
Improve Program Integrity
    Greater program oversight is always a welcomed proposal. As 
reported in the new 2009 Budget in Brief, the Health Care Fraud and 
Abuse Control (HCFAC) program is responsible for detecting and 
preventing health care fraud, waste, and abuse. This is accomplished 
through investigations, audits, educational activities and data 
analysis. From 1997 to 2007, HCFAC returned more than $10 billion to 
the Medicare Trust Fund. While this is impressive, we can only imagine 
how much more money could be saved and/or returned with a more 
streamlined process among the involved agencies.
    Equipping health care providers with knowledge about problems and 
ways to increase accuracy will undoubtedly save money. As reported for 
2007, improper Medicare payments have dropped to a new low of 3.9 
percent. TSCL supports strong enforcement and greater audits of claims, 
especially when considering the problems occurring with Part D plans.
    Also, it has been widely reported that the Medicare payment system 
should take a closer look at excessive payments for certain items. The 
New York Times has reported that Medicare pays much higher amounts for 
durable medical equipment than are charged to individuals buying the 
same product.\2\ According to the 2007 NYT article, ``. . . Even for a 
simple walking cane, which can be purchased online for about $11, the 
government pays $20, according to government data.'' Another example of 
overspending occurs when the government rents oxygen equipment for up 
to 36 months at a cost of more than $8,000 per individual. The article 
reports that the same equipment could be purchased from a retailer for 
``as little as $3,500.''
---------------------------------------------------------------------------
    \2\ Duhigg, C., ``Oxygen Suppliers Fight to Keep a Medicare Boom,'' 
New York Times, Nov. 30, 2007.
---------------------------------------------------------------------------
    TSCL is not suggesting that oxygen equipment not be provided for 
those in need. What we do believe is that there are more fiscally 
responsible ways to provide the same care, which in the end could save 
Medicare billions of dollars annually.
Conclusion
    Although we are pleased that the Administration has put together 
suggestions for strengthening the Medicare Trust Fund, TSCL and its 
members are concerned about what the cost to the public will be. While 
we do not have a perfect solution, there are some simple actions that 
could be taken in the meantime.
    For example, TSCL is encouraging all Members of Congress to support 
a recently introduced bill, H.R. 4338, introduced by Rep. Timothy 
Walberg (MI-7). H.R. 4338, titled the Social Security and Medicare 
Lock-Box Act, would establish a procedure to safeguard the surpluses of 
the Social Security and Medicare hospital insurance trust funds. Thanks 
to Rep. Stephanie Tubbs Jones (OH-11), an original co-sponsor, this 
legislation had bi-partisan support from the start. Additionally, 
similar legislation, S. 302, was introduced last year during the first 
session of the 110th Congress by Senator David Vitter (LA).
    As the Administration suggests, tougher enforcement and increased 
transparency will save Medicare billions of dollars annually. A 
significant portion of the expenditures comes from fraud and abuse that 
hurts the solvency of important entitlement programs like Medicare for 
current and even future retirees.
    Regardless of which solution Members of Congress believe is best, 
TSCL sincerely hopes that the Medicare and Social Security Trust Funds 
are protected and strengthened for future generations.

                                 
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