[Congressional Record Volume 153, Number 45 (Thursday, March 15, 2007)]
[Senate]
[Pages S3204-S3206]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Ms. MURKOWSKI (for herself, Mr. Schumer, Mr. Stevens, and Mr. 
        Sanders):
  S. 896. A bill to amend the Public Health Service Act and the Social 
Security Act to increase the number of primary care physicians and 
medical residents serving health professional shortage areas, and for 
other purposes; to the Committee on Health, Education, Labor, and 
Pensions.
  Ms. MURKOWSKI. Mr. President, I rise again this evening to speak 
about a growing crisis in rural America. This crisis is found in rural 
New England, throughout Appalachia, spans the Great Plains, crosses the 
Western deserts, and reaches the mountains of the great Northwest. It 
impacts the seniors, children, the women, and the men of rural America. 
What I am speaking about today is a lack of access to quality health 
care.
  In rural America, patients have long gone without care. Despite the 
fact that one-fifth of the U.S. population lives in rural America, only 
9 percent of the Nation's physicians are practicing in these areas. 
Over 50 million of these rural Americans live in areas that have a 
shortage of physicians to meet their basic needs.
  Now, physician recruitment to rural America is a big problem. Part of 
this problem comes about through high student debt, which often forces 
many students away from a rural practice and

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into urban specialty medicine where they can probably command higher 
salaries.
  I recently held a Senate HELP Committee field hearing in Alaska. This 
was during the February recess. I held this field committee hearing on 
the physician shortage crisis in rural America. At that hearing, I had 
a young woman come up and speak. She is a medical student who is 
currently part of the WAMI Program, the Western States medical program. 
This young woman, Melissa Howell, is 26 years old. She stated the 
student debt she has accumulated is a huge concern that hangs over the 
decisions she makes as she decides where she is going to practice. 
Simply put, she said that the $100,000 student debt she faces is ``kind 
of scary.'' I have to admit, that is kind of scary.
  A dozen States already report severe physician shortages. These 
shortages exist in the areas of cardiology, radiology, neurology, to 
name a few. But the greatest shortages persistently have been in 
primary care. In fact, the shortage of primary care physicians in rural 
areas of the United States represents one of the most intractable 
health policy problems of the past century.
  It will only worsen. In 20 years, 20 percent of the U.S. population 
will be 65 or older, and this is a percentage larger than at any other 
time in our Nation's history. Just as this aging population places the 
highest demand on our health care system, we have some experts who 
predict a national shortage of close to 200,000 physicians. If that 
becomes a reality, 84 million patients could be potentially left 
without a doctor's care.
  So the question has to be asked, where are the doctors going? We are 
losing some of our doctors through attrition. One-third of physicians 
are 55 years old and older and are likely to retire as this baby boom 
generation moves into its time of greatest medical need. Additionally, 
for the last quarter of a century, medical schools have kept their 
student enrollments virtually flat.
  We are also losing a lot of our doctors, quite simply, through 
frustration. Low Medicare and Medicaid reimbursement rates, coupled 
with complex regulations and paperwork, leave physicians aggravated, 
leave them disappointed with the practice of medicine.
  In Alaska, we have lived with provider shortages since statehood. I 
grew up in a part of the State down in the southeastern area where you 
did not have doctors who were available to deliver babies except on 
Tuesdays and Thursdays. You hoped you could give birth on a Tuesday or 
a Thursday. Still, in many parts of our State, we do not have providers 
who can deliver. If you are out in the Aleutian chain, you are told by 
your physician's attendant to come to Anchorage, some 600 miles away, 
to wait out the remaining month of your pregnancy because they do not 
have the facilities, do not have the doctors available to take care of 
you in the event of an emergency.
  So we have lived with provider shortages for a long time. Because our 
State is larger than Texas and California and Montana combined, 
``rural'' brings on a new meaning and the physician shortage crisis is 
even more amplified, as I have given in my two examples. But we have 
had some recent events in the State that have created a situation far 
worse than Alaska has known in the past. Currently, in the State, we 
have the sixth lowest ratio of physicians to population in the United 
States. That is when you take into account Anchorage, which is our 
largest population center. In rural Alaska, it is the worst physician-
to-population situation in the Nation. Alaska needs nearly 400 more 
doctors to provide the same level of care as elsewhere in the country.
  One of our problems is we do not have a medical school, and we are 
not likely to be getting a medical school in the near future. We also 
have the lowest per capita number of medical school slots in the 
country and the lowest number of residency slots. We have two small but 
very successful programs; this is the University of Washington Medical 
School Partnership and the Alaska Family Residency Program. These two 
programs help train Alaskans as physicians and also help us bring 
doctors to Alaska. But despite the success of these programs, each is 
far too small to meet our population's needs.
  Each week, without fail, I receive faxes, phone calls, letters, and 
e-mails from Alaskan seniors who simply cannot find a doctor to treat 
them. I wish to read a few excerpts from recent e-mails we have 
received. The first one is from a gentleman in Anchorage. Keep in mind, 
Anchorage is our largest population center; about half the population 
of the State is here.

  He writes:

       My mother . . . has had difficulty in the extreme in 
     getting a doctor who will take her on as she is a medicare 
     patient . . . doctors are telling potential patients that 
     they are no longer taking medicaid. My mother has made in 
     excess of 100 calls to physicians in Anchorage.

  Another constituent writes--and this is also from Anchorage:

       During the past year, I've tried to find a doctor that 
     accepts Medicare. I used the Anchorage Yellow pages and 
     called over 100 doctors, only to be told that they won't 
     accept any more Medicare patients.

  She then writes to say:

       I'll tell you ahead of time, we'll be going to the hospital 
     emergency rooms, to receive, even the basic medical care, 
     i.e.: colds, flu, and other basic medical care, that could 
     have been treated through seeing a doctor, at their 
     established practice. This doesn't sound like good fiscal 
     management.

  Another constituent--and this was actually in a letter to the editor 
in the Anchorage Daily News--says:

       My friends telephoned more than 80 doctors recently, and 
     not one was accepting new Medicare patients.

  A third gentleman from Kenai, AK, writes:

       My mom has Medicare and she had to wait 5 months to be seen 
     by a Neurologist because she had been put on a waiting list 
     to be seen due to the fact she was a Medicare patient.

  Another woman from Anchorage says:

       I just got through trying to find a physician for an 
     elderly Medicare-dependent friend. At this time I have found 
     no one who will take her. Most physicians take no Medicare 
     patients or have a quota which is full. The Providence health 
     care provider list has no one who takes Medicare.

  The last e-mail was from Anchorage stating:

       Almost no family practice office in Anchorage is accepting 
     new Medicare patients.

  This is just a sample of what we get from constituents around the 
State of Alaska saying: I don't have anyone who can see my mother. I 
can't get in to see anyone myself.
  I mentioned in my comments this is a crisis that is growing. In 
Alaska, we don't often think of it as being a State where we have a 
large senior population. We think of some of the Southern States as 
being the ones that attract our seniors. But the fact is Alaska has the 
second fastest-growing senior population in the Nation, second only to 
Nevada.
  So again we ask the question: Why aren't Alaska's doctors able to 
provide care to our seniors? Why are they saying: No, we are not 
accepting any new Medicare patients? Well, a lot of it has to do with 
the reimbursement rates. Recent Federal reductions in Alaska Medicare 
reimbursement rates have been so severe that primary care physicians 
report that Medicare pays them only 37 cents--it is actually between 37 
cents to 40 cents--for every dollar that it costs to treat a patient. 
So the doctor is spending a dollar in the care provided but is getting 
reimbursed about 40 cents to every dollar. We had one physician testify 
at the field hearing, and he said that in order for him to basically 
break even with his medical practice, he would have to see one Medicare 
patient every 7 minutes in order for him not to lose money. For those 
of us who go into our doctor's office, if we only had 7 minutes in 
there with our medical provider, I don't think we would feel we were 
getting the care and the attention our medical issues deserve.
  Losing money by seeing Medicare patients has meant that many of our 
physicians have stopped accepting Medicare patients entirely. They are 
making a decision not to accept any new Medicare patients. Or if you 
have been a patient of a particular physician and you turn 65, you may 
have had a good relationship with that physician, but if he tells you: 
I am sorry, I am not accepting any new Medicare patients, that date of 
your birthday comes and all of a sudden you don't have the care that 
you had relied on for some period of time.
  During this committee field hearing, we had testimony that revealed 
that

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only one neighborhood health clinic in the entire city of Anchorage--
and again, this is a city that has half the State's population--only 
one neighborhood health clinic is still accepting new Medicare 
patients.
  So if you are lucky enough to find a physician, it often takes weeks 
or months for an appointment. So when you are faced with this kind of a 
delay, you have one of two options. You either go to the emergency room 
if the conditions are severe enough or you go without care entirely, 
putting it off until perhaps it becomes even more complicated down the 
road.
  We had testify at the field hearing one gentleman who is from the 
city of Bethel. Bethel is in the western part of the State. He said he 
was willing to fly the 500-some-odd miles from Bethel to Anchorage if 
only he could find a primary care doctor who would accept him. He kind 
of joked because he said he counted himself lucky because he had a 
heart condition, and he was at least able to get in to see a specialist 
once in awhile.
  The chairman of the Alaska Commission on Aging, Mr. Frank Appel, 
called the lack of access to health care for seniors ``the most 
critical problem facing Alaska's seniors.''
  I know Alaska is not alone. The crisis is not just Alaska. It is 
nationwide. We as a body, as a Congress, should find this situation 
intolerable.
  I haven't been in the Senate for as long as many of my other 
colleagues, but I have been here long enough to know that we fight a 
lot about health care. We debate the solvency issues, the funding 
issues, the insurance, the benefit coverage, universal coverage, health 
savings accounts, the prescription drug benefit. We debate and argue 
about a lot of these issues as they relate to health care, and each and 
every one of these issues is certainly worthy of great debate. But I 
would submit that not one of those very worthy debates matters in the 
least to one of the seniors I have mentioned in these letters who can't 
find a primary care doctor after making 100 phone calls.
  So instead of this body debating how health care is delivered, it is 
time we focus on the fact that it is not delivered in much of America. 
We have a crisis that, simply put, cannot wait. We have to do two 
things. We have to help current physicians stay in the practice of 
medicine, and we must vastly increase our health care work force.
  Earlier this year, Senator Stevens and I introduced the Rural 
Physician Relief Act, and this is a bill that provides tax incentives 
for physicians to practice in our most rural and frontier locations in 
the country. Today, along with my colleagues, Senator Schumer, Senator 
Stevens, and Senator Sanders, we are introducing legislation entitled 
the ``Physician Shortage Elimination Act.'' This legislation will 
double the funding for the National Health Service Corps, a program 
that is dedicated to meeting the needs of the underserved. Despite its 
success over the years, it has been vastly underfunded. We understand 
that 85 percent of the applicants to this worthy program have to be 
turned away each year because we don't fund it.
  This legislation will also allow rural and underserved physician 
residency programs to expand by removing barriers that prevent programs 
from developing rural training programs.
  We will also double certain title VII funding to create programs that 
target disadvantaged youth in rural and underserved areas and nurture 
them to create a pipeline to careers in health care. We need to get 
more people interested in the field.
  Finally, we must bolster the cornerstone of rural health care, which 
is the community health center, through additional grants and by 
allowing them to expand their residency programs.
  I would suggest that the prognosis for the quality of health care in 
America is poor. Fifteen million Americans in underserved areas across 
the Nation already do without care. Soon, with even greater physician 
shortages, it could mean that potentially another 84 million patients 
will be left without a physician's care.
  The time for Congress to act is now. In fact, it is past time. I look 
forward to working with my colleagues on this issue that again is not 
just Alaska-specific. I think the facts on the ground up North perhaps 
make the arguments more accentuated, but I think it points to a 
situation in this Nation that we must deal with now before the crisis 
is felt throughout the country.
  I appreciate the attention of the Chair.
                                 ______