[Congressional Record Volume 154, Number 19 (Wednesday, February 6, 2008)]
[House]
[Pages H597-H603]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                              {time}  1945
                              HEALTH CARE

  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. Madam Speaker, I come to the floor tonight to talk about 
health care, which we sometimes do in this hour. It's an important 
subject, and we are going to hear a lot about this over the coming 
year. We have got a Presidential election that is now in full throttle 
across the country.
  We just had Super Tuesday, and by a strange turn of events the 
nominations are not settled and my home State of Texas now next month 
will, in fact, play a big role in helping select the nominees of the 
two parties. During this coming month, I expect we will hear a great 
deal about the plans and visions and the aspirations of the different 
candidates for health care.
  But let's not forget, when we talk about health care, that it is on 
the floor of this House where about 50 cents out of every health care 
dollar that is spent in the United States of America today, it is on 
the floor of this House where that spending originates. I can't help 
but observe the last speaker who was addressing the House on the 
subject of the budget was critical of the President's budget, which is 
his prerogative and his right, but I would remind the previous speaker 
that it is his party that is in charge, as it was last year, and while 
it is the President's obligation to present a budget to the Congress 
every year, it is then the Congress' obligation to work on that budget 
and pass a budget, which will be voted on later in the year, that 
either accepts or rejects those proposals put forth by the President.
  Indeed, last year, that is exactly what happened. So the budget that 
went forward last year was not the President's budget, I would point 
out to the gentleman from New York, but the budget last year was the 
budget passed by the majority on the House of Representatives floor 
last year, and the same thing will be true this year. They are in 
charge. It is their right and prerogative under the rules of the House 
that they will have absolute authority to create the budget and, as a 
consequence, those things that are felt to be important are going to be 
those things that are championed by their side. Those things that are 
felt to be less important will be those things that are left of the 
budget. That responsibility lies in the House of Representatives. Under 
the rules of the House, that responsibility lies with the majority 
party. Currently, the majority party is the party of the gentleman who 
just spoke.
  So while I appreciate his passion, I appreciate his fervor in talking 
about the President's budget, I think he would be better served to 
actually spend some time talking to his leadership about the priorities 
as they come forward over this next year, because there are some 
significant problems that faced this House last year that were simply 
kicked down the road at the end of the year.
  In fact, we saw a repeat of that last week. We were obliged to 
reauthorize the Foreign Intelligence Surveillance Act so that we have 
the tools necessary, our intelligence community has the tools necessary 
to prevent terrorist attacks on our homeland security and to help 
protect our soldiers who are serving in Iraq and Afghanistan. We 
couldn't do it, so we kicked the can

[[Page H598]]

down the road a couple of weeks right at the end of the year, December.
  We were supposed to do something about Medicare because physicians 
across the country were facing a 10.1 percent reduction in their 
reimbursement, a 10.1 percent pay cut if Congress didn't act. Well, we 
did act. We prevented that, but we prevented it for 6 months. Six 
months. What an insult. What an insult to the physicians of this 
country who are taking care of our Medicare patients, the patients we 
have asked them to care for. We couldn't even do our work to give them 
the certainty of what they would be reimbursed for the next year? No, 
it's 6 months is all you get, Doc, and then we're going to come back 
and visit it again. And, oh, by the way, we'll be in the middle of that 
Presidential campaign by then, so don't expect us to devote much more 
attention to it in June than we were able to muster in December.
  But I digress. My purpose in being here tonight is to speak a little 
bit about what is going on in the practice of medicine, and, in spite 
of the fact that I may sound a little bit despondent, I will tell you 
that I am so optimistic about the world ahead, what the future holds 
for the young people today who are contemplating a career in health 
care.
  When I was a young medical student in the mid 1970s in Houston, 
Texas, I could never have imagined that the day would come in my 
lifetime when a person could, of their own volition, go to the Internet 
and, with a couple of mouse clicks, find a place that would analyze 
their DNA and for less than $1,000 provide them vital insights into 
their genomic makeup so that they might be forewarned about some 
diseases, so that they might be forewarned about some conditions and 
use those tools to help manage their health well into the future.
  Now, we hardly know what the results of this type of investigation 
are going to be. It has only been in the last couple of months, in 
fact, I think it was Thanksgiving that I read the New York Times 
article that talked about one of these labs that would provide this 
service. But who would have thought when I was in medical school in the 
mid-1970s that this day would have dawned where that information is 
available not just to the physician, it's available to the patient, to 
anyone who wishes to go on the Internet and seek out that information, 
seek out that lab and have that type of analysis done.
  Think back on 20 or 30 years ago, a patient went to the doctor, the 
doctor gave a diagnosis, recommended a treatment plan to the patient, 
who pretty much had to accept what was given or go get a second 
opinion. Then, of course, in the late 1990s, and I know this very well 
because I was practicing actively at that time, render a diagnosis, 
write out a treatment plan, the patient would go to the Internet and 
check it out and then they come back and say, Doctor, this is what 
you're supposed to be doing. I went to the Internet and read about 
this.
  Now in the 21st century a patient will be coming to their physician 
and providing genomic information and saying, Doctor, here's what I'm 
at risk for developing. How are you going to help me keep that from 
occurring? You know, Dr. Elias Zerhouni, the head of the National 
Institutes of Health, talks about a world where medicine becomes a 
great deal more personalized. It's no longer one size fits all, it's no 
longer just one antidepressant is out there for everyone. It's a much 
more personalized endeavor.
  Because of the ability to know this information about the human 
genome, it's going to be a great deal more predictive. As a 
consequence, because of that predictive value, preventive medicine is 
going to take on new meaning, a meaning that, again, I would have never 
thought possible early in my training.
  Finally, medicine is, of necessity, going to become more 
participatory. A patient will no longer be just a passive passenger 
along for the ride on their medical journey. No, they will have to be 
an active participant in managing their health care from times of 
health and times of disease.

  Medicine is right on the verge of a truly transformational time. You 
add what we know, what we are beginning to understand and learn about 
the human genome and look how fast information comes at us nowadays. It 
is, again, just hard to think that back in the mid-1970s when I was in 
medical school, Internet, never heard of an e-mail, what's that? And 
now these are things that we take for granted. To our children, these 
modalities are simply second nature. They cannot imagine existing for 
even a day in a world where a cell phone and e-mail are not readily at 
their fingertips.
  The speed at which information comes to us is truly phenomenal and, 
as a consequence, in professions such as the health care professions, a 
dramatic effect is going to be felt because of the ability to sort 
through large amounts of information over a short period of time and to 
extract data from those large amounts of information.
  On the floor of this House, in September of this year, we 
reauthorized legislation pertaining to the Food and Drug 
Administration. It was truly landmark legislation. I don't know if my 
friends on either side of the aisle really recognized how significant 
that legislation was, because, for the first time, for the first time 
the Food and Drug Administration is provided with the tools for 
collecting that type of information and proactively researching that 
database.
  The day may well dawn when a problem like Vioxx is discovered early, 
early in its release into general use and the types of difficulties 
that were encountered with that medication several years ago will, in 
fact, be a thing of the past. The red flags will be up. The warnings 
will be there. They will come immediately to someone's attention 
because of the type of database management that will be available. 
Truly, we will have a system that is totally interactive. The resultant 
effect on public health will be profound, because it's not just the 
side effects and the untoward effects that we are talking about, what 
if there was an unexpected beneficial effect where, perhaps, more 
people ought to be offered the benefits of this therapy or this 
medication.
  Certainly, the story that we have learned with the type of medicine, 
the class of medicine called statins that lower cholesterol, that story 
has evolved significantly over the last several years. In the early 
1990s, a LDL cholesterol of less than 130, you're in good shape. Then a 
couple of years later, it was less than 100, and now it's well under 
100. The numbers to shoot for have gone down because the experience 
with that medicine, the information and data that has been gathered has 
pointed the way for physicians to understand that a subsequent lowering 
of that value will, indeed, protect a person's health in ways that they 
wouldn't have imagined when those medicines were first released.
  Medicine is in a transformational time. Congress is going to have a 
lot to do with how medicine is practiced and paid for and regulated, 
not just in the next couple of years, but in the next 20 years, 30 
years, 40 years, 50 years. The decisions that we make on the floor of 
this House today are going to extend far into the future, probably far 
beyond the lifetimes of many of us who serve in this House today.
  But Congress really is not in the business of being transformational. 
Congress is transactional. We heard that just a few moments ago with 
the discussions on the budget. What does Congress do? We take money 
from this group and we give it to this group, and it defines who we are 
morally if we listen to the rhetoric of the last speaker. But that's 
what Congress does. We transact, we take money from this group, and we 
give it to this group. If you will watch the discussion that unfolds on 
the budget over the next several weeks, that will become intuitively 
obvious to the most casual of observers.
  However, in a body that is so focused on the transactional, is it 
possible to keep an eye on the transformational and be certain that we 
don't derail the transformation that is likely to be occurring in 
medicine today? That's one of the tasks, that's one of the challenges, 
that's one of the obligations that we have serving in this body.
  Now, I would submit if Congress wants to participate in the 
transformation, if they want to participate in improving health care, 
they are, in fact, capable of doing so. In fact, Congress could be a 
partner in the transformation if we can step back from the 
transactional long enough to focus on

[[Page H599]]

the transformational. This is not just theoretical.
  I had an opportunity to speak to Dr. Michael DeBakey, pioneer in 
heart surgery, a gentleman of great renown. We honored him on the floor 
of this House with a Congressional Gold Medal earlier this year. I had 
an opportunity to sit down with Dr. DeBakey. He talked about some of 
the changes that he has seen in his lifetime. He related how when he 
was a young man and graduated from medical school and then did his 
residency at Tulane Charity Hospital in New Orleans, he wanted to go 
into research. But he knew that in order to have the credentials to go 
into research he would have to go to Europe in order to obtain those 
credentials. This was back in the 1930s. Well, nowadays, someone who 
graduates from medical school and finishes their training and wants to 
devote a lifetime to research gets those credentials in the United 
States of America. In fact, other physicians travel to this country, to 
our hospitals, to our Texas Medical Center in Houston, to our 
Southwestern Medical Center in Dallas, to our M.D. Anderson Hospital in 
Houston. They travel to our country to get those credentials because 
that's where the best science is being done.
  Dr. DeBakey reflected what caused the change between the time he 
graduated in the mid-1930s and what we see now at the end of the 20th 
century and the beginning of the 21st century. He maintained the cause 
of that change was the focus and attention, and, yes, the funding that 
Congress provided to medical research right after the Second World War. 
Indeed, the funding and the vision of the entire National Institutes of 
Health was a product of that type of visionary thinking.
  So as Dr. DeBakey presented that thought to me, it was with the 
underscored emphasis that Congress can do this because Congress has 
done this before. So if we stay focused on helping and protecting and 
promoting that transformation in medicine, then it is possible for 
Congress to be, again, a participant in that transformation and not an 
enemy of that transformation.
  Now, I am fortunate, because I did spend a number of years practicing 
medicine, working one time in a multispecialty practice, part of my 
time in a solo practice, part of my time in a single specialty 
practice, having practiced medicine in several different modalities 
during my lifetime, it gives me the ability to see things from the 
provider's side and now to see things from the policy side.

                              {time}  2000

  It is so important that we spend the effort understanding those 
things that will work and understanding those things that will not 
work.
  I alluded earlier when I first started speaking about the problems 
that we face because we couldn't do our work in December and we 
postponed any real reform on the reductions in physicians' payments 
that we see year after year. You have seen me put up the posters that 
detail how hospitals, drug companies, HMOs are paid on a cost-of-living 
adjusted basis year over year, but physician reimbursement is paid on a 
crazy formula that reduces and ratchets down reimbursements year over 
year. That just simply won't work.
  When I talk about Congress being a transactional body and that 
transactional activity being the enemy of the transformational, that is 
precisely the type of transactional activity to which I am referring.
  Think of it. We always talked about the laws of supply and demand. 
What are we doing to the supply side of that equation if we are 
actually telling our doctors we don't value what you do, and we don't 
care about the fact that you take care of our sickest patients, our 
Medicare patients? That is just not important to us in Congress, and 
then we underline that by postponing dealing with it for 6 months. 
Again, an assaulting concept to the doctor who is toiling day after day 
to take care of the patients that we have asked them to take care of 
for us.
  Another aspect of that activity, as the year wound down last year, 
was the attempt to attach a rather inflexible program of e-prescribing 
to whatever fix we managed to achieve for the Medicare payment. Now, e-
prescribing is not inherently a bad concept.
  Madam Speaker, you think about it, I am left-handed so my handwriting 
has never been good. And then I went to medical school and had to take 
notes fast, and my handwriting got worse. And then I got old, and my 
handwriting got even worse. And so it is very difficult to read those 
handwritten prescriptions that we scribble out quickly at the end of a 
patient visit. What a benefit it would be to the patient, to the 
pharmacist, and to the physician to have a method whereby that 
prescription was shot to the pharmacist via e-mail at the time of the 
patient encounter. It would save waiting time, no problems with 
legibility, and there could be computer algorithms that were developed 
that would prevent a patient receiving a medicine to which they were 
allergic or which would counteract or interfere with another medicine 
they were taking. So a good concept. And then like so many things, 
Congress deals with it in a way that makes it untenable.
  The e-prescribing bill introduced by a Senator on the other side of 
the Capitol, said, Doctor, if you do this, we will provide you a carrot 
and a stick. The carrot is a 1 percent increase in your reimbursement 
for taking care of that patient and providing an electronically written 
prescription at the end of that patient visit. Just 1 percent.
  Now I am going to make some numbers up because it makes the math 
work. In fact, the numbers are probably much lower than what I am going 
to make up. But assume a physician working in an average practice in a 
city like mine sees a Medicare patient, return visit, moderate 
complexity. Assume they are paid $50 for that visit. That is actually 
pretty generous if you look at most of the Medicare fee schedule 
reimbursement rates. But because it makes the math easy, let's say $50.
  So if that doctor participates in an e-prescribing regimen, what does 
that mean? It means they get an extra 1 percent. That is 50 cents for 
those of you slow at math. So that visit is going to take about 15 
minutes if you do it correctly. Again, remember it is a moderately 
complex Medicare patient, a senior citizen. So you get an extra 50 
cents if you, instead of writing that prescription by hand, you put it 
into a laptop or BlackBerry and send it off to the pharmacist 
electronically.
  You can see four of those patients in an hour. If you are really 
pushing yourself and you have everything firing on all eight cylinders 
in the office and the front desk and nurses are moving along, you can 
see four patients in an hour. So four $50 visits. So that is $200 
reimbursed for that hour's work. That is not the doctor's pay. Don't 
misunderstand me. He has to pay all of the overhead as well. 
Nevertheless, during that hour, that physician will generate $200 in 
revenue. For that, if they do e-prescribing, we will reward them and 
give them an additional $2 for that hour's work.
  That is not a great incentive, but let's think about it also from the 
fact that it is not just one prescription that doctor writes for that 
Medicare patient, no. The average Medicare patient has three or four 
prescriptions. So when you figure it on a per prescription basis, the 
actual benefit to the physician is somewhat less than 10 cents for 
every prescription that is handled electronically. And it is a little 
bit more involved to do that. A doctor who is used to writing out a 
prescription quickly can do so quickly. Typing it into a laptop or 
BlackBerry is going to take longer, maybe a minute or two minutes. But 
if you are seeing 30 patients a day, 2 minutes per patient, that adds 
up to an extra hour, and that extra hour is an hour away from hospital 
activities, seeing other patients, an hour away from family. It comes 
from somewhere, because we all know that the hours in the day is a zero 
sum game. If you take an extra hour, it comes from somewhere else.
  So we are going to compensate for that. We are going to pay a little 
less than 10 cents per prescription as it is written.
  What if you don't do it? You say it isn't worth it. You cut my 
reimbursement every year in Medicare, I have to take on this big 
expense, I have to learn a new technology, pay the expense of the 
software maintenance, I am not going to participate.
  Well, the bill that was introduced last December, after 4 years' 
time, would have applied the stick to encourage, again, our physician 
community

[[Page H600]]

to utilize this technology. And the stick was a 10 percent penalty.
  Wait a minute, a 1 percent up tick and a 10 percent penalty. That is 
imbalanced. Let's go back to our hypothetical return visit, moderately 
complex Medicare patient, a $50 reimbursement, 10 percent penalty, that 
is a $5 penalty for that visit. And if you are seeing four patients an 
hour, that is a $20 penalty for that hour's work. You see the balance. 
If you do it, we will pay you $2 because we think it is worth that. If 
you don't do it, it will cost you $20.
  And we wonder why our senior citizens call up to get an appointment 
with a physician when they get covered on Medicare and no one wants to 
see them? This is the way we behave. We cut their pay. We can't agree 
amongst ourselves to do something rational to protect physician 
reimbursement rates at the end of the year. And by the way, we want to 
add this thing on top, this secondary insult on top of the others.
  I urge Congress to not focus on the transactional; focus on the 
transformational. What do you need? If you are going to move from a 
system we have today, which is based on a written prescription, to a 
true electronic prescription environment, who do you need on your side 
on that? I am telling you, if you don't have the doctor on your side, 
it is not going to happen. Yes, you can frighten and cajole and preach 
all you want, but it is important for Congress to remember that this 
transformation will take place faster, with much more expediency, if we 
will take the time and trouble to instruct, educate, provide for, 
provide the proper support and proper compensation for our physician 
community if they undertake it, embracing this type of technology.

  One of the things we are going to hear a lot of as we go through this 
Presidential election year, terms like ``universal coverage,'' 
``universal access,'' and they don't mean the same thing, so it is 
important to spend a few minutes differentiating between the two. We 
will hear talk about mandates and whether they are a good thing or a 
bad thing. We will hear ``individual mandates,'' ``State mandates,'' 
``employer mandates,'' and it is important to spend a few minutes 
discussing the differences between those terms as well.
  Let's deal with the concept of universality of medical care. That is 
one that many people in this body and many people on the Presidential 
trail today say they want to see.
  Now, universal coverage, universal access. Universal access, everyone 
has insurance whether they want to do it or not. It is a little tough 
to do that in a free society, but yes, we can write laws that can make 
that happen. See the discussion on mandates in a few minutes. But 
universal coverage is one of the options available to us.
  Universal access would say that everyone has access, everyone has the 
ability to go out and purchase an affordable policy. And if they can't 
afford it, they have the ability to access a funding mechanism that 
will provide the type of premium support, the type of premium 
assistance to get them that coverage. And that debate will occur over 
this next year.
  Universal coverage, universal access.
  On the whole issue of mandates, and this is an important concept for 
people to understand, is it better to say this is law, this is 
something you have to have, or is it better to create the types of 
programs that people will actually want to have? Let's think about that 
for just a minute.
  What does the term ``individual mandates'' mean? It means a law is 
passed by a legislative body, in this case the Federal Government, 
although it has been tried at the State level. An individual mandate 
means that everyone has to go out and buy insurance. In my home State 
of Texas, we have that with our automobile policies now. Everyone has 
to buy an automobile policy. With an individual mandate, that is how we 
would achieve universal coverage. You have to buy insurance, and if you 
don't, there is a penalty to be paid of some sort.
  In the State of Massachusetts, in really what I consider a very bold 
attempt to provide coverage for everyone, an individual mandate was 
instituted. It hasn't worked out exactly as planned, and some of the 
difficulties encountered in Massachusetts were cited in California as a 
reason why that State's plan for universal coverage was recently 
defeated in the California State Senate. Many people looked at the 
option, or the requirement, I should say, of buying insurance and said, 
I don't know. And then remember the law of supply and demand. We 
increase the demand because we mandate it, you have to do it. What 
happens? The price goes up, and as a consequence some people looked at 
that and said, I really can't afford that. I will pay the fine rather 
than buying the insurance. Truly a perverse incentive.
  So some of the support for the concept being talked about in 
California found itself lacking when faced with that equation in 
another part of the country. How can you consider putting an individual 
mandate on when it drives costs up and people find themselves in a 
position that they would rather pay the fine for not having the 
insurance than they would to purchase the insurance itself?
  When we talk of mandates, and there have been several studies done on 
this, think back to the 1960s. The United States Congress put a mandate 
out there that every motorcycle rider in the country would have to wear 
a helmet. They reversed that mandate and put that obligation, 
correctly, in the court of the States to make that decision. And the 
reason Congress reversed that decision was the hue and cry and outcry 
from across the land from motorcycle riders saying that you can't make 
me wear a helmet in a free society, and Congress eventually backed 
down. And so that was kind of an unpleasant experience with mandates.
  Most States do have an individual mandate for automobile insurance, 
and they get good compliance with that. But it is interesting, one of 
the States with the best compliance has no individual mandate. So 
mandates don't always equal better compliance, and nowhere is that more 
evident than our current tax structure.

                              {time}  2015

  The Internal Revenue Service, which collects our taxes, there's a 
mandate, an individual mandate on every person who earns above a 
certain income level that you will pay taxes. You will pay a percentage 
of that in taxes and, in fact, everyone knows, it's no secret that if 
you don't pay that tax the punishment is going to be sure, it's going 
to be swift, and it's going to be extremely unpleasant.
  We've got 15 percent of the country right now that lacks health 
insurance. Can we get improvement on that number by putting an 
individual mandate on?
  Look at the case with the Internal Revenue Service. A severe mandate, 
severe penalties for noncompliance, and what is our compliance rate 
with the Federal income tax? It's about 85 percent. In other words, 15 
percent don't comply. So this requires a good deal more study and a 
good deal more attention than just simply making that leap of faith and 
saying everyone needs insurance, therefore, there will be an individual 
mandate that everyone will have insurance.
  Again, there were some problems with the cost structure when that was 
tried in Massachusetts to the point that the people in California, the 
State Senators in California, when they looked at that, said, maybe 
that's not the best idea for us.
  Well, once we determine what the overall goal is, then perhaps our 
path will be a little bit easier. Certainly we want to democratize our 
health care in a way that preserves choice, makes certain that patient 
focus is the central theme, and we want to continue to promote 
innovation, because, remember, America is the country that is known for 
medical and scientific innovation.
  Well, what about the concept of creating products that people 
actually want? Do we have a model? Do we have a template that we can 
look at to perhaps discuss that a little further?
  And, in fact, we do. We passed a bill on the floor of this House, 
late in the night of November 22, 2003, called the Medicare 
Modernization Act which provided for a prescription drug benefit for 
citizens on Medicare who had not had one previously. It was called 
Medicare part D.
  What's been the experience with Medicare part D? And I will stipulate

[[Page H601]]

that there were people on both sides of the aisle in this House, there 
were people on the right who were critical of the Medicare part D 
program, and there was certainly no shortage of critics on the left who 
were critical of the Medicare part D program.
  But as that program was instituted and has now been up and running 
for over 2 years, what lessons have we learned from Medicare part D? 
Well, we've learned that more than 90 percent of the persons who were 
eligible for that coverage have, in fact, enrolled.
  Wait a minute. With the IRS, with severe and certain and sure 
penalties, we only get 85 percent compliance. With Medicare part D, by 
creating programs that had value to patients we've got 90 percent 
compliance, and 80 percent are happy with the program. If we go back to 
our friends at the IRS and say, what's the percentage of people that 
are happy with the way our tax system is administered, I don't think 
the number is 80 percent.
  Consider that when we passed that bill on the floor of this House in 
the early morning hours of November 22, or actually I guess it started 
on the night of November 22. It was in the early morning of November 23 
that the bill actually passed. Consider at that time we were told by 
the best actuaries at the Office of Management and Budget and the 
Center for Medicare and Medicaid Services that it was going to cost 
about $37 a month for that coverage. What has the experience been? The 
average plan costs less than $24 a month now, over 2 years into the 
program.

  So this is a Federal program that relies on some competitive forces 
and relies on some participation of the private sector, and, in fact, 
has reined in some of the increase in spending that was feared to 
accompany this program by restoring the savings and incentives and 
leveraging competition and getting the buy-in from the patients 
themselves. What would be the more favorable trajectory? Force people 
into a program, difficult to do in a free society, and your compliance 
rate may not be exactly what you want it. Or would it be better to 
create a program of value that also relied a little bit on some 
competitive forces to keep that cost down.
  Now, one of the great debates that was had on the floor of this House 
a year ago when the current majority party took over was the whole 
concept of reforming the part D benefit. And we don't hear much about 
that anymore. They weren't successful. One of the big proponents, or 
one of the big themes that was proposed was to cause or ask or demand 
that the Secretary of Health and Human Services negotiate drug prices 
with drug companies. I will just tell you from a lifetime in health 
care that HHS or CMS, they don't negotiate prices, they set prices. 
That's what they do. And many of us on my side of the aisle felt that 
that would be counterintuitive to the way this program was working, and 
in fact, it was working.
  And, you know, Madam Speaker, and this is only partly in jest, but if 
we wanted to create a program where the head of a Cabinet agency, an 
agency secretary was to negotiate, maybe we ought to look to the 
Department of Education and ask the Secretary of Education to negotiate 
prices with college deans for the cost of higher education. That might 
be a better trajectory. I'm waiting to see that legislation come 
forward from the majority.
  But, nevertheless, part D was left untouched last January. I'm 
grateful that it was, and I think again the numbers speak for 
themselves. This is a template. This is a model, this is a program that 
we perhaps should seek to duplicate because it created a condition of 
value, that consumers, that patients, that individuals wanted, and the 
compliance rates are high. The satisfaction rates are high. And, most 
importantly, seniors now are getting the medicines they need to keep 
them out of the hospitals and out of the doctors offices, and the 
overall cost for delivering Medicare, while it is still extremely high 
and still likely unsustainable over time, it has at least moderated or 
ameliorated over the last couple of years. In fact, the trustees' 
report from June of last year that came out said the bad news is 
Medicare is still going to be broke. The good news is it's going to go 
broke a year later than what we told you before. So seeing the 
beginnings of that cost savings and how that can change the practice of 
medicine and the delivery of health care in this country, that's a 
powerful anecdote for people to consider.
  One of the things that we talked about is the speed at which 
information will come to us in the future. And there's no question that 
it's increasing every day. Most of us wear a Blackberry on our belt 
that has more computing power than the big computers on Apollo 13. It's 
astounding what's happened with computer power over the last two or 
three decades. And we hear a lot about the improvements of health 
information technology, the improvements in the platforms and what that 
improvement can mean to patient care, what it can mean to the practice 
of medicine, what it can mean to bringing down the cost of medicine. 
And, indeed, these are powerful influences.
  Madam Speaker, I will tell you I haven't always been a big proponent 
of things like electronic health records. But as my experience on the 
ground in Louisiana in 2005 and early 2006 taught, getting to visit the 
medical records room at Charity Hospital shortly after it had been 
dewatered, I didn't know that dewatered was a verb, but, nevertheless, 
that's what the Corps of Engineers told us they did, and indeed, these 
flooded basements were now available for people to go into, the scene 
in the medical records room, the medical records that were damaged by 
the high water, damaged by the chemicals that circulated in that water, 
the black mold that was going on these paper records made it abundantly 
clear that these were records that could never provide useful 
information to a physician or a patient again. And how much more 
powerful would it have been to have that information available 
electronically, available to be transmitted from New Orleans to Dallas 
or Houston or wherever the person had had to travel to after that 
terrible storm and in the ensuing aftermath. It changed my thinking on 
electronic health records and electronic medical records.
  But I will also tell you, I'm concerned about the Federal 
Government's ability to create the structure that people feel is 
necessary for that day to dawn where electronic health records are, 
indeed, the standard. And I say that because when I came here 5 years 
ago, the discussion was, the Federal Government is going to create 
those platforms. It is going to create the software. It is going to 
create the type of information technology that private industry will 
then follow the leadership of the Federal Government. And, Madam 
Speaker, it's 5 years later and we still don't have it.

  I did have the opportunity to speak to a CEO of one of the larger 
insurance companies in this country a few months ago. In fact, he 
talked at a symposium that was put on by Health Affairs downtown the 
first of November. He talked about within his company he has 45,000 
employees, and fully 15 percent were employed in the development of 
software. Fifteen percent were employed in the development of that 
information technology architecture that we all talk about here on the 
floor of this House. In fact, he said if his software development 
portion was a stand-alone company, it would be one of the largest 
software development companies in the United States of America. And yet 
it is a single branch of a single private insurance company. And more 
to the point, they had developed algorithms, mostly from financial 
data, but they had tens of thousands of conditions, medical conditions 
that they had studied, again using purely financially data, and they 
had found some things that actually seemed clinically very relevant and 
certainly important for a company that might be interested in holding 
down the costs of administering health care. They found that if they 
paid for A and B, C was very likely to follow, and guess what? They 
were very likely to have to pay for D, and D cost a lot of money. The 
example given to me was of treating an individual with a heart attack. 
If that individual with a heart attack, if they did not anticipate an 
episode of depression following that individual's illness, it would 
very likely interfere with their rehabilitative efforts after they got 
out of the hospital, and so their likelihood of a long term return to 
health and productivity was curtailed.

[[Page H602]]

And again, they found this by analyzing financial data, that if they 
put someone in the hospital for a heart attack, successfully treated 
them, discharged them, but did not anticipate depression, they were 
very likely at some point to pay for a hospitalization for depression, 
pay for treatment of another heart attack because they didn't comply 
with the regimen after they got out of the hospital. Very powerful 
information. And as someone who spent 25 years in clinical medicine, I 
will tell you, that's just exactly the type of information that would 
be extremely valuable to the clinician.
  Well, what's the problem? The Federal Government said 5 years ago 
that it was going to develop the platforms that private industry would 
then take up and follow, and we haven't done it. And yet here's an 
individual from the private sector excitedly telling me about what his 
company is doing and the benefits that they've found. And you have to 
ask yourself, would it not perhaps be better for the Federal Government 
to allow that to happen, allow a company to develop that type of 
software, to develop those types of programs, to perhaps bring the 
clinicians now and begin to populate some of those fields with clinical 
data so that they could get even better and more accurate information.
  And I asked that individual, well, what would it take? What would you 
need to see from us to allow this to work better for you? And, no great 
surprise, he talked about the things that we talk about on the floor of 
this House all the time. He said, it wouldn't hurt to have some 
regulatory reform. It wouldn't hurt to have some reform in what are 
known as the Stark laws that prevent hospitals and physicians from 
doing too much together for fear of some type of unjust enrichment. We 
would need some modifications to some of the privacy laws. And at the 
end of the day, too, we're going to need some safe harbors with 
liability. But if you provided us that, we could really take this to 
the next level. And we won't. And yet they're ready to make the 
investment and they're already making the investment, even without any 
Congressional activity, because they find it delivers value to their 
patients, to their physicians and, yes, to their bottom line because 
they're a profit-oriented company.
  What is the difficulty with this body recognizing that that type of 
activity is going on all around us, and maybe we don't need to reinvent 
the wheel here on the floor of this House. Maybe we just need to wake 
up and look around at what is happening literally just across the 
street.

                              {time}  2030

  Now, some of the other things I want to talk about this evening 
before I run out of time, I have already alluded to the problem with 
supply and demand in our physician workforce.
  Just a little over 2 years ago when he was finishing up his term as 
Chairman of the Federal Reserve Bank, Alan Greenspan came and talked to 
a group of us one morning and the inevitable question about Medicare 
came up: How are we going to pay for it in the future? What is it going 
to cost? And the Chairman was concerned as well, but he did say, When 
the time comes, I think Congress will make the hard decisions that 
Congress is required to make so that the program will continue. He 
stopped, and then he went on to say, What concerns me more is will 
there be anyone there to deliver the care when you need it?
  And we've already talked about some of the problems that are inherent 
in the formula by which Medicare reimburses physicians.
  And one of the things I don't think I can stress enough on the floor 
of this House, because I don't think Members understand this, they 
think, well, that's just Medicare; that's just a part of the practice 
of medicine. That's not the whole story. Well, it is about half the 
story. Actually, the Federal Government does pay for about half of the 
health care expenditure in this country, if you go back to the first 
moments of this discussion.
  But the other thing is that the rates by which Medicare reimburses 
for health care informed the rates that are set by the private 
insurance companies in this country.
  So indirectly, we have a system of Federal price controls on medicine 
in this country today. And that's why, when we ratchet down the 
reimbursement rate for physicians on Medicare, and everyone in the body 
is quick to say, Oh, well, doctors make plenty of money. There's no 
need to worry about that. Remember, also, we are affecting not just 
Medicare, over which we have jurisdiction, but we are also affecting 
those reimbursements in the private sector as well because there is not 
a level playing field between provider and third-party payer. That's 
one of the problems inherent in our system now. People that go to the 
physician don't actually pay the physician; they pay the insurance 
companies. Same with the employers. They don't actually pay the 
physician; they pay the insurance company.
  So that interposition of a third-party intermediary has created a 
good deal of the tensions and a good deal of the problems that we see 
today.
  But we must not forget, that is a system that is there, that is a 
system that is in place, and when we make a decision about Medicare 
reimbursement rates, the ripple effect throughout the health care world 
in the reimbursement is significant, it's profound, and it is 
immediate.
  One of the things that I feel very strongly about is that we do need 
to help people know what they're buying and what they're getting in 
health care. And one of the bills that I introduced early in the first 
session, the last year of this Congress, was H.R. 1666, which does deal 
with health care transparency.
  It sets a floor of a level of transparency that should be available 
in every State. Many States have already undertaken this work. My home 
State of Texas has, and, in fact, patients can go to the Internet to a 
Web site. It's texaspricepoint.org, abbreviation txpricepoint.org, and 
they can get information about the hospitals in their county. Most of 
it is pricing information. Other information, other useful clinical 
information such as length of stay is also available.
  At some point I expect there will also be the transparency about 
things like complication rates and infection rates, but it's still a 
work in progress. Other States have done similar activities. The State 
of Florida with its RxCompare. People can compare prices for different 
prescriptions, which has been useful for the people of Florida.
  What the intent of H.R. 1666 was to not provide a Federal standard 
but at least to provide a level of transparency below which States 
should not go. And I would like to see this House of Representatives at 
some time take on this problem, because I think it is one that is 
extremely important.
  And it does lead in to the other issue of how States and hospitals 
report complications, such as infections. And, again, I do think there 
is a role for Congress, I do think there is a role for the Federal 
Government, not so much in writing that legislation State-by-State, but 
providing the framework by which the reporting can occur to allow a 
Federal agency such as the Centers for Disease Control the ability then 
to aggregate that data and provide useful information back in real-time 
to the States and to the hospitals and to the physicians about 
infection rates in their particular areas.
  Most epidemiologists will tell you the chance to measure is the 
chance to cure, or the chance to prevent, in the case of infections. 
And the metrics, just the activity of undergoing the metrics in those 
conditions, will oftentimes lead to improvements that were 
unanticipated at the beginning of that program of metrics.
  Other legislation that's out there that deals with our physician 
workforce, H.R. 2583, H.R. 2584, both bills designed to affect 
individuals earlier in their career, in the health care workforce even 
prior to the entrance into medical school, the ability to provide a 
little bit more flexibility and a little bit more balance in the health 
profession scholarship, a little bit more flexibility in loan 
forgiveness and tax incentives for individuals who are going to medical 
school and will agree to practice in medically underserved areas in 
high-need specialties, and that is essentially primary care, also 
fields like OB/GYN and general surgery, to provide a little bit more 
flexibility to help incent people who are willing to make those types 
of decisions. And there is significant lifestyle decisions that they 
are making to undertake those type of careers.

[[Page H603]]

  And then there's another program to increase the number of primary 
care residencies that are available, again, in high-need areas, 
medically underserved areas for specialties that are in high demand, 
and, again, we are principally talking about the primary care 
specialties.
  The barriers for entry for a medium-sized to moderate-sized hospital 
to start up a residency program are essentially costs. And some of 
those start-up costs in this legislation can be provided for in a loan. 
And there will be a loan that is paid back so that money will recycle, 
and the overall return to the taxpayer is increased that way. It will 
allow those hospitals the ability to set up a residency program where 
none has existed in the past. And I can think of many, many hospitals 
in my home State of Texas that could benefit from that type of 
activity.
  And one of the things when people study how physician manpower is 
distributed, you can say a lot of things about doctors, but sometimes 
we are not very imaginative and we don't tend to go very far from where 
we trained, and there are some valid reasons for that. You get 
comfortable with referral patterns. People know you from your training 
program, so they're apt to refer to you. There's a degree of comfort 
there. And myself, for example, I went into practice less than 25 miles 
from where I did my training. A lot of doctors do follow that same sort 
of trajectory.
  So if we can move the training programs into the areas that need the 
physicians, it may then follow that those physicians who train in those 
programs will end up staying in those medically underserved areas.
  It's difficult for me to come to the floor of the House and talk 
about things related to health care and at least not mention some of 
the problems that we face with our medical justice system in this 
country. And I know there are lots of people out there with a lot of 
different ideas, caps on noneconomic damages, medical courts, early 
offer arbitration. The time has come for us to have a serious 
discussion to put some of the partisan differences aside, to put some 
of the special interests aside and have a rational discussion about how 
we can meaningfully impact that problem in this country.
  My home State of Texas passed rather significant legislation 4 years 
ago dealing with the issue of caps on noneconomic damages. It was 
patterned after an earlier California law, the Medical Injury Reform 
Act of 1975. It was passed out in California, which put a $250,000 cap 
on noneconomic damages. The Texas legislation was a little bit 
different. Instead of a single cap, there were three different caps, 
each capped at $250,000, but the aggregate was $750,000 compensation 
available for noneconomic damages. It has worked very well in my home 
State of Texas.
  The year that I left practice to come to Congress, we were in crisis. 
We had gone from 17 medical liability insurers down to two. You 
certainly don't get much in the way of competition when you only have 
two insurers, and as a consequence, the price for those premiums was 
ever escalating. Now we have had many insurers come back to the State. 
They've come back to the State without an increase in premiums. And, in 
fact, Texas Medical Liability Trust, my last insurer of record, has 
returned, the last time I checked, 22 percent reductions and dividends 
back to their physicians that they cover. And that's significant 
because, remember, these premiums were going up by 10, 15, 20 or 25 
percent year over year, and then on the past 4 years, they've not only 
stabilized, but they've come down 22 percent.
  Small and medium-sized hospitals that self-insure for medical 
liability have had to put less in reserve against a bad judgment, and 
as a consequence, there has been more money to spend on just exactly 
the kinds of things you want your community hospital to be spending its 
money on; things like nurses' salaries, capital improvement, investing 
in their capital infrastructure.

  So it is a good news story from the State of Texas in terms of what 
we've been able to do with liability in my home State, and I'm not 
going to say that's the only answer, but I think it is a very good 
answer. I introduced legislation, H.R. 3509, to essentially provide the 
Texas legislation on a national scale.
  In fact, we had a lot of talk about the budget earlier tonight. Last 
year, I offered that bill to the Budget Committee because the 
Congressional Budget Office scored it as nearly a $4 billion savings 
over 5 years. I realize that's not much when you are talking about a $3 
trillion budget, but that's $4 billion. That's a significant savings, 
and I was willing to donate that to the Congress.
  Take up that concept, write it into law in your budget resolution, 
and let's get something done to stabilize medical liability prices in 
this country, not so much for my home State of Texas, as we've already 
done it. But what about Pennsylvania? What about New Jersey? What about 
Maryland? What about New York? Maybe those areas could benefit from 
some of that same type of thinking as well.
  Well, suffice it to say that that concept was not accepted, but I 
will extend the offer to members of the Budget Committee on both sides 
of the aisle that $4 billion in savings is still available to you. H.R. 
3509 is the bill, and I will be happy to relinquish all ownership 
rights and donate that to the greater good of the United States 
Congress and the people of the United States.
  One last piece of legislation that I want to mention, and it was 
introduced right at the end of the year, H.R. 4190. We talk on the 
floor of this House a lot about the problem of the uninsured. In fact, 
I've spent some time talking about it this evening.
  H.R. 4190 isn't a new insurance program. It isn't a new expansion of 
Medicare or Medicaid or SCHIP. What H.R. 4190 does is take the concept 
of being uninsured and extend that privilege to everyone who serves in 
the United States Congress. H.R. 4190 would remove us, as Members of 
Congress, from the Federal Employee Health Benefits plan, provide us a 
voucher, if you will, to go out and purchase insurance on the open 
market. And I can't help but think, if we were put in the position of 
many Americans who are faced with those decisions about having to buy 
health care coverage on their own out in the open market, perhaps we 
would get a little more creative about the unequal treatment from the 
Tax Code for employer-derived insurance versus an individually owned 
policy. Perhaps we would get a little bit more creative about providing 
a little more flexibility in a health savings account.
  Perhaps we would get a little bit more flexible even if we are of the 
mindset that said, Well, we are going to extend our single-payer health 
care to more and more people. Well, what if Members of Congress had the 
same problem finding a doctor that your senior citizens at home tonight 
are having when they call up the doctor they've seen all of their lives 
and are told, Sorry, we can't take any more Medicare patients?
  Well, H.R. 4190 is an intriguing concept. I haven't had much interest 
as far as cosponsorship is concerned, but it's still out there. It's 
still available, and I welcome Members from both sides of the aisle to 
think about that, to look at that, and see if we couldn't forge a 
common bond and a good-faith effort to really do something for the 
people who lack insurance coverage in this country or the people who 
are fearful that they will lose their insurance company if their job 
changes or their financial situation changes.
  There's a lot of things out there on the horizon, Madam Speaker. 
There is a lot of good that this Congress can do. I think it is 
important for me to make the point one last time that medicine is 
evolving in a big way. It's going to change significantly in our 
lifetime.

                              {time}  2045

  Congress can participate in that evolution, and actually participate 
and be a force for good if we're only willing to pick up and take on 
the work that the American people have sent us here to do.
  Thank you, Madam Speaker, for your indulgence.

                          ____________________