[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.
____________________