[Congressional Record Volume 155, Number 87 (Thursday, June 11, 2009)]
[House]
[Pages H6611-H6615]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                           HEALTH CARE REFORM

  The SPEAKER pro tempore. Under the Speaker's announced policy of 
January 6, 2009, the gentlewoman from Pennsylvania (Ms. Schwartz) is 
recognized for 60 minutes.
  Ms. SCHWARTZ. Mr. Speaker, I rise this evening to begin what I hope 
will be a Special Order time with my colleagues. It's a little earlier 
than we thought, so we're going to see as they make their way to the 
floor. Hopefully they will be joining me.
  But, as you know, there has been a great deal of discussion about 
health care reform. We just heard a Special Order now from my 
colleagues on the other side of the aisle talking about health care 
reform and some of their thoughts about it, and I think sometimes we 
focus very much on controversial issues and some of the difficult 
decisions we have to make as we move forward, and let me start with 
what we're trying to do on health care reform, on this.
  What we want to talk about tonight is some of the very important work 
we want to do as we really meet the President's goals.

                              {time}  1930

  He has laid out to us the goals for health care reform, and they are 
really threefold. They are to make sure that we contain costs. The fact 
is that our businesses have said to us that the high cost of health 
coverage, providing health benefits for their employees, has gone up 
almost double digits every year. And what that really means is that we 
have doubled the cost of health care benefits to our companies in the 
last 10 years. That's unsustainable for our businesses, whether they 
are small businesses that are trying to be economically competitive in 
their communities or very large businesses that are really functioning 
on the global marketplace and really competing with companies that are 
in countries where health care is not an individual employer's 
responsibility and where costs are more controlled. So we know it's

[[Page H6612]]

an economic competitive issue. There's no question about that.
  We also know that it is an issue for government. I serve on the 
Budget Committee. The costs, and we talk about this, for Medicare is 
really unsustainable if we don't do a better job of containing costs 
and improving quality and improving outcomes for our seniors. We're 
going to talk more about that this evening.
  But we also know that it's a huge problem for our families. We hear 
all the time from our constituents about families that have break in 
coverage and then suddenly find themselves faced with buying a family 
policy with a preexisting condition, someone in their family with a 
preexisting condition, and the cost of that policy, if they can find 
one, is too high for them to be able to afford.
  Typically, I know in the Philadelphia area, a decent insurance policy 
costs anywhere from $12,000 to $15,000 a year. Well, a family that's 
earning even $50,000, $60,000 a year, after paying their mortgage and 
paying their expenses and maybe trying to save something for their 
children to go to college and meeting all the taxes, local and State, 
really just don't have those kinds of dollars left for them to find 
$12,000 to buy a decent policy. So they're shut out, completely shut 
out, which is really a very significant problem when they want to go 
for health coverage. So we know cost is absolutely a major issue for 
our businesses, for our families, and for our government.
  So what can we do about it? How can we actually ensure that we will 
contain costs and improve quality and also be able to extend coverage 
for the 47, almost 48, million Americans who do not have ongoing health 
insurance coverage? And the fact is we can do numbers of things, and we 
have been working hard on this to make sure that we create the kind of 
market reforms that will enable people to buy meaningful coverage that 
is affordable for them and that they will have the kind of coverage 
that will really matter.
  We also know that we need to make some real changes in the delivery 
system. And, again, that's what we are hoping to focus on tonight. And 
what I mean by that, if for all of us who go to see doctors and nurses 
and spend time at all in a doctor's office either for ourselves or for 
our loved ones, we know, and our numbers bear this out, that, in fact, 
we tend to go to more specialists. We have very fragmented care. What 
we don't have is access to a primary care provider who knows us, who 
follows us, works with us when we get a serious disease, helps us know 
what it is that we need to be doing, helps us comply with 
recommendations, and really also helps us sort through if we need to 
see numbers of specialists.
  So whether you are basically fairly healthy or have a major health 
care crisis or a chronic disease, we know that we cannot only get 
better quality care, help improve health status for all of us and each 
of us, but also contain costs.
  And I'm happy to give you some of the numbers that we have in terms 
of some of the primary care shortages. We often talk about primary care 
physicians, but the fact is we also have a shortage of nurses, nurse 
practitioners, physician assistants, and so many of the health care 
providers that really should be there for us and want to be there for 
us but there is simply not enough of them.
  The Council on Physician and Nurse Supply says the United States may 
lack as many as 200,000 needed physicians by 2020. So here we are 
saying that we want you to go see the primary care physician or nurse 
practitioner. We don't want to go to the emergency room. Look at the 
Massachusetts experience where they really worked very hard and 
effectively to extend coverage to the uninsured. What they found was 
people were still going to the emergency room because there simply were 
not enough primary care providers or clinics or community health 
centers in their communities for them to go to.
  Let me go on with some other numbers, if I may. They estimate that 
there could be a shortage of 800,000 nurses by 2020; 46,000 of those 
physicians and nurses need to be primary care providers. The U.S. 
population rose 31 percent between 1980 and 2003, but the number of 
medical school graduates remained the same. So the population is 
growing. We're looking at a 30 percent growth in population, and the 
number of physicians is the same. And what is so interesting about that 
is I think for a long time we've heard we have enough physicians but 
they're just not in the right place. Well, I think we've gotten that a 
little bit wrong. There are simply not enough primary care 
practitioners, physicians, or other practitioners.
  Interestingly, the number of medical students who are choosing 
primary care is steadily declining. Even amongst those who are 
specializing in internal medicine, I will say that in 1985, half of all 
internal medicine residents chose primary care; now only 20 percent do.
  I was at a press conference this morning with Congresswoman Kathy 
Castor and Congressman John Sarbanes and a young woman who has just 
graduated from osteopathic school. And she talked about the statistics, 
and she said that most medical school graduates graduate with almost 
$200,000 in debt. Their first job as a resident, and still training 
actually, is usually paid about $40,000. So how do you train for 
another 3 or 4 years, make $40,000 a year, and pay $200,000? That's 
just medical school. You may have a course debt from college as well. 
So it is a major issue going forward to make sure that we have more 
primary care physicians.
  Older Americans also are seeking primary care services twice as often 
as other age groups. So as the population is aging, and we know the 
baby boomers are coming, and we are talking about them, of course, in 
terms of Social Security, but the fact is we know that as we are aging 
and needing more health services, it is very, very important for us to 
have access to primary care providers.
  Let me also talk about one of the reasons we need primary care 
providers, and that is all of us, but particularly those with chronic 
conditions. We think about needing health care when we get sick and 
have an episodic experience where we might need to go to the hospital 
and might need to see a physician, might even end up in the emergency 
room. But for many people, they have chronic conditions, and they need 
to have an ongoing relationship with health care providers so that they 
can get the kind of care they need, get the advice, get the right 
prescriptions, and then be able to work with their medical 
practitioners to be able to comply with that advice and to be able to 
make sure that they are healthy. And the number out there is that only 
50 percent of Americans who do get health care comply with the 
recommended health care that they're told to comply with. So obviously 
we need some work here.

  This is a shared responsibility. This is not only a responsibility of 
those who pay for health services and are reimbursed for health 
services and those providers but, of course, for patients as well.
  So let me just say on chronic conditions, some of these numbers may 
surprise us. But the five most costly chronic conditions are 
cardiovascular disease, cancer, diabetes, asthma, and mental health 
disorders. Over 133 million Americans suffer from at least one of these 
chronic diseases, and over 75 percent of all Medicare expenditures can 
be attributed to patients with five or more chronic conditions. Just 10 
years ago, these beneficiaries accounted for only 50 percent of the 
Medicare costs.
  So something's wrong. We have to fix this problem. We have to make 
sure that people can hopefully prevent some of these chronic disease. 
We might be able to do that in a number of ways. I know there's a lot 
of discussion about wellness programs for prevention. We have seen some 
very good models. Particularly some of the larger employers, smaller 
employers, some of the insurance companies are really working hard to 
try to incentivize people to eat right, to exercise to be able to 
prevent some of these conditions and some of these conditions from 
worsening. But clearly we have a long way to go and we have much work 
to do to make sure we, again, help folks with chronic diseases be able 
to be healthier, to get better, to not have the disease get any worse. 
And, of course, in that process it will save them money and it will 
save all of us the high cost of taking care of patients.

[[Page H6613]]

  Any of us who has ever visited a renal dialysis center knows that if 
we can do more to make sure that somebody who, for example, is 
diagnosed early as a diabetic follows the prescribed treatment, does 
try to eat right, exercise, really takes care of themselves, and gets 
good consistent health care and can prevent themselves from becoming 
more seriously ill and, of course, going into any kind of renal failure 
and needing renal dialysis is something that would save them many 
problems and would save us all a lot of the costs involved.
  Just a few more numbers because I think they're pretty telling. 
Chronic conditions cost American businesses nearly $1 trillion each 
year in lost productivity. We don't even think about the number of 
dollars that are lost as workers take time off for serious illnesses. 
About $125 billion of this is due to lost workdays, and the balance is 
due to diminished capacity while they are at work. So for businesses 
it's not only the cost of the insurance and the benefits, but it's also 
a cost when their own workers are not being able to really work at the 
full scale of their potential and their capacity.
  So we know that we can do more. Economic conditions, the health 
benefits, really taking serious action to make sure that we have enough 
primary care providers, and that we do a much better job of 
coordinating care for those with chronic diseases will really have a 
dramatic impact on the health status of Americans and on the cost to 
all of us. And that's really what we want to do.
  I think that we have heard some others talking earlier about the need 
to do medical research. We believe very strongly in that, and we have 
already made a very good commitment to doing that by putting $10 
billion more into NIH. We did that in the Recovery and Reinvestment 
Act, and that was very significant. Of course, we want to see better 
treatments and we do want to see cures. That takes dollars for medical 
research and a real commitment to the science of biomedical research 
into some of the new products and devices. But it also takes prevention 
and it also takes better coordination of care.
  Patients with chronic diseases need to have access to primary care 
providers. We talked a bit about that. We need to be able to make sure 
that they get good ongoing chronic disease management.
  And I have introduced legislation. It's House bill 2350, and I have 
to say it's got enormous support here in the House, 100 cosponsors. I'm 
very proud of that. And many others are looking another it, and I have 
only introduced it just a couple of weeks ago. The idea of that 
legislation is to make sure that we preserve patient access to primary 
care. And one way to do that is to increase the number of primary care 
providers by increasing the number of residency program slots for 
primary care. We're going to hopefully do that. And for more nurse 
practitioners and more nurses in this country. That would be very 
helpful. But another concept, and I see another colleague of mine is 
going to join us, which is just great, but just to finish this thought, 
there's also reimbursement for a concept called ``medical home.'' This 
isn't a place. This is a group of services. It's a commitment on behalf 
of the provider, the doctor, the nurse practitioner, the physician 
assistant to be able to provide a medical home so that you know you 
have ongoing care, particularly when you have a chronic disease. And we 
can talk more about that going forward.
  But I want to thank my colleague for joining me. I see Congressman 
Jason Altmire has joined us. He's also from Pennsylvania, from the 
other side of the State, from a community, Pittsburgh, which is known 
for its medical care, medical schools, and it has a lot of health care 
providers. But I bet and would imagine that Congressman Altmire has 
some of the same experiences I do, that while we have great quality 
health care, it is also too often fragmented and is too often not 
accessible and too often not affordable for too many of our 
constituents.
  So we're here tonight to talk about health care reform, particularly 
the commitment that we're making as we move forward on health care 
reform to expand and extend access to more Americans, to make it more 
affordable. It also means a commitment to fixing our delivery system, 
and that means a commitment to primary care.
  I want to thank Congressman Altmire for joining us, and I welcome his 
comments.
  Mr. ALTMIRE. I thank the gentlewoman for yielding. It's been a 
pleasure working with the gentlewoman as part of the New Democratic 
Coalition. We are the co-Chairs of that group.
  The gentlewoman hit it right on the head, that we do have the best 
health care system anywhere in the world if you can afford to get it. 
If you have access, and there are millions of Americans that have 
insurance and they like it and they have access to the system, our 
medical innovation, as the gentlewoman said, our research, our 
technology far exceeds anything available anywhere else in the world. 
Our quality at the high end exceeds anything available anywhere else. 
It's why people come from all over the world to the United States to 
get their transplants, to get their heart taken care of, to get their 
high-end, high-tech care because we do it better than anybody else, and 
there is no question about that.

                              {time}  1945

  The problem is the costs are skyrocketing with our health care 
system. Every family, every business, every individual in this country 
is impacted by the cost of health care and not just with what you're 
paying directly for your health care costs--what your copayment, your 
premium or your deductible is. The cost of everything that you buy in 
this country is higher because of health care costs. We use the example 
of an American-made car. $1,500 of the price of every car made in this 
country goes to health care costs--to the health care costs of the 
workers who are involved in putting that car together.
  It's more than that. It's every level of the supply chain, every 
segment. If you think about the company that manufactures the good, the 
people who ship the good, the people who receive it and stock the 
shelves, and the people who sell it, at every level, there is a 
component of cost that is increased because of health care costs of the 
companies involved in that. This is at every level of the supply chain.
  If you think about every segment of our lives, health care is a part 
of that. What we are trying to grapple with here in this Congress over 
the next few months is how to preserve what works in our current 
system, because we don't want to throw the baby out with the bath 
water. We don't want to lose the good things about our health care 
system, but we do want to address the things that don't work. So we 
think about the fact that we spend $2.5 trillion a year on health care 
in this country, far more than in any other country in the world.
  Yet, with some things, we don't get mediocre results; we get bottom-
of-the-pack results when compared with other countries--in life 
expectancy and in infant mortality. We're not in the middle of the 
pack. We're at the bottom of the pack. We can do better. We're not 
getting our moneys worth, especially when you consider the 50 million 
Americans who don't have any health insurance at all. Now, when they 
show up at the emergency rooms, they get covered; they get treated, but 
the bill gets passed to the millions of Americans who do have health 
care coverage. The reason you pay $10 for an aspirin at a hospital is 
due to the cost shift that takes place, making up for the difference of 
the people who can't afford their health care. There are tens of 
millions more who live in fear of losing their coverage. They are one 
accident, illness or job loss away from losing everything, and that, in 
the United States of America, is unacceptable.
  So we have very high quality at the high end, but we have very high 
costs, way more than any other country. We have millions of Americans 
who have coverage and who appreciate their coverage and who like it, 
but we have tens of millions more who don't have coverage or who are 
underinsured.
  So the challenge we have as a Congress is how to fix what doesn't 
work--what's broken--and how to preserve what does work. We've put 
forward a plan, and we're in the very beginning stages. There is a lot 
of negotiation that's going to go into this, both in the House and in 
the other body, to talk about how we can achieve that goal--

[[Page H6614]]

but make no mistake. As the gentlewoman knows, we are not going to 
fail. We are going to pass a health care bill this year because the 
American people have demanded that we do that.
  As I said, it affects everybody in this country. The cost increases 
that are double and triple the rate of inflation every single year are 
simply unsustainable. We are never going to get ourselves out of the 
budget crisis that we have over the long term, our annual budget 
deficit and our structural debt that we have, unless, as the President 
says, we bend that cost curve on health care. We have to bring costs 
more into line with the rate of general inflation.
  Ms. SCHWARTZ. Would the gentleman yield for just a moment?
  I think, when some of our constituents hear some of those words, they 
really want to know--and I think that's one of the things that we're 
really interested in pursuing here. They want to know: Well, does it 
mean I'm going to get less health care? Does it mean I'm not going to 
get what I need? Does it mean I'm going to go to the emergency room, 
and they're going to turn me away?
  The fact is we're trying to be smarter than that. We want to say no. 
What we're saying instead is that we want to make sure you get the 
right services when you need them. I'm sure you hear from constituents 
who find that they don't go to emergency rooms because there simply 
aren't doctors in their communities. I remember when I was growing up 
that there was a general practitioner down the street. We all went to 
him. I'll bet there's no general practitioner there anymore. I know, in 
parts of my own district, we've seen some hospital units close. We've 
seen doctors' offices close. It just isn't the way medicine is 
practiced right now.
  The truth is, with reimbursement to insurance companies and with what 
we've done under Medicare, we've not created any incentive for doctors 
or nurse practitioners to go and open offices in small communities and 
provide those kinds of services. Instead, we've encouraged them to 
become specialists, to really do the fancy kinds of things. While we 
need them and while we want to make sure we have those specialized 
physicians there and available for us and while that has got to be 
covered, if we only cover that, if we only focus on that, we've really 
forgotten sort of the simple things, you know, which are:
  How do you really talk to patients and make sure that they understand 
what they need to do? How do we actually make sure that we have a 
shared responsibility instead of a patient's saying: Oh, I'm sure I can 
just go and get a pill for that. Wouldn't we all love that, to be able 
to take a pill and we'd all be fine. It takes more personal 
responsibility, and it takes a patient-doctor relationship. That's 
often what's missing is that ongoing relationship with primary care 
providers--that's both physicians and nurse practitioners--and it's one 
of the things we want to address.
  I'm sure that the gentleman has heard the concept of medical homes. 
Maybe you'll want to talk about that, about the idea of an ongoing 
relationship, about the fact that we're really interested in this 
health care form of creating a new opportunity to reimburse primary 
care practitioners for that kind of ongoing relationship with patients 
so that they know which specialists to see and so that they can help 
people sort through the many medications they take. I was just going to 
give you one number, which my staff gave me earlier, which I was really 
quite struck by.
  It said that medical beneficiaries with 5 or more chronic conditions 
see an average of 13 different physicians per year and are prescribed 
an average of 50 different prescriptions.
  That's a lot to sort through if you're not an expert. It really is. 
Think about actually having someone you can talk to and say: Wait a 
minute, do I really need to take these? Should I still be taking these? 
Shouldn't I? You know, who do I ask about this?
  I'm sure you've heard some of these stories from your own 
constituents and probably from some of your own providers as well.
  Mr. ALTMIRE. I have, and I thank the gentlewoman.
  There is a lot to talk about just with this one concept, with this 
one component of health care. Part of the issue that we'll, I'm sure, 
get into is that of computerized medical records, of having an 
electronic health record that you carry with you everywhere so you 
avoid this situation that the gentlewoman described where you have, as 
a consumer, 50 different medications when you show up at a provider's 
somewhere that's out of your hometown.

  If I go to San Diego and put my ATM card in the machine, I can pull 
up all of my financial records safely and securely. I never think about 
privacy. If on that same trip I end up in the emergency room, they 
don't have my medical history. They don't have my family's medical 
history. They don't have my allergies, my prescription drug regimen. 
They don't have any imaging that I might have had taken--x rays and so 
forth.
  There is no reason that health care has to be the only industry in 
the country that hasn't gone to an interconnected/interoperable health 
information technology system, which is part of where the gentlewoman 
is going.
  The other part--and this is a great point--is we have to begin to 
have our reimbursement system structured in a way that we incentivize 
the quality of care rather than the volume of care. We should not just 
talk about how often the patient goes to see a doctor and then 
reimburse based solely on that. We should be reimbursed based on: What 
is the appropriate setting for the patient? Where would the patient 
rather be? Where is the patient going to get the highest quality care?
  We don't do that right now in our health care system. If you have a 
chronic disease, there are some cases--and certainly it would be on an 
individual basis and in conversation with your physician--where it 
shouldn't be determined based on reimbursement, based on money, as to 
what setting in which you're going to get that care. It should be: What 
is the best outcome likely based on the setting that you get? If home- 
and community-based care is the best setting, we shouldn't provide a 
financial disincentive to get it there. If that's the most appropriate, 
cost-effective setting and, most importantly, that's where the patient 
wants to be and that's where his family wants the patient to be, then, 
by all means, we should incentivize that setting. We're not doing that 
today.
  Ms. SCHWARTZ. If the gentleman would yield, I appreciate very much 
your raising the issue of health information technology. You're 
absolutely right.
  The health industry has been so slow to really be involved--to really 
use the computer, to use information technology--in a way that so many 
other industries have been. As any of us know who started out in our 
professional careers not using computers, I think we sometimes were 
slow or were anxious to do it. We were nervous about that.
  I remember someone who worked for me a number of years ago who 
resisted it completely. She said: Don't be silly, I know exactly what 
I'm doing. I take notes. I do fine. We finally told her she had to use 
a computer. We just told her that we were doing it. Just a few months 
later, I remember the computer system went down, and she was like: Oh, 
my goodness. How can I function?
  Well, you can imagine this in health care, which has been so paper-
driven and so labor-intensive, the idea that physicians would have this 
at their fingertips even within their own city or even within their own 
medical practice sometimes. I was talking with a medical practitioner 
who said: Sometimes--I don't know--a patient could have been in my 
office, seeing another doctor the day before, and because the notes 
weren't transcribed yet, I don't know happened--or 3 days ago.
  Another example: A patient who is just visiting Geisinger health 
system in Pennsylvania--a great model. The primary care physician has 
the ability to see the hospital records while patients are in the 
hospital. So they don't have to wait 3 weeks for specialists who saw 
them in the hospital to write them a summary, have it dictated and 
mailed to the primary care physician 3 weeks later or 4 weeks later.
  It turns out those 3 or 4 weeks are incredibly important, after 
discharge, for the patient to be following the advice of the physician 
and knowing what to

[[Page H6615]]

do. It's a very uncertain time. You need to be able to have contact 
with your primary care physician during that time, and the primary care 
physician needs to know firsthand what happened to you.
  An electronic medical record is extremely important in helping a 
primary care physician provide the right care for you and prevent a re-
admission, which is a huge cost for all of us. We've talked a lot about 
that in terms of infections, but there are a lot of reasons people get 
re-admitted to the hospital. If we can prevent that by the right kind 
of home care, as you pointed out, or by the right care and attention 
from a primary care physician, that is not only going to help that 
person stay healthier, but it is also going to help that person get the 
care he wants.
  I know we talked about this, too, which is, in terms of improving 
quality, there are now critical protocols. We like to think that every 
one of our physicians knows exactly what to do for us. By and large, 
most of our physicians, fortunately, are pretty good. As for all of us, 
if you have to do five things for somebody when one comes to you 
because one has some particular health condition and you tend to do 
four of those five most of the time, you're probably pretty good. It 
turns out, if you actually do all five every time, your patients are 
going to be a whole lot better off for it.
  So, you know, maybe we're not used to the fact that the doctor might 
actually look that up on the electronic medical record and have to 
check it off, but it turns out that it really makes a big difference 
when you really did remember to remind one to stop smoking and when you 
really did remember to tell a parent to put a child in a seatbelt. I 
mean all of those things may not seem so directly connected to what a 
physician was seeing one for, but it enables the physician to make sure 
one gets the care one needs: Remind them about mammograms. It's time. 
If a woman hasn't had a mammogram for 3 or 4 years, maybe it's time, 
not to mention making sure that they take the right medications and 
follow the right orders.
  So electronic medical records are what--you're right--the new Dems 
have really championed, and we have, of course, a President who has 
championed it as well. We put in $19 billion in the Recovery and 
Reinvestment Act to really help push this forward in a much more 
ambitious way--the use of electronic medical records in our physicians' 
offices and in our hospitals and having them be secure, private and 
interoperable. It's absolutely key.
  I don't know if you wanted to comment on that or on other issues 
related to primary care or on other things that we can do with the 
delivery system that really will help us be able to contain costs and 
to give better care to people.
  Mr. ALTMIRE. I wanted to comment, following up on the gentlewoman's 
comment on quality of care and medical errors.
  According to the Institute of Medicine, there are 100,000 people 
every year who lose their lives due to a preventable medical error. 
Needless to say, with each one of those individuals, there is a tragic 
component to their personal stories--to their families or certainly to 
their own losses of life. There is also a burden to the health care 
system of medical errors because there are hundreds of thousands more 
who, because of preventable medical errors, are injured. Their 
treatment costs more, and each one of those individuals, more 
importantly, has suffered a severe medical setback. Their families are 
impacted by that. Their lives may never be the same.
  In the aggregate, when we talk about cost reduction, something as 
simple as preventing infection, as the gentlewoman talked about, or as 
simple as preventing medical errors through the use of information 
technology, these are things that are going to save billions of dollars 
for our health care system in the aggregate. More importantly, they're 
going to increase quality for every individual who enters our health 
care system and will prevent these medical errors.
  So the gentlewoman is correct that, when you look at even that one 
segment of health care reform, you're talking about billions of 
dollars. You're talking about the quality component--impacting lives in 
a way that is exponential throughout the health care system, not just 
involving one person.

                              {time}  2000

  Ms. SCHWARTZ. I was going to mention something else, too, that I 
think that's a really important and good point is that one of the other 
points that we make that we're also trying to do in health care reform 
in terms of prevention and chronic disease management is that so many 
health policies that people buy, the up-front costs are really on them 
and so that preventative services--the screening, the early 
intervention, the simple doctor visits that can reduce the incidents of 
disease and keep you out of the hospital and keep you healthy--
sometimes that's what you have to pay out of pocket for.
  Some people say, Good. You should pay out of pocket. I think we have 
to understand what we're doing in health care reform is very much about 
a shared responsibility.
  We were talking about providing some subsidies for lower-income 
working people. Everybody is going to have to pay into the system. 
We're going to keep the employer-based system. We're going to help 
those who really are at a lower income be able to pay on a sliding-
scale basis for health insurance either in the private system or public 
option. But the fact is that we should be creating incentives to get 
early care: not wait too long, not wait until they're sick, not wait 
until they go to the emergency room. And that's what we're going to do 
as well.
  So I did want to just finish up by saying that this health care 
reform effort that we are engaged in is complicated, but it's also very 
important. We want to make sure that, again, our businesses are able to 
continue to provide health coverage for their employees, that families 
can afford it if they're on their own, and small businesses or 
individuals can afford to pay for health care, and that government can 
continue to meet our obligations under Medicare for our seniors, 
something so important.
  And we're only going to be able to do that if we do a better job of 
incentivizing, providing reimbursement, for delivery systems, medical 
providers, doctors and nurses, and all of the many health care 
practitioners that are so important to us. We have to make sure that 
they have the reimbursement, they have the tools to be able to provide 
the care in the right settings in the community to help us, have the 
information we need, have the right medical device to work with us to 
be healthier.
  At the end of the day, our hope, I believe, is not only that we will 
extend coverage, not only that we will contain costs, not only that we 
will improve quality, but at the end of the day, Americans will be 
healthier. And if Americans are healthier, we will, in fact, contain 
costs and be able to afford to make sure that we have no child in 
America without health coverage, that we don't have families who are 
bankrupt as a result of health coverage, that we don't have families 
worrying every day because they have one family member with a chronic 
disease and they can't get insurance and that they can't act 
responsibly. That is certainly something that we want to do.
  It's a goal that the President has set out. It's a goal that many of 
us have worked for years on. We're working hard right now to make it 
happen, and I look forward to standing on this floor to have the 
opportunity to vote for comprehensive health care reform that will 
contain costs, that will improve quality, that will help enable every 
American to have access to affordable, meaningful health coverage in 
this country.
  I yield back the balance of my time.

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