[Congressional Record Volume 150, Number 50 (Monday, April 19, 2004)]
[Senate]
[Pages S4088-S4092]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                   NOW CAN WE TALK ABOUT HEALTH CARE

  Mr. DASCHLE. Madam President, yesterday's New York Times Magazine 
contained a very insightful article written by our colleague from New 
York, Senator Clinton. This article, entitled ``Now Can We Talk About 
Health Care?,'' is truly a call to action.
  Senator Clinton could not be more right when she points out that if 
we were starting from scratch in designing a health care system, ``none 
of us, from dyed-in-the-wool liberals to rock-solid conservatives, 
would fashion the kind of health care system America has inherited.'' 
She pointedly asks why we should carry this flawed system and its 
problems into the future. It is a rhetorical question, of course, but 
the answer, unfortunately, is that we are doing just that.
  Last year, 43.6 million Americans were without health coverage--an 
increase of over 2 million from the year before. About 74,800 people in 
my State of South Dakota--12 percent of the population--are without 
health insurance. But statistics alone do not communicate the anguish 
felt by so many people in our country regarding an issue as personal as 
their health care.
  Senator Clinton correctly notes that things will only get worse. Her 
article explains that the very manner in which we finance care is ``so 
seriously flawed that if we fail to fix it, we face a fiscal disaster 
that will not only deny quality care to the uninsured and underinsured 
but also undermine the capacity of the system to care for even the well 
insured.'' This a sobering warning.
  It does not have to be this way. The United States is the only major 
industrialized nation that fails to provide guaranteed health care to 
all its citizens. And, in many countries--Canada, the United Kingdom, 
Japan, France, and Sweden to name a few--they do it while spending less 
per capita than we do in the United States. Yet in each of those 
countries, citizens have greater life expectancies and lower rates of 
child mortality than we have in the United States.
  We must act. The nonpartisan Institute of Medicine recently 
recommended that by 2010, everyone in the United States should be 
insured. That is no small task, and it won't come free. But, as Senator 
Clinton points out, it will save us money in other ways. People will 
get the preventive care they need and deserve, and this will save us 
the cost of treating conditions and diseases that have progressed. And, 
certainly, it is a moral imperative when we are talking about people's 
health.
  We must invest in our public health infrastructure, in preventive 
care, and in covering the care people need. We can save money by 
increasing our reliance on information technology with appropriate 
privacy protections. And we can use every tool we have--including 
genetic testing--to prevent and contain disease. We can encourage these 
tests by enacting the Genetic Information Nondiscrimination Act, a 
bipartisan bill that has already passed the Senate but awaits action in 
the House. We can reduce health disparities by passing the Healthcare 
Equality and Accountability Act, a bill I introduced with each of the 
House minority caucuses last year. And we can address the problem of 
the uninsured in a serious manner rather than proposing tax credits 
that will do little to help those most in need or pushing consumer-
driven plans that shift cost and risk onto the individual.
  I commend Senator Clinton on her thoughtful article. It is something 
we

[[Page S4089]]

all should read. Health care should not be a partisan issue. It is a 
necessity. Whether someone receives the health care they need should 
not depend on whether they are fortunate enough to access and afford 
adequate health insurance under our current system. I ask unanimous 
consent that Senator Clinton's article be printed in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                [From the New York Times, Apr. 18, 2004]

                   Now Can We Talk About Health Care?

                      (By Hillary Rodham Clinton)

       I know that you're thinking. Hillary Clinton and health 
     care? Been there. Didn't do that!
       No, it's not 1994; it's 2004. And believe it or not, we 
     have more problems today than we had back then. Issues like 
     soaring health costs and millions of uninsured have yet to 
     fix themselves. And now we are confronting a new set of 
     challenges associated with the arrival of the information 
     age, the technological revolution and modern life.
       Think for a moment about recent advances in genetic 
     testing. Knowing you are prone to cancer or heart disease or 
     Lou Gehrig's disease may give you a fighting chance. But just 
     try, with that information in hand, to get health insurance 
     in a system without strong protections against discrimination 
     for pre-existing or generic conditions. Each vaunted 
     scientific breakthrough brings with it new challenges to our 
     health system. But it's not only medicine that is changing. 
     So, too, are the economy, our personal behaviors and our 
     environment. Unless Americans across the political spectrum 
     come together to change our health care system, that system, 
     already buckling under the pressures of today, will collapse 
     with the problems of tomorrow.
       Twenty-first-century problems, like genetic mapping, an 
     aging population and globalization, are combining with old 
     problems like skyrocketing costs and skyrocketing numbers of 
     uninsured, to overwhelm the 20th-century system we have 
     inherited.
       The way we finance care is so seriously flawed that if we 
     fail to fix it, we face a fiscal disaster that will not only 
     deny quality health care to the uninsured and underinsured 
     but also undermine the capacity of the system to care for 
     even the well insured. For example, if a hospital's trauma 
     center is closed or so crowded that it cannot take any more 
     patients, your insurance card won't help much if you're the 
     one in the freeway accident.
       Let's face it--if we were to start from scratch, none of 
     us, from dyed-in-the-wool liberals to rock-solid 
     conservatives, would fashion the kind of health care system 
     America has inherited. So why should we carry the problems of 
     this system into the future?


                         21st-century problems

       At the dawn of the last century, America was coping with 
     the effects of the industrial revolution--crowded living 
     conditions, dangerous workplaces, inadequate sanitation and 
     infrastructure in cities and pollution and infectious 
     diseases like typhoid fever and cholera that exacted a huge 
     toll on the oldest and youngest in society.
       Since then, a century's worth of advances yielded 
     remarkable results. Antibiotics were developed. Anesthesia 
     was improved. Public health programs like mosquito control 
     and childhood immunizations succeeded in reducing or even 
     eradicating diseases like malaria and polio in this 
     country. Congress passed legislation regulating the 
     quality of food and drugs and assuring that safety and 
     science guided medical developments. Workplace and 
     product-safety standards resulted in fewer deaths and 
     injuries from accidents. Effective campaigns cut tobacco 
     use and alcohol abuse. Employers began providing some 
     workers with health care coverage, primarily for 
     hospitalization costs. And to aid some of those left out, 
     President Lyndon B. Johnson persuaded Congress to 
     establish Medicare and Medicaid to address the poorest, 
     sickest, oldest and highest-risk patients in our society. 
     As a result of these accumulated gains, life expectancy 
     grew from 47 years in 1900 to 77 years for those born in 
     2000.
       As astounding as those changes were, we are likely to see 
     even more revolutionary changes in the next 100 years. 
     Advances in medicine coincide with advances in computers and 
     communications. The American workplace is changing in 
     response to global pressures. But even positive advances may 
     come with a negative underside. Our affluence contributes to 
     an increasingly sedentary lifestyle that, combined with a 
     diet filled with sugar and fat-rich foods, undermines our 
     ability to fend off chronic diseases like diabetes. And 
     research is proving that the pollutants and contaminants in 
     our environment cause disease and mortality.
       It is overwhelming just thinking about the problems, never 
     mind dealing with them. But we have to begin applying 
     American ingenuity and resolve or watch the best health care 
     system in the world deteriorate.


                            medical advances

       The pace of scientific development in medicine is so rapid 
     that the next hundred years is likely to be called the 
     Century of the Life Sciences. We have mapped the human genome 
     and seen the birth of the burgeoning field of genomics, 
     offering the opportunity to pinpoint and modify the genes 
     responsible for a whole host of conditions. Scientists are 
     exploring whether nanotechnology can target drugs to diseased 
     tissues or implant sensors to detect disease in its earliest 
     forms. We can look forward to ``designer drugs'' tailored to 
     individual genetic profiles. But the advances we herald carry 
     challenges and costs.
       Think about the potential for inequities in drug research. 
     Today, pharmaceutical and biotech companies have little 
     incentive to research and develop treatments for individuals 
     with rare diseases. Never heard of progeria? That's the 
     point. This fatal syndrome, also called premature-aging 
     disease, affects one in four million newborns a year. It's 
     rare enough that there is no profit in developing a cure. 
     This is known as the ``orphan drug'' problem. Genetic 
     profiles and individualized therapies have the potential to 
     increase the problem of orphaned drugs by further fragmenting 
     the market. Even manufacturers of drugs for conditions like 
     high blood pressure might focus their efforts on people with 
     common genetic profiles. Depending on your genes, you could 
     be out of luck.
       The increasing understanding and use of genomics may also 
     undermine the insurance system. Health insurance, like other 
     insurance, exists to protect against unpredictable, costly 
     events. It is based on risk. As genetic information allows us 
     to predict illness with greater certainty, it threatens to 
     turn the most susceptible patients into the most vulnerable. 
     Many of us will become uninsurable, like the two young 
     sisters with a congenital disease I met in Cleveland. Their 
     father went from insurance company to insurance company 
     trying to get coverage, until one insurance agent looked at 
     him and said, ``We don't insure burning houses.''
       Many have worked to get laws on the books to protect people 
     from genetic discrimination, but we have yet to pass 
     legislation that addresses job security and health coverage. 
     The challenges do not stop there. Health insurance will have 
     to change fundamentally to cope with predictable, knowable 
     risks. Will health insurance companies offer coverage 
     tailored to a person's future health prospects? Right now, if 
     you have asthma, or even just allergies, insurers in the 
     individual market can exclude your respiratory system from 
     your health insurance policy. Will all health plans stop 
     offering benefits that relate to genetic diseases?
       The ability to predict illness may overwhelm more than just 
     the insurance system; it may overwhelm the patient and the 
     provider. Studies in The Journal of the American Medical 
     Association found that nearly 6 out of 10 patients at risk 
     for breast and ovarian cancer declined a genetic test, and a 
     similar fraction of those at risk for colon cancer also 
     declined testing. Why? One reason is probably to avoid higher 
     insurance premiums. But the decision to undergo genetic 
     testing is a complex one that involves many issues. Positive 
     test results often indicate increased risk but no certainty 
     that a disease will occur. Negative results also come without 
     guarantees. The development of genetic profiles and 
     individual therapies will exponentially increase the amount 
     of information a physician is expected to manage. Instead of 
     remembering one or two drugs for any condition, a physician 
     will have to analyze all the different genetic, demographic 
     and behavioral variables to generate optimal treatment for a 
     patient.
       Medical advances have the potential to overwhelm the health 
     care system top to bottom. At the very least, the pace of 
     technological progress is so rapid that our antiquated health 
     care system is ill equipped to deliver the fruits of that 
     progress. But these advances are not occurring in isolation 
     from other factors affecting both how we finance health care 
     and how much care we need and expect.


                             Globalization

       The globalization of our economy has changed everything 
     from how we work as individuals to what we produce as a 
     nation to how quickly diseases can spread. American 
     companies--and workers--compete not only with one another but 
     all over the world. It is called competitive advantage, but 
     it can put American businesses and workers at a disadvantage.
       The United States' closest economic rivals have mandatory 
     national health care systems rather than the voluntary 
     employer-based model we have. Automakers in the United States 
     and Canada pay taxes to help finance public health care. But 
     in the United States, automakers also pay about $1,300 per 
     midsize car produced for private employee health insurance. 
     Automakers in Canada come out ahead, according to recent news 
     reports, even after paying higher taxes.
       At the same time, American companies are outsourcing jobs 
     to countries where the price of labor does not include health 
     coverage, which costs Americans jobs and puts pressure on 
     employers who continue to cover their employees at home.
       And many new jobs, especially those in the service sector 
     and part-time jobs, don't include comprehensive health 
     benefits. More uninsured and underinsured workers impose 
     major strains on a health system that relies on employer-
     based insurance. In addition, the failure of government to 
     help contain health costs for employers has led to a fraying 
     of the implicit social contract in which a good job came with 
     affordable coverage.
       Gone are the days when a young person would start in the 
     mail room and stay with the company until retirement. 
     Employee

[[Page S4090]]

     mobility is now the rule rather than the exception. Those who 
     pay for health care--insurance companies and employers--
     increasingly deal with employees who change jobs every few 
     years. This has the effect of not only increasing the numbers 
     of uninsured but also of decreasing the incentive for 
     employers to underwrite access to preventive care.
       At the same time, war, poverty, environmental degradation 
     and increased world travel for business and pleasure mean 
     greater migration of people across borders. And with people 
     go diseases. The likes of SARS can travel quickly from Hong 
     Kong to Toronto, and news of a strange flu in Asia worries us 
     in New York. Welcome to the world without borders.
       The Pulitzer Prize-winning science writer Laurie Garrett 
     has described it as ``payback for decades of shunning the 
     desperate health needs of the poor world.'' No matter the 
     blame, the need to act now to address issues of global health 
     is no longer just a moral imperative; it is self-interest.


                   Lifestyle and Demographic Changes

       One hundred years ago, who could have predicted that living 
     longer would be a problem?
       In three decades, the number of Medicare beneficiaries will 
     double. By the year 2050, one in five Americans will be 65 or 
     older. We will have to find a way to finance the growing 
     demand not only for health care but also for long-term care, 
     which is now largely left out of Medicare.
       Our society's affluence is only half of the story. Widening 
     disparities in wealth and in health care too often cleave 
     along ethnic lines. Today, a Hispanic child with asthma is 
     far less likely than a non-Hispanic white child to get needed 
     medication. African-Americans are systematically less likely 
     to get state-of-the-art cardiac care. As our country becomes 
     more and more diverse, these disparities become more obvious 
     and more intolerable.
       Our changing lifestyles also contribute to behavior-induced 
     health problems. We can shop online, order in fast food, 
     drive to our errands. Entertainment--movies, TV, video games 
     and music--is one click away. The physical activity required 
     to get through the day has decreased, while the pace and 
     stress of daily life has quickened, affecting mental health. 
     Persistent poverty, risky behaviors like substance abuse and 
     unprotected sex and pollution from cars and power plants all 
     add to the country's health problems. As Judith Stern of the 
     University of California at Davis so aptly put it, genetics 
     may load the gun, but environment pulls the trigger.


                          old problems persist

       If all we had to do was face these tremendous changes, that 
     would be daunting enough. But many of the systemic problems 
     we have struggled with for decades--like high costs and the 
     uninsured--are simply getting worse.
       In 1993, the critics predicted that if the Clinton 
     administration's universal health care coverage plan became 
     law, costs would go through the roof. ``Hospitals will have 
     to close,'' they said, ``Families will lose their choice of 
     doctors. Bureaucrats will deny medically necessary care.''
       They were half-right. All that has happened. They were just 
     wrong about the reason.
       In 1993, there were 37 million uninsured Americans. In the 
     late 90's, the situation improved slightly, largely because 
     of the improved economy and the passage of the Children's 
     Health Insurance Program. But now some 43.6 million Americans 
     are uninsured, and the vast majority of them are in working 
     families.
       While employer-sponsored insurance remains a major source 
     of coverage for workers, it is becoming less accessible and 
     affordable for spouses, dependents and retirees. In 1993, 46 
     percent of companies with 500 or more employees offered some 
     type of retiree health benefit. That declined to 29 percent 
     in 2001. When you think about the new economy and worker 
     mobility, it's no wonder employees are dropping retiree 
     health benefits. You can only wonder how many yet-to-retire 
     workers are next.
       Even those Americans not among the ranks of the uninsured 
     increasingly find themselves underinsured. In 2003, two-
     thirds of companies with 200 or more employees dealt with 
     increasing costs by increasing the share that their 
     employees had to pay and dropping coverage for particular 
     services. With rising deductibles and co-pays, even if you 
     have insurance, you may not be able to afford the care you 
     need, and some benefits, like mental health services, may 
     not be covered at all.
       The problem of the insured and underinsured affects 
     everyone. A recent Institute of Medicine study estimates that 
     18,000 25- to 64-year old adults die every year as a result 
     of lack of coverage. But even if you are insured, if you have 
     a heart attack, and the ambulance that picks you up has to go 
     three hospitals away because the nearby emergency rooms are 
     full, you will have suffered from our inadequate system of 
     coverage.
       If, as a nation, we were saving money by denying insurance 
     to some people, you could at least say there's some logic to 
     it--no matter how cruel. But that's not the case. Despite the 
     lack of universal coverage in our country, we still spend 
     much more than countries that provide health care to all 
     their citizens. We are No. 1 in the world in health care 
     spending. On a per capita basis, health spending in the 
     United States is 50 percent higher than the second-highest-
     spending country: Switzerland. Our health costs now 
     constitute 14.9 percent of our gross domestic product and are 
     growing at an alarming rate: by 2013, per capita health care 
     spending is projected to increase to 18.4 percent of G.D.P.
       What drives skyrocketing spending? The cost of prescription 
     drugs rose almost twice as fast as spending on all health 
     services, 40 percent in just the last few years.
       Hospital costs have been rising as well, in large measure 
     because more than one in four health care dollars go to 
     administration. In 1999, that meant $300 billion per year 
     went to pay for administrative bureaucracy; accountants and 
     bookkeepers, who collect bills, negotiate with insurance 
     companies and squeeze every possible reimbursement out of 
     public programs like Medicare and Medicaid. Asthma and other 
     pulmonary disorders linked to pollution contribute 
     significantly to these costs, according to the health 
     economist Ken Thorpe. Diabetes, high blood pressure and 
     mental illness are also among the conditions that keep these 
     costs rising.
       If we spend so much, even after administrative costs, why 
     does the United States rank behind 47 other countries in life 
     expectancy and 42nd in infant mortality?
       A lot of the money Americans spend is wasted on care that 
     doesn't improve health. A recent study by Dartmouth 
     researchers argues that close to a third of the $1.6 trillion 
     we now spend on health care goes to care that is duplicative, 
     fails to improve patient health or may even make it worse. A 
     study in Santa Barbara, Calif., found that one out of every 
     five lab tests and X-rays were conducted solely because 
     previous test results were unavailable. A recent study found 
     that for two-thirds of the patients who received a $15,000 
     surgery to prevent stroke, there was no compelling evidence 
     that the surgery worked.
       In situations in which the benefits of intervention are 
     clear, many patients are not receiving that care. For 
     example, few hospitalized patients at risk for bacterial 
     pneumonia get the vaccine against it during their hospital 
     stays. A recent study in The New England Journal of Medicine 
     by Elizabeth McGlynn found that, overall, Americans are 
     getting the care they should only 55 percent of the time.
       As a whole, our ailing health care system is plagued with 
     underuse, overuse and misuse. In a fundamental way, we pay 
     far more less than citizens in other advanced economies get.


                          how we deliver care

       There is no ``one size fits all'' solution to our health 
     care problems, but there are common-sense solutions that call 
     for aggressive, creative and effective strategies as bold 
     in their approach as they are practical in their effect.
       First, the way we deliver health care must change. For too 
     long our model of health care delivery has been based on the 
     provider, the payer, anyone but the patient. Think about the 
     fact that our medical records are still owned by a physician 
     or a hospital, in bits and pieces, with no reasonable way to 
     connect the dots of our conditions and our care over the 
     years.
       If we as individuals are responsible for keeping our own 
     passports, 401(k) and tax files, educational histories and 
     virtually every other document of our lives, then surely we 
     can be responsible for keeping, or at least sharing custody 
     of, our medical records. Studies have shown that when 
     patients have a greater stake in their own care, they make 
     better choices.
       We should adopt the model of a ``personal health record'' 
     controlled by the patient, who could use it not only to 
     access the latest reliable health information on the Internet 
     but also to record weight and blood sugar and to receive 
     daily reminders to take asthma or cholesterol medication. 
     Moreover, our current system revolves around ``cases'' rather 
     than patients. Reimbursements are based on ``episodes of 
     treatment'' rather than on a broader consideration of a 
     patient's well-being. Thus it rewards the treatment of 
     discrete diseases and injuries rather than keeping the 
     patient alive and healthy. While we assure adequate privacy 
     protections, we need care to focus on the patient.
       Our system rewards clinicians for providing more services 
     but not for keeping patients healthier. The structure of the 
     health care system should shift toward rewarding doctors and 
     health plans that treat patients with their long-term health 
     needs in mind and rewarding patients who make sensible 
     decisions about maintaining their own health.


                        harnessing modernization

       As paradoxical as it is that advances in medical technology 
     could potentially break our antiquated system, advances in 
     other technologies may hold the answer to saving it. Using a 
     20th-century health care system to deal with 21st-century 
     problems is nowhere more true than in the failure to use 
     information technology.
       Ten years ago, the Internet was used primarily by academics 
     and the military. Now it is possible to imagine all of a 
     person's health files stored securely on a computer file--
     test results, lab records, X-rays--accessible from any 
     doctor's office. It is easy to imagine, yet our medical 
     system is not there.
       The average emergency-room doctor or nurse has minutes to 
     gather information on a patient, from past records and from 
     interviewing the patient or relatives. In the age

[[Page S4091]]

     of P.D.A.'s, why are these professionals forced to rely on a 
     patient's memory?
       Information technology can also be used to disseminate 
     research. A government study recently documented that it 
     takes 17 years from the time of a new medical discovery to 
     the time clinicians actually incorporate that discovery into 
     their practice at the bedside. Why not 17 seconds?
       Why rely solely on the doctor's brain to store that 
     information? Computers could crunch the variables on a 
     particular patient's medical history, constantly update the 
     algorithms with the latest scientific evidence and put that 
     information at the clinician's fingertips at the point of 
     care.
       Americans may not be getting the care they should 45 
     percent of the time, but the tools exist to narrow that gap. 
     Research shows that when physicians receive computerized 
     reminders, statistics improve exponentially. Reminders can 
     take the form of an alert in the electronic health record 
     that the hospitalized patient has not had a pneumonia vaccine 
     or as computerized questions to remind a doctor of the 
     conditions that must be fulfilled before surgery is 
     considered appropriate.
       Newt Gingrich and I have disagreed on many issues, 
     including health care, but I agree with some of the proposals 
     he outlines in his book ``Saving Lives and Saving Money,'' 
     which support taking advantage of technological changes to 
     create a more modern and efficient health care system. I have 
     introduced legislation that promotes the use of information 
     technology to update our health care system and organize it 
     around the best interests of patients. Improvements in 
     technology will end the paper chase, limit errors and reduce 
     the number of malpractice suits.
       I strongly believe that savings from information technology 
     should not just be diffused throughout the system, never to 
     be recaptured, but should be used to make substantial 
     progress toward real universal coverage. By better using 
     technology, we can lower health care costs throughout the 
     system and thereby lower the exorbitant premiums that are 
     placing a financial squeeze on businesses, individuals and 
     the government. At the same time, some of those savings 
     should be used to make substantial progress toward real 
     universal coverage. (I may have just lost Newt Gingrich.)


         taking the broader view: public health and prevention

       While we focus on empowering the individual through 
     technology, we also have to recognize the larger factors that 
     affect our health--from the environment to public health.
       If asthma and other pulmonary disorders are the main 
     drivers of increased health spending, that argues strongly 
     that we should rethink how social and environmental factors 
     impact our collective health. Consider that over the last 
     century we have extended life expectancy by 30 years but that 
     only 8 of those years can be credited to medical 
     intervention. The rest of our gains stem from the 
     construction of water and sewer systems, draining mosquito-
     infested swamps and addressing spoilage, quality and 
     nutrition in our food supply. Yet we continue to underinvest 
     in these important systematic measures--resulting in 
     expensive health consequences like the explosion of asthma 
     among children living in New York City or the harmful levels 
     of lead found among children drinking water from the District 
     of Columbia water system.
       Our neglect of public health also contributes to spiraling 
     health costs. We tend to address health care--as a nation and 
     as individuals--after the sickness has taken hold, rather 
     than addressing the cause through public health. Public 
     health programs can help stop preventable disease and control 
     dangerous behaviors. Take obesity, for example. Individuals 
     should understand that they put their lives at risk with 
     unhealthy behavior. But let's face it--we live in a fast-food 
     nation, and we need to take steps, like restoring physical-
     education programs in schools, that support the individual's 
     ability to master his or her own health. Studies conducted by 
     the Centers for Disease Control and Prevention have 
     identified ``Programs That Work,'' which should be financed. 
     It comes down to individual responsibility reinforced by 
     national policy.
       The public health system also needs to be brought up to 
     date. The current public health tools were developed when the 
     major threats to health were infectious diseases like malaria 
     and tuberculosis. But now chronic diseases are the No. 1 
     killer in our country. We need to be concerned not just about 
     pathogens but also about carcinogens.
       Over the last three years, I have introduced legislation to 
     increase investment in tracking and correlating environmental 
     and health conditions. I have met with people from Long 
     Island to Fallon, Nev., who want answers about cancer 
     clusters in their communities. The data we have seen about 
     lead and mercury contamination in our food and water suggest 
     that the effects they have on the fetus and children may 
     have contributed to the increasing number of children in 
     special education with attention and learning disorders. 
     We need more research to determine once and for all if 
     increasing pollution in our communities and increasing 
     rates of learning-related disabilities are cause and 
     effect.
       We should also be looking at sprawl--talking about the way 
     we design our neighborhoods and schools and about our 
     shrinking supply of safe, usable outdoor space--and how that 
     contributes to asthma, stress and obesity. We should follow 
     the example of the European Union and start testing the 
     chemicals we use every day and not wait until we have a rash 
     of birth defects or cancers on our hands before taking 
     action. And we should look at factors in our society that 
     lead to youth violence, substance abuse, depression and 
     suicide and ultimately require insurance and treatment for 
     mental health.
       After Sept. 11, mental health was a significant factor in 
     the health toll on our nation's first responders. And yet our 
     mental health delivery system is underfinanced and 
     unprepared.
       Finally, as a society, we need greater emphasis on 
     preventive care, an investment in people and their health 
     that saves us money, because when families can't get 
     preventive care, they often end up in the emergency room--
     getting the most expensive care possible.


                           expanding coverage

       All that we have learned in the last decade confirms that 
     our goal should continue to be what every other 
     industrialized nation has achieved--health care that's always 
     there for every citizen.
       For the first time, this year a nonpartisan group dedicated 
     to improving the nation's health, the Institute of Medicine, 
     recommended that by 2010 everyone in the United States should 
     have health insurance. Such a system would promote better 
     overall health for individuals, families, communities and our 
     nation by providing financial access for everyone to 
     necessary, appropriate and effective health services.
       It will, as I have been known to say, take the whole 
     village to finance an affordable and accountable health 
     system. Employers and individuals would share in its 
     financing, and individuals would have to assume more 
     responsibility for improving their own health and lifestyles. 
     Private insurers and public programs would work together, 
     playing complementary roles in ensuring that all Americans 
     have the health care they need. Our society is already 
     spending $35 billion a year to treat people who have no 
     health insurance, and our economy loses $65 billion to $130 
     billion in productivity and other costs. We are already 
     spending what it would cost if we reallocated those resources 
     and required responsibility.
       In the post 9/11 world, there is one more reason for 
     universal coverage. The anthrax and ricin episodes, and the 
     continuing threat posed by biological, chemical and 
     radiological weapons, should make us painfully aware of the 
     shortcomings of our fragmented system of health care. Can you 
     imagine the aftermath of a bioterrorism attack, with 
     thousands of people flooding emergency rooms and bureaucrats 
     demanding proof of insurance coverage from each and every 
     one? Those without coverage might not see a doctor until they 
     had infected others.
       Insurance should be about sharing risk and responsibility--
     pooling resources and risk to protect ourselves from the 
     devastating cost of illness and injury. It should not be 
     about further dividing us. Competition should reward health 
     plans for quality and cost savings, not for how many bad 
     risks they can exclude--especially as we enter the genomic 
     age, when all of us could have uninsurable risks written into 
     our genes.
       So achieving comprehensive health care reform is no simple 
     feat, as I learned a decade ago. None of these ideas mean 
     anything if the political will to ensure that they happen 
     doesn't exist.
       Some people believe that the only solution to our present 
     cost explosion is to shift the cost and risk onto individuals 
     in what is called ``consumer driven'' health care. Each 
     consumer would have an individual health care account and 
     would monitor his or her own spending. But instead of putting 
     consumers in the driver's seat, it actually leaves consumers 
     at the mercy of a broken market. This system shifts the 
     costs, the risks and the burdens of disease onto the 
     individuals who have the misfortune of being sick. Think 
     about the times you have been sick or injured--were you able 
     under those circumstances to negotiate for the best price or 
     shop for the best care? And instead of giving individuals, 
     providers and payers incentives for better care, this cost-
     shifting approach actually causes individuals to delay or 
     skip needed services, resulting in worse health and more 
     expensive health needs later on.
       Meanwhile, proposals like those for individual health 
     insurance tax credits, without reforms for the individual 
     insurance market, leave individuals in the lurch as well. We 
     know that asthmatics can have their entire respiratory 
     systems excluded from coverage. Individual insurance 
     companies can increase your premium or limit coverage for 
     factors like age, previous medical history or even flat feet. 
     Those in the individual market cannot pool their risk with 
     colleagues or other members of the group. The coverage you 
     can get and the price you pay for it will reflect individual 
     risk, and you simply don't receive many of the benefits of 
     what we consider traditional insurance when people pool 
     risks. So the proposal to give individuals tax credits to buy 
     coverage in the individual market, without any rules of fair 
     play, won't provide much help for Americans who need health 
     care. In the same way, the recent Medicare bill, which seeks 
     to privatize Medicare benefits, long a government guarantee, 
     threatens to leave the ``bad risks'' without any affordable 
     coverage. With the new genetic information at our disposal, 
     that could

[[Page S4092]]

     mean any one of us could one day be denied health insurance.
       When many of those who opposed the Health Security Act look 
     back, they are still proud of their achievement in blocking 
     our reform plan. The focus of that proposal was to cover 
     everybody by enabling the healthier to pool the ``risk'' with 
     others. The plan was to redirect what we currently pay for 
     uninsured care into expanding health coverage.
       We could make cosmetic changes to the system we currently 
     have, but that would simply take what is already a Rube 
     Goldberg contraption and make it larger and even more 
     unwieldy. We could go the route many have advocated, putting 
     the burden almost entirely on individuals, thereby creating a 
     veritable nationwide health care casino in which you win or 
     lose should illness strike you or someone in your family. Or 
     we could decide to develop a new social contract for a new 
     century premised on joint responsibility to prevent disease 
     and provide those who need care access to it. This would not 
     let us as individuals off the hook. In fact, joint 
     responsibility demands accountability from patients, 
     employers, payers and society as a whole.
       What will we say about ourselves 10 years from today? If we 
     finally act to reform what we know needs to change, we may 
     take credit in building a health care system that covers 
     everyone and improves the quality of all our lives. But if we 
     continue to dither and disagree, divided by ideology and 
     frozen into inaction by competing special interests, then we 
     will share in the blame for the collapse of health care in 
     America, where rising costs break the back of our economy and 
     leave too many people without the medical attention they 
     need.
       The nexus of globalization, the revolution in medical 
     technology and the seismic pressures imposed by the 
     contradictions in our current health care system will force 
     radical changes whether we choose them or not. We can do 
     nothing, we can take incremental steps--or we can implement 
     wide-ranging reform.
       To me, the case for action is clear. And as we work to 
     develop long-term solutions, we can take steps now to help 
     address the immediate problems we face. As Senator John Kerry 
     has proposed, we should cover everyone living in poverty, and 
     all children; allow people to buy into the federal employee 
     health benefits program; and also help employers by 
     reinsuring high-cost claims while assuming more of the costs 
     from hard-pressed state and local governments.
       We can pass real privacy legislation that will ensure that 
     Americans continue to feel secure in the trust they place in 
     others for their most intimate medical information. And we 
     can realize the promise of savings through information 
     technology and disease management by passing quality health 
     legislation now.
       If we do not fix the problems of the present, we are doomed 
     to live with the consequences in the future. As someone who 
     tried to promote comprehensive health care reform a decade 
     ago and decided to push for incremental changes in the years 
     since, I still believe America needs sensible, wide-ranging 
     reform that leads to quality health care coverage available 
     to all Americans at an affordable cost.
       The present system is unsustainable. The only question is 
     whether we will master the change or it will master us.

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