[Congressional Record Volume 155, Number 117 (Thursday, July 30, 2009)]
[House]
[Pages H9183-H9190]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                              DOCTORS HOUR

  The SPEAKER pro tempore (Mr. Kratovil). Under the Speaker's announced 
policy of January 6, 2009, the gentleman from Louisiana (Mr. Cassidy) 
is recognized for 60 minutes as the designee of the minority leader.
  Mr. CASSIDY. Mr. Speaker, we are pleased to be here. We call this the 
Doctors Hour because there is a fair number of us on the Republican 
side who are physicians or in some way health care providers, 
optometrists, a practicing psychologist, or in some other way connected 
with the health care field. So we give our own perspective.
  Now, my own bio, if you will, aside from being a physician, I have 
worked with the uninsured in my State of Louisiana for the last 20 
years.

                              {time}  2030

  That's almost 90 percent of my practice, working with the uninsured 
in a public hospital. And so, when I speak of what we need to do to 
help the uninsured, it is purely flowing out of my life experience. I 
think that as the others come up I'll give them a chance to speak as to 
it what they're about. I'll start off with a couple of comments. I've 
learned in my 20 years of, whether private practice or public practice, 
that the only thing that lowers costs is if you make things patient-
centric. If the government is in charge, or the insurance company or a 
bureaucracy run by anybody is in charge, it becomes something that 
doesn't work for the patient. The patient's separated from costs. They 
have a harder time accessing benefits. It just doesn't work.
  On the other hand, if you put the patient in the middle, if you tell 
that woman, listen, you can go see the physician you wish to see and 
when you go in there there's minimal administrative hassle. And if you 
don't like that physician, you can go see another physician. It really 
works. The patient's satisfied, and typically, the patient/physician 
relationship is stronger. And key to getting good health care is having 
a strong patient/physician relationship.
  Now, frankly, I think the only thing innovative that we've heard from 
the other side, although their plan kind of is changing on a day-by-day 
basis, is in one sense, the only thing about that plan which is radical 
is that it nationalizes health insurance. I was a little amused by my 
Democratic colleagues earlier who were saying, Oh, my gosh, Republicans 
are defending insurance companies. No, actually I think they're 
defending insurance companies. They like insurance companies so much 
they want to nationalize it and have a national insurance company.
  Now I'm thinking, now we have an insurance company run by the private 
sector that, if it doesn't work, constituents call Congresswomen, 
Congressmen, we pass a law that changes that, changes that so that the 
private insurance company plays by better rules. Now, though, it's 
going to be both the referee and the player. Now the government will 
make the rules, but also compete. And as it does that, in some way, 
we're supposed to expect that the government-run insurance company is 
going to be kinder and gentler, more cost-effective, higher value 
product than is the private insurance company.
  I think it's the triumph of hope over experience. We hope it will be 
better. We know Medicaid and Medicare don't work as we wish; in fact, 
they're going bankrupt, and their bankruptcy is what's driving this 
plan. And so we're going to believe that the third try is going to be 
the charm and that this time we get it right. Well, without going 
further, I'll yield to my fellow physician from Louisiana, John 
Fleming.
  Mr. FLEMING. Well, I thank my friend and fellow colleague, both a 
physician and fellow Member of Congress, Bill Cassidy, and also fellow 
Louisianan. And of course tonight we're going to be talking about a lot 
of different things relative to what is really the hottest topic maybe 
in a decade, health care reform, which both sides of the House are very 
interested in.
  You know, you hear often from this side of the aisle that well, for 
heavens

[[Page H9184]]

sakes, we want health care reform. But you guys, on the other hand, 
Republicans, you want the status quo. Well, I can tell you personally, 
that I ran for Congress with the overarching intent of getting up here 
and participating in reform. What I want to bring forth first, before 
we get into some more details is, I think there's a litmus test as to 
how good a government-run system is, that proposed by the President and 
the Democrats. And so, the question is, a rhetorical question is, if 
it's so good, then shouldn't Congress be the first ones to sign up for 
it individually, for them and their families?
  And, in fact, to see to that, I set forth House Resolution 615, which 
is supported by 66 Republicans, including our leadership on down, and 
all it says is that if a Member of Congress votes for a government-run 
health plan, a public option, if you will, then he or she is willing to 
forego the waiver, the carve out, the exception, if you will, that's 
built into their version, and join it immediately for themselves.
  Mr. CASSIDY. Now, Congressman Fleming, how many Democratic cosponsors 
do you have?
  Mr. FLEMING. I'm sad to say to my friend, and I thank you for 
yielding back, that so far we have no Democrats, goose egg, zero 
Democrats.
  Mr. CASSIDY. Now, reclaiming my time, because we heard a presentation 
prior to this that, by golly, this is the best thing since sliced 
bread; this is the plan that's going to fix everything, and why 
wouldn't you be on it. So I'm kind of asking you, Dr. Fleming, why 
wouldn't they want to be on it.
  Mr. FLEMING. Well, I think that is the $100,000, or shall I say, $1.6 
trillion question, because apparently they're not so enthralled with it 
that they would like to be in it themselves. And in fact, I put it to 
the test by actually putting it on my Web site and asking people if 
they would like their congressman to support it, that they would 
actually reach out. We have 150,000 Americans who signed the petitions, 
and the number is growing drastically every day.
  And so I would say that, as we go through this debate, that we simply 
ask our constituents out there to hold us in Congress accountable by 
contacting your Congressperson or Senator or even the President and 
say, Mr. President, Mr. or Ms. Congressperson, Mr. or Ms. Senator, will 
you go to fleming.house.gov and sign up, cosponsor or whatever, House 
Resolution 615, that simply says that if you're willing to vote for it 
you're willing to join it.
  Mr. CASSIDY. Now, reclaiming my time, and I appreciate that because, 
again, what we've heard before is that this plan does not put 
government between the patient and their physician. And yet, I would 
have to think, if that weren't the case, why wouldn't anyone agree to 
your bill? I think your amendment was proposed in our committee, and it 
was defeated on party line votes. So I think Dr. Roe, from Tennessee, 
may have some thoughts as to what would come between the patient and 
the physician. I keep emphasizing that because if something's patient-
centered, we know the closer it is to the patient, the more likely it 
works. So let's ask Dr. Roe, a physician from Tennessee, what might 
come between the patient and the physician. Dr. Roe.
  Mr. ROE of Tennessee. Thank you, Dr. Cassidy. This evening members of 
the GOP Doctors Caucus want to talk to you about health care solutions. 
All of us are physicians who ran for Congress, in part, because we saw 
challenges in our health care system and wanted to be part of a debate 
on how to improve it. This is my first term. And when I first arrived I 
was energized by the opportunity to reform how the health insurance 
industry works and help make health care more affordable, which are 
probably the two biggest complaints about today's system.
  I quickly realized, however, that the House Democratic majority had a 
radically different vision of how health care should be delivered. 
Rather than allowing patients and doctors to make health care 
decisions, House Democrats' plan is to have Washington bureaucrats 
decide what is and is not allowed based on its cost effectiveness.
  Mr. CASSIDY. Dr. Roe, can I reclaim my time?
  Mr. ROE of Tennessee. Yes.
  Mr. CASSIDY. Can you show me up there where there is a Washington 
bureaucrat on that chart? Where might there be a bureaucrat on that 
chart? Show me where the patient is and show me where a bureaucrat is.
  Mr. ROE of Tennessee. Well, the patient, Dr. Cassidy, is here and 
here. These are the patients over here. And this person right here, 
whoever this may be, will be one of the most powerful people in the 
U.S. This will be a health care commissioner who will decide what is 
adequate and not adequate insurance coverage. This bureaucrat right 
here will be very much in those health care decisions.
  Mr. CASSIDY. So unlike the Republican plans, which are patient-
centric, what you're telling me is this is kind of a top-down, let's 
figure it out from Washington and lay it on the rest of the country.
  Mr. ROE of Tennessee. That's correct. And the solution should come 
the other way, from the grassroots up. Absolutely. In addition, they, 
the bureaucrats would create a system so complex that today's system 
would look like a walk in the park. And then to put the framework in 
place for government-run health care, the plan called for creation of a 
government-run insurance company, the so-called public option, which 
would, over time, bleed out the private insurance industry, because it 
would be mandated to pay rates less than the cost of care.
  In my district, the First District of Tennessee, they call this 
socialized medicine, and they've sent me here with a very clear message 
to deliver. Please defeat this bill. People in my district want health 
care reform. They really, really do. I talk with people all the time 
who hate insurance companies, and in my time as a doctor, as you all 
have, I've often spent more time on the phone getting an insurance 
company to approve a procedure than I did actually doing the procedure. 
I also talk with people all the time who believe that reform is 
possible and that results in them getting the same care for less money. 
And I tell them it's possible, if we focus on rooting out waste in the 
system.
  But even with this desire for reform, people in my district are clear 
that increasing Washington bureaucrats' roles in health care is not the 
direction they want our health care system moving in.
  Mr. CASSIDY. Dr. Roe, can I reclaim my time?
  Mr. ROE of Tennessee. Yes.
  Mr. CASSIDY. Of course we don't want this to be a partisan issue. Now 
frankly, as far as I know, Republicans have not been invited into the 
discussion. And there are actually some things in that Democratic plan, 
those thousand pages, that I think are very good. But there's other 
things, and I think they kind of general concept top-down. But it's not 
just us.
  David Brooks is a columnist for The New York Times. You see him on 
TV, a very thoughtful man. I have a quote here. The health care system 
is as big as the entire British economy. There's no way something that 
big and complex and dynamic can be run out of Washington. We have to 
set up a dynamic system, not trying to establish a set of rules to be 
imposed by fiat. Now, I think what you're telling me is that this is a 
big, complex plan run out of Washington, and not the dynamic system, 
but rather a set of rules, and whoever that really powerful person is 
in that purple box, that person will be establishing the rules by fiat. 
Is that a fair statement?
  Mr. ROE of Tennessee. That is correct. And one of the things, Dr. 
Cassidy, I think that's very important, that I've heard, and I've got 
some other comments in a minute. But I think it's very important when 
you hear about the cost of this health care plan. This plan's somewhere 
around $1 trillion over 10 years, which doesn't start paying any money 
out in the plan till 2013. So really, it's $1 trillion over 5\1/2\ 
years. Now, let me just explain why that is an extremely low number.
  Mr. CASSIDY. Hang on. Hold that thought. Let me give one more David 
Brooks quote and call on our colleague, Dr. Fleming okay? Another David 
Brooks quote talking about the CBO report, speaking about how much it 
would cost. This is devastating. The plan was sold as a way to bend the 
cost curve to reduce the rate of health care cost growth. Instead, the 
cost of the plan to the Federal budget would rise by 8 percent a year, 
and there wouldn't be anything close to offsetting revenues to pay for 
it.

[[Page H9185]]

  Now, Dr. Fleming, can you sustain a health care system which has out 
of control inflation, if you will?
  Mr. FLEMING. Well, my answer to the gentleman is that I would look to 
the experience of other health care systems in other countries. If you 
look at Medicare and Medicaid, we've not been able to do that. Medicare 
is running out of money. We don't have a solution to that. The States 
all across the country are having tremendous difficulty figuring out 
how they're going to pay for Medicaid budgets, their part of it. And 
then if you look at the U.K., you look at Canada, countries around the 
world who have these systems, none of them have been able to claim that 
they can control costs. They're inflation rates are 10 percent or more.
  Mr. CASSIDY. Reclaiming my time, part of this plan is to increase 
Medicaid eligibility, i.e., put more people on to Medicaid. Yet what 
we've just heard is that Medicaid is bankrupting States, or causing 
them to raise taxes.
  Mr. FLEMING. Absolutely.
  Mr. CASSIDY. So going back to my question, if you cannot control 
costs, can you sustain a health care system?
  Mr. FLEMING. In my opinion, no, because, again, if you can't do it 
for a smaller system, how can you enlarge the system and somehow make 
it mysteriously work, particularly when there are no models? 
Massachusetts, Tennessee, TennCare, and so on and so forth, no one has 
an example of a government-run system that works.
  Mr. ROE of Tennessee. Will the gentleman yield?
  Mr. CASSIDY. I will yield.
  Mr. ROE of Tennessee. Let me just tell you the folks out there, and 
we're going spend about the last half of this hour talking about the 
positive solutions and what we do agree on. But when I first came to 
D.C. and I heard of this public option I said, I've heard this before. 
And in Tennessee, in the early nineties we had managed care that was 
going to control the cost. We got a waiver from HHS and formed a 
program called TennCare, where we had about 8 different managed care 
organizations competing for your business. Now we have one.
  In the 1993-1994 year, the State of Tennessee spent combined Federal, 
State revenue, $2.5 billion. Eleven years later, 10 to 11 years later, 
that had gone to over $8.5 billion. It had tripled and took up almost a 
third of the State's entire budget. We were complaining about 17 
percent now. This took up almost a third and almost every new dollar 
that the State took in.
  Mr. CASSIDY. Reclaiming my time, let me just praise the motivations 
of the people in Tennessee. They clearly cared about the uninsured, as 
our Democratic colleagues, are. But it was a flawed model and couldn't 
be sustained, and we know that those patients were now uninsured again, 
probably worse off than before the experiment.
  Mr. ROE of Tennessee. Well, actually, what happened, just to go over 
that a little bit, over that period of time, in Tennessee, it was a 
noble goal to cover as many of our people in our State as we could. But 
over a short period of time, 45 percent of the people who got on 
TennCare had private health insurance.

                              {time}  2045

  Our Governor is a Democrat, Governor Bredesen. As you all know and as 
everyone in this Hall knows, in a single-payer system, the way costs 
are controlled is by rationing care. Well, what we did in Tennessee 
was, about 200,000 people were removed from the rolls, and what did a 
significant number of those people do? They went back on their private 
health insurance.
  There is another thing that, I think, you have to ask yourself. By 
tripling the amount of money you spend on health care, what kind of 
outcomes will there be? Ultimately, that is what you're really 
interested in.
  What we ended up with in Tennessee was the highest per capita 
prescription drug use in the Nation, and number two, we were 47th in 
health outcomes.
  I yield back.
  Mr. CASSIDY. Dr. Boozman, I would like your opinions on this. You're 
an optometrist from Arkansas.
  Mr. BOOZMAN. Well, thank you very much.
  You know, it's interesting. I think we bring up a good subject. When 
I'm home, one of the things that I hear very, very much from the 
seniors is, we have a Medicare system that's functioning pretty well. 
Yet, when you look at it in 2017, it has all kinds of fiscal problems. 
Their question to me is: Why aren't you fixing the government program 
you have now before you expand it greatly to millions of people? You 
guys can correct me or can add to this: I've heard anywhere from 10 
percent of the Medicare bill that we pay is just waste and fraud. Why 
aren't we addressing that?
  Mr. CASSIDY. Reclaiming my time, 10 percent in Medicare, a generally 
accepted figure, is in waste and fraud. So we hear from our colleagues 
across the aisle that Medicare has lower overhead costs. If you include 
in that the 10 percent, which is a common way to define ``overhead,'' 
actually, that 3 percent becomes at least 13 percent. A fair statement. 
I think an economist would say, if your overhead is so meager that you 
can't watch out for fraud and abuse, then you need to lump the cost of 
the fraud and abuse into your overhead.
  Mr. BOOZMAN. I agree. As a guy from Arkansas, I just know that 
there's a heck of a lot of fraud and waste in the system. Rather than 
expand it like we're talking about doing now, why not fix that first? 
We hear about the pizza parlors that are charging for dialysis and, you 
know, things like that.
  So, again, I would say that we need to get our act together there and 
reform the Medicare system that we've got.
  I know I'm in a situation now. It's not uncommon at all for me to 
have people my age call and say, My mom has moved to town, and I can't 
find a Medicare provider because the fees are so low for physicians 
that people have started either limiting the slots that they use for 
the Medicare practice or they've simply discontinued the practice in 
their clinics.
  Mr. CASSIDY. Thank you.
  Dr. Broun, you've joined us. May we have your thoughts on this, 
please?
  Mr. BROUN of Georgia. Well, I thank y'all. I appreciate y'all doing 
this tonight, and I appreciate your yielding me some time. I think the 
American people need to know several things about this, and y'all have 
brought up some very good points.
  The CBO says that this ObamaCare plan is not going to save money. It 
says that, in 10 years, we're still going to have almost 20 million 
people in this country who won't have health insurance. They need to 
understand that illegal aliens are going to be given free health 
insurance by the Federal Government.
  Now, last night I was watching C-SPAN, and one of our Democratic 
colleagues was just railing on about how illegal aliens will not get 
ObamaCare.
  The reality is, in the Energy and Commerce Committee, just today, 
this morning, one of my Georgian colleagues introduced an amendment to 
the bill that basically said that you have to look at people's 
citizenships and confirm whether they're U.S. citizens or not. That was 
defeated almost on a party-line vote. All of the Republicans voted for 
the amendment. Most all of the Democrats did not. I think there were 
one or two who voted with my Republican colleague from Georgia. The 
amendment was to just affirm that somebody was here legally to get free 
health insurance. We saw that with SCHIP.
  When I first came up here during the last Congress, we had numerous 
debates about SCHIP, and we had fights over giving State Child Health 
Insurance Programs to illegal aliens. Our Democratic colleagues 
absolutely fought and won the fight on this issue. People who come are 
going to be asked a question, Are you an illegal alien? When they say, 
No, I am not an illegal alien, then they're not going to do anything to 
check the legality or the truth of that statement. So it's a self-
determination by the applicants as to whether they're legal or not. If 
they say they're not illegal, then they're going to be given free 
health insurance under this government plan.
  The other thing that, I think, is extremely important for the 
American people to understand is that this plan is going to cost 
American workers a tremendous salary decrease. Plus, it is going to put 
a lot of American workers out of work. In fact, it has been projected 
that over 100 million people are

[[Page H9186]]

going to be forced off of their private insurance. Also, as Dr. Roe was 
just talking about, it happened in the TennCare.
  So I've heard a figure of 114 million people who have private 
insurance today who are going to be forced off their private insurance 
plans onto this so-called ``public option.'' Well, how does that work?
  Well, I have businesses in my own district in northeast Georgia that 
have told me, businessmen and -women, that they'd rather pay the 8 
percent tax, the pay-or-play tax. It would cost them less to pay the 
extra tax and then put their folks, whose insurance they're paying for 
today, over on the government plan, the socialized medicine/government 
plan.
  I saw a video today of Barney Frank, who was questioned about the 
government option. He said in this video, in his own words, that this 
is the way to get everybody in this country on a single-payer system. 
So, as to the claim that our Democratic colleagues put forth, which is, 
if you have private insurance you can keep it but if you don't then 
we'll give you a public option, is not factual.
  They're setting up the game such, as Barney Frank just very blatantly 
said in this video today--and I think it's on YouTube, and you can go 
look at it--that this government option is the means to get everybody 
on one single-payer system provided by the Federal Government, 
socialized medicine.
  Mr. CASSIDY. If I can reclaim my time, let's give credit where credit 
is due, because the advocates for a public option plan--I'm not an 
advocate of one, though--will point out that there's a decrease in 
administrative costs.
  So, Dr. Roe, will you look up at that chart once more--or maybe you 
will, Dr. Boozman--and give us a sense of what will be the 
administrative costs, do you imagine, with this publicly run health 
insurance plan.
  Mr. ROE of Tennessee. Well, here, Dr. Cassidy--and then I'll turn it 
over to John--if you'll look at this--and it's so complicated that it's 
almost comical--the problem with it is that this is how your health 
care is going to be administered.

  I do want to say for every physician in this room and in this 
Congress, both Democrat and Republican, and this is truly from the 
bottom of my heart, it has been a privilege to be a physician and to be 
able to provide care for people and to administer to them. I believe, 
and I think every Republican and Democrat believes, that health care 
decisions should be made between a family, a patient and the doctor.
  Now, having said that, if you take a look at having to go through 
this, you're going to have a Benefits Advisory Committee--and I don't 
mean this funny, but when the Lord got tired, a committee built a 
moose, anything that ugly. Basically, this here is going to be deciding 
what's adequate here as administered by this down here. You'll have the 
Bureau of Health Information. We'll have comparative effectiveness 
outcomes.
  I want to tell you the other thing. The people who really need to be 
fearful are senior citizens when you start looking at getting rid of 
Medicare Advantage and when you start talking about carving as much as 
$500 billion out. I don't think our seniors right now feel like too 
much is being spent if you'd talk to them and see what their 
supplementals cost. Well, do you know what that means when you spend 
less money? You're going to provide less care, and there's no plan in 
the world that can provide more and more care for a lot less money.
  Mr. BROUN of Georgia. Dr. Roe, would you yield for 1 minute?
  While you're talking about the seniors, I think the seniors need to 
understand, too, about this ObamaCare plan and understand that it 
mandates that those seniors have counseling, I think it is, every 5 
years. They have to go get counseling every 5 years about dying. This 
is a government bureaucracy. I'm not sure where it is in your chart 
there because it's so hard to figure out what all this bureaucracy is 
that's being placed between the patient and the doctor.
  Yet one of those bureaucracies is going to every 5 years tell people 
over 65 years of age, basically, that they have a responsibility to 
look at how they're going to die and how they're not going to cost the 
American taxpayer money, is basically what they're going to tell them.
  Mr. CASSIDY. I thank you for offering that.
  Reclaiming my time, Dr. Boozman, John, when you look at that, some 
patients aren't as sophisticated as others. Let's face it, some folks 
don't have the same education. Maybe they've had to struggle a little 
bit to get through life. Imagine if a patient had a problem with that 
and didn't have a counselor coming to them, as Dr. Broun mentions, but, 
by golly, they just have a doctor they don't like, don't get along 
with, and they want to complain to someone. Where would they complain?
  Mr. BOOZMAN. I think that's a real problem.
  As was mentioned, one of the things that we see in this type of plan 
is rationing for seniors. Are they going to be able to get the knees? 
the hips? In my case, being very familiar with cataract surgery, is 
somebody going to allow them to have that as they get older and allow 
them to ease their pain and lead a quality of life?
  You know, we're talking about getting preventative care and all this. 
Well, you do a great job, and you live, and you get up in years, and 
then we're going to take away the ability for you to go ahead and 
continue that quality of life.
  Mr. FLEMING. Will the gentleman yield?
  May I add that the bill, itself, is scored at over $400 billion to be 
taken out of the current Medicare program. That's over $400 billion to 
be taken out of the current Medicare program. So that's actually in 
their bill itself. So I don't see how they can claim that the elderly 
will get more care. They're only going to get less care.
  Mr. BOOZMAN. I agree with the gentleman. If he would yield?
  Mr. FLEMING. Yes.
  Mr. BOOZMAN. There are so many questions that are unanswered when you 
look at this chart. If you get denied, you know, who do you appeal to? 
Is there any appeal?
  Mr. CASSIDY. Reclaiming my time, I know there's supposed to be an 
ombudsman. In the 1,000-page bill, I've found one page that spoke of an 
ombudsman whom you would call up if you had a complaint.
  I guess the point I'm making about administration--I read an article 
in the McKinsey Quarterly. They said there are three things you 
absolutely have to do if you're going to control costs. You've got to 
decrease administrative costs. I look at that and it just gives me a 
migraine.
  Mr. BOOZMAN. If the gentleman will yield, the first thing you've got 
to do is have some tort reform, and you guys can, you know, very well 
spell out how you practice defensive medicine when people come in with 
headaches and things like that, and there's one thing that's not on 
that chart. There's nothing about nuisance lawsuits, which are driving 
up the costs of medicine and which make it such that we have counties 
in Arkansas, where I'm from, that don't have any OB because the guys 
can't afford the malpractice insurance.
  Mr. CASSIDY. If I can reclaim my time, Dr. Broun, as far as you know 
with the bill, how does the bill address tort reform?
  Mr. BROUN of Georgia. It does not.
  Mr. CASSIDY. I'm sorry?
  Mr. BROUN of Georgia. It does not address tort reform.
  Mr. CASSIDY. We just heard from our colleague from Arkansas that 
that's a critical thing to do.
  Mr. BROUN of Georgia. Well, I was just fixing to ask Dr. Boozman to 
yield so I could tell him a story.
  Two days ago, I talked to the administrator of one of the major 
hospitals; it's a regional hospital within my congressional district in 
northeast Georgia. He was telling me just that day that one of the CAT 
scan techs, a lady, was up in his office, asking for more help in their 
CAT scan unit at night.
  He asked her, Why do you need so much in the way of help there? She 
said, Because of all the massive amounts of CAT scans that we're 
running up here through the night which are ordered through the 
emergency room.
  They did 10 CAT scans in one night on patients who'd come in. The 
administrator's question was, How many of those CAT scans were 
positive? Zero. Not the first one.
  I've worked full time for part of my career as a director of 
emergency medicine at Baptist Hospital in Georgia.

[[Page H9187]]

I've been involved in emergency medicine throughout my medical career, 
sometimes part time, sometimes no time, when I was just doing family 
medicine, and other times full time.
  Particularly doctors in the emergency room are having to do CAT scans 
on people who come in with all sorts of aches and pains when they 
really don't need to do those, but they're having to do those CAT scans 
and MRIs just because somebody might come back later on and sue them 
for missing a diagnosis.
  Mr. CASSIDY. Now, Dr. Broun, if I could reclaim my time, earlier, Dr. 
Roe had suggested--we spent the first half in kind of a critique of 
what our folks, our colleagues across the aisle, have put forward; but 
we've set aside our second half to kind of talk about what works. This 
is kind of a nice segue because I think, one, we know that lowering 
administrative costs will help, and we know that malpractice reform can 
also address some of these issues.
  I'll go back to the central theme, which has to be that any effective 
reform has to put the patient in the middle; and when you put the 
patient in the middle, you've got to give them transparent costs so 
they know what they're buying before they go in there, and you need to 
encourage them to make the lifestyle changes because, ultimately, a 
patient, she or he, is ultimately responsible for his own health.

                              {time}  2100

  I know that, Dr. Fleming, in your business--because you're not only a 
physician, a congressman, husband, and a father, but you're also a 
small business man--could you relate your experience with health 
savings accounts? Perhaps define them for us and say how it worked in 
your small business.
  Mr. FLEMING. Absolutely. I will tell you, approximately 5 years ago, 
and this is when health savings accounts really----
  Mr. CASSIDY. Will you define what that is, please?
  Mr. FLEMING. Yes. A health savings account is really very simple, 
where either the subscriber--the employee--or the employer, as in our 
case, puts part of the subscription costs into a savings account.
  Mr. CASSIDY. Reclaiming my time, you put a portion of that health 
premium into a bank account of sorts that the patient/employee then 
controls?
  Mr. FLEMING. Not only does he control, but it is nontaxed, and he can 
use it to buy prescription drugs, to pay the deductible or whatever.
  And we were up against a situation where, like many small businesses, 
our premiums were going up 9, 10 percent, sometimes 15 percent per 
year, and we were pulling our hair out trying to figure out what else 
we could do. And this idea of health savings accounts came out, and we 
said, Well, let's try this. I had some reluctance from my employees, 
but we increased the deductible, and the extra amount that we would 
have paid for the increase in subscription costs, we put it into a 
health savings account for each and every one of them.
  The results were dramatic. The costs flatlined. They did not go up. 
And since then, they've never gone up more than 3 percent a year. It's 
empowered the employee, the patient, the family, to buy medications at 
will.
  And it was very interesting. I had one employee who was complaining 
as we implemented. She said, Well, gee, I spend $200 a month for 
inhalers, and how is this going to help me out because I'm going to be 
spending a lot of time. I said, Well, let me suggest that you stop 
smoking, and with the money that you save by not having to use 
inhalers, you will have plenty of money left over. She took me up on 
it, and now she doesn't need them.
  Mr. CASSIDY. Reclaiming my time, could she have used her HSA to buy 
the medication to help her get off of cigarettes?
  Mr. FLEMING. Absolutely.
  Mr. CASSIDY. Now, I like that because it puts the patient, the 
empowered patient in the middle so that she's making the best decisions 
not only for her wallet, but also for her health and, by the way, for 
her job because you are able to keep your costs down and keep her 
employed.
  Fair statement?
  Mr. FLEMING. Absolutely.
  Mr. CASSIDY. Dr. Roe, I think also you've had experience with putting 
patients in the middle with these health insurance plans. Can you 
relate that, please.
  Mr. ROE of Tennessee. In our own practice, we had traditional health 
insurance, as most people did, 80/20 cost. As Dr. Fleming was saying, 
costs were continuing to go up, and about 3 years ago we introduced 
this plan for the physicians. There are 11 of us in the group, and all 
of us decided to go on this plan. And 2 years ago, we have a group that 
has 294 employees that elected to get their health insurance through 
our plan at the office: 294, 70 providers, doctors, and extenders. 
Eighty-four percent of those, of our people, our employees in our 
office, chose this plan because it put them in control of the dollars.
  Let me explain to you how that is. If you believe in wellness and 
prevention--and the way our plan worked was you had a $5,000 
deductible. That scares everybody to death. But our group put $4,200 
per person in there.
  Mr. CASSIDY. Reclaiming my time, you had a savings account for the 
patient, $4,200, that you put in there to help pay that high 
deductible?
  Mr. ROE of Tennessee. Yes.
  Mr. CASSIDY. But now it's coming out of their pocket if they buy the 
expensive medicine as opposed to the insurance company.
  Mr. ROE of Tennessee. And guess what the empowered person does? At 
the end of the year, they've been healthy, they've taken care of 
themselves, they keep that money. But let's say they have an illness or 
a wreck or something happens to them. Anything above that deductible is 
paid 100 percent. So you have catastrophic coverage, but you're in 
control of the first dollars. And by doing that, again, I think as you 
pointed out in our Education and Labor meeting, that particular type of 
insurance protection is 30 percent lower than standard.
  Mr. CASSIDY. Reclaiming my time, for a similar-size family, similar 
benefits, with a health savings account costs are 30 percent lower 
relative to traditional insurance.
  Now, we've talked about and quoted David Brooks talking about the 
Congressional Budget Office comment that the plans being presented to 
us do not bend the curve; they elevate the cost curve. And yet here is 
something which has been proven--it's not a hope, but it's experience--
to lower costs by 30 percent.
  Mr. ROE of Tennessee. That is correct. And when you empower 
consumers, as I've said, how many of us have driven across four lanes 
of interstate to buy gas 3 cents a gallon cheaper? Americans are great 
shoppers, and they will look after it, as opposed to--when they're 
spending their own money, they are very careful with it, as opposed to 
the government up here which is not careful with their money.
  Mr. CASSIDY. Reclaiming my time, John, if I can ask you, those 
patients we talked about earlier, and maybe they haven't had the same 
educational opportunity, the same economic opportunity, but 
nonetheless, if gas were cheaper 3 cents a gallon on the other side of 
the interstate, do you think they would go over four lanes to get it?
  Mr. BOOZMAN. Very much so. I was looking on the chart, and it's not 
up there. But other things, the associated health plans, where if 
you're a florist, a small business man and you've got your little store 
and you go in and try to negotiate with the insurance company, you 
don't have a very strong negotiating position. But if we would allow 
them to go in with others, thousands of florists, then they could 
negotiate as a group and get a much better rate like a major 
corporation.
  Mr. CASSIDY. May I add, that is part of some of the Republican 
alternatives that are being proposed. Allow those small business women 
and men to band together perhaps to purchase one of these empowering 
HSAs.
  Mr. FLEMING. Why is it that they can't do that now?
  Mr. BOOZMAN. In doing that, then you have to go across State lines. 
Also, different States have different mandates as far as what they--you 
have to offer in particular States.
  So we could do that at the Federal level and get rid of all of that 
stuff and not go across the State line.
  Mr. BROUN of Georgia. If you would yield just a moment, I would like 
to point out something. The commerce

[[Page H9188]]

clause of the Constitution--I'm an original constitutionist, as many 
people in this House know. In fact, I carry a copy in my pocket. I 
carry it all the time, even when I'm home doing all sorts of things. 
I don't take it with me when I go in the shower, but almost.

  But the commerce clause under its original intent was supposed to do 
just exactly what you're talking about, Dr. Boozman, is allow 
interstate commerce across State lines. And what we've done is we've 
perverted the Constitution in many ways. And this is one way that 
commerce clause has been perverted tremendously.
  The commerce clause was supposed to make sure that there would not be 
a lockbox of goods and services at the State line. It was supposed to 
facilitate interstate commerce, not to control interstate commerce but 
to facilitate it.
  And so we have perverted the Constitution markedly. And this is one 
good point that the Republicans are pointing out today about trying to 
give patients the ability to buy the insurance directly from an 
insurance company across State lines or have these pools with their 
alumni association. I went to the University of Georgia. We could have 
a University of Georgia Alumni Association pool. I went to the Medical 
College at Georgia for medical school. We could have an MCG pool. I'm a 
Rotarian. We could have a Rotary pool. We could have these huge pools 
that would help stop some of these problems with portability. It would 
help solve some of the problems that we have.
  Mr. CASSIDY. Reclaiming my time, you always give me these nice 
bridges to segue into. Some of the Republican alternatives--and you're 
actually addressing all of those very nicely. And if you're a member of 
Rotary, you can do that. Now, I like that.
  So can I call on my good friend, Dr. Fleming, if he can initiate some 
of the discussion of just what the Republican Study Commission is 
putting forth, not necessarily what Mr. Ryan has put forth or others, 
but even this step plan.
  Mr. FLEMING. You often hear rhetoric from the Democrat side of the 
aisle that we are the party of the status quo, the party of no, we 
don't want reform. That is the main thing I ran on to come to Congress. 
I want health care reform. But I want commonsense reform, not nonsense 
reform, and that's what the Democrats are offering us.
  The first completed bill--there are different versions of bills on 
the Republican side, but the first completed bill that's actually been 
dropped because we've been working behind the scenes for weeks and 
months to get it perfect, is the Empowering Patients First Act, which I 
am a proud original cosponsor, and here are some basic parts of it.
  No. 1, access to coverage for all Americans. It covers preexisting 
conditions, and that is the big problem that everybody is talking about 
here tonight, risk pools.
  Mr. CASSIDY. Reclaiming my time, so if you will, what's being said by 
our colleagues across the aisle to misrepresent our positions, we 
absolutely favor insurance reform to allow folks with preexisting 
conditions to get coverage, correct? That's what you just said, 
correct?
  Mr. FLEMING. Yes.
  Mr. CASSIDY. So next time someone gets up to the podium and says we 
don't believe that, that is incorrect; am I correct?
  Mr. FLEMING. You are correct.
  Mr. CASSIDY. The fact is that is misleading. And that is one thing I 
like in their plan and I like in our plan.
  I yield back.
  Mr. FLEMING. It also protects employer-sponsored insurance. But on 
the other hand, it actually gives ownership of the plans to the 
individual, and also the individual can buy it outside of their 
employer.
  Mr. CASSIDY. Reclaiming my time, the anecdotes that you gave and Dr. 
Roe gave regarding the empowered patients by giving them these health 
savings accounts or something such as that, we empower patients. That's 
in our plan. It's not the government bureaucracy between our friends up 
there; rather, it is empowering patients.
  Mr. FLEMING. This does not exist. This matrix that you see there with 
Dr. Boozman, that does not exist in this plan.
  Mr. BROUN of Georgia. Dr. Cassidy if you will yield for a second, to 
draw a contrast here, too, is this the plan that you were just talking 
about, Mr. Fleming. A patient or an employee can choose whether they 
want to purchase their plan through their employer or not; is that 
correct?
  Mr. FLEMING. That is correct.
  Mr. BROUN of Georgia. Well, in the Democratic plan, they're going to 
be forced to buy the employer-provided health care insurance or they're 
going to be taxed at a 2 percent increased tax rate over what they're 
being taxed today. So their taxes are going to go up by 2 percent. 
They're going to be forced into that employer-provided health care plan 
that's going to be dictated--if you'll hold just a second, I want to 
make one very strong point here that people need to understand.
  That employer-provided health care plan is going to be dictated by 
the health care czar panel. It is established on this menagerie of 
colors and blocks and things.
  Mr. FLEMING. Yes.
  Mr. BROUN of Georgia. So the employers won't have a choice anymore 
about the plan that they offer their employees, and the employee won't 
have a choice either. And both of them are going to pay a penalty if 
they don't do what the Federal Government mandates or dictates to them; 
is that correct?
  Mr. FLEMING. That is correct. And also, the government will have to 
actually certify all health plans. It will be a one-size-fits-all.
  Mr. ROE of Tennessee. Would you yield?
  Mr. FLEMING. Yes.
  Mr. ROE of Tennessee. The Empowering Patients First Act that you just 
talked about does not contain, as Dr. Broun just described, these 
mandates, these taxes.
  Mr. CASSIDY. So, Dr. Roe, may I interrupt for a second?
  A clear contrast between our plan, if you will, or one of our plans 
and their plan, aside from their increased administrative costs, aside 
from their top heavy, aside from ours being lower administrative costs 
and patient-centered, you're saying that one of the plans being 
presented to us has the mandates but the Republican plan does not.
  Mr. ROE of Tennessee. That's correct.
  Mr. BROUN of Georgia. That's the point I was trying to bring up, too, 
doctors, if I could speak directly to the American citizens, as I 
cannot due to the rules here.
  But if the American citizens understand, the Democratic plan is going 
to dictate their plan to them. It's all going to be run by government 
dictation or dictum from Washington, D.C., and this health care czar; 
whereas, the Republican plan gives the patient and the employer the 
choice of what they want to do. And that's why I wanted to try to draw 
that contrast as you were talking.
  I yield back.

                              {time}  2115

  Mr. FLEMING. Let me finish up because there are only a couple more 
points left. It also reins in out-of-control costs. This goes back to 
malpractice reform. This has malpractice reform. The government-run 
plan has not a word about malpractice reform. And finally, this is 
budget-neutral. That plan over on this side of the aisle is $1 trillion 
to $1.6 trillion, depending on which year span you are talking about, 
of course, with the CBO telling us that the costs curve up, not curve 
down, over time, despite what our President has told us. This one 
starts out with no cost, no net cost. There are savings built into it.
  Mr. CASSIDY. If I may reclaim my time, it's important that the people 
watching realize that that is not just Republicans saying this. Again, 
I'm going to quote. The Congressional Budget Office, as we know, has 
spoken about how costly this bill would be.
  From nytimes.com, I, again, quote David Brooks:
  ``The theory of the Democratic bills seems to be that 98 percent of 
Americans can party on, with the latest and costliest health care 
imaginable, no matter how ineffective, and the top 2 percent will pay 
for it all.'' He goes on to say, ``If you don't control the rate of 
health care inflation, even the rich won't be able to pay for the cost 
increases.''

[[Page H9189]]

  So it's others, not in this Chamber, commenting on the cost of that 
program and, indeed, commenting on the Congressional Budget Office 
comments.
  Mr. FLEMING. And really, just to get down to the basics, if the 
patients, if the public, the consumer doesn't have skin in the game, 
there's no money to be saved in this. If it's all on the providers and 
all on the government, you will never see costs controlled.
  Let me add one other thing before I yield. We were talking a moment 
ago about the fact that illegal immigrants will be covered under this 
plan, 10 million or more.
  Mr. BROUN of Georgia. Not our plan but the Democratic plan.
  Mr. FLEMING. I'm sorry. The Democratic plan provides coverage for 
illegal immigrants. The Republican plan does not. The Republican plan 
presumes that we will deal with immigration problems through an 
immigration reform process. But getting to my final point here is, the 
other thing that the government-run plan, the Democrat plan, provides 
for is taxpayer-funded abortions. Not only taxpayer-funded abortions, 
but an actual mandate, the requirement for convenience. There will have 
to be convenience centers throughout the country so that young women 
will not only have access but will have easy access, all at the 
taxpayers' expense. None of that, of course, is provided for in the 
Republican plan.
  Mr. ROE of Tennessee. If the gentleman will yield, I have a letter 
that I received from a constituent which was given to me this past 
week; and I think it's worth passing on. It says:
  ``Dear Dr. Roe,
  ``My wife Missy and I are aware of the struggle you face on Capitol 
Hill over government-run health care. We wish to offer you our personal 
story of how the current system saved our son, Robby, to use as you see 
fit to put a human face on our side of this issue. Robby suffers from 
unbearable pain that began when he had a severe infection he contracted 
September 2007. It began one Saturday. He went to bed feeling a little 
off and woke up the next morning with a severe ear ache. Within 5 
hours, his eardrum ruptured. In spite of several courses of 
antibiotics, this infection continued to spread into every cavity of 
Robby's head, and it began to attack his nervous system and his brain. 
The pain was torturous. Robby was admitted to the Knoxville Children's 
Hospital for over a week. The infection finally stopped with I.V. 
antibiotics, but the damage had been done. Robby lost the ability to 
walk. He also developed a motor vocal tick associated with constant 
shooting pain in his head. We researched Robby's symptoms and found 
doctors at Vanderbilt Children's Hospital in Nashville and Children's 
Hospital of Philadelphia where Robby was treated by the head of 
pediatric neurology. We were able to visit these doctors and receive 
treatment for our son only because our private health insurance gives 
us the flexibility to do so. In the last 18 months, Robby's been 
hospitalized six times, including most of this March. Pain medicine, 
including morphine, PCA, hydrocodone and Demerol gave no relief. He had 
to be sedated for over a week until the pain subsided. There is still 
no definitive diagnosis. In spite of this, Robby has had multiple 
exploratory procedures, MRI, CT, et cetera, and tried nearly 20 
medications. We finally found the medicine that helped 4 months ago. 
This has eased his symptoms significantly. He is doing much better but 
is still not able to return to school. Throughout this ordeal, the 
medical system has been helpful, responsive, timely and accessible at 
all levels. We were always around to be a part of the decision-making 
process in our son's care from medicines and procedures to which 
doctors and hospitals treated him. We recently learned of another boy 
in our area who was about Robby's age that suffered from similar 
symptoms. He died. We believe competent, fast, flexible care that would 
be impossible under a government-controlled system saved Robby from 
this fate. Missy and I lived under a government health care system in 
the Army. I grew up in an Army family. I remember sitting for hours in 
the military emergency room with a broken arm.''
  He goes on, ``and we had no recourse. You can't sue the government. 
We are not wealthy people. We make well below the median income and 
have had to pay thousands of dollars out of our own pocket to get Robby 
where he is now. It has been a struggle, but we would gladly pay any 
amount to ensure the timely care and freedom of choice needed to treat 
our son. It is true that under a government-controlled system we 
wouldn't have had these medical expenses. We believe they would have 
been funeral expenses. Please feel free to use our story. We would be 
glad to testify or do anything else you feel would be beneficial.''
  This is Rob and Missy Mathis from Newport, Tennessee.
  Mr. CASSIDY. If I may reclaim my time, one, it's a tremendous 
testament to the faith of that family, their love for their son and to 
those fine physicians at Vanderbilt. I think all of us share the hope 
to have high-quality health care affordable, accessible to all 
Americans. Our concern is that the solutions being brought upon us are 
going to not only not achieve that but interfere with that 
relationship, and it's not just folks who are conservatives.
  I have an editorial in my local paper by Susan Estrich. You will 
recall that Susan Estrich was chief of staff for Walter Mondale--I 
think I have this right--when he ran for President. I don't agree with 
her, but I respect her thoughts. She's a bright woman. She wrote Don't 
Risk Your Health Care.
  She begins:
  The President is ``not familiar'' with the bill. No one can explain 
how it will work yet, as Senator Ben Cardin told a contentious town 
meeting. There are various plans, and negotiations are still in the 
early stages. But whatever it is, we should be for it.
  She goes on to say, ``Am I missing something?''
  Then she describes the relationship that she and her family have with 
their physician. They are not sure. She wants to be reassured and has 
seen nothing that reassures her yet that that relationship will be 
preserved. So it isn't just folks in this arena. It's folks across the 
country.

  Dr. Boozman, what are your thoughts?
  Mr. BOOZMAN. Well, I would just say that all of us--and in hearing 
the letter, all of us have seen patients in our practices that we knew 
as we prescribed the treatment that they couldn't afford, hardworking 
people that just didn't have the ability to afford that. So we 
definitely need reform, and we've talked about that. We need 
portability. We need more competition, things like that. What we don't 
need, though, is to try to get this thing done in 2 or 3 weeks.
  I was on this school board for 7 years. If we were trying to change 
the curriculum of the high school class, we'd spend more than 2 or 3 
weeks doing due diligence. But to try to do that in a period of 2 or 3 
weeks makes no sense at all.
  The other thing I would say is that we don't need government-run 
health care. We don't need to go down the path towards Great Britain 
and Canada. And something I'd like for you guys to comment on--because 
you have treated them and things--tell us about the results of cancer 
and things like that in the Canadian and Great Britain systems compared 
to the United States. I guess my concern is, in an effort to fix our 
pretty good system--you know, it's working pretty good--that we 
actually destroy the system to fix the part that's broken.
  Mr. CASSIDY. Reclaiming my time, I would say that it works for 85 
percent of the people; but we would favor the reforms that would ease 
the insecurity that if you get sick, you lose your insurance or it's 
priced out. So we favor the reform that deals with preexisting 
conditions. At the same time, we don't want to ruin it for the 85 
percent.
  I yield to my friend.
  Mr. BROUN of Georgia. I thank you, Dr. Cassidy, for yielding. I just 
wanted to give you a couple of quick stories, one that goes along with 
Dr. Roe's story. I have a surgical colleague that I was talking to who 
told me about getting a phone call from a government bureaucrat about a 
Medicare patient that he had in the hospital. The doctor got the call 
from the Medicare bureaucrat in Atlanta who said, Doctor, we have 
reviewed such-and-such a patient that I understand you have in the 
hospital. Yes. We have reviewed it. She does not meet criteria to be 
hospitalized, and we want you to discharge her today.

[[Page H9190]]

  The doctor said, Well, have you seen my patient?
  No.
  Are you a doctor?
  No.
  Are you a nurse?
  No.
  So you're just a government bureaucrat, is that correct?
  Well, I work for CMS.
  He said, You've not seen my patient at all?
  No.
  But you have determined that this patient should not be in the 
hospital, and you want me to discharge her?
  That's correct.
  He said, This patient is extremely ill; and if I discharge her, she 
is very likely to die. I'm not going to discharge her.
  The government bureaucrat said, Doctor, you don't understand. We've 
determined that if you don't discharge this patient today, we're going 
to fine you $2,000 a day.
  So the doctor went and talked to the patient's family and the 
patient. What were they to do? Well, he discharged her. She died that 
night at home.
  Mr. CASSIDY. Reclaiming my time just for a second, CMS is the agency 
that governs Medicaid and Medicare, the Federal program.
  Mr. BROUN of Georgia. This was a Medicare bureaucrat.
  That's the kind of care that the Democratic plan is going to not only 
give us more of, but it's going to take it down to lower age groups 
besides those 65 years of age and older. It's government intrusion into 
the health care system that has run up the cost tremendously. CBO has 
already said that the Democratic plan is going to cost more money. It's 
not going to bring the costs down.
  Y'all were talking about the cost curve going up. What that means to 
the people who don't understand, that means it's going to be more 
costly for the health care system under the Democratic plan than what 
we have today.
  Mr. CASSIDY. If I may reclaim my time, we're almost out. I just want 
to wrap that in with a comment that Dr. Fleming said about how the best 
system is one in which the patient is involved. I think you said ``skin 
in the game.'' The McKinsey Quarterly talks about transparent pricing 
for value-conscious people. Again, quoting from David Brooks, the New 
York Times columnist, a very thoughtful man: ``I'd say that there have 
to be cost-conscious consumers within a closely regulated market. 
Unless you get proper incentives for both providers and consumers, I 
doubt you're going to go very far. In the current plans,'' meaning 
those across the aisle, ``all the emphasis is on the providers.''
  Mr. BROUN of Georgia. Dr. Cassidy, if you don't mind yielding for 
another moment, let me tell you about something that happened in my 
medical practice down in rural southwest Georgia. Congress passed CLIA, 
the Clinical Laboratory Improvement Amendments. I had a fully automated 
lab in my office where I would do blood sugars, blood counts and things 
like that. If a patient came in to see me with a red sore throat, 
running a fever, white patches on the throat, coughing, runny nose, I 
would do a complete blood count to see if they had a bacterial 
infection and thus needed antibiotics to treat it. Or if they had a 
viral infection, they could have the same clinical picture but didn't 
need the cost or the exposure to the antibiotics. CLIA shut my lab down 
and every doctor's lab in this country down. Prior to CLIA, I charged 
$12 for that CBC. It took 5 minutes to do with quality control. After 
CLIA, I had to send patients across the way to the hospital, it took 2 
to 3 hours to get the test and cost $75 for one test. It goes from $12 
to $75, and 5 minutes to 3 hours. Now this is how government intrusion 
into health care markedly drives up the cost.
  Mr. CASSIDY. If I may reclaim my time, I think you are involved in 
what is called as a concierge practice or a patient-centered practice 
where the patient will prepay you, say, $50 a month; and if you don't 
satisfy that patient, she goes to see another doctor.
  Do I recall that correctly?
  Mr. BROUN of Georgia. Well, not exactly. In fact, I have discharged 
patients at the time I see them. I don't have that concierge practice 
where I am prepaid. But actually, I charge less. My practice was a 
full-time house call practice. I was not working in an office.
  Mr. CASSIDY. If you would yield back, because I just want to mention 
that one thing. There are some physicians, a lot of them on the west 
coast, that have a practice that is so patient-centered, it works 
beautifully. In that practice, the patient pays $50 to $100 a month and 
gets all the primary and preventive services cared for. If the patient 
doesn't like it, they find another doctor the next month. It's like 
Target or Wal-Mart. If my wife doesn't like the sale at Target, she 
goes over to Wal-Mart; and if she doesn't like the service at Wal-Mart, 
she will go back to Target. The fact is, is that the physician, knowing 
that those folks can go, is going to be more patient-sensitive.
  Mr. BROUN of Georgia. And the Republican plan allows patients to do 
that, where the Democratic plan does not.
  Mr. CASSIDY. Thank you all very much.

                          ____________________