[Congressional Record Volume 153, Number 132 (Friday, September 7, 2007)]
[Senate]
[Pages S11264-S11267]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
HEALTH CARE
Mr. WYDEN. Mr. President, Senator Bennett of Utah and I have brought
to the Senate the first bipartisan universal health care coverage
legislation in more than 13 years. I thought today I would open my
remarks on health care in something of a light fashion. There is a
brand new study that has recently found Americans are no longer the
tallest people in the world. Over the past 50 or so years, the U.S.
population has lost that status and now ranks among the shortest among
industrialized countries. The Netherlands now holds the honor for the
tallest nation. The authors of this new study speculate this change may
stem from the fact that most other affluent countries have health care
systems that cover their entire population and that particularly
healthy lifestyles and healthy diets are also significant factors.
Senator Bennett is 6 foot 6. I am 6 foot 4. We would like our country
to get its rightful position back as the leader among nations in the
height department. We think part of what is going to be necessary to do
that, in all seriousness, to make our health policies more health
focused rather than just spending on health care, is to adopt some
fresh policies. We have been particularly interested this week because
the Wall Street Journal, which colleagues know displays a preference
for private health care sector solutions, has written a fascinating
front page article this week on the special accomplishments in Holland
with respect to health care. I have long been of the view that as we
look finally to accomplishing what this country has not been able to do
for 70 years, which is to get all Americans good quality, affordable
health care, we are going to have to devise our own system. It is not
going to be possible to import some other country's system of health
care to our Nation and pretty much plop it down on the United States
and say: This is the way to go.
But as the Wall Street Journal said in their article this week, there
are some important lessons to learn as it relates to the experience of
other countries.
I ask unanimous consent to print in the Record this front page
article from the Wall Street Journal with respect to health care.
There being no objection, the material was ordered to be printed in
the Record, as follows:
In Holland, Some See Model for U.S. Health-Care System
(By Gautam Naik)
The Hague.--The Netherlands is using competition and a
small dose of regulation to pursue what many in the U.S.
hunger to achieve: health insurance for everyone, coupled
with a tighter lid on costs.
Since a new system took effect here last year, cost growth
is projected to fall this year to about 3% after inflation
from 4.5% in 2006. Waiting lists are shrinking, and private
health insurers are coming up with innovative ways to care
for the sick.
The Dutch system features two key rules: All adults must
buy insurance, and all insurers must offer a policy to anyone
who applies, no matter how old or how sick. Those who can't
afford to pay the premiums get help from the state, financed
by taxes on the well-off.
The system hinges on competition among insurers. They are
expected to cut premiums, persuade consumers to live
healthier lives, and push hospitals to provide better and
lower-cost care.
Some are already taking unusual steps. The insurance
company Menzis has opened three of its own primary-care
centers to serve the patients it insures, and plans to open
dozens more in a move to lower costs. Rival UVIT offers
discount vouchers to customers who buy low-cholesterol
versions of yogurt, butter and milk.
To prevent insurers from seeking only young, healthy
customers, the government compensates insurers for taking on
higher-risk patients. Insurers get a ``risk-equalization''
payment for covering the elderly and those with certain
conditions such as diabetes. to pay her back about $676 for
gym membership--provided Ms. Boel lost 7.5% of her weight
in 15 months.
The 45-year-old, who lives in the town of Tilburg, says she
stopped eating french fries and pizza and took up an
intensive regimen of walking, cycling and rowing. She met her
weightloss target and used the gym-membership rebate to buy
some new clothes.
Ms. Boel now hopes to manage her diabetes more efficiently
and lose more weight. ``I don't like exercising,'' she says,
``but at least I can now walk without a stick.'' That's
welcome news to UVIT. Says spokesman Bert Rensen, ``Once she
stops using insulin, which we pay for, it will save us K900
[about $1,200] a year.''
Likely Opposition
What works in the Netherlands, a small country of 16.6
million people, may not readily apply to America. A Dutch-
style scheme would likely raise opposition among U.S. doctors
and Republicans who are cautious about higher taxes. But many
U.S. states are similar in size, and one, Massachusetts, is
already experimenting with a universal-coverage scheme.
``The lesson for America is that this is what we ought to
do,'' says Alain Enthoven, a professor at Stanford
University.
Three decades ago, Prof. Enthoven published a pioneering
proposal for what he called ``managed competition,'' a
version of which the Dutch have now adopted.
The Enthoven plan partly inspired the Clinton
administration's failed health-care overhaul effort in the
1990s. It has now come full circle. Last October, an
economist from the Dutch health ministry was invited to
describe his country's new approach to about 50 Massachusetts
politicians and policy makers in Boston, as the state was
developing its own plan for mandatory health insurance.
After being sidelined for more than a decade, health care
is once again a hot issue on the U.S. political agenda. Two
leading Democratic presidential candidates, Sen. Barack Obama
of Illinois and former Sen. John Edwards of North Carolina,
have backed the idea of universal coverage and suggested ways
to achieve it. California Gov. Arnold Schwarzenegger, a
Republican, has pushed a proposal to require all state
residents to obtain health insurance, but he hasn't been able
to strike a deal with state legislators to enact a plan.
The notion of competition among insurers is nothing new to
Americans. Most Americans under 65 get insurance via their
employer, which can compare plans and pick the one that it
thinks offers the best coverage for the money. To cut costs,
U.S. insurers bargain with doctors for discounted rates and
try to weed out overbilling and frivolous treatments.
The system has failed to stop U.S. health costs from
shooting up, and it has left many doctors complaining that
their medical judgment is being second-guessed by bean
counters. It isn't clear that a Dutch-style system, also
centered on insurer competition, could do any better. Dutch
doctors were among the most vociferous opponents of an
overhaul and many remain skeptical.
Still, there are some differences in the Dutch way that may
work to its advantage. One is the emphasis on individuals
buying coverage. In the U.S., employers tend to be poor
buyers of health care. They're unfamiliar with the needs of
the people actually using the health care--their employees--
and it is difficult for a large company to switch insurers.
By putting the onus on consumers, Dutch officials hope that
more people will get the coverage they need. The ``risk
equalization'' that helps Dutch insurers cover sicker people
is also critical. In the U.S., competition among insurers
often means competition to find the healthiest customers,
especially in the individual market.
The Netherlands began to overhaul its health system in 1987
after a government committee concluded that the best approach
was ``managed competition,'' the idea first proposed by Prof.
Enthoven of Stanford.
The task was enormous. The country had four different
coverage schemes. The wealthiest third of the population was
required to get health insurance without government
assistance. Some in this group received help from employers
in paying premiums, while others paid the whole bill
themselves. The bulk of the Dutch population was covered
under a compulsory state-run health-insurance scheme financed
by deductions from wages. Civil servants and older people
were insured under two separate plans within this state-run
scheme.
The government closely regulated hospital budgets and
doctors' fees, but provided few incentives to cut costs. When
hospitals lost money on a particular kind of care, they
rationed it. Many patients ended up on waiting lists.
People in line for heart transplants were particularly
affected. In the mid-1990s, fewer than three Dutch people per
million received such transplants. By comparison, a study of
12 European countries showed that only Greece had a lower
rate of such operations. ln the U.S., there were about nine
heart transplants per million people.
In 1999, waiting lists increased by 2%, despite a $54
million initiative to reduce them. ``Dead on the waiting
list,'' read one cover story of Vrij Nederland, a weekly
magazine that, like other Dutch media, relentlessly
criticized the country's health system.
[[Page S11265]]
``We felt frustrated,'' recalls Hans Hoogervorst, who was
the health minister from 2003 to early 2007 and a major force
in pushing through the overhaul.
Though the Dutch still enjoyed better health than the
residents of many developed countries, standards were
slipping. Between 1960 and 2000, the increase in Dutch life
expectancy was 4.5 years, while its neighbors, Germany and
Belgium, showed far better increases of 8.1 and 7.1 years,
respectively, according to the Organization for Economic
Cooperation and Development. In the U.S., the increase was
nearly seven years.
As in the U.S., medical costs began to increase, driven by
an aging population and the increased use of expensive new
technology. Between 2000 and 2004, Dutch health spending as a
share of gross domestic product shot up to 10% from 8%.
In late 2004, the Dutch House of Representatives passed a
law to usher in mandatory health insurance and switch people
on state-run insurance to private carriers. But family
doctors fretted that it would allow insurers to interfere in
medical decisions, for example by pushing cheaper drugs.
The following May, thousands of Dutch general practitioners
went on a three-day strike. Some tied their hands together
with rope to symbolize their helplessness. In response, Mr.
Hoogervorst promised to provide some protections for doctors
in the new legislation. One of them was that patients
wouldn't bear a big financial cost if they chose to go to a
doctor not under contract with their insurer. Soon after, the
senate approved the new plan.
It took effect on Jan. 1, 2006. Despite predictions of
chaos, the changeover was surprisingly smooth. The government
set up a Web site where consumers could analyze insurers'
offerings. Consumers were allowed to switch insurers once a
year. As 2006 approached, the health ministry predicted that
only 5% would bother. Instead, nearly 20% of people switched,
either to get a better price or because they were
dissatisfied with their insurer.
Premium War
Consumers also benefited from a premium war as insurers
made a grab for market share. The Dutch health ministry had
predicted that insurers in 2006 would price the annual
mandatory premium at an average of K1,106, or about $1,500.
Instead, market forces set it at K1,028, 7.6% lower. This
year, it has risen to K1,103, partly because of an easing in
the price war. That's still less than the K1,134 the
government predicted for 2007.
Included in the overhaul was a deal the government
negotiated with generic-drug makers to cut prices by about
40%. The generic-drug makers made up for some of their lost
revenue by reducing the rebates and bonuses they provided to
pharmacists to recommend their drugs to customers. From 2004
through 2006, annual drug spending grew at an average annual
rate of 2.8%, down from 9% annual growth earlier in the
decade.
Insurers have taken a hit, though. UVIT, which has more
than four million customers, was forced to open a 200-person
call center to help consumers switch between plans. In 2005,
UVIT had total revenue of about $7.6 billion and made a
profit of about $202 million from health insurance, which is
its main business. Last year, the company's health business
posted a loss of $30 million. UVIT expects to return to
profitability this year, partly by negotiating lower prices
with hospitals.
In most European countries, consumers have no idea what
their health insurance costs because they are covered by
national health-insurance schemes financed by payroll taxes,
as used to be the case in the Netherlands. On a visit to
Germany last year, Mr. Hoogervorst boasted that thanks to his
country's switch to private insurance paid by individuals,
``no other European country has a population so keenly aware
of the costs of their health-care insurance.''
Now that they see the bills more clearly, some consumers
feel their payments have gone up. In one survey mainly of
labor-union members, about 70% said they were financially
worse off in some ways.
Insurers get risk-equalization payments for patients with
about 30 major diseases. They can use these to offer
discounted premiums and programs tailored to those with heart
disease, diabetes and other ailments.
One shortcoming is that many diseases aren't subject to
risk equalization. The excluded diseases--such as migraine
headaches--are harder to diagnose and their treatment costs
are harder to predict. ``Seen from the side of migraine
patients, this is highly unfair,'' says Peter Vriezen,
president of the Dutch Headache Patients Association.
The real test of the Dutch approach is yet to come: Can
insurers push hospitals to lower their costs and improve
their quality? Insurers have clout because they can direct
large numbers of patients toward particular hospitals. But,
in a holdover from the old system, insurers can currently
negotiate prices * * *. The figure will rise to 20% by the
end of this year, and continue to go up.
Because Dutch hospitals used to receive fixed prices for
their services, and got more money for more service
regardless of quality, they had little incentive to improve
their care. Under the new system, insurers should be
providing that incentive, but Mr. Hoogervorst acknowledges,
``Thee's still a long way to go to increase competition among
hospitals.''
Market Incentives
One concern is the potential for overconcentration among
insurers. UVIT, for example, is the result of a merger
between four insurers. ``If eventually you have only three or
five insurers, you might wonder how many market incentives
will remain,'' says Niek Klazinga, professor of social
medicine at the University of Amsterdam.
Last fall, Prof. Enthoven delivered a speech to health
economists in Rotterdam. He congratulated the Dutch for being
``in the lead'' in health-care change. However, he cautioned,
``you still have considerable work ahead of you to transform
your present success with insurance'' into a system that
delivers improving care.
Some insurers are taking unusual steps to get there. Menzis
rewards doctors with bonuses if they prescribe generics
instead of more expensive branded drugs. UVIT ranks hospitals
based on the quality of care.
To put pressure on Dutch hospitals, some insurers let
patients go to other countries where high-level care for
certain ailments costs less. Thea Gerits, 71, went to Germany
for a hip replacement and spent four weeks in a
rehabilitation center there, receiving physical therapy and
enjoying yoga, massages and mud baths.
UVIT paid the $19,000 bill. It says the same amount in the
Netherlands would buy only the surgery and basic therapy. Ms.
Gerits came home happy, and soon was riding her bicycle
again. ``I got lots of attention,'' she says. * * *.
Mr. WYDEN. I am going to read one paragraph at the outset of the
article:
Since a new system took effect here last year, cost growth
is projected to fall this year to about 3 [percent] after
inflation from 4.5 [percent] in 2006. Waiting lists are
shrinking, and private health insurers are coming up with
innovative ways to care for the sick.
What struck Senator Bennett and I is, there is an awful lot of
comparison between our bipartisan legislation and the experience of the
Dutch. For example, both in Holland and in the United States under our
proposal, there would be a requirement that individuals would have to
purchase their own health insurance. Insurers under our proposal, as in
Holland, would not be able to discriminate against individuals who have
had illnesses. We saw in the movie ``Sicko'' that wonderful scene with
the ``Star Wars'' music describing all the various conditions that
individuals might have that would exclude them from insurance coverage.
That would be illegal under what Senator Bennett and I are advocating.
It is illegal, according to the Wall Street Journal, in the
Netherlands.
Finally, in the Netherlands and under our legislation, there is a
sharp and specific focus on prevention and wellness. The tragedy in our
country is, we don't have health care at all. What we largely have is
sick care. Medicare shows this probably more clearly than anything
else. Medicare Part A will pay huge expenses for senior citizens'
hospital bills. The check goes from the Government to the hospital. But
Medicare Part B, on the other hand, will pay for virtually nothing for
prevention and keeping people well. Senator Bennett and I seek to
change that. For the first time under our legislation, Medicare would
be authorized to discount the premiums for seniors who lower their
blood pressure, lower their cholesterol, practice good health in their
individual lives. I am struck by this Wall Street Journal article,
where insurers in Holland are adopting much the same kind of approach.
The article states on the front page that insurers now are offering
discounts to customers who buy low cholesterol versions of yogurt,
butter, and milk.
The point is, worldwide the message is getting out. Prevention works.
Wellness, a new focus on personal responsibility, and keeping our
citizens healthy makes sense. They are doing it in Holland. The Wall
Street Journal describes the positive benefits there. I and Senator
Bennett, along with our cosponsors, Senators Bill Nelson, Lamar
Alexander, and Judd Gregg, are trying to build a bipartisan coalition
in the Senate to do exactly the same.
Our legislation, the Healthy Americans Act, would require that
everyone not on Medicare or in the military would have to purchase
private health insurance. But to make sure that is doable, we fix the
broken marketplace. Under our legislation, private insurance companies
wouldn't be able to cherry-pick. They wouldn't be able to take just
healthy people and send sick people over to Government programs more
fragile than they are. They couldn't discriminate against those with
illnesses. They would have to spread risks through large groups of
people. Right now essentially much of the private insurance business is
about
[[Page S11266]]
filtering out those people who have illnesses and finding a way to
cover just those who are healthy. Our legislation would change that.
We also take critical steps to make sure that if you are going to
require that people purchase coverage, you have generous subsidies for
folks with modest incomes. What Senator Bennett and I propose--and
apparently they are doing something along these lines in Holland--is to
subsidize those up to 100 percent of poverty completely and for those
between 100 percent of poverty and 400 percent of poverty, there would
be a partial subsidy. The most generous subsidies of any program
anywhere in our country would be offered under this legislation that we
are offering, with Senators Alexander, Gregg, and Nelson of Florida.
How do we pay for it? The Lewin Group, which is kind of the gold
standard for looking at health policies, scored the administration's
approaches, many of the States and ours and said we can find a lot of
the savings under our legislation through an administrative process
that establishes that once you sign up in Ohio, once you sign up in
Oregon or anywhere else in the country, you are in for life. You don't
have to sign up again and again and again. In my State, my guess is it
is very similar to the situation in Ohio, if you are on Medicaid, there
is something like 31 or 32 categories of coverage. A poor person has to
try to squeeze themselves into one of those boxes in order to get
coverage. It is degrading to the poor and a big waste of money.
What Senator Bennett and I have offered is a one-stop process so you
sign up once, and everything else from that point on is essentially
accomplished through the magical world of electronic transfers. An
individual's contribution would be taken out of their paycheck while
they are working. Ours is fully funded.
There is an opportunity for bipartisan cooperation, particularly
should the Bush administration want to assist in this effort. For
example, every single economist who has come before the Finance
Committee, before the Budget Committee, has talked about the Tax Code
as it relates to health care disproportionately favoring the most
affluent and rewarding inefficiency at the same time. To put it another
way, if you are a high-flying CEO in the United States, if you want to
go out and get a designer smile put on your face, you can write off the
cost of that service on your taxes. But if you are a hard-working woman
without any health plan and a local furniture store, you get nothing.
So I and Senator Bennett redirect the current tax expenditures. They
are the biggest part of private health care spending.
The Lewin Group establishes in their analysis of our report that
would ensure we could expand coverage over the next few years without
any additional cost to taxpayers. The Lewin Group has said the proposal
now being sponsored by five Members of the Senate would slow the rate
of growth in health care spending by $1.5 trillion.
I know the distinguished Presiding Officer has a great interest in
health. We are so pleased he is here because we have worked together on
these issues often. It is clear this is the premier domestic issue of
our time. A combination of today's demographics with a rapidly aging
population, escalating costs, the huge increase in chronic illness, our
current health care system is not sustainable. It is not one we can put
on automatic pilot and say: Let us run it this way for years and years
in the future.
The tragedy is with all the wonderful doctors and hospitals and
nurses in Ohio and Oregon, all across the country, we are spending
enough money on health care to do this job. We are simply not spending
it in the right places.
To give an idea of how out of whack American health care spending is,
for the amount of money we are spending today, $2.3 trillion, 300
million of us in the country, you divide 300 million into $2.3
trillion, and you could go out and hire a doctor for every seven
families in the United States and say: Doctor, your job will be for
this year to take care of seven families, and we will pay you $200,000
a year.
My experience, I say to the Acting President pro tempore, is that
when I bring this up to physicians at home in Oregon, they say: Ron,
where do I go to get my seven families? It sounds pretty good to be
able to get back into the business of practicing medicine again and
advocating for my patients rather than going through all this paperwork
and bureaucracy and redtape.
So we are spending enough on health care today. We are not spending
it in the right places. That is what they have begun to change in
Holland, according to the Wall Street Journal this week. That is what I
and Senator Bennett and our colleagues on both sides of the aisle are
seeking to do in the Senate.
One last comment, Mr. President. I know there is a hectic schedule
for all Senators, and certainly the Senator from Ohio.
The question is whether there should be action now or the Congress
should simply wait for another Presidential election. Here are the
consequences of waiting for several more years. The Census Bureau
reported last week that 2.2 million additional Americans were without
health insurance between 2005 and 2006. If this Congress waits a couple
of years more, we can expect that number to increase and the number
without coverage in this country to hemorrhage further.
That is a moral abomination, No. 1; and it is going to be costly to
taxpayers, No. 2, because those people very often will have to go to
hospital emergency rooms to get their coverage. Of course, those bills
will be passed on to businesses in Ohio and Oregon and across the
country and to our taxpayers. So the costs of delay are very direct and
immediate.
Second, with respect to employer-based coverage, the new numbers
indicate the number of employers offering coverage has now fallen below
60 percent. It is pretty easy to see why, with these double-digit
premium hikes, Price Waterhouse says health costs are going to average,
this year, a little over 11 percent. A lot of our employers want to do
the right thing by their workers and simply cannot offer coverage.
If this Congress decides to stand down on the question of overhauling
health care and say, ``Let's just wait until 2009,'' you are going to
see more businesses in Ohio, in Oregon, and across this country lose
coverage. I do not think we ought to sit by and just let our coverage
continue to melt away along the lines of these statistics that I
mentioned.
Finally, on the question of prevention and what Holland is doing, and
what we are seeking to do in the Healthy Americans Act, there is a very
significant cost with respect to chronic illness as it relates to doing
nothing to change our policies. The new numbers with respect to chronic
illness indicate that in 31 States over the last year obesity has risen
once again; of course, there is a direct link here between heart and
stroke and diabetes and so many illnesses. Not one State--not one--
experienced a decline.
So if the Congress says: Well, we will pass on overhauling American
health care until 2009, we can expect to have missed another
opportunity--yet another opportunity--for doing something about
enacting health care policies that put a new focus on prevention and
wellness.
So this question of waiting for 2 more years and saying: Let's just
spend our time looking at what the various candidates for President
from both political parties are saying about health care--certainly it
is getting a lot of attention in terms of debates on TV and all of us
trying to look at the various merits of the candidates' proposals; and
they are good people; and they have good suggestions--but I want to
make it clear to the Senate there are very real costs of waiting to fix
health care.
I think the question of fixing health care is so urgent we ought to
get on with it, and we ought to get on with it in a bipartisan way,
which is what I and Senator Bennett are trying to do. We are very proud
to have been able to get the support of business and labor leaders.
When we offered the initial proposal, Andy Stern, the president of
the Service Employees International Union, stood on one side of me, and
Steve Burd, the CEO of the Safeway company, a very large Fortune 500
company, stood on the other side. We had individuals such as Ron
Pollack, of
[[Page S11267]]
Families USA, and advocates for compassionate end-of-life health care
with us as well.
The last time Congress looked at this--and the Acting President pro
tempore, I think, remembers this--during a period in the early 1990s,
the people who stood with me for the kickoff of the Healthy Americans
Act were spending millions to pretty much beat each other's brains out.
That was the last time the Congress and the President, during the
Clinton years, debated health care.
So this is a different climate, certainly a different climate for
businesses in Ohio and Oregon. What I hear from businesses at home--
unlike in 1993, the Clinton years, when they said: We cannot afford
fixing health care--they are now saying: We cannot afford the status
quo. That is why they are joining Senator Bennett and I and others on
these proposals.
My hope is as Congress looks at the evidence, whether it is the Wall
Street Journal reporting on promising developments--very often people
think of Europe and socialized countries--the Wall Street Journal is
putting on the front page of the paper--a publication that clearly
favors private health care coverage--an example of a country in Europe
where they seem to be making great progress.
So as we devise our own system, one that is uniquely American, I and
Senator Bennett want to work with every Member of the Senate--I think I
can speak for Senators Bill Nelson, Lamar Alexander, Judd Gregg, and
the others we have been talking to--that we think this is the premier
domestic issue of our time. Certainly, the conflict in Iraq is the
premier national security issue. But the premier domestic issue at home
is fixing American health care.
I think based on the evidence that comes in every day, we know what
needs to be done. Now the question is making sure there is the
political will to go forward. I look forward to working with the Acting
President pro tempore, who has a great interest in these matters, and
all our colleagues.
Mr. President, I yield the floor.
Mr. President, I suggest the absence of a quorum.
The ACTING PRESIDENT pro tempore. The clerk will call the roll.
The legislative clerk proceeded to call the roll.
Mr. BROWN. Mr. President, I ask unanimous consent that the order for
the quorum call be rescinded.
The PRESIDING OFFICER (Mr. Casey). Without objection, it is so
ordered.
____________________