[Congressional Record Volume 155, Number 148 (Wednesday, October 14, 2009)]
[Senate]
[Pages S10391-S10393]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                              HEALTH CARE

  Mr. COBURN. Mr. President, I plan on taking about 10 minutes of our 
time.
  I serve on the HELP Committee with the distinguished chairman. There 
is no question we have not emphasized prevention in this country, but 
there is a reason we have not. We do not pay for it. Medicare does not 
pay for it. The insurance companies follow what Medicare does.
  We have heard some pretty good claims this morning in terms of the 
HELP bill. I sat through almost 3 weeks of markup on that bill. I don't 
believe there is anybody in Congress who does not want us to change the 
way we look at prevention because there is no way we can control health 
care costs unless we both try to prevent chronic disease and also 
manage the chronic disease we have.
  One of the reasons we have more chronic disease than other countries 
is because we keep people with chronic disease alive a lot longer. They 
let them die. They ration the care out, and they determine what the 
value of their life is. With a chronic disease, eventually they quit 
treating them. The numbers get skewed because we do a pretty good job. 
Even though we did not prevent it, we do a wonderful job, and we can 
actually do far better in managing chronic disease.
  What the Senator and the HELP committee put out is a government-
centered bill. Let me give an example. Duke University set up a clinic 
for heart failure patients. They were having phenomenal results. These 
are all Medicare patients, class III, class IV, class V heart patients. 
They dropped hospital admissions 27 percent. They shut it down. Why did 
they shut it down? Medicare would rather pay--because they are not 
flexible, they will not recognize prevention--they shut down a clinic 
that was saving them $100 million a year, even though it cost about a 
significant portion of that, 10 percent or so, to run the clinic. They 
would rather spend the $90 million than to pay for prevention. So what 
was a great clinic--keeping people out of the hospital, maintaining 
their chronic disease. Medicare did that.
  That is the reason I am very opposed to the bill--not the principles 
of the bill but the bill that came out of committee. The bill that came 
out of our committee creates 88 new government programs--88. Think 
about it. What do we want in health care? What we want in health care 
is to be able to determine our own future, to determine our own doctor, 
and to be able to afford to buy the health care our families need. That 
is what we want. We create 88 new Federal Government programs managing 
our health care, and that freedom to choose, that freedom to make a 
judgment is going to go out the window.
  The other points the Senator mentioned, he talked about increasing to 
30 percent the ability of performance bonuses for people to get into 
reduction plans, wellness plans. He mentioned Safeway. They can spend 
21 percent under HIPAA now. Safeway's testimony was, give us the 
flexibility everybody else in the country has and let's go up to 50 
percent. We don't trust them to do that, even though Safeway has had no 
increase in health care costs in the last almost now 5 years because 
they have truly incentivized prevention.
  He mentioned workforce development, and he mentioned all these 
incentives to help people become primary care doctors. They are not 
going to become primary care doctors. Do you know why? I am a primary 
care doctor. They are not going to pay them. The reason we have a 
disproportionate number of specialists versus primary care doctors in 
this country is because there is a 350-percent payment differential. 
How do you think that came about? Medicare created that differential.
  If we want more primary care doctors, then what we have to do is pay 
people to go into primary care, and they will come running because it 
is the best place in the world to practice medicine. They get to care 
for entire families. They get to manage every type of conceptual 
disease one can think of, and the rewards are out of this world. But 
when the average medical student comes out of medical school owing 
$170,000, and their pay is one-fourth of somebody who spends 1 or 2 
more years in training, there is no reason to think why they don't all 
go into additional training so they can be compensated at a level that 
matches the debt and the sacrifice they put in. They average 8 years of 
medical school and residency. We don't have many other people who have 
that kind of training. Yet Medicare created the shortage we have today 
by limiting the payment to primary care physicians.
  The reason I make that point is the plans that are coming to the 
Senate floor are totally government centered. They are totally 
government managed. They are totally government created. He talked 
about sidewalks and bike paths. In that bill, we set up $10 billion a 
year for concrete, supposedly for wellness. I can think of a whole lot 
better things. We can put $10 billion in NIH and do a whole lot more in 
terms of savings for this country in terms of our health care.
  Where do I agree with the chairman? We will never control our costs 
in health care and we will never make health care affordable for us as 
a nation or individually until we manage the chronic disease we have 
out there officially and until we incentivize the prevention of it. He 
is right on that. But there are two approaches to doing that. One says 
the government is going to do all of it, and the other says maybe we 
could incentivize individuals in the public to make good decisions for 
themselves. One costs a whole lot of money; the other does not cost 
any.
  Let me tell you how well the government does. Go to any School Lunch 
Program you want to today. Go look at it. Look at what we feed our kids 
at breakfast and lunch, and then ask yourself: No wonder our kids are 
unhealthy. We are feeding them a high-fat, high-carbohydrate, simple-
sugar, simple-starch meal. We are creating, through the government 
School Lunch Program and breakfast program, the very obesity the 
Senator says he wants to stop.
  Then look at the food stamp purchases we incentivize. There are no 
limits on them--a government program. Then look at the people on the 
Food Stamp Program--and this is no discrimination toward them at all; 
they need the help--but look at the choices they make. There is no 
effort to limit to only buy what are good foods with food stamp money 
rather than junk food that, in fact, enhances chronic disease.
  There are a lot of ways to approach it, but if we look at what the 
government is doing now--what does it do? In health care, what does the 
government do right now that is effective and efficient? Nothing.
  The chairman talked about the fact that Medicare is going to go 
broke. It is. In 5\1/2\ years, the Medicare trust fund will be belly 
up. Nobody disputes that point. The Medicare trustees are saying that. 
We have all these problems in Medicare. Why don't we fix those? We have 
a full 15 percent, at a minimum, of fraud in Medicare. Where is the 
fix? Why don't we fix it? Instead, we are going to bring to the floor 
88 new government programs, a government-centric run health care system 
that is going to defeat and destroy the best health care system in the 
world.
  It is not the most efficient, but there is no question if you are 
sick, this is the best place in the world to get sick. If you have 
cancer, your cure rate is 40 to 50 percent better than anywhere else

[[Page S10392]]

in the world. If you have heart disease, your outcome is better than 
any other place in the world. Prevention is key, but as we try to fix 
the problems in health care, our first goal ought to be ``do no harm'' 
to what is good about American health care.
  I yield for my colleague from Tennessee and note I have consumed over 
10 minutes. I apologize to him for that.
  The PRESIDING OFFICER. The Senator consumed 10 minutes.
  Mr. ALEXANDER. Mr. President, the Senator from Oklahoma, a practicing 
physician who has delivered hundreds or thousands of babies----
  Mr. COBURN. Thousands.
  Mr. ALEXANDER. Thousands of babies is one of the most eloquent 
spokesmen for what needs to be done in health care in the Senate. I am 
delighted he took time to come to the Senate floor today. It helps to 
have someone here who has such a passion for patients and who can talk 
to the American people on this complicated subject in terms of what 
this health care plan means for us. That is why so many of us on the 
Republican side agree with what eight Democratic Senators wrote to the 
majority leader the other day.
  They said: We would like to read the bill and know what it costs 
before we start voting on it. That seems so sensible that maybe the 
American people would laugh out loud if that would be a request, but it 
is. It is important to us and them and many more of the Senators--I 
believe virtually all of the American people--that we honor that 
request.
  What that means is that the legislative text being put together by 
Majority Leader Reid somewhere--the merging of the Finance bill and the 
HELP bill--that full text, and as the Democratic Senator said, the 
complete budget scores should be made available for 72 hours on the 
Internet before we begin to vote.
  The Director of the Budget Office has said it might take 2 weeks, 3 
weeks, to have complete budget scores so we can know what the bill 
costs. But if it takes 2 weeks, if it takes 3 weeks, if it takes 4 
weeks, we need to know. The President has said we cannot add a dime to 
the deficit. How are we going to know if we are adding a dime to the 
deficit if we do not read the bill and do not know what it costs? We 
cannot guess what is in the bill. We cannot guess at what it costs when 
we are talking about huge numbers--hundreds of billions, trillions of 
dollars.
  We have our work cut out for us. We can stay here and do this. We are 
prepared to do this. We Republicans agree with the Democratic Senators 
that we need to read the bill and know what it costs. We need to see 
the complete legislative text and the complete budget numbers.
  Why is that so important? Among other reasons, what we are hearing is 
that what the bill coming out of the Finance Committee does is, among 
other things, three big things. Instead of reducing costs, it has 
higher premiums, it has higher taxes, and it has Medicare cuts. That is 
not health care reform if it has higher premiums, higher taxes, and 
Medicare cuts for more government.
  What is the goal of this exercise? The first goal is reducing costs 
for each person who buys insurance. How many of us go home and hear 
that every weekend? I cannot afford my insurance; do something about 
it. Reducing costs.
  What else do we hear? People are saying: I cannot afford my 
government. You guys are running up the debt trillions of dollars, 
hundreds of billions of dollars.
  What we need to do is to reduce the cost of health care for 
individuals across America and for the government of individuals. But 
this bill raises premiums, raises taxes, and cuts Medicare to create 
more government.
  How does it drive up premiums? The Congressional Budget Office has 
said the obvious, which is that when we impose taxes on medical devices 
and on the insurance companies, what do they do with it? It is $900 
billion-plus worth of taxes. They pass it on to us. So our premiums go 
up.
  Or there are new ``government approved'' policies that we will need 
to buy. If you are one of those Americans who likes to buy a 
catastrophic policy--that is, pay a lower premium so that you pay your 
own medical expenses unless something really terrible happens to you or 
your family--that is a pretty wise choice for many Americans. You may 
not be able to do that quite so easily under this bill because you will 
have to buy a government-approved plan or pay a fine. And then younger 
Americans may be surprised by the amount of money they have to pay. So 
it is very likely that for millions of Americans this bill will raise 
their premiums instead of reducing their cost, and 250 million 
Americans either pay premiums or have premiums paid for them.

  Then raising taxes. Here we are in the middle of a recession, 10 
percent unemployment, and we are talking about nearly $1 trillion of 
tax increases that will be passed on to us in one way or the other. 
There is a $1,500 penalty per family if you don't buy insurance. There 
is an employer mandate. So if you are a small business, you will have 
to either provide insurance or pay that penalty.
  Then the governors of both parties--Democrats and Republicans--are in 
a near cardiac arrest over the prospect of the Medicaid expansion. I 
mean 14 million new people--low-income Americans--dumped into State 
Medicaid Programs. I say ``dumped'' because doctors and hospitals are 
reimbursed so poorly that only 40 percent of doctors will see Medicaid 
patients. So we are going to say: Congratulations, Mr. and Ms. Low-
Income American, into the Medicaid you go in your State.
  Not only is it not health care reform for those individuals, but the 
governors can't manage it, the legislators can't manage it, and the 
taxpayers can't manage it. I have read, on the floor, comments from 
most Democratic Governors and most Republican Governors. They are in a 
situation where their States' budgets are in the worst shape since the 
1960s. Medicaid is going up at 6 and 7 percent. They are taking money 
from higher education and K-12 grades and spending it on Medicaid, and 
now we are about to dump not only more low-income Americans into 
Medicaid, but we are going to send a part of the bill to the State 
governments which can't afford it. So that is State taxes, and it cuts 
your Medicare.
  The question I would like to raise is, what about those Medicare cuts 
and are doctors themselves going to be paying for this bill? There is 
an article today, or October 13, the former head of the Congressional 
Budget Office, Douglas Holtz-Eakin. These Congressional Budget Office 
heads are known to be pretty straight. This one was appointed by the 
Republican Congress; Mr. Elmendorf, whom we all respect, was appointed 
by a Democratic Congress, but they are all nonpartisan. Mr. Holtz-Eakin 
says:

       . . . the plan proposed by the Democrats and the Obama 
     administration would not only fail to reduce the cost burden 
     on middle-class families, it would make that burden 
     significantly worse. The bill creates a new health 
     entitlement program that the Congressional Budget Office 
     estimates will grow over the longer term at a rate of 8 
     percent annually. To avoid the fate of the House bill . . . 
     the Senate did three things: It promised that future 
     Congresses would make tough choices to slow entitlement 
     spending, and it dropped the hammer on the middle class.

  Mr. President, could you let me know when I have consumed 10 minutes?
  The PRESIDING OFFICER. The Chair will let the Senator know.
  Mr. ALEXANDER. I thank the Chair.
  Here is what Mr. Holtz-Eakin said:

       One inconvenient truth is the fact that Congress will not 
     allow doctors to suffer a 24 percent cut in their Medicare 
     reimbursements.

  Doctors today are paid about 80 percent of what private insurers will 
pay if they see Medicare patients and, under the law, that gets cut 
every year and every year we come in and fix that. Continuing to read 
from his article:

       Senate Democrats chose to ignore this reality and rely on 
     the promise of a cut to make their bill add up. Taking note 
     of this fact pushes the cost of the bill well over $1 
     trillion and destroys any pretense of budget balance.

  In other words, Mr. Holtz-Eakin is saying he doesn't believe we in 
Congress are going to cut doctors' pay when they serve Medicare 
patients by roughly $250 billion over the next 10 years. That is about 
the amount of money it would take just to pay doctors 10 years from now 
what they are being paid today, and most wouldn't be happy with that. 
So either the doctors are going to pay for this bill--$250 billion of 
it--or you are, because it is going to add to your debt, or your 
children or your grandchildren are. It is

[[Page S10393]]

one way or the other. It is either doctors pay or your kids pay because 
it is not deficit neutral.
  He says:

       It is beyond fantastic to promise that future Congresses, 
     for 10 straight years, will allow planned cuts in 
     reimbursements to hospitals, other providers, and Medicare 
     Advantage--thereby reducing the benefits of 25 percent of 
     seniors in Medicare.

  His point is these are not only cuts in Medicare--$\1/2\ trillion 
worth of cuts--the cuts are being used to start a new government 
program. And here, as both Senator Harkin and Senator Coburn reminded 
us, Medicare in 5 or 6 years is going bankrupt--belly up.
  The PRESIDING OFFICER. The Senator has used 10 minutes.
  Mr. ALEXANDER. I thank the Chair very much. I will conclude my 
remarks.
  What we are proposing to do is cut Medicare--take money from 
grandma--and instead of spending it on grandma by making Medicare more 
solvent, we are going to take that money, while the program is about to 
go insolvent, and create a new program. So these are the kinds of 
questions the American people have a right to ask and have answered.
  That is why we want to read the bill. Because we see, as we look at 
this bill, higher premiums, higher taxes, Medicare cuts for more 
government, and we don't believe that is health care reform.
  Mr. President, I ask unanimous consent to have printed in the Record 
the entire article from which I quoted.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

             [From the Wall Street Journal, Oct. 13, 2009]

                     The Baucus Bill Is a Tax Bill

                        (By Douglas Holtz-Eakin)

       Remember when health-care reform was supposed to make life 
     better for the middle class? That dream began to unravel this 
     past summer when Congress proposed a bill that failed to 
     include any competition-based reforms that would actually 
     bend the curve of health-care costs. It fell apart completely 
     when Democrats began papering over the gaping holes their 
     plan would rip in the federal budget.
       As it now stands, the plan proposed by Democrats and the 
     Obama administration would not only fail to reduce the cost 
     burden on middle-class families, it would make that burden 
     significantly worse.
       Consider the bill put forward by the Senate Finance 
     Committee. From a budgetary perspective, it is 
     straightforward. The bill creates a new health entitlement 
     program that the Congressional Budget Office (CBO) estimates 
     will grow over the longer term at a rate of 8% annually, 
     which is much faster than the growth rate of the economy or 
     tax revenues. This is the same growth rate as the House bill 
     that Sen. Kent Conrad (D., N.D.) deep-sixed by asking the CBO 
     to tell the truth about its impact on health-care costs.
       To avoid the fate of the House bill and achieve a veneer of 
     fiscal sensibility, the Senate did three things: It omitted 
     inconvenient truths, it promised that future Congresses will 
     make tough choices to slow entitlement spending, and it 
     dropped the hammer on the middle class.
       One inconvenient truth is the fact that Congress will not 
     allow doctors to suffer a 24% cut in their Medicare 
     reimbursements. Senate Democrats chose to ignore this reality 
     and rely on the promise of a cut to make their bill add up. 
     Taking note of this fact pushes the total cost of the bill 
     well over $1 trillion and destroys any pretense of budget 
     balance.
       It is beyond fantastic to promise that future Congresses, 
     for 10 straight years, will allow planned cuts in 
     reimbursements to hospitals, other providers, and Medicare 
     Advantage (thereby reducing the benefits of 25% of seniors in 
     Medicare). The 1997 Balanced Budget Act pursued this strategy 
     and successive Congresses steadily unwound its provisions. 
     The very fact that this Congress is pursuing an expensive new 
     entitlement belies the notion that members would be willing 
     to cut existing ones.
       Most astounding of all is what this Congress is willing to 
     do to struggling middle-class families. The bill would impose 
     nearly $400 billion in new taxes and fees. Nearly 90% of that 
     burden will be shouldered by those making $200,000 or less.
       It might not appear that way at first, because the dollars 
     are collected via a 40% tax on sales by insurers of 
     ``Cadillac'' policies, fees on health insurers, drug 
     companies and device manufacturers, and an assortment of odds 
     and ends.
       But the economics are clear. These costs will be passed on 
     to consumers by either directly raising insurance premiums, 
     or by fueling higher health-care costs that inevitably lead 
     to higher premiums. Consumers will pay the excise tax on 
     high-cost plans. The Joint Committee on Taxation indicates 
     that 87% of the burden would fall on Americans making less 
     than $200,000, and more than half on those earning under 
     $100,000.
       Industry fees are even worse because Democrats chose to 
     make these fees nondeductible. This means that insurance 
     companies will have to raise premiums significantly just to 
     break even. American families will bear a burden even greater 
     than the $130 billion in fees that the bill intends to 
     collect. According to my analysis, premiums will rise by as 
     much as $200 billion over the next 10 years--and 90% will 
     again fall on the middle class.
       Senate Democrats are also erecting new barriers to middle-
     class ascent. A family of four making $54,000 would pay 
     $4,800 for health insurance, with the remainder coming from 
     subsidies. If they work harder and raise their income to 
     $66,000, their cost of insurance rises by $2,800. In other 
     words, earning another $12,000 raises their bill by $2,800--
     marginal tax rate of 23%. Double-digit increases in effective 
     tax rates will have detrimental effects on the incentives of 
     millions of Americans.
       Why does it make sense to double down on the kinds of 
     entitlements already in crisis, instead of passing medical 
     malpractice reform and allowing greater competition among 
     insurers? Why should middle-class families pay more than 
     $2,000 on average, by my estimate, in taxes in the process?
       Middle-class families have it tough enough. There is little 
     reason to believe that the pain of the current recession, 
     housing downturn, and financial crisis will quickly fade 
     away--especially with the administration planning to triple 
     the national debt over the next decade.
       The promise of real reform remains. But the reality of the 
     Democrats' current effort is starkly less benign. It will 
     create a dangerous new entitlement that will be paid for by 
     the middle class and their children.

  Mr. ALEXANDER. I thank the Chair, and I yield the floor.
  The PRESIDING OFFICER. The Senator from Arizona.

                          ____________________