[Congressional Record Volume 153, Number 111 (Thursday, July 12, 2007)]
[Senate]
[Pages S9145-S9149]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. ENZI:
  S. 1783. A bill to provide 10 steps to transform health care in 
America; to the Committee on Finance.
  Mr. ENZI. Mr. President, I rise for the purpose of introducing a bill 
on health care reform. I know the Presiding Officer has immense 
interest in it, as do a number of other Senators. I have read his bill 
and incorporated many parts of that.
  Health care reform is one of the biggest needs in this country. It is 
the fastest escalating price in this country. It is the biggest cost to 
companies and individuals in this country. We need to have a solution.
  I have been working with Senator Kennedy, who is the chairman of the 
Health, Education, Labor and Pensions Committee. He has a very full 
plate with the Higher Education Act, the higher education 
reconciliation, information technology, and I could go on to mention 
about 53 bills we are working on in that committee. So I have had some 
latitude as ranking member to try to pull together some information--
some legislation that would deal with health care for this Nation. This 
is a work in progress. This is not a finished document.
  I wish to thank Senator Kennedy for working with me and his staff and 
my staff to come up with some health care principles we wanted to 
follow. Of course, I appreciate the work Senator Nelson did with me in 
previous times and currently on small business health plans. I 
appreciate Senator Baucus's efforts on health care and how the tax

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package goes together with that. We can see there are a lot of moving 
parts to anything we do with health. Senator Coburn has an outstanding 
and very comprehensive package on how we can solve many of the health 
care and health insurance problems in this Nation. Senator Lott, 
Senator DeMint, Senator McConnell; as I mentioned, the Presiding 
Officer, Senator Whitehouse; Senator Lincoln, Senator Carper, Senator 
Salazar, and Senator Durbin--these are all people who have come up with 
either a comprehensive plan or a piece of a plan that would work to 
make an important difference in health care in this country.
  Congressman McCreary on the House side has been a real leader on this 
and, of course, the President and the administration have made 
contributions as well. The President, in his State of the Union speech, 
made some comments about how taxes would fit in with solving some of 
the uninsured problems in the country, and some of those provisions are 
in here as well.
  Without the work of everyone on this, it can't be done. If it gets 
polarized, it can't be done. This is something which has to be done in 
a very bipartisan way. I hope we have a framework from which we can all 
operate, making changes, finding third ways.
  I work on an 80-percent rule. I anticipate and from experience have 
found that usually everybody can agree on 80 percent of the issues, and 
among the 80 percent of the issues on which they agree, they can agree 
on 80 percent of any one of those issues. You never get a perfect bill 
around here. If you can get 80 percent, you can get a lot done. That is 
what we are trying to do on health care--make an 80-percent change for 
the people of America. Eighty percent would be a huge difference and 
will help out a lot of people.
  So I rise today to talk about an issue that is literally a heartbeat 
away from devastating the lives of every American; that is, our current 
health care crisis. Undeniably, we have a problem. There are 46.1 
million Americans, according to the last tabulation, who are uninsured. 
Now, we always talk about that figure and change it slightly 
differently because there are 7 million of those people who make over 
$80,000 a year and don't have insurance, so they must choose not to 
have insurance, but they are uninsured. People who are on Medicaid, 
they don't have to sign up for anything before they have an emergency. 
When they go to the hospital, they can sign up then. That is a 
significant number of the 46.1 million people as well. So I don't know 
whether to really say they don't have insurance, but at any rate, let's 
just use that figure of 46.1 million Americans who are uninsured and 
figure out a way to solve that, as well as to help people who also have 
insurance to perhaps be able to handle the situation even better.
  Health care costs are outstripping inflation. They are increasing 
annually at three times the rate of the Consumer Price Index. It is 
little surprise that three out of every four Americans are concerned 
about health care--three out of four. I think probably, if you are 
talking to people, you would think the percentage was even higher than 
that.
  Employer-provided health insurance is voluntary and in critical 
condition. Sixty percent of the country's employers offer insurance 
today, but that is down 9 percent from a few years ago. It is partly 
due to the fact that the cost of health insurance for companies has 
nearly doubled in the same amount of time. With employers expected to 
pay over $8,000 per employee versus $4,000 5 years ago, we have no 
choice but to stabilize the system and provide more options for 
businesses so they can continue to provide health care for their 
employees.

  We must also provide real options--real options for those without 
employer-based health care. My own home State of Wyoming is hard-hit. 
On average, one in five Wyoming residents is uninsured, and more and 
more residents are losing the coverage they do have as the costs go up. 
It is largely due to the fact that much of Wyoming's economy is small 
business. Nearly 70 percent of Wyoming employers are small business. 
Actually, if you use the Federal definition of small business and you 
talk about companies headquartered in Wyoming, 100 percent of the 
companies are small business. We don't have a single one, according to 
the Federal definition, that is based in Wyoming. But nearly 70 percent 
of the employers find that it is nearly impossible to afford health 
care coverage for their employees.
  Thankfully, I am not here today to talk about these problems; I am 
here to provide real solutions. Americans need and deserve real 
solutions to this crisis now, and they are counting on this body to 
work together to get that. The time has come to move beyond the 
rhetoric and principles to true comprehensive health care reform.
  Congress could enact 10 major steps for health care reform. These 10 
steps are the basis of the legislation I am introducing today, the Ten 
Steps to Transform Health Care in America, or simply ``Ten Steps.''
  In putting together these 10 steps, I first wanted to understand the 
problem, and all the proposals others have been discussing help with 
that. I have studied those other proposals very carefully, and my 
colleagues will find that I have included many of the concepts of those 
other proposals in the 10 steps. I particularly wish to recognize again 
and thank Senator Baucus, Senator Kennedy, Senator Nelson, Senator 
Coburn, Senator Lott, Senator DeMint, Senator McConnell, Senator 
Whitehouse, Senator Lincoln, Senator Carper, Senator Salazar, Senator 
Durbin, Congressman McCreary, the President, the administration--all of 
them for their contributions, for their patience, and for their 
willingness to share their ideas.
  However, to truly do this right, we have to move beyond the usual 
jurisdictional issues, beyond the usual reauthorizations of a single 
program at a time. We have to examine the whole health care system and 
together--together, we have to put forward a bold and comprehensive 
solution that addresses our health care crisis. That is what Ten Steps 
does. It is a comprehensive solution to a very big problem. It can be 
done in parts. It doesn't have to be done as one structure.
  It needs to go through the committee process. I have pointed out 
several times that bills that don't go through the committee process 
usually don't make it through the process at all. They are good for 
making rhetoric, they are good for making points, they are sometimes 
good for advancing a principle, but they seldom ever make it to the 
President's desk for signature. So I know this will have to go through 
more than one committee. I know the jurisdictional issues between 
Health, Education, Labor and Pensions and the Finance Committees. I 
have no problem. We did the pensions bill last year, going through 
those same kinds of multiple committees and getting agreement from 
everybody, and that can be done on this issue as well--of course, as 
long as we don't polarize it.
  So I want to reiterate again that this is not a final bill. One of 
the things we have done in the HELP Committee which has helped to move 
things along is to consider every bill a work in progress. At a lot of 
the committee meetings, when you have a markup, different amendments 
are presented and they are voted up or down, just like on the floor. 
Well, that doesn't result in a lot of compromise. So what we have done 
on the HELP Committee is use the markup process as an indication of 
problems and the level of intensity of those problems, and we have 
agreed to work through those problems even after the bill makes it 
through committee. As a result, it seldom makes it through committee 
unanimously, but it makes it through committee in a bipartisan way, and 
that encourages people to work together to find solutions. Sometimes it 
is one way or the other, but usually it is finding a third way to come 
up with a mechanism to do what we are trying to do. Once we can put 
away some of the old ``diving into the weeds'' things that have 
happened year after year, we are able to come up with something new and 
different that actually reaches the goal we have been trying to reach 
as we jumped into the weeds through the whole process.
  So I want to remind everybody that it is a work in progress. We want 
more ideas. We want some of those third ways. But primarily, we want 
everybody to take a look at what is in here because it is a compilation 
of a number of people who have really taken a look at the situation.
  So what does it do? These 10 steps--I will break them down into the 
actual 10 steps and go through each of them.

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  First, we eliminate unfair tax treatment of health insurance, which 
expands choices and coverage and gives all Americans more control over 
their health care.
  Our current health insurance system is biased toward employer-based 
coverage--kind of due to a historical accident. The wage controls of 
World War II increased competition among employers for recruiting the 
best employees and incentivized employers to offer health benefits 
instead of what they couldn't do, which was increase wages. In 1954, 
Congress codified a provision declaring that such a contribution would 
not count as taxable income. This tax policy made it very favorable for 
individuals to get their health benefits through their employers and 
consequently has penalized individuals who get coverage through the 
individual market. So if you work for a big company--a tax break. If 
you don't--penalized.
  The Joint Committee on Taxation estimated that moving this tax bias 
and a few related health care tax policies will save the Government 
$3.6 trillion over the next 10 years. Even around here, that is a lot 
of money. That is a lot of money which can and should be used to expand 
choices and access and give individuals more control over their health 
care. Ten Steps ensures that every American can benefit from this 
savings--whether they get their health care from their employer, from 
the individual insurance market or they decide they want to get off 
Medicaid and switch to private insurance.

  Let me be clear. My goal is not to erode employer-based health 
insurance, given that the Ten Steps does not alter the way employers 
treat health insurance. Rather, I wish to provide more options for 
individuals who don't currently have insurance through their employer. 
Everyone should be treated equally.
  Once the employee exclusion for health care insurance is eliminated, 
we must provide additional tax incentives for the purchase of health 
care insurance. Ten Steps is a hybrid approach, combining the standard 
deduction for health insurance with a tax subsidy for those who need it 
the most. That way, no particular population is adversely affected.
  The second step of Ten Steps would increase affordable options for 
working families to purchase health insurance through a standard tax 
deduction. The national above-the-line standard deduction for health 
insurance will equal $15,000 for a family and $7,500 for an individual. 
I wish to also note the earned-income tax credit for taxpayers with 
qualifying children is held harmless--that is very important--so those 
receiving the earned-income tax credit will not be affected by these 
changes. Actually, they will be affected in a positive way.
  For example, say Bob from Gillette, WY, has total compensation of 
$38,000, made up of $34,000 in wages and $4,000 in health insurance 
premiums paid by his employer. Because of the current unfair tax 
treatment of premiums, Bob's current taxable income is reduced to 
$34,000, which means he paid about $5,000 in taxes. To an accountant, 
this is all fascinating; for other people, I am not so sure.
  Under the Ten Steps, which eliminates the exclusion of premiums from 
tax, Bob's total compensation and thus taxable income would be $38,000. 
By providing Bob with a $7,500 standard deduction for health insurance, 
his taxable income under this bill would be lowered to $30,500, which 
means he would pay about $4,000 in taxes. So Bob's total savings under 
this proposal is $1,000 a year.
  The third step of Ten Steps is what makes this a hybrid approach. I 
couple the standard deduction with a refundable, advanceable, 
assignable tax-based subsidy. That is a mouthful, but it ensures that 
Americans receive this credit in a meaningful way that allows them to 
purchase real insurance coverage.
  Given that everybody is not familiar with these terms, I will explain 
them. As a refundable credit, it benefits folks even if they don't have 
tax liability. They don't have to owe taxes in order to get it. This 
helps low-income individuals. Advanceable means the subsidy would be 
paid at the beginning of the year so individuals can use the funds to 
immediately purchase health insurance. If it wasn't advanceable, 
individuals would need to first pay for their health insurance and then 
get the money back at the end of the year to pay them back for that 
purchase. To encourage everyone to obtain health insurance right away, 
we should provide those funds upfront. Further, to ensure that the 
subsidy goes toward the purchase of health care insurance, it is also 
assignable--paid directly from the IRS to the insurance carrier that 
the individual chooses.
  Ten Steps includes the tax subsidy equal to $5,000 for a family or 
$2,500 for an individual. The full subsidy amount is available to 
individuals at or below 100 percent of the Federal poverty level, which 
is $20,650 right now for a family of four. The subsidy is phased out 
between up to 300 percent of Federal poverty level, with individuals at 
200 percent receiving half the subsidy and individuals at 301 percent 
receiving the standard deduction instead of the subsidy. I am sure 
everybody got that.
  The fourth key step for health care reform is to provide market-based 
pooling to reduce growing health care costs and increase access not 
only for small businesses, unions and other kinds of organizations and 
their workers, members, and families. That is a change from anything I 
have done on pooling before, but it is a change that was requested by 
the other organizations and unions, as well as small business. Those of 
you who know me well recognize how central this would be to any health 
care reform proposal of mine.
  While I have not yet introduced the small business health plan 
legislation from last year, I have not abandoned those key principles. 
Every day, emergency rooms treat more than 30,000 uninsured Americans 
who work for or depend on small businesses. That is at least 30,000 
reasons why I will not abandon the concept. However, in the proposal I 
am introducing, I have addressed some of the criticisms of the bill, 
and I have offered what I believe are appropriate solutions.
  For instance, while the earlier bill focused heavily on small 
businesses--and this one still does--it simply became clear that other 
organizations, including unions and churches, can benefit from better 
pooling options too. Therefore, under this bill, the umbrella of the 
pooling option has been expanded to include more kinds of organizations 
but with the same strong focus on consumer protections and State-based 
oversight.
  Of course, a big elephant in the room was dealing with those who were 
misled to fear how the initial proposal dealt with insurance mandates. 
I hope those who were so vocal before will pause this time around. By 
incorporating what many have described as the Snowe amendment--which I 
am sure we would have passed at the time we were talking about that 
before--the legislation would require benefit mandate categories if a 
majority of the States required them. While I still have some concerns, 
I am comfortable with this compromise because the mandate requirement 
is coupled with something it needs to encourage pooling and that is a 
common definition of what that mandate means. We do it with the Federal 
insurance plan because definitions in all the States run a little bit 
different. If you are trying to do something comprehensively, it is 
pretty hard to figure out what each definition means, so there needs to 
be a way of streamlining it and coming up with a common definition for 
that mandate. I don't think people have a problem with that, especially 
since we do it with the Federal plan.
  As I learned with the previous debate, mandates for many different 
services and items are not consistent from State to State. Thus, if we 
are to discuss requiring those, we should at least have a consistent 
definition of what those mandates require. We should not further 
complicate the pooling option with a multitude of definitions. We want 
to make insurance as simple as possible. I know that is kind of an 
oxymoron, I am sure, because I know nobody in America relishes having 
their insurance agent come over and spend an evening explaining the 
bill to them. But we want to have this little bit of streamlining so it 
is simpler and people will be able to understand it, to the degree that 
is possible with insurance.

  While the next step is probably one of the most obvious ones, it is 
also one many have not yet discussed. Currently, HIPAA portability 
protections

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are provided to group health plans. The protections provide assurances 
to consumers that insurers will deal with preexisting conditions fairly 
and provide coverage, even to small groups.
  These protections have been a great help for individuals purchasing 
health care coverage in the group market. However, those consumer 
protections are not provided nearly as well to individuals who are 
purchasing in the individual market. Ten Steps blends the individual 
and group market to extend important HIPAA portability protections to 
the individual market so the insurance security can better move with 
you from job to job. It allows people to take that new opportunity and 
still be sure they will be covered, even if they have had some 
preexisting conditions.
  The sixth step emphasizes preventive benefits and helps individuals 
with chronic diseases better manage their health. America should have 
health care, not sick care. Prevention, prevention, prevention. That 
makes a big difference in the cost.
  We have all been discussing the need to do more to prevent disease, 
not just treat its symptoms. Even though I leave much to the markets to 
define some health insurance components, the one thing we must 
emphasize is the need for prevention. Any plan purchased with the tax 
subsidy must include basic preventive services and a medical self-
management component.
  This concept is modeled after a very successful program in Wyoming. 
In 2005, Wyoming EqualityCare, our Medicaid Program, began providing 
one-on-one case management for Medicaid participants with chronic 
illnesses, such as diabetes, asthma, depression or heart disease, to 
encourage better self-management of these conditions. The program 
provides educational information on self-management, as well as a nurse 
health coach who follows up with each patient to ensure they have what 
they need to take care of themselves.
  In addition, EqualityCare provides a nursing hotline so all patients 
have a direct line to a health care provider when they are concerned 
about an illness. These programs targeting those with chronic illnesses 
were estimated to save nearly $13 million for the EqualityCare program 
in 2006. In a lot of States, that would not sound like a lot, but 
Wyoming is the least-populated of all of the States. We are hoping to 
get 500,000 people in the next census. When you talk about $13 million 
being saved in this EqualityCare Program dealing with Medicaid 
participants, it is a lot of money, proportionately, particularly 
because it cut down on inappropriate use of emergency room services.
  Now, another key step of the Ten Steps for health care reform is to 
give individuals the choice to convert the value of their Medicaid and 
SCHIP program benefits into private health insurance, putting them in 
control of their health care, not the Federal Government. The rationale 
for this step is simple. If the market can provide better coverage at a 
lower price, why not allow Americans to access that care?
  This gives low-income individuals more options about where they can 
receive their care and what care is available to them. Some providers 
don't see Medicaid and SCHIP patients. This provision will change that 
by letting the market forces work and give all patients more choices. 
It is time for people to start making decisions about their care. Let's 
get the Government out of the doctors office.
  About 6,000 kids are enrolled in the Wyoming SCHIP program. An 
additional 6,000 kids are eligible for the program but are not 
enrolled. I wonder why that is. Maybe it is because folks in Wyoming 
are wary about accepting Government help, and they think there is a 
negative stigma associated with SCHIP and Medicaid. Well, under Ten 
Steps, they can use that money to purchase health care insurance 
through the private sector so that their family can attain the high 
quality care they need and deserve. This will cover more people.
  The eighth step in Ten Steps is a bipartisan proposal which the HELP 
Committee approved last month--the ``Wired for Health Care Quality 
Act,'' which encouraged the adoption of cutting-edge information 
technologies in health care to improve patient care, reduce medical 
errors, and cut health care costs. Some of the most serious challenges 
facing health care today--medical errors, inconsistent quality, and 
rising costs--can be addressed through the effective application of 
available health information technology linking all elements of the 
health care system.
  The widespread use of health IT can save lives. If somebody is 
traveling and gets in a car wreck or gets hurt in some other way, the 
emergency room doctor would be able to find out everything he or she 
needs to know to make the right treatment decisions, without the person 
having to fill out one of those little papers at the doctors office, 
which they may not be capable of doing if they have been in a requiem 
or have some other problem.
  Better use of health IT would also allow medical data to move with 
people when they go to other locations. When someone goes to the 
doctor's office, they won't have to take the clipboard and a pencil and 
write down everything they can remember about their history. It will 
already be recorded and go with them. It will make a huge difference.

  Beyond saving lives and saving time, more effective use of health 
information technology would save us a lot of money. A RAND study 
suggested that health IT has the potential to save--listen to this--
$162 billion a year. Even around here that is real money. In order for 
these savings to be realized, we have to create an infrastructure for 
interoperability.
  All the different health providers and insurers and doctors have to 
be able to get the information electronically, but doctors, hospitals, 
health care advocates, the business community, including small 
businesses, are clamoring for Congress to take action and establish 
uniform health IT standards. That will cut down on the cost of the 
software.
  Time is of the essence. If Congress does not act, our health care 
system will move forward in a highly inefficient, fragmented, and 
disjointed way. Among other things, this bill will eliminate 
duplicative tests and reduce medical errors. That is a lot of where 
that $162 billion a year in savings comes from.
  Health care reform cannot simply expand health insurance coverage. It 
must also expand access to actual providers of care. There are growing 
shortages of health care providers nationally, with a shortage of up to 
200,000 primary care physicians and 1 million nurses expected by 2020. 
Who is going to take care of us at the hospital if we don't have 
nurses? Who is going to help make a diagnosis if we don't have doctors?
  That is why the ninth step of Ten Steps helps future providers and 
nurses pay for their education while encouraging them to serve in areas 
with great need with five key reforms.
  This legislation provides competitive matching grants for States to 
encourage nurses to return to the profession after having left the 
workforce for 3 years or more while reaffirming the commitment to 
current programs targeting nurse educators and nurse education. So this 
will encourage people to come back into providing that excellent 
service. To deal with the shortage right now, this legislation will 
expand the number of nonimmigrant skilled workers visa slots for nurses 
serving in medically underserved areas.
  To expand access to those most vulnerable, Ten Steps reaffirms the 
commitment to current programs that are working, such as the Community 
Health Centers program and the loan repayment programs at the National 
Health Service Corps. Working together, these two programs provide key 
support in underserved areas.
  To allow for greater access to health care services, clarification 
will be made that convenient care clinics may accept and receive 
reimbursement from Medicaid and SCHIP patients. These convenient care 
clinics are small health care facilities located in retail outlets 
providing affordable and accessible nonemergency health care from 
nurses, physician assistants, and physicians. Often open 7 days a week, 
these clinics provide an option for those seeking routine and 
preventive care services in a more convenient setting--at the retail 
outlets--and with patients seen typically within 15 minutes.
  Finally, building upon the successes of current rural health 
programs, Ten Steps will ensure appropriate development of rural health 
systems and access to care for residents in rural areas.

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  In providing access to health care, I believe it is important to 
envision where we want to provide that care. Community and home-based 
care is often much preferred, less costly, and proven to increase 
quality of life. To encourage innovative approaches to keeping long-
term care in residential settings, competitive grants will be available 
to give seniors more options for receiving care in home or community-
based settings. We just had a hearing on that subject in the HELP 
Committee. It was both very helpful and very convincing.
  The final step to Ten Steps decreases the skyrocketing cost of health 
care by restoring reliability in our medical justice system through 
State-based solutions. The bill I have been discussing today includes 
the Fair and Reliable Medical Justice Act, which I just introduced with 
Senator Baucus, for States to encourage early disclosure of preventable 
health care errors, prompt and fair compensation for injured patients, 
and careful analysis on patterns of health care errors to prevent 
future injuries. By funding demonstration projects, States are enabled 
to experiment with and learn from ideas leading to long-term solutions 
tailored to the unique circumstances of each State.
  No one--not patients or health care providers--is appropriately 
served by our current medical litigation procedures. Right now, many 
patients who are hurt by negligent actions receive no compensation for 
their loss. Those who do receive merely 40 cents of every premium 
dollar, given the high cost of legal fees and administrative costs. 
That is simply a waste of medical resources.
  Furthermore, the likelihood and the outcomes of lawsuits and 
settlements bear little relation to whether the health care provider 
was at fault. Consequently, we are not learning from our mistakes. 
Rather, we are simply diverting our doctors. When someone has a medical 
emergency, they want to see a doctor in an operating room, not a 
courtroom.
  The medical liability system is losing information that could be used 
to improve the practice of medicine. Although zero medical errors is an 
unattainable goal, the reduction of medical errors should be the 
ultimate goal in medical reform. The Institute of Medicine, in its 
landmark study called ``To Err is Human,'' estimated that preventable 
medical errors kill somewhere between 44,000 and 98,000 Americans each 
year. That study further emphasized that to improve our health care 
outcomes, we should no longer focus on individual situations but on the 
whole system of care that is failing American patients.
  In the 8 years since that study, little progress has been made. 
Instead, the practice of medicine has become more specialized and 
complex while the tort system is more focused on individual blame than 
on a system safety.
  I realize I have talked for quite a bit about Ten Steps, and given 
the current crisis, we should be talking a lot more about real 
solutions, not just problems. I also want everyone to know I believe 
the introduction of this bill today is simply the first step forward. I 
look forward to talking with others about their thoughts on how to 
improve this proposal, how to better refine it so it can better serve 
all Americans.
  With all of that talk, I also want action, real action, to provide 
real coverage for Americans, not a large expansion of a government 
program with a huge pricetag that does little to impact those who are 
uninsured.
  We have an opportunity, we have an obligation to take care of the 
people of this country, and they are demanding it. Let's work from a 
basis of some information and see where we can take it so that we get a 
solution and we get action now.
                                 ______