[Congressional Record Volume 153, Number 170 (Monday, November 5, 2007)]
[House]
[Pages H12725-H12732]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                        AMERICAN MEDICINE TODAY

  The SPEAKER pro tempore. Under the Speaker's announced policy of 
January 18, 2007, the gentleman from Texas (Mr. Burgess) is recognized 
for 60 minutes as the designee of the minority leader.
  Mr. BURGESS. Mr. Speaker, I come to the floor tonight to talk a 
little bit about health care. Of course, we are enmeshed in the great 
State Children's Health Insurance Program debate here this week, that 
load having been taken by the Senate at the end of last week, the bill 
being sent off to the President, we expect a veto, and probably 
sometime before this week is over, we will, one more time, test whether 
or not that veto will be overridden or sustained. I suspect the numbers 
will not have changed from the last time when the veto was sustained. 
So we are going to continue to have this debate in front of us for some 
time.
  I do want to talk about the State Children's Health Insurance Program 
in some detail. But I want to put it in context. I want to put it in 
the context of what is happening in American medicine today, the 
transformational process that is going on in American medicine today 
and how those rapid advances in science are being affected by the 
policies that we craft here in this body and indeed how that has 
happened several times during the last hundred years, and we may expect 
it to happen in the future, but why the decisions we make today in this 
body are so critical for the future of health care in this country not 
just for next November, not just for a year from now, but for decades 
into the future.
  Mr. Speaker, it is so critical, so critical that we develop a near-
term, a mid-term and a long-term plan or strategy when it comes to 
crafting our health care policy. Sadly, I don't think this House has 
really been engaged in that process. We have been more fascinated by 
the political aspects of the fight.
  Mr. Speaker, indeed, medicine is at a critical crossroads. This is a 
time of great transformation within the science. Down one of these 
pathways is a whole new genre of personalized care, changes in 
information technology, changes in the study of the human genome, 
changes in protein science, changes in imaging, the speed of 
information transfer; and indeed a time of rapid learning all serve to 
increase value for the patient.
  Late last week at a conference downtown, Dr. Elias A. Zerhouni, the 
head of the National Institutes of Health put it in terms of the four 
Ps. He described a type of medicine in the future which will be 
predictive, personalized, preemptive, and participatory.
  Now, Mr. Speaker, down the other path leads to the continued 
expansion of the reach and grasp of the Federal Government. Could this 
path equate to increased value for the patient? Well, the answer might 
be yes, but history has not been kind to that experience so far for 
this type of trajectory. The trend tends to become process driven, 
intensely process driven to a greater and greater degree rather than 
creating a true patient-centered environment.
  Medical care, in fact, could be rationed in some of the most 
insidious ways that medical care can be rationed, and that is in the 
treatment room itself. That is by not paying for the care, not paying 
for the imaging, not paying for the physician services,

[[Page H12726]]

having the physician not be there for the patient in the treatment 
room. That is the type of rationing that we may be talking about.
  It becomes all about the transaction, very little attention being 
paid to delivering value for the patient. And, Mr. Speaker, no secret 
about it, I am a physician. I practiced for 25 years back in my home 
State of Texas. I will tell you, this is also injurious to providers. 
It is injurious to doctors. And that, in turn, increases an already 
existing problem with the physician workforce and aggravates an already 
existing supply-and-demand inequity. This, in turn, creates a further 
imbalance between workforce required versus workforce produced.
  Prices are then set administratively rather than by the marketplace, 
and this disconnect heightens the insensitivity to market demands, and 
indeed, we end up with a system much as we see today where physicians 
are anesthetized as to the true cost of delivering the care that they 
deliver, and, in turn, the patient is unaware of the cost of the care 
that they receive. And this becomes a true hindrance to the 
transformational process itself. Again, the process becomes entirely 
transactional, and this hinders, or reverses, the transformational 
process.
  Now, Mr. Speaker, I would like for us to consider three events, or 
three epics in the last hundred years where health care policy and 
changes in science kind of came together to alter, fundamentally alter, 
the way medicine is practiced and alter it forever into the future.
  The first time would be early in the last century, 1910 to 1920, 
where significant advances in medicine including new discoveries 
related to immunizations, advances in public hygiene, discoveries of 
anesthesia and modern blood banking weren't too far removed from that 
era, but they did occur a little bit earlier. That was such a far cry 
from the way medicine had been practiced up even into the late part of 
the 19th century. Back then, the order of the day was burning, 
bleeding, and blistering; and those were accepted as scientifically 
proven ways to deliver value or to deliver care for the patient. So 
there was a rapid change in the science that was going on, and there 
also occurred that intersection of a sudden change in public policy 
that, again, altered the direction of medical care forever after then.

  In fact, now the policy that was developed we pretty much regard as a 
State function. And it is ultimately a change in State policy. It did 
originate at the Federal level with the commissioning of what became 
known as the Flexner Commission, which subsequently delivered the 
Flexner Report. This report, delivered to Congress in 1910, 
characterized the uneven structure of medical schools across the 
country. Indeed, the variability of medical schools was truly 
startling. As a consequence of the Flexner Report, there was a 
standardization of medical school curricula at a time when the science 
was, indeed, rapidly advancing. This set the stage for the 
transformation of medicine literally out of the Dark Ages into the 
illumination of the 21st century.
  Then let's skip forward several decades, Mr. Speaker, to the 1940s. 
And again we see vast changes occurring. Penicillin had been discovered 
a little bit before that. Back in 1928, Sir Alexander Fleming, we all 
know Sir Alexander Fleming, there is a big statue erected to him by the 
bullfighters because he obviously changed the way bullfighting injuries 
could be treated, but penicillin was discovered in 1928. It was really 
little more than a laboratory curiosity at first, this substance 
produced by a mold that would inhibit the growth of bacteria on an agar 
plate in a Petri dish, but only small amounts could be produced, and it 
was fairly labor intensive and extremely expensive. So it is a compound 
that showed great promise, but there really was no way amenable for 
treating large numbers of patients so its social impact was really 
quite, quite muted.
  But then came the discovery of new fermentation techniques in this 
country in the 1940s. Suddenly, penicillin moved from a laboratory 
curiosity to a compound that was readily available, readily available 
in the clinics and dispensaries across the country, readily available 
and the price subsequently came down significantly. This new life-
saving antibiotic was even available to treat our soldiers who were 
wounded during the invasion and the landing in Normandy in 1944. For 
the first time battlefield medicine had a way of combating infected 
wounds which obviously had a significant impact on saving life and 
limb.
  Now, a similar story could be told about cortisone. It had been 
discovered prior to the 1940s, but the production of cortisone was very 
labor intensive. In fact, you had to derive it from the adrenal glands 
of oxen so it required someone going down to the slaughterhouse and 
collecting these glands and then doing whatever extractive process that 
was required to pull the cortisone out. So you can imagine that there 
just wasn't a lot of cortisone available and what was available was 
pretty expensive to produce.
  But a bright young scientist name Percy Julian, and parenthetically, 
Mr. Speaker, we honored Dr. Julian here in this House in the last 
Congress, an African American scientist of great renown and turned out 
to be responsible for a great number of discoveries in the 1940s, 1950s 
and 1960s. And it was appropriate that this House honored his memory.
  But Percy Julian discovered a way of producing cortisone in large 
amounts using precursors that he derived from a plant product, from 
soybeans. Thus, again, a medicine which had heretofore been only a 
laboratory curiosity or a research oddity became readily available, 
became readily available in large supply, and the price fell to within 
reach of the average patient.
  So in the 1940s, we see the near-simultaneous introduction of large-
scale quantities of an anti-infective agent, penicillin, and an anti-
inflammatory agent, cortisone; and that was to forever alter the 
landscape of medicine.

                              {time}  2145

  But, at the same time, we saw the intersection, again, of a major 
policy change and how that policy change has affected and has impacted 
the practice of medicine now for decades into the future. In some ways, 
in many ways, Mr. Speaker, that change in policy, that social change 
that occurred in medicine at that time had just as profound an effect 
as the scientific advances of the 1940s. Of course, during the 1940s we 
were a country at war. The Second World War was raging. Because a lot 
of the workforce was tied up in fighting that war, there weren't many 
people left to do the manufacturing work in this country, but it was 
work that was required because, after all, they were producing for the 
war effort.
  So, employers wanted to keep their employees working, they wanted to 
keep them happy, they wanted to keep them healthy, but the President 
issued wage and price controls so employers were not able to pay higher 
and higher wages. The President did this with all good reasons, to 
prevent an inflationary spiral from getting out of control. With wage 
and price controls on, employers looked around: Well, how are we going 
to improve things for our employees so they will want to stay here 
working for us and won't go off looking for work in some other 
location? They hit upon the idea of providing benefits to their 
employees, both health insurance benefits and retirement benefits.
  Well, there was a lot of controversy over whether or not that 
violated the spirit and the context of the wage and price controls. So 
they did what all good people do; they went to court and eventually it 
worked its way up to the Supreme Court. In 1944, the Supreme Court 
ruled that indeed these health benefits that were being provided to 
employees could be provided without violating the spirit and the intent 
of the wage and price controls. Moreover, that these benefits could be 
supplied to the patient with pre-tax dollars; that is, they were not a 
taxed benefit given to the employee.
  So, simultaneously, we had the era of employer-derived health 
insurance ushered in, which has proved to be exceedingly popular and 
endures to the present time. Although it has experienced some problems 
recently, it is still a very popular way for people to obtain their 
health insurance coverage. Also, near simultaneously, we began the time 
of the uneven tax treatment between employer-provided insurance as 
opposed to individually owned or individually provided insurance, which 
is paid for with after-tax dollars.

[[Page H12727]]

  So then, Mr. Speaker, we fast-forward to 1965. Again, there were vast 
changes occurring in the science and medicine. At that time, new 
antipsychotic medicines were introduced, and for the first time the 
mentally ill could be treated with medication as opposed to simply 
restraining someone or holding someone in an incarcerated environment. 
So it truly changed the landscape of medicine in the mid-1960s.
  Also, at that time you had the introduction of antidepressant 
medications. Although the antidepressants have undergone many, many 
changes since that time, for the first time medication was available to 
treat a condition of depression, and this opened up whole new worlds 
for treatment of patients in the 1960s.
  Newer antibiotics were introduced to fight more aggressive 
infections. There was the beginning of the understanding that 
biochemistry played in the development of coronary artery disease, why 
high cholesterol had an impact and was important in the subsequent 
development of coronary artery disease. And, Mr. Speaker, conditions 
like malignant hypertension, which had claimed President Franklin 
Roosevelt the generation before, now saw newer medications that were 
available to treat this malady, medications that had not been 
previously available.
  But, Mr. Speaker, again, there was that intersection of public policy 
which combined with rapid changes in the scientific arena to forever 
alter the landscape of the practice of medicine. In 1965 we saw the 
introduction of a program that we now know as Medicare, and then 
subsequently the Medicaid system was introduced in the years that 
followed. Now, for the first time, for the first time the Federal 
Government had an established role in paying for health care. Again, 
the medical world was forever altered.
  Mr. Speaker, now in the present time we find ourselves in a highly 
political year. Health care is foremost in a lot of people's minds, 
particularly those that seek to lead the country via the office of the 
Presidency. The next administration is likely to be under significant 
pressure for the expansion of the Federal role in delivery of health 
care. Indeed, we see evidence of that now with the debate that is 
occurring over the State Children's Health Insurance Program.
  Before we get to the State Children's Health Insurance Program, Mr. 
Speaker, history tells us that policy makers will, we will put the 
emphasis on the transactional and the administrative aspects of health 
care reform and we'll ignore the transformational process as it is 
occurring all around us.
  Mr. Speaker, I think it is helpful to consider what is the unit of 
production of this vast American medical machine that is all around us. 
In its simplest terms, the unit of production is the interaction that 
occurs between the doctor and the patient in the treatment room. That 
is the widget. That is what the American medical system produces.
  So all of our focus, all of our focus should be directed at driving 
up or delivering value at the level of the doctor-patient interaction. 
But all too often, all too often, our attention is diverted into other 
things. This, in turn, degrades the doctor-patient interaction.
  Now, at the health fair's 25th anniversary symposium downtown last 
Thursday, Dr. Mark McClelland, former Director of the Food and Drug 
Administration, former Director of the Center for Medicare and Medicaid 
Services, started off his talk with: We want to know what works best at 
the lowest cost for each patient. In a nutshell, that is what 
personalized medicine is all about.
  Right now we don't know. We don't know. But that concept defines a 
whole new era of the type of medicine that will be practiced in the 
latter part of our lifetimes, and indeed in our children's lifetimes 
and certainly in our children's children's lifetimes. That's the type 
of medicine that we will be practicing. Short-term gains in 
affordability, unfortunately, could lead to long-term stifling of 
patient access and interfering with the supply-demand relationship that 
occurs and exists in the medical marketplace. Certainly accountability 
may suffer with the subsequent reduction in quality because, quite 
frankly, the best and the brightest may self-exclude themselves from 
the medical workforce. Thus, we could have a situation where care is 
delivered by those who do not represent the best and brightest 
physicians or perhaps physician extenders or other paramedical 
personnel, and the overall quality of medical care to what, arguably, 
is the most challenging group of patients, our seniors, that might be 
further eroded.
  Advancements in medicine might be placed in peril. Indeed, it is some 
of the tension in the current system, that hybrid system that is part 
public and part private. It is partly the tension that exists in that 
system that is a dynamic for change. Not all the change is good, but 
generally, generally it moves in the right direction.
  Mr. Speaker, I'd ask us to consider for a moment the dilemma of 
health information technology. When I first came to Congress in 2003, 
the Department of Health and Human Services said it's going to develop 
a platform for the establishment of a national information technology 
effort. In fact, please, Congress, don't do anything right now because 
we are going to do this. We are going to establish this platform. We 
are going to get it right, and industry will follow what we do. 
Unfortunately, that reality has yet to be delivered.
  Now, there are some bright spots. There is advanced informational 
technology within the Veterans Administration, but it lacks the 
interoperability with the system used by the Department of Defense, and 
this lack of interoperability may well have been the root cause for 
some of the problems encountered by our soldiers on medical hold at 
Walter Reed Hospital. Let me just give you an example of that, Mr. 
Speaker.
  Mr. Speaker, of course The Washington Post broke the story, I 
believe, in January of this year about some of the treatment being 
received by some of our soldiers at Walter Reed Hospital. So, like many 
Members of Congress, within a week I took a trip out to Walter Reed 
Hospital, and indeed the physical characteristics of Building 18, the 
building in question, were deplorable, and the building was 
appropriately decommissioned and those soldiers were moved into more 
reasonable accommodations actually inside the campus of the Walter Reed 
Medical Center.
  Building 18 was outside the garrison, it was outside the actual 
confines of the campus of the Medical Center, and, as a consequence, 
that made it desirable for some individuals. But the reality was the 
building itself was just not up to standards, not up to code, and 
realistically our soldiers on medical hold should not have been there.
  What happens too, Mr. Speaker, is soldiers on medical hold, they are 
trying to decide if the injuries that they are there for which they are 
being treated are serious enough that they will now be discharged from 
the military and their care will transition over to the Veterans 
Administration system so it will be more of a disability-type of 
assessment that they undergo, or are their injuries such that they can 
in fact rejoin their unit. The individuals in that situation are placed 
on what is called medical hold, and there were facilities outside the 
garrison at Walter Reed Hospital to house those individuals on medical 
hold.
  Now, here is a picture of Master Sergeant Blades, who took me around 
and showed me the rooms in Building 18 that were the point of some 
contention. But Master Sergeant Blades told me when I was there that 
the real problem he and his men were encountering, yes, the 
accommodations were crummy, but the real tragedy was the work that went 
into preparation of this medical record, the Department of Defense 
medical record, in getting it ready to send over to the Veterans 
Administration to perhaps make the case for the disability, make the 
case for what the disability allowances should be, what the disability 
payments should be, what care could be available at the VA hospital.
  He said that he would spend hours and hours and hours preparing his 
medical chart, highlighting things with a yellow highlighter. This 
large chart in front of him, it looks about the size of the Washington, 
DC phone book, would then go sit on a desk for 2 weeks and then be lost 
and he would have to start all over again.

[[Page H12728]]

  I said, well, wait a minute. I thought the VA system had this new 
fancy computer equipment and that this should no longer be a speaker. 
But as it turns out, Mr. Speaker, the Department of Defense can't speak 
to the computers in the VA system, and, as a consequence, it depends 
entirely on a hand-prepared record, and you see Master Sergeant Blades 
there preparing it as we visited that day at Walter Reed Hospital.
  Here in Congress, the legislative process dealing with health 
information technology is completely stalled. We had a chance to act 
last year in the last Congress. The bills we were considering were to 
provide either grants or buying equipment outright for medical 
practices. But in the end, we couldn't get our work done, and the 
current legislative attempts that we see this year seem even more 
desperate and futile from those of last year. We have gone from bad to 
worse.
  Considerable expense could be borne by individuals in private 
practice, physicians in private practice, trying to purchase or upgrade 
equipment. These informational systems and costs and learning of the 
operating of these new systems are significant barriers to entry.
  Relaxation or moderation of what are known as the Stark laws could 
allow for hospitals and doctors to be cooperative and involve 
themselves in the investment in this type of technology. But barriers 
to entry for physicians are that the equipment is expensive. And in 
addition to the initial cost and the cost of maintenance and the cost 
of software and the cost of software upgrades, there is a problem: If 
there is no established criteria for interoperability, how is a guy out 
in private practice or a lady out in private practice who goes and buys 
a computer system from a vendor, how are they to know that they are 
making the correct purchase at all?
  Now, that is the public sector. That is the government working on 
this. Remember one of the things I first said, the change of the speed 
of delivery of information is one of the things that is going to 
transform medicine. We are kind of stuck here and have been stuck here 
for 4 or 5 years.
  What is happening on the private sector? Consider the experience of 
Aetna Insurance Company. A single company employing 34,000 individuals 
and has 15 percent of its workforce involved with information 
administration and maintenance. In fact, according to their CEO, if the 
Aetna Information and Technology Department was a standalone company, 
it would be one of the largest software development firms in the United 
States of America.
  They have developed a Web-based electronic health record, not an 
electronic medical record controlled by the doctor, but a Web-based 
electronic health record that is controlled by the patient, the access 
is controlled by the patient, and that is available then to a patient 
anywhere in the country where they have computer access.
  So, if they are traveling and they have got a medical condition that 
is under pretty tight control and good control at home and they have a 
problem, that information can be handed over to the treating physician 
in an emergency room at a distant location, because all that 
information is going to be available to them up on the Web. And when 
that patient returns home and returns to their doctor at home, the 
information derived, the testing done by that doctor in the different 
location, will be available to the patient when they return to their 
home for care.

                              {time}  2200

  Mr. Speaker, I have to tell you, I haven't always been a big believer 
in things like computerized medical records. Sometimes they are hard to 
learn. There is a learning curve associated with them. It takes some 
time to get up to speed with them. No one is interested in paying for 
the time it takes to get up to speed.
  But in January 2006, taking my second trip down to the City of New 
Orleans after Hurricane Katrina came through there, all of the water 
came in, this is the basement of Charity Hospital. The water has been 
removed. You can't see in the picture, but there was still water about 
ankle deep. This is just one of hundreds of rows of charts as you might 
imagine a hospital of that size might contain.
  This black here, they haven't been burned, this is mold growing on 
the medical records. This vault now is a hazmat site. Someone wanting 
to review a record for a patient would have to take extraordinary 
precautions not to inhale the spores from the mold when they opened the 
record. These records are unusable and unavailable and no one knows 
what has been lost here. There might be someone's leukemia, childhood 
asthma; those records are lost forever. This changed my mind on the 
concept of having an electronic medical record or, as Aetna has 
developed, an electronic health record that is owned and controlled by 
the patient and is Web-based.
  Mr. Speaker, I ask which system now, remember my fundamental 
criteria: Do we deliver value to the doctor-patient interaction in the 
treatment room? Which system is delivering value to the doctor-patient 
interaction in the treatment room right now? Is that what we are doing 
at Health and Human Services, where we are trying to get things up and 
running, develop a national platform and one of these days we are going 
to roll this out? Or in the Halls of Congress, we are going to craft 
legislation if we can get the pieces right. But watch out, the 
unintended consequences of that legislation may turn around and bite 
you when you try to practice medicine a few years in the future.
  Or the experience at Aetna U.S. Health Care. You have one system that 
is mired in entrenched bureaucratic wrangling, and the other one 
providing real data for real patients and advancing their health. Which 
system is making the maximum capital investment at the same time 
demanding accountability to deliver value for its covered individuals? 
Which system continues to hamper the growth and development of the 
technology that everyone acknowledges is necessary to bring medicine 
into the next generation?
  I talked about a short-term, mid-term and long-term strategy. That 
long-term strategy is the explosion in health infomatics that is going 
to bring us the type of personalized care we want in the future.
  Now, Mr. Speaker, the American medical system takes a fair amount of 
criticism from around the world. I want to bring to the attention of 
this House the Washington Post and the Wall Street Journal today, two 
stories in two different newspapers today talking about some things 
that are happening when you export American medicine, American know-
how, American technology half the way around the world.
  From the ``World in Brief'' section under the heading of Afghanistan: 
``Six years after the Taliban's ouster, medical care in Afghanistan has 
improved such that nearly 90,000 children who would have died before 
the age of 5 in 2001 will survive this year.'' That's thanks to the 
efforts of the United States Agency for International Development that 
has brought modern American medical technology to the country of 
Afghanistan. They still have a long ways to go, but I thought I would 
share that with the House.
  Another story from the Wall Street Journal about how we export 
American technical medical know-how to other countries. This is 
actually in the ``Marketplace'' section of today's Wall Street Journal. 
The title is: ``Health care building booms in the Persian Gulf.'' It 
says that the region's families are recruiting brand-name U.S. medical 
institutions and private investors with plans over the next 20 years to 
more than quadruple the estimated $12 billion spent annually on health 
care. They are essentially trying to duplicate Harvard Medical School 
and its residency programs at the Massachusetts General Hospital in the 
City of Dubai.
  As I stated previously, we are at a transformational time in 
medicine. There are changes occurring on many fronts. At the same time, 
we have the intersection of changes in public policy which can vastly 
affect the practice of medicine for years, decades into the future.
  Mr. Speaker, there is a risk here. If health care policies are based 
on political expediency, and if they are not patient-centered, there is 
a risk of continuing to be beholden to the special interests and not 
empowering patients. There is a risk of delivering for the status quo 
and not delivering for the future.

[[Page H12729]]

  Indeed, the transactional could triumph over the transformational. 
Prevention of this scenario will require development of, certainly with 
physician leaders within the house of medicine, they have to be engaged 
for their patients and not for the enduring bureaucracies or special 
interests. We do have some relatively new products that have emerged on 
the scene in the last several years. Health savings accounts and their 
precursors, medical savings accounts, are just a little over 10 years 
old, and they show some significant promise by putting purchasing power 
back in the hands of the patient and rekindling that doctor-patient 
relationship that has been so many times stifled by the current system.
  Improvements to the health savings accounts could include methods for 
paying for preventive care and adding new coverage to include disease 
management for chronic conditions. In other words, move health savings 
accounts from the type of patient that is only going to purchase one 
because they don't think they will get ever get sick, to the type of 
patient who knows they have a medical condition but they want the power 
over their medical condition, and a medical savings account is a way to 
do that in an affordability fashion and still retain power over their 
illness.
  Mr. Speaker, we should encourage new thinking by third-party payers. 
At some companies that is going on already. It could help move borders 
for affordability. A business that provides a premium reduction for 
individuals who engage in preventive practices and periodic screenings 
would represent a reasonable way to deliver increased affordability. It 
is a way of delivering value for the patient.
  If the legislators and Federal agency personnel have the vision and 
discipline to focus on the long term, we may yet see delivery on the 
promise of the pending transformation in American medicine.
  Mr. Speaker, former Speaker of this House, Newt Gingrich, in his book 
on transformation, I think his second principle of transformation where 
he asserts real change requires real change. What does he mean by that? 
He means in order to affect real change, you have to walk the talk. 
There has to be a culture and leadership not just embracing of the 
concept of change, but they have to act on it. They have to live it and 
breathe it and work it every single day. That is a valid concept, and I 
think the Speaker is right on the money when he brings that concept up.
  But look at it another way. Real change requires real change. There 
is real change occurring in medicine, whether Congress knows it or not, 
whether Congress likes it or not, and whether Congress helps it or not. 
Real change is occurring in American medicine right now. Because of 
that real change that is occurring in the science part of medicine, 
real change is required here in this Congress, in the other body as to 
how we approach our health care policy so, again, we don't let the 
transactional become the enemy of the transformational.
  Mr. Speaker, a short-term, a mid-term and a long-term strategy are 
essential, and we must avoid sacrificing this concept and giving it all 
up for short-term political gain, which brings us back to the subject 
of the State Children's Health Insurance Program. When I think of 
health care policy, I try to put it in the context of what is 
delivering value for that doctor-patient interaction in the treatment 
room, not the cost, but what delivers value to that interaction.
  What diminishes value? What happens if we have a significant negative 
effect on the physicians who are providing the care for our pediatric 
patients? Is there a cost to providers for shifting populations from 
commercial insurance onto public insurance? Well, I believe there is.
  Mr. Speaker, I don't really know why and where insurance companies 
get the idea it is okay to only partially cover the cost of providing 
care, but I have a suspicion they get that because that's the way the 
Federal reimbursement structure works. That is the way it works in 
Medicare and Medicaid; and if we expand the reach and grasp of the 
Federal Government in the SCHIP program, I think we will find to the 
detriment that process is alive and well and subsequently we have the 
negative effect on the physician workforce.
  Mr. Speaker, before I yield to other speakers, let me bring up this 
slide from the American Enterprise Institute. This points out at 
successive income levels, and these are rated at the percentage of the 
Federal poverty level, so here is between 100 and 200 percent of the 
Federal poverty level. This is about $41,000 to $42,000 a year. Here is 
between 200 to 300 percent of the Federal poverty level, so that is up 
to just over $60,000 a year. And 400 percent of poverty would represent 
a figure of over $80,000 a year.
  So in the group between 100 and 200 percent of poverty, and this is 
the group that SCHIP was originally designed to cover, about half of 
those children have private coverage. If you move into the 300 percent 
of Federal poverty limit, they earn up to $60,000 a year, three-
quarters of those kids already have health insurance. And nine out of 
10 and 95 percent have health insurance. Why do we want to go and take 
these children who are already covered and bring them back into the 
SCHIP program? Are we delivering value to the patient? Are we 
furthering the concept of good patient care?
  Mr. Speaker, I would point out that on the floor of this House 2 
weeks ago when we had the debate on the new State Children's Health 
Insurance Program bill that we passed which was exactly like the one 
that the President vetoed and we sustained, when we were debating the 
new bill, I asked the chairman of the Committee on Energy and Commerce 
to enter into a colloquy with me, and he graciously did. We talked 
about State income set-asides. If the bill said that the maximum amount 
available for coverage under the program was 300 percent of the Federal 
poverty limit, so a little over $60,000, where again three-quarters of 
those children already have insurance, if that is our upward limit of 
coverage, were there income exclusions available to the State that 
could take that upper income level even higher, and I asked 
specifically about the cost of housing. And indeed within the bill was 
the language that States could exclude $20,000 of annual income 
involved in housing. And States could exclude $10,000 of annual income 
that is there for clothing. And States could exclude $10,000 of annual 
income that is available for transportation. Mr. Speaker, we are 
already over $100,000 in annual earnings for a family of four when we 
talk about this bill that was introduced and passed by this House.
  Mr. Speaker, I am just a simple country doctor and there is so much 
about the budgeting process that I don't understand that I am so 
grateful that I have been joined by the gentleman from New Jersey (Mr. 
Garrett) who sits on both our Budget Committee and our Committee on 
Financial Services. I think he is going to provide us all with some 
valuable insight as to some of the numbers involved in this process.
  So I do now want to yield the floor to the gentleman from New Jersey 
(Mr. Garrett).
  Mr. GARRETT of New Jersey. I thank the gentleman from Texas for 
yielding. I thank the gentleman also for bringing this issue once again 
to the floor. I was in my office earlier this evening when you began 
your remarks, and I have heard you on the floor on numerous occasions 
speaking to medical topics.

                              {time}  2215

  We appreciate very much your background, the expertise that you 
bring.
  And on that point, I should just say that on my 3-hour trip from New 
Jersey traveling on good, old reliable, semi-reliable, slow Amtrak, I 
had the opportunity to read a number of your articles that you have 
written. I would commend anyone who is listening to us here tonight. I 
should ask the gentleman, is much of this material I read, one a 
position paper, another is called Addressing America's Health Care 
Challenge: A Solution, are these articles by any chance up on your Web 
site? Can I commend the audience here that listens to us tonight to go 
to your Web site and look to find these things?
  Mr. BURGESS. Yes. You're very kind to point that out, and those 
writings, as well as several other musings and lamentations are 
available on my Web site. The bulk of the writing on the Web site is 
devoted to health policy because obviously that is one of my interests 
and one of my passions. So

[[Page H12730]]

there's a good deal of information available; www.house.gov/burgess 
will take, scrolling back through the previous stories will give 
someone an insight as to what's available on the Web site.
  Mr. GARRETT of New Jersey. I appreciate that, and just a couple of 
them, Addressing America's Health Care Challenge, with that and what 
you've talked about here, as I put the expression, you step back for a 
moment and look at the bigger picture, which is what I'm going to talk 
about in a moment. So I think this is a good one.
  Another one is the cure to the physician crisis, and I'm not going to 
get into it here. This article gets into it pretty well to say, you can 
do all that you want to do when it comes to the issue of health 
insurance, but if we don't have enough docs out there such as yourself 
and other docs out there, physicians that are out there taking care of 
the patients, it's not going to mean anything.
  When I'm back in my district and I tour my hospitals, what is one of 
the first complaints or concerns that I have, and I bet it's the first 
complaints and concerns that you hear from your hospitals, is a 
shortage of nurses. And whether it's long-term care facilities, 
hospitals or clinics, they say we just can't get enough visiting 
nurses, we just can't get enough trained nurses as well.
  If we don't get that aspect of the problem solved, everything else 
that you and I and the rest of Congress talks here tonight and in the 
future will mean nothing because we're not getting the providers to the 
patients.
  So, again, I just wanted to start where I should probably end, and I 
think I will in a little bit, thank you for your work in this area.
  Where you left off and some of the points you were touching about 
goes along this line, and that is, that you have to look at some of the 
bigger picture.
  In my office, I was looking at some data, and one of them is on data 
from the World Health Organization, and I think this is interesting. 
Again, regardless of what we do on health insurance and regardless of 
what we do in the government, whether it's in the Federal level, the 
State level or anything else, here's what they tell us. Here's what the 
World Health Organization tells us. That if Americans, and I guess the 
world community as well, but Americans in particular, would address 
three areas, smoking, eating disorders and eating, what your diet is, 
and exercise, if you address those in a logical coherent manner, 
presumably after consultation with your physician, 80 percent, an 
amazing number when I read it, 80 percent of Type 2 diabetes could be 
addressed and resolved. Eighty percent of heart disease could be 
resolved. Forty percent of cancer issues could be resolved.
  Nothing about buying insurance. Nothing about spending more money. 
Matter of fact, you'd probably end up spending less money if you ate 
right and didn't go to McDonald's as much as I do. Those three areas.
  The one on diabetes, I just had the opportunity in the last week to 
10 days to have folks from that organization come and speak to me back 
in the district, and they pointed out a statistic. Approximately a 
little less than one-third of the dollars that we spend on Medicare 
goes to diabetes or diabetes-related injuries or other illnesses that 
are related to it.
  So can you imagine, if we were able to resolve that issue, how we 
would be able to address our health care costs in this country. Costs 
being one factor, but obviously, the bigger factor is improving the 
quality of life.
  So you're right on the target when you say how do we improve the 
health quality of individuals in this country first and foremost; and 
secondly, how do you do that through a proper physician relationship.
  As I come to the floor this night, and I always make reference to 
this mark, here we are in November, the 11th month of the year, and we 
have to ask ourselves what has now under the new Democrat leadership 
wrought when it comes to the issue of health care in this country.
  Somebody else pointed out some numbers to me the other day. I think 
it was this past week. So far the ledger is 106 bills have made its way 
to the President's desk. Forty-six of those bills have been to do with 
the naming of post offices and Federal buildings. Forty-four just have 
to do with Special Orders and special days and the like. That's almost 
two-thirds. Ninety bills out of 106 of no real major significance, and 
here we are at the floor tonight I think addressing something that is 
of major significance, second perhaps only to what our colleague Tim 
Walberg and others were talking about as far as their faith issues, and 
that is the quality of life and the health of the citizens.
  This, though, is not a new issue. President Clinton, when he was 
President of the United States, said that he had an answer to this 
problem, and it goes in a totally different direction that you were 
addressing before. His solution was larger Federal Government 
intrusions into this part of the economy. It's approximately what, one-
fifth of the overall spending of the GDP on health care. He wanted it 
to be even larger and more of a centralized control, government-
controlled health care, if you will, socialized health care.
  And he told us back at that time how he intended to bring this 
country, that he realized after Hillary's failure to address the issue 
through her secretive meetings that we heard about later on, he said 
how can we get there. He said we can get there through a centralized, 
government-run health care system incrementally. First, we'll insure 
and control the health care for indigent children, then all children 
and for indigent adults, and then for all adults. So all of us 
eventually will come under the control of the Federal Government.
  That means we were basically putting that very personal, that you 
referred to before, and you know as well from the doctor side, we all 
know from the patient side, the placing of doctor-patient relationship 
under the control of the Federal Government, bureaucrats, faceless, 
nameless, maybe very nice people and well-intended, but bureaucrats.
  I scratch my head to think when people actually advocate such a 
government control. This is the same Federal Government that we saw 
handle the Katrina situation and FEMA terribly, loss of life, loss of 
homes and what have you, that Federal Government. This is the same 
Federal Government during this past summer when families were trying to 
go on vacation and asked the Federal Government to do one of its basic 
functions, issue visas so families could go on family vacations. The 
government couldn't get the visas out the door. This is the same 
Federal Government that to this day we're still arguing and debating on 
this floor how do we close and secure our country's borders so that 
illegals and terrorists and drug traffickers can't come into this 
country. That same Federal Government can't control this, but they want 
to control our health care delivery system.

  So he told us how he was going to do it, and one of the charts up 
that you have, I have a variation of it, but if I could just ask the 
gentleman from Texas to put that one chart back up with regard to the 
coverage. It tells us how he was going to do it, and they're now trying 
to do it through SCHIP.
  By very definition, a middle-class entitlement means that you are 
going to be providing an entitlement, in this case, health care, for 
people who are making over or at the middle-class level of income and 
above. Well, we know that the poverty level is, for a family of four is 
around $42,000. I'm not sure if that's showing that on that chart, for 
a family of four is around $42,000. We also know that the median or the 
middle range of income in this country, again for a family of four in 
this country, is around $48,000.
  So, by definition, if you're going to be providing a benefit to 
people over that level, over $48,000, then you're providing a middle-
class entitlement. It's no longer talking about poor children first. I 
know there was another chart, benefits should go to poor children 
first. We're no longer talking about the indigent. We're now talking 
about just about everyone.
  A family of four making over 300 percent makes around $62,000. So by 
definition we're saying, under the proposal that came before the House 
with regard to SCHIP, we want to provide benefits to a larger group of 
people, to a middle-class entitlement. And who is going to pay for that 
is the next question that should come to mind.

[[Page H12731]]

  Well, the plan that is in place to pay for those various ranges, and 
without my far glasses it's hard to see them, says that that is going 
to come out of various sources, but one of the biggest sources will be 
smokers. And the interesting thing about this is that in order to get 
enough money to provide for that level of coverage, not just for the 
indigent anymore, but people above the 200 level of poverty, 300. As 
you know, in the State of New York they tried to go up to the 400 level 
of poverty, which means around $84,000 a year. In order to do that, 
they will have to look to smokers, which is fine on the one hand until 
you get into the weeds a little bit on this issue. And the Heritage 
Foundation did a little bit of study and said how many people do we 
have to actually have start smoking in this country in order to come up 
with that money, and they found out at the end of the day that we will 
actually be looking to find 22,000 more smokers in this country in 
order to fund this program.
  Now, you are a physician and you could probably speak ad nauseam that 
smoking is harmful for your health, and actually it's most harmful 
probably for little kids more than anybody else. But in order to fund 
this program for the indigent poor and also for a middle-class 
entitlement, a government-controlled health care system, they will be 
looking to say we need 22,000 more children in this country in order to 
start smoking tomorrow so that we will have funding for this program 
down the road for the next few years.
  It's an absurd situation, and it's even a little more absurd when you 
think about who actually does smoke in this country. This is a little 
bit of a sad situation. Lower income individuals smoke to a higher 
percentage than upper income individuals. And in fact, if you look at 
the numbers, it's something like this. People who make under $10,000 a 
year, so very low-income people, pay twice as much in taxes from 
smoking than people who make over $50,000 a year.
  So what are we really saying? We're saying that we need 22,000 more 
kids to start smoking to pay for this program. And who are those people 
that are actually going to pay for it? The lowest of the low-income 
people who are smoking are going to pay the biggest percentage of their 
income towards this program.
  It's an absurd situation to fund it, and it goes back then to the 
final point, and I'll close and I'll yield back to the gentleman, as I 
think our time is coming to a close. It's an absurd funding formula to 
come up with for a government-run program. And unfortunately for the 
advocates of the program, the money runs out. The money runs out.
  You see on our little chart here, starting, if this program, as 
proposed by the other side of the aisle, Democrat side of the aisle, it 
would start in 2008, and there's little kids being encouraged to sign 
up. Indigent children are being encouraged to sign up for this program. 
I notice this picture does not have the children smoking. So, to be 
actually correct, we should have the children smoking, because they're 
encouraging them to smoke in order to pay for this program, but it 
would only last for 5 years. Then, after the 5 years, the funding is 
cut off almost entirely, 80 percent. That's why we have the chart go 
demographically down, and the kids are left hanging, in this case 
parachuting.
  Why this is bad is twofold. One is because we're leading people to 
believe that we're actually setting up a program that's going to be 
paid for perpetually for the children. And two, who is this child 
that's now left jumping off of this cliff here? As your previous chart 
showed, he may very well have been a child who was already covered by 
your insurance. And your chart shows 55, 75, 80, 90 percent of the 
children had insurance prior to this program coming along, but now they 
were encouraged to join into this program and go into it, give up their 
prepaid plans under their father's programs, mother's programs, company 
plans, what have you. Five years from now under this program, it's 
designed to fail. They will jump off. They will not have anymore 
government program, and they also will no longer have any private 
insurance.
  So we are setting up a system, encouraging kids to smoke in order to 
pay for it, and leading them to have to basically fall off the cliff in 
5 years without having any health insurance at all.
  At the end of the day, and I'll close on this, I commend the 
gentleman for leading us to look at this issue from a larger 
perspective, to ask a basic question. It's not so much about health 
insurance; it's about health care. And it's not so much of whether you 
have the coverage to provide you with insurance; it's whether or not 
you're actually going to have a doctor or a nurse out there to provide 
those services for you. And it's not so much as whether the government 
is supposedly going to do it, because we know at the end of the day 
they can't, by the numbers; it's whether or not at the end of the day 
we can come up with something to actually make sure that the patient is 
in control with his doctor of the delivery system and that it's the 
best care in order to provide the services to them, and at the end of 
the day the quality of life of those individuals as well.
  I commend the gentleman from Texas for bringing this to the American 
public's attention tonight, and I look forward to reading more of his 
material, as well both on-line and in person.

                              {time}  2230

  Mr. BURGESS. One of the points that I probably did not make 
eloquently enough tonight is that the practicing pediatrician, not the 
pediatrician in an academic setting, not the pediatrician in a 
federally qualified health center, but the pediatrician is out there 
with a mix of different payer groups in his practice or her practice.
  The average reimbursement for a child on the SCHIP program is about 
30 percent less in my State of Texas than it is for one of the 
commercial insurances. If we take those children off of commercial 
insurance and move them to an SCHIP program, we are negatively 
impacting the bottom line of the pediatrician who is providing the 
care. We can only do that for so long before they will decide that they 
have got something else that they might do.
  Mr. GARRETT of New Jersey. You make a perfect point. Again, it goes 
to what we were saying before. It doesn't matter whether you have 
insurance or not. It matters whether or not there is actually a doctor 
who will be there to take the insurance.
  How many individuals that you know, senior citizens that you know 
right now that are Medicare or Medicaid, and they went out to find a 
doctor to treat them for their ailment, and they found out there are no 
longer doctors in their community who are taking Medicare or Medicaid 
patients. They had all the great socialized programs, coverage, that 
they needed. They just didn't have any doctors who would pick it up.
  You are explaining the same thing very eloquently. The same thing 
will happen to these poor indigent children. We lead them down the road 
to believe that they actually are going to have coverage now, that 
think that there is going to be a doctor there to take care of them. If 
their reimbursement rates are anything like they are for Medicaid, 
there may not be a doctor there to deliver the services.
  Mr. BURGESS. One of the things before the time completely leaves us, 
I just want to draw attention to a recent poll put out by U.S.A. Today 
that does show that the plurality of Americans, a majority of American 
citizens, believe that the benefits in the SCHIP program should go to 
poor children first, and that's not to the children at the upper-income 
levels that we were showing on the other slide. That is the group of 
children for which this program was originally intended, that is 
children whose parents make too much money to qualify for Medicaid, yet 
not enough money to reliably afford their health insurance.
  When this program was first enacted in 1997, by a Republican Congress 
with a Democratic President when this program was first enacted, that 
was a group of children that the Congress was trying to help. The 
concept of poor children first is one that the American people 
embraced.
  In fact, I introduced legislation earlier this year, H.R. 1013, that 
would have put the children back in SCHIP and removed adults from the 
program. Now, I am grateful, very grateful that the Democratic majority 
has now embraced that concept and at least their

[[Page H12732]]

latest iteration of the SCHIP reauthorization bill said that there will 
be no adults on the program within one year of the enactment of the 
bill.
  It's a bittersweet victory because there are so many other aspects of 
the bill that are flawed that Mr. Garrett has just alluded to. The 
funding mechanism absolutely disappears in the fourth year of the 
program. The funding mechanism itself is based on a belief that there 
will be an increasing number of smokers in this country, and public 
policies that I support to decrease the number of smokers and decrease 
the number of young people who begin this habit.
  It makes no sense to be saying we are going to fund this entire 
program based upon that type of tax and, on the other hand, try to put 
our maximal effort behind trying to reduce the number of smokers in 
this country. It is certainly a conflicted mindset that the Democratic 
majority seems to be propounding here.
  One of the other things that I do want to bring up just before we 
close, another poll from U.S.A. Today that the American people are 
concerned, are concerned that the program as proposed would pull those 
children off of private health insurance and put them onto a government 
plan.
  Then as Mr. Garrett so eloquently pointed out, then the funding dries 
up, and where are you then? At the same time, if you have driven 
pediatricians out of practice because of lower reimbursement rates, you 
have now the trifecta, the triple whammy, where health care for 
children may be seriously jeopardized in the mid-term or the long-term 
because of the fact that we are sacrificing for political expediency 
today.

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