[Congressional Record Volume 155, Number 172 (Thursday, November 19, 2009)]
[House]
[Pages H13289-H13319]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




             MEDICARE PHYSICIAN PAYMENT REFORM ACT OF 2009

  Mr. WAXMAN. Mr. Speaker, pursuant to House Resolution 903, I call up 
the bill (H.R. 3961) to amend title XVIII of the Social Security Act to 
reform the Medicare SGR payment system for physicians, and ask for its 
immediate consideration.
  The Clerk read the title of the bill.
  The SPEAKER pro tempore (Mr. Salazar). Pursuant to House Resolution 
903, the bill is considered read.
  The text of the bill is as follows:

                               H.R. 3961

       Be it enacted by the Senate and House of Representatives of 
     the United States of America in Congress assembled,

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Medicare Physician Payment 
     Reform Act of 2009''.

     SEC. 2. MEDICARE SUSTAINABLE GROWTH RATE REFORM.

       (a) Transitional Update for 2010.--Section 1848(d) of the 
     Social Security Act (42 U.S.C. 1395w-4(d)) is amended by 
     adding at the end the following new paragraph:
       ``(10) Update for 2010.--The update to the single 
     conversion factor established in paragraph (1)(C) for 2010 
     shall be the percentage increase in the MEI (as defined in 
     section 1842(i)(3)) for that year.''.

[[Page H13290]]

       (b) Rebasing SGR Using 2009; Limitation on Cumulative 
     Adjustment Period.--Section 1848(d)(4) of such Act (42 U.S.C. 
     1395w-4(d)(4)) is amended--
       (1) in subparagraph (B), by striking ``subparagraph (D)'' 
     and inserting ``subparagraphs (D) and (G)''; and
       (2) by adding at the end the following new subparagraph:
       ``(G) Rebasing using 2009 for future update adjustments.--
     In determining the update adjustment factor under 
     subparagraph (B) for 2011 and subsequent years--
       ``(i) the allowed expenditures for 2009 shall be equal to 
     the amount of the actual expenditures for physicians' 
     services during 2009; and
       ``(ii) the reference in subparagraph (B)(ii)(I) to `April 
     1, 1996' shall be treated as a reference to `January 1, 2009 
     (or, if later, the first day of the fifth year before the 
     year involved)'.''.
       (c) Limitation on Physicians' Services Included in Target 
     Growth Rate Computation to Services Covered Under Physician 
     Fee Schedule.--Effective for services furnished on or after 
     January 1, 2009, section 1848(f)(4)(A) of such Act is amended 
     by striking ``(such as clinical'' and all that follows 
     through ``in a physician's office'' and inserting ``for which 
     payment under this part is made under the fee schedule under 
     this section, for services for practitioners described in 
     section 1842(b)(18)(C) on a basis related to such fee 
     schedule, or for services described in section 1861(p) (other 
     than such services when furnished in the facility of a 
     provider of services)''.
       (d) Establishment of Separate Target Growth Rates for 
     Categories of Services.--
       (1) Establishment of service categories.--Subsection (j) of 
     section 1848 of the Social Security Act (42 U.S.C. 1395w-4) 
     is amended by adding at the end the following new paragraph:
       ``(5) Service categories.--For services furnished on or 
     after January 1, 2009, each of the following categories of 
     physicians' services (as defined in paragraph (3)) shall be 
     treated as a separate `service category':
       ``(A) Evaluation and management services that are procedure 
     codes (for services covered under this title) for--
       ``(i) services in the category designated Evaluation and 
     Management in the Health Care Common Procedure Coding System 
     (established by the Secretary under subsection (c)(5) as of 
     December 31, 2009, and as subsequently modified by the 
     Secretary); and
       ``(ii) preventive services (as defined in section 
     1861(iii)) for which payment is made under this section.
       ``(B) All other services not described in subparagraph (A).

     Service categories established under this paragraph shall 
     apply without regard to the specialty of the physician 
     furnishing the service.''.
       (2) Establishment of separate conversion factors for each 
     service category.--Subsection (d)(1) of section 1848 of the 
     Social Security Act (42 U.S.C. 1395w-4) is amended--
       (A) in subparagraph (A)--
       (i) by designating the sentence beginning ``The conversion 
     factor'' as clause (i) with the heading ``Application of 
     single conversion factor.--'' and with appropriate 
     indentation;
       (ii) by striking ``The conversion factor'' and inserting 
     ``Subject to clause (ii), the conversion factor''; and
       (iii) by adding at the end the following new clause:
       ``(ii) Application of multiple conversion factors beginning 
     with 2011.--

       ``(I) In general.--In applying clause (i) for years 
     beginning with 2011, separate conversion factors shall be 
     established for each service category of physicians' services 
     (as defined in subsection (j)(5)) and any reference in this 
     section to a conversion factor for such years shall be deemed 
     to be a reference to the conversion factor for each of such 
     categories.
       ``(II) Initial conversion factors.--Such factors for 2011 
     shall be based upon the single conversion factor for the 
     previous year multiplied by the update established under 
     paragraph (11) for such category for 2011.
       ``(III) Updating of conversion factors.--Such factor for a 
     service category for a subsequent year shall be based upon 
     the conversion factor for such category for the previous year 
     and adjusted by the update established for such category 
     under paragraph (11) for the year involved.''; and

       (B) in subparagraph (D), by striking ``other physicians' 
     services'' and inserting ``for physicians' services described 
     in the service category described in subsection (j)(5)(B)''.
       (3) Establishing updates for conversion factors for service 
     categories.--Section 1848(d) of the Social Security Act (42 
     U.S.C. 1395w-4(d)), as amended by subsection (a), is 
     amended--
       (A) in paragraph (4)(C)(iii), by striking ``The allowed'' 
     and inserting ``Subject to paragraph (11)(B), the allowed''; 
     and
       (B) by adding at the end the following new paragraph:
       ``(11) Updates for service categories beginning with 
     2011.--
       ``(A) In general.--In applying paragraph (4) for a year 
     beginning with 2011, the following rules apply:
       ``(i) Application of separate update adjustments for each 
     service category.--Pursuant to paragraph (1)(A)(ii)(I), the 
     update shall be made to the conversion factor for each 
     service category (as defined in subsection (j)(5)) based upon 
     an update adjustment factor for the respective category and 
     year and the update adjustment factor shall be computed, for 
     a year, separately for each service category.
       ``(ii) Computation of allowed and actual expenditures based 
     on service categories.--In computing the prior year 
     adjustment component and the cumulative adjustment component 
     under clauses (i) and (ii) of paragraph (4)(B), the following 
     rules apply:

       ``(I) Application based on service categories.--The allowed 
     expenditures and actual expenditures shall be the allowed and 
     actual expenditures for the service category, as determined 
     under subparagraph (B).
       ``(II) Application of category specific target growth 
     rate.--The growth rate applied under clause (ii)(II) of such 
     paragraph shall be the target growth rate for the service 
     category involved under subsection (f)(5).

       ``(B) Determination of allowed expenditures.--In applying 
     paragraph (4) for a year beginning with 2010, notwithstanding 
     subparagraph (C)(iii) of such paragraph, the allowed 
     expenditures for a service category for a year is an amount 
     computed by the Secretary as follows:
       ``(i) For 2010.--For 2010:

       ``(I) Total 2009 actual expenditures for all services 
     included in sgr computation for each service category.--
     Compute total actual expenditures for physicians' services 
     (as defined in subsection (f)(4)(A)) for 2009 for each 
     service category.
       ``(II) Increase by growth rate to obtain 2010 allowed 
     expenditures for service category.--Compute allowed 
     expenditures for the service category for 2010 by increasing 
     the allowed expenditures for the service category for 2009 
     computed under subclause (I) by the target growth rate for 
     such service category under subsection (f) for 2010.

       ``(ii) For subsequent years.--For a subsequent year, take 
     the amount of allowed expenditures for such category for the 
     preceding year (under clause (i) or this clause) and increase 
     it by the target growth rate determined under subsection (f) 
     for such category and year.''.
       (4) Application of separate target growth rates for each 
     category.--
       (A) In general.--Section 1848(f) of the Social Security Act 
     (42 U.S.C. 1395w-4(f)) is amended by adding at the end the 
     following new paragraph:
       ``(5) Application of separate target growth rates for each 
     service category beginning with 2010.--The target growth rate 
     for a year beginning with 2010 shall be computed and applied 
     separately under this subsection for each service category 
     (as defined in subsection (j)(5)) and shall be computed using 
     the same method for computing the target growth rate except 
     that the factor described in paragraph (2)(C) for--
       ``(A) the service category described in subsection 
     (j)(5)(A) shall be increased by 0.02; and
       ``(B) the service category described in subsection 
     (j)(5)(B) shall be increased by 0.01.''.
       (B) Use of target growth rates.--Section 1848 of such Act 
     is further amended--
       (i) in subsection (d)--

       (I) in paragraph (1)(E)(ii), by inserting ``or target'' 
     after ``sustainable''; and
       (II) in paragraph (4)(B)(ii)(II), by inserting ``or 
     target'' after ``sustainable'';

       (ii) in the heading of subsection (f), by inserting ``and 
     Target Growth Rate'' after ``Sustainable Growth Rate'';
       (iii) in subsection (f)(1)--

       (I) by striking ``and'' at the end of subparagraph (A);
       (II) in subparagraph (B), by inserting ``before 2010'' 
     after ``each succeeding year'' and by striking the period at 
     the end and inserting ``; and''; and
       (III) by adding at the end the following new subparagraph:

       ``(C) November 1 of each succeeding year the target growth 
     rate for such succeeding year and each of the 2 preceding 
     years.''; and
       (iv) in subsection (f)(2), in the matter before 
     subparagraph (A), by inserting after ``beginning with 2000'' 
     the following: ``and ending with 2009''.
       (e) Application to Health Care Group Demonstration Program 
     and Successor Accountable Care Organization Pilot Program.--
     In applying the target growth rate under subsections (d) and 
     (f) of section 1848 of the Social Security Act to services 
     furnished by a practitioner to beneficiaries who are 
     attributable to a health care group under the demonstration 
     program provided under section 1886A of such Act (or to an 
     accountable care organization under a pilot program that is a 
     succcessor to such demonstration program under a section of 
     such Act), the Secretary of Health and Human Services shall 
     develop, not later than January 1, 2012, for application 
     beginning with 2012, a method that--
       (1) allows each such group or organization to have its own 
     expenditure targets and updates for such practitioners, with 
     respect to beneficiaries who are attributable to that group 
     or organization, that are consistent with the methodologies 
     described in such subsection (f); and
       (2) provides that the target growth rate applicable to 
     other physicians shall not apply to such physicians to the 
     extent that the physicians' services are furnished through 
     the group or organization.

     In applying paragraph (1), the Secretary of Health and Human 
     Services may apply the difference in the update under such 
     paragraph on a claim-by-claim or lump sum basis

[[Page H13291]]

     and such a payment shall be taken into account under the 
     demonstration or pilot program.

  The SPEAKER pro tempore. The gentleman from California (Mr. Waxman) 
and the gentleman from Texas (Mr. Barton) each will control 30 minutes.
  The Chair recognizes the gentleman from California.
  Mr. WAXMAN. Mr. Speaker, I yield myself 3 minutes.
  Today, we consider legislation that will maintain and strengthen 
Medicare for seniors and individuals with disabilities. A law passed in 
1997 set a limit on payments to Medicare physicians. The idea was to 
save money, but the limit was set too low and required draconian cuts, 
forcing Congress to intervene with temporary fixes.
  In 2004, the law required a 4.5 percent cut. In 2008, it was a 10.1 
percent cut. This year, doctors face a 21 percent cut. These are 
unsustainable cuts that would bring about havoc in the Medicare 
program. Congress has responded by enacting temporary 1-year fixes. 
These temporary fixes only make the problem worse the next year. The 
result has been a cycle of ever increasing cuts followed by ever 
costlier fixes.
  This is not a problem of mere budget or fiscal discipline; it is a 
kitchen table problem for America's seniors and for the physicians who 
are partners in the Medicare program. Medicare's ability to guarantee 
health care for seniors would be eliminated if these cuts went into 
effect.
  We are rightly asking much of the health care providers in health 
reform. We are demanding they provide care more efficiently, that they 
improve the quality of care, and that they give taxpayers good value 
for their dollars. In return, we need to pay them fairly for their 
efforts and to be an honest partner. We have two basic choices. We can 
solve this problem permanently or we can enact another 1-year Band-Aid. 
This legislation says that we will finally enact a lasting reform.
  The House recognized in our budget that honest accounting means 
facing this problem squarely and finding a way to address it. This 
legislation meets that call, replacing the sustainable growth rate for 
physicians, or SGR, which Congress enacted in 1997, with a more 
responsible and stable system for the future. We must be honest about 
this problem and address it responsibly and immediately. We can take 
that step today by passing this bill and combining it with statutory 
PAYGO, which will help restore fiscal discipline.
  I urge Members to support adoption of this bill and reserve the 
balance of my time.
  Mr. BARTON of Texas. I ask unanimous consent that of the 30 minutes 
that I control, the ranking member of the Ways and Means Committee, the 
gentleman from Michigan (Mr. Camp), control 15 of those minutes.
  The SPEAKER pro tempore. Is there objection to the request of the 
gentleman from Texas?
  There was no objection.
  Mr. BARTON of Texas. I would yield myself 1 minute.
  Mr. Speaker, the only fix that's in this bill before us is ``the fix 
is in.'' This is nothing more than a repayment to the American Medical 
Association for endorsing the larger health care bill that was on the 
floor several weeks ago. There is not one dime of pay-for in this bill. 
It is a wave the magic wand, erase the accumulated deficit of the last 
10 years or so in the SGR formula, and let's kick the can on down the 
road.
  The bill is so narrowly construed that we couldn't offer in the 
motion to recommit a real pay-for because this bill doesn't have a pay-
for. This is nothing more than a political payoff to the American 
Medical Association. Republicans support really fixing the SGR system, 
but we think it ought to be done all at the same time. So we would hope 
that we would vote against this sham today.
  I reserve the balance of my time.
  Mr. WAXMAN. Mr. Speaker, I'm pleased at this point to yield 1 minute 
to the distinguished majority leader to speak on the legislation, the 
gentleman from Maryland (Mr. Hoyer).
  Mr. HOYER. I thank the distinguished chairman for yielding, and I 
rise in strong support of this legislation. I want to say to my friend 
who has just spoken, the ranking member of the committee who chaired 
the committee, who said they wanted to pay for things, what this bill 
does is put statutory PAYGO into law. He's right. But what he didn't 
say to you is when their side controlled the Presidency, the House, and 
the Senate, they jettisoned paying for things. They did away with 
statutory PAYGO, they did away with PAYGO generally, and what happened? 
We went from substantial surpluses under the Clinton administration to 
substantial deficits under the Bush administration.
  Now we were told those substantial deficits and deficits that were 
being created would create economic growth in our country. In point of 
fact, however, after 8 years of that economic policy where they 
jettisoned PAYGO, a PAYGO which provided $5.6 trillion of surplus 
available in March 2001, according to President Bush; but they 
abandoned PAYGO, which is in this bill.
  This is not a question of payoff to anybody. This was in the 
President's budget when he sent it down here earlier this year. It was 
in our budget that passed the House and the Senate. We said we were 
going to do this. Why? Because it's the right thing to do. Today, we 
have the chance to vote for health care our seniors can count on and a 
fiscal future for all Americans that they can have faith in.
  Very frankly, my friend also said, We on the Republican side want to 
fix this. My question is simply: Why didn't you? Why do we still have 
this issue that confronts us year after year after year because we 
didn't have the courage to face it? I'm going to talk about the 
deficit, because this adds to the deficit. I will lament that, but 
there is not an option, as you added to the deficit every time you 
fixed it one year at a time. Doctors couldn't rely on it. More 
importantly, seniors couldn't rely on the fact that their doctors 
wouldn't have a big cut and push them out. I'm going to talk about that 
as well. We can do it by stopping a massive Medicare payment cut and by 
committing future policies to the tested principle of pay-as-you-go.
  Now my friends on the other side of the aisle don't like pay-as-you-
go because it constrained them in cutting revenues over a trillion 
dollars, which is one of the reasons we have such a large deficit, 
because they didn't pay for what they bought. Interestingly enough, my 
friends, they bought at a rate twice the growth in spending that 
occurred during the 1990s, in the 2000s, which was about 3\1/2\ percent 
per year. It was 7 percent a year when my friends on the other side of 
the aisle controlled all of the levers of power. So they decreased 
revenue and increased spending, and we had large deficits and the 
biggest recession we have faced since the 1930s were inherited by this 
administration and, frankly, by this Congress.
  Now going back to the pay-as-you-go. First, the Medicare payment rate 
cut, if we do nothing, payments to doctors treating Medicare patients 
will drop by 21 percent in the new year with more cuts in the years to 
come. If we allow that to take place, many seniors will find their 
doctors no longer available to treat them.
  So this is not only about compensating doctors for the services that 
are vitally important and we want them to give, but it is also 
protecting seniors' access to doctors. That will mean less access to 
health care, longer waiting lists, and serious conditions going 
untreated and.
  In sum, if we do not act on this bill, it will mean sicker seniors. 
That's why it's essential that we stop these cuts before they're 
allowed to take effect. The cuts, of course, will occur on January 1 of 
this year, approximately 1 month from today.
  It is important to remember that this bill would simply prevent cuts, 
not increase payments to doctors. But it is true that ensuring our 
seniors' access to their doctors will add to our deficit, just as 
extending any of the Bush tax cuts that are set to expire next year 
would do. Because seniors' health is at stake in this bill, I believe 
that stopping these payment cuts is worth the cost.
  It's also worth pointing out that this bill represents a new honesty 
in budgeting. As far as Democrats are concerned, the days of pretending 
that the costs of the ``doctor fix'' will be made up by even deeper 
cuts next year are over. That, of course, is a policy we followed in 
the first 8 years of this decade. We pretended that somehow we'd

[[Page H13292]]

fix it later, and we never did. Indeed, most of the costs associated 
with this bill are the result of stopping the gimmicks that were used 
for years and cleaning up the mess created by those gimmicks. The first 
step to getting out of debt is being honest about the debt we're in. It 
is too deep, it is dangerous, and we need to address it.
  So let's be honest. Our country is in a deep fiscal hole for reasons 
that go far beyond Medicare payments. In fact, there's no one reason 
for our record national debt. It's bipartisan in nature, not 
exclusively Republican or Democrat.
  The causes include the previous administration's debt financed tax 
cuts, which I've spoken of, for America's essentially wealthier 
citizens who got most of the tax cuts; the cost of two wars, which we 
did not pay for; our escalating entitlements programs, which all of us 
have supported; the recession that we have confronted and that started 
in the seventh year of the previous administration's term; and the 
deficit spending--and we need to clean up that economic mess; spending 
that economists tell us is necessary to stimulate demand and recession.
  In other words, we needed to spend the money to preclude a 
depression, not just a deep recession that we're in, and almost every 
economist, including Marty Feldstein, said that that was necessary.
  A recent New York Times analysis tells us that 90 percent of our 
deficit has been brought about by the policies of the previous 
administration and the extension of its policies and the economic 
crisis that it left behind.

                              {time}  1400

  No one step will get us out of our fiscal hole, but the most 
important immediate step we can take is to commit ourselves to the 
principle that in new policies of our country, we will pay for what we 
buy. That is the principle of pay-as-you-go, or PAYGO, which was in 
place in the 1990s as we went from deep debt into surplus and that $5.6 
trillion surplus that President Bush inherited in 2001. In the 1990s, 
President Clinton used it to turn huge deficits into a record surplus, 
and when President Bush abandoned PAYGO, and my friends on the other 
side of the aisle abandoned PAYGO, record deficits returned.
  When Democrats took back the House majority in 2006, we demonstrated 
our commitment to fiscal responsibility by making PAYGO a part of the 
House rules. It's sometimes been difficult. And now with the support 
from President Obama and both Chambers of Congress, we have a real 
chance to give PAYGO the force of law by passing this bill. Under 
PAYGO, Congress will be forced to offset all new policies reducing 
revenues or expanding entitlements, so that they add nothing to our 
deficit.
  In essence, we will be forced to make the hard budgeting choices that 
are so tempting to avoid. We are avoiding them today. We ought to admit 
that very honestly. Why are we doing it? Because as a practical matter, 
in the deep recession that we're in, we cannot pay for it without 
depressing the economy further.
  That is not an acceptable alternative. If we want to cut taxes, we'll 
have to explain which programs will suffer cuts. If we want to expand 
entitlements, we'll have to spell out how we are going to pay for it. 
And no matter which party is in power, we'll be forced to distinguish 
wasteful spending and subsidies from the long-term priorities that 
really matter to our country.
  Some have explained that statutory PAYGO would not apply to 
extensions of some existing policies that have bipartisan support, one 
of which is the one we're talking about today. Policies on the 
alternative minimum tax, which we've already done. And by the way, I am 
one of those--wasn't in the majority--who voted against extending the 
alternative minimum tax if we did not pay for it. In addition to that, 
Medicare doctor payments, which we're talking about today, and the 
estate and middle-income tax cuts passed in 2001 and 2003.
  I sympathize with their concerns. They are not specious concerns. I 
have said repeatedly that I would fight to pay for all of these 
policies. Hear me, if the Senate sends this back paid for, I will 
support it. I challenge all of you on that side of the aisle and all of 
you on this side of the aisle to do the same. That stands in contrast, 
frankly, to the first 8 years of this decade, when repeatedly it was 
stated that they do not believe that extensions of tax cuts need to be 
paid for.
  Unfortunately, it's a political reality that the votes to pay for 
extensions of the Bush policies are most likely not there. A PAYGO law 
that ignored that fact would be waived for those policies and then 
again and again. I prefer a law that we can enforce consistently. And 
very frankly, that is supported by some of the most consistent voters 
for fiscal responsibility on this floor.
  Mr. Speaker, in our country's economic meltdown last year, we all saw 
the damage that deep debt can do. It's time for our Federal Government 
to learn that lesson and act on it. If we fail to act, liberal and 
conservative, Democratic and Republican, priorities will suffer alike. 
We can still prevent that outcome, ladies and gentlemen of this House. 
We cannot get back to fiscal health in one afternoon's vote, and we 
will not, perhaps not in this President's term or the next, but we must 
start. We must take a step toward that end.
  This bill does that. It supports not only ensuring our seniors access 
to quality medical services but also ensures that we, again, adopt the 
policy that brought us $5.6 trillion in surplus.


                         Parliamentary Inquiry

  Mr. BARTON of Texas. Parliamentary inquiry.
  The SPEAKER pro tempore (Mr. Salazar). The gentleman will state his 
parliamentary inquiry.
  Mr. BARTON of Texas. Under the rules that we operate where we 
alternate back and forth, is it allowable for myself to make a rebuttal 
and then recognize the gentleman from Indiana? Or do I have to do one 
or the other?
  The SPEAKER pro tempore. The Chair may exercise his discretion in 
recognition in that fashion.
  Mr. BARTON of Texas. I am going to recognize myself for 1 minute to 
comment on my friend from Maryland's comments. Then hopefully the Chair 
will let me recognize the gentleman from Indiana (Mr. Pence) for 3 
minutes.
  Mr. Speaker, first of all, under Republican control, every bill that 
we brought to the floor, except one bill, was paid for either in that 
bill or in our budget resolution. There was one exception to that where 
we did not pay for it. So that is answer number one. Answer number two, 
this is not paid for. Under a bill that my friends in the majority 
passed in July, they say we're going to start pay-for, but it doesn't 
count for the doctors fix, it doesn't count for the alternative minimum 
tax, and it doesn't count for the estate tax.
  But once we do all that without paying for it, then the pay for will 
kick in. So in that sense, my good friend from Maryland is accurate. 
But in the sense of this bill, he is totally inaccurate. This bill is 
not paid for.
  Now, Mr. Speaker, if I am allowed to, I yield 3 minutes to my good 
friend from Indiana (Mr. Pence).
  (Mr. PENCE asked and was given permission to revise and extend his 
remarks.)
  Mr. PENCE. I thank the gentleman for yielding and for his leadership 
on this critical issue.
  Mr. Speaker, I rise in opposition to H.R. 3961, which, rightly 
understood, is just the latest deficit-spending bill championed by my 
Democrat colleagues here on Capitol Hill. It is, in a very real sense, 
an addendum to the government takeover of health care that was rammed 
through this House just 2 short weeks ago with a pricetag in excess of 
$1.3 trillion.
  You know, the President of the United States just said in China, If 
we keep adding to the debt even in the midst of this recovery, people 
could lose confidence in the U.S. economy. Maybe it would help if the 
President said that in America instead of China. Then maybe his party 
would get the message. Two days ago, we learned the national debt just 
pushed past $12 trillion. That means every man, woman and child in this 
country bears the burden of more than $38,000 in Federal Government 
debt.
  In October alone, the deficit reached $176.4 billion and now comes 
one more deficit-spending bill to facilitate passage of a government 
takeover of health care. Under the guise of helping

[[Page H13293]]

doctors and seniors, this will cost the taxpayers of future generations 
$200 billion, and it all goes straight to deficits and debt. One 
analysis by the Heritage Foundation estimates the cost of this bill 
over 75 years at nearly $2 trillion, and Medicare premiums are 
estimated to increase by some $50 billion.
  It seems there is no level of spending and debt that Washington 
Democrats aren't willing to pile on struggling families and future 
generations. We're here today considering this latest deficit-spending 
bill because Democrat leaders refuse to address health care reform in a 
fiscally responsible way. It is worth noting that this so-called 
doctors fix was a part of earlier versions of health care reform, but 
to perpetrate the fiction that their government takeover of health care 
was passed in a fiscally responsible way, we are doing this addendum to 
the Pelosi health care bill.
  The truth is, the spending policies of this Congress and this 
administration are a fiscal timebomb being placed on the doorstep of 
our children's future. We have a responsibility to put our fiscal house 
in order. But sadly, there are those who would rather pursue an 
ambitious liberal agenda, no matter what the cost, at the possible 
expense of our children's posterity and prosperity.
  There is a Republican plan which we support. It will fix the problem 
that we are trying to address over the next 4 years. It will pay for 
the bill. It will lay the groundwork for meaningful health care reform 
by ending an era of defensive medicine. I just hasten to repeat, this 
is just one more deficit-spending bill in an era when the American 
people are bone weary of runaway Federal spending.
  Frankly, when Republicans were in control, we did our share of 
deficit spending, and the American people showed us the door. What we 
have here in Washington, D.C., as evidence today, is runaway Federal 
spending on steroids. You know, there is a rule back in Indiana, where 
I grew up. When you are in a hole, stop digging. Today we're going to 
dig the hole of the deficit even deeper, and the American people 
deserve better.
  I urge my colleagues to oppose this measure and support the 
Republican plan.
  Mr. WAXMAN. Mr. Speaker, I yield myself 1 minute.
  I do want the American people to understand the Republican position, 
because this is what they would do to Medicare. If we didn't have 
health reform, we still have to deal with the problem we are having 
with Medicare, where millions of seniors are relying on that program. 
And if they produce a 20 percent cut in physician fees, the people in 
Medicare will not be able to get access to doctors. That means that if 
we don't deal with the whole health care system and hold down the 
costs, and we don't do health reform, Medicare will face deeper and 
deeper cuts, and the Republicans are giving a clear indication of 
that's exactly what they would do.
  Mr. Speaker, I yield 2 minutes to our champion on health reform, the 
gentleman from Michigan (Mr. Dingell).
  (Mr. DINGELL asked and was given permission to revise and extend his 
remarks.)
  Mr. DINGELL. Mr. Speaker, I rise as a proud supporter of H.R. 3961, 
and I urge my colleagues to join me in supporting it. H.R. 3961 
fulfills a promise to our doctors that they're going to be 
appropriately paid for their services, and it assures that Medicare 
will continue to be available to provide services for our seniors.
  In my home State of Michigan, this bill will prevent a loss of $610 
million next year for the care of elderly and disabled patients. On 
average, H.R. 3961 will prevent cuts of $23,000 to each Michigan 
physician next year. Our Republican colleagues would have us think that 
this is a gimmick. What this legislation does is do away with a 
gimmick. I would remind my colleagues that H.R. 3961 solves a problem 
that's plagued the Congress since 2002 and actually ends a budget 
gimmick that artificially reduces the deficit by assuming that 
physician payments will be cut by 40 percent over the next several 
years, even though the Congress consistently intervenes to prevent 
those cuts from occurring.
  Due to our failure to fix this problem permanently, the price tag has 
grown each year and will continue to do so. In 2005, the cost of fixing 
the problem was $48 billion. Today, just 4 years later, the cost has 
skyrocketed to $210 billion. We can no longer kick the can down the 
road. That is fiscally responsible. So today the choice is clear: 
Either we're going to be serious about protecting our seniors and 
protecting Medicare by providing a fiscally responsible, permanent fix 
to our perennial problems or we're going to play political games.
  I urge my colleagues to choose the former. Vote in favor of H.R. 
3961. Vote for fair treatment for our doctors. Vote to make Medicare 
payments available for doctors and for seniors. And make sure by so 
voting that you will have a situation where our doctors will be 
available to provide service for our senior citizens.
  Mr. BARTON of Texas. I yield 1 minute to the gentleman from Kentucky 
(Mr. Whitfield), a member of the Health Subcommittee.
  Mr. WHITFIELD. There is certainly enough blame to go around for both 
parties in the U.S. Congress as far as the debt is concerned. I have 
heard a lot of discussion today about being concerned about senior 
citizens having access to Medicare, and yet the health care bill that 
passed this House takes $500 billion out of Medicare. We've heard a lot 
about the PAYGO rules. In the 110th Congress, the PAYGO rules were 
waived 12 times for almost $500 billion.
  As I have said, both parties have a lot of blame for the debt that 
we're in, and the American people want us to be responsible. We have a 
$12 trillion debt today. Within 10 years, it's supposed to be $23 
trillion. At some point, we have to meet our obligation, meet our 
responsibility and try to pay for some of these programs. All of us 
support the purpose of this legislation, but there must be a way that 
we can do it and have it paid for. So for that reason, I would have 
great difficulty voting for this legislation without it being clearly 
paid for.

                              {time}  1415

  Mr. WAXMAN. Mr. Speaker, I am pleased at this time to yield 2 minutes 
to the gentleman from New Jersey (Mr. Pallone), the chairman of the 
Health Subcommittee of the Energy and Commerce Committee.
  Mr. PALLONE. Mr. Speaker, I respect my Republican colleagues, but I 
think they are suffering from a severe case of amnesia when I listen to 
what they are saying on the other side. It was they who contributed to 
this problem in the first place. It was they who stuck their heads in 
the sand year after year and refused to enact any kind of meaningful 
reform. They talk about pay-for. They never paid for anything. They 
just kicked the can down the road and said, Okay, we won't have a cut 
this year but we will have a larger cut next year. If this continues, 
we will have a 40 percent cut in the reimbursement rate in the next 2 
years. So there is no pay-for on their side. There never has been. It 
is just a budget gimmick.
  Now this year, we have a permanent solution to the problem, and we 
are saying enough is enough with the threat of severe payment cuts that 
will drive physicians from Medicare and put beneficiaries' access to 
doctors in jeopardy.
  Mr. Speaker, this legislation is an important element of our overall 
effort to improve Medicare for seniors. We have done a lot in health 
care reform. Two weeks ago we passed comprehensive health reform that 
made critical investments in Medicare. Amongst those, we closed the 
doughnut hole, thereby making prescription drugs more affordable. We 
improve access to preventative, primary, and coordinated care, and we 
increased financial assistance so that low-income seniors can better 
afford their monthly premiums.
  We are helping seniors with this bill today by making them have a 
choice of physicians and quality physicians. We are helping them with 
the doughnut hole. We are helping them with everything with this larger 
health care reform.
  I would just ask my Republican colleagues, don't kick the can down 
the road again. Don't give us all these budget gimmicks again. This is 
a real solution to the problem. Join us. Make this a bipartisan effort 
today, and let's pass this comprehensive reform.
  Mr. BARTON of Texas. I yield myself 1 minute.
  I would ask the distinguished chairman of the Health Subcommittee:

[[Page H13294]]

Where is the fix? There is no fix in this bill.
  They split one formula into two, but there is no reform in it. It is 
not based on medical expenses. It is not based on anything. There is no 
automatic reduction. It simply erases the current deficit in the 
account, has two formulas instead of one, and then 4 or 5 years from 
now, we will kick the can down the road again.
  If there really is a fix, let's have somebody on the majority side 
explain it. You can't explain it because it is not there.
  I yield 1 minute to a member of the Health Subcommittee, the 
gentleman from Georgia (Mr. Gingrey).
  Mr. GINGREY of Georgia. Mr. Speaker, I rise today as a medical 
practitioner, one of 13 on the Republican side, in strong opposition to 
H.R. 3961. H.R. 3961 does not fix our physician reimbursement problem. 
It simply replaces one system of cuts with another. The bill, however, 
would add more than $200 billion to the Federal deficit at a time when 
our patients are struggling to find or keep the jobs they have today.
  Mr. Speaker, if the details of this bill are not bad enough, the 
political reality is even worse. The Senate tried a similar sham of a 
bill last month, and 13 Senate Democrats sided with every Republican to 
reject it; however, House Democrats don't seem to be listening.
  The time for empty promises has long since passed. We as a Nation can 
no longer afford to walk blindly down this path of fiscal 
irresponsibility. As mentioned, with $12 trillion in debt, I, for one, 
refuse to add another quarter trillion dollars to that debt.
  I urge my colleagues to vote against this empty promise.
  Mr. WAXMAN. Mr. Speaker, I am pleased to yield 2 minutes to the 
chairman of the House Budget Committee, the gentleman from South 
Carolina (Mr. Spratt).
  Mr. SPRATT. Mr. Speaker, I was here at the creation of the 
sustainable growth rate formula. It was part of the balanced budget 
agreement of 1997. I am here today to say that the SGR has not worked.
  Here is the problem MedPAC presented to us in 1997:
  In year 2, when we sought to curb or cut Medicare rates, volume 
increases in year 2 tended to make up the difference due to reduced 
rates.
  In year 3, therefore, an automatic adjustment factor or formula was 
needed to target and recoup excess payments. Sound complicated? Well, 
that is a simple version. Suffice it to say, the SGR has proven to be 
so complex, so blunt an instrument, and so draconian that it has barely 
been used.
  For example, in 2008, we reversed a 10.6 percent decrease in 
physicians' rates and replaced it with a 1.1 percent increase. In 2010, 
the SGR dictates a 21 percent cut in physicians' payment rates. You and 
I know that is not going to happen.
  By assuming that the SGR will be applied, when we know it has not 
been applied, and is unlikely to be followed in the future, Medicare 
spending is substantially understated. CBO says that the rewrite of SGR 
now before us will result in a net spending increase of $210 billion 
over 10 years. The CBO has to assume that the SGR will be strictly 
applied in each of those 10 years. CBO is bound by its rule of 
projecting the budget; we are not. We know that the SGR is unlikely to 
be applied, and so the right step, straightforward step, is to pass 
this bill and change the SGR, not by wiping it out, but by replacing it 
with an updated formula that is realistic and likely to be used.
  The bill before us reflects two agreements that are in the budget 
resolution for this year. One is to strengthen fiscal responsibility by 
enacting a statutory pay-as-you-go rule. The other is to institute 
realistic budgeting by changing this flawed formula called the 
sustainable growth rate factor.
  The budget resolution allows the budget effects of changing the SGR 
to be calculated against a realistic baseline, one that reflects 
current policy. This means the baseline assuming the payment rates in 
effect for physicians in 2009 will stay in effect through 2019.
  The SPEAKER pro tempore. The time of the gentleman has expired.
  Mr. WAXMAN. I yield the gentleman an additional 1 minute.
  Mr. SPRATT. This baseline assumption represents a realistic benchmark 
against which to measure the fiscal effects of legislation reforming 
Medicare's physician payment system. Without a realistic baseline, we 
will revisit this issue every year, as we have in the past, by passing 
short-term fixes that do nothing to address the long-term problems. 
Without the reforms in this legislation, the budget will continue to 
understate the real cost to the Treasury of Medicare payments.
  So now is the time to adjust the SGR. The bill before us is a 
constructive solution. After 6 years of short-term fixes that did 
little to address the underlying causes of excess cost growth, we now 
have the opportunity to vote for a substantive bill. This bill does not 
allow for uncontrolled spending growth. It provides realistic spending 
targets that are fair, frugal, and holds physicians accountable.
  This bill does address two of the most important challenges in health 
care: better support for primary care and better coordination of care. 
It does so by, among other things, providing an extra growth allowance 
for primary care services. The bill also provides incentives for the 
creation of accountable care organizations which encourage providers to 
improve quality and control costs by coordination among all providers 
serving a patient. This is the type of structural reform we need.
  This is a good bill. I urge its support.
  Mr. BARTON of Texas. Mr. Speaker, I yield 1\1/2\ minutes to the 
gentleman from Texas (Mr. Gohmert).
  Mr. GOHMERT. Mr. Speaker, you know, we are still hearing blame for 
Bush and blame for the Republican-controlled House from the Democrats. 
The Speaker of the House has been a Democrat for right at 3 years now. 
It is time to take responsibility. We keep hearing that word 
``responsibility.'' This is a good time to take it.
  Now, we heard about the PAYGO rules that were passed, and now it is 
going to be PAYGO. And I tell you what, it didn't apply. It wasn't used 
like it should have been. And then in July, some of my Democratic 
colleagues convinced me that, you know what, we are really, really, 
really serious this time about PAYGO. Just vote with us. We'll show you 
how serious we are. I was one of 24 Republicans that voted for the 
PAYGO bill. But then we find out, no, no, no, this time we are really, 
really, really, really serious about PAYGO if you'll just pass it again 
this time. Come on now.
  The docs do need a fix, but we don't need lectures on this side about 
the seniors not needing cuts when the bill that is before the House, 
that passed the House, is going to cut Medicare $400 billion or so.
  Let's fix the problem for the doctors permanently. They deserve that. 
Let's not stockpile more debt on our grandchildren irresponsibly. We 
can do it, but this is not a permanent fix as some have said; 
otherwise, it wouldn't have a year limitation on it. Let's do the right 
thing by seniors, by doctors and our grandchildren and vote this one 
down and really, really, really get serious about PAYGO.
  Mr. WAXMAN. Mr. Speaker, I am pleased at this time to yield 1 minute 
to the gentleman from New York (Mr. Engel), an important member of our 
committee.
  Mr. ENGEL. I thank my friend for yielding to me.
  You know, it is always amazing to me when my Republican friends 
lecture us about debt or fiscal responsibility when they were in the 
majority here for 12 years, and for six of those years they did nothing 
to stop the debt. They did nothing to balance the budget. And now we 
get lectured.
  But I rise in strong support of the Medicare Physician Payment Reform 
Act, a key component of comprehensive health insurance reform. It is 
providing our seniors with stable access to their trusted health care 
providers.
  Each year, due to a flawed Medicare payment policy, our physicians 
face mounting cuts which threaten their ability to care for the 
patients that depend on them, and at the 11th hour, we have done a 
short-term patch each and ever year. It is not a good way to run 
Medicare. This year we are doing it differently. We are ending that. 
Not only will we eliminate the scheduled 21 percent reduction, but we 
will replace the flawed sustainable growth rate formula which is 
responsible for these annual cuts with a more rational payment system.

[[Page H13295]]

  By doing so, we will preserve access to care and provide physicians 
with the financial stability they need. The 11th hour is not a way to 
do it. Our physicians face these mounting cuts, threatening their 
ability. This is the best way to go about it.
  I urge my colleagues to support the bill.
  Mr. BARTON of Texas. Mr. Speaker, I yield myself 1 minute.
  Since my friends on the Democrat side won't explain their procedure, 
their bill, I am going to try and do it, and if I am wrong, I am sure 
that they will correct me.
  Current law, we have one SGR formula. It is based on GDP and 
inflation. It is not based on any kind of medical index. Whatever that 
is perceived to be each year, that is the amount of increase we can pay 
our physicians. All physicians get the same increase.
  Under this bill, they say if you are a primary care doctor, you get 
the formula plus 2 percent. If you are a specialist, you get the 
formula plus 1 percent, but they don't change the formula. The formula 
is the same as it is under the current law, and they don't change the 
enforcement mechanism. The enforcement mechanism is the same as it is 
under current law; i.e., Congress has to vote to either accept the cuts 
or to not accept the cuts and provide a temporary fix. As I understand 
it, that is their fix. Now, if I am wrong in that, I want my friend Mr. 
Waxman or Mr. Pallone or Mr. Rangel or Mr. Stark to tell me how I am 
wrong.
  Mr. WAXMAN. Mr. Speaker, I am pleased at this time to yield 1 minute 
to the gentleman from Maryland (Mr. Sarbanes), a member of the Energy 
and Commerce Committee and the Health Subcommittee.
  Mr. SARBANES. Mr. Speaker, I thank the chairman for yielding me this 
time.
  I just want to say to all of the seniors in my district and seniors 
across the country who have expressed anxiety over the last few months, 
and really for longer than that, that this physician payment cut would 
go into effect, that we heard what you were saying and we will take 
action today. Many of you are concerned because your doctors have been 
telling you that this payment cut is coming. Frankly, these physicians 
don't feel they are treated as professionals when we jerk them around 
at the end of a string every year. That is why we want to permanently 
fix this problem.
  We make sure that physicians are reimbursed properly and fairly so 
they will have an incentive to remain in the Medicare program, and that 
way there will be a good, robust supply of physicians to serve the 
Medicare population. That is why we are doing this today.
  Mr. BARTON of Texas. Mr. Speaker, I yield 1 minute to the gentleman 
from Nebraska (Mr. Terry), a member of the Energy and Commerce 
Committee.
  Mr. TERRY. Mr. Speaker, I don't think there is really any debate 
whether on one side or the other. This side supports a permanent fix to 
SGR. The argument here today, and the dispute here today is that we 
have, what, $270 billion that is not being paid for or offset properly.
  If we are going to be about fiscal responsibility and protecting the 
future of our kids by not piling on deficit and then debt onto them, 
this is where the buck stops, literally, here today is that we need to 
pay for this, not just put it to the deficit and the debt.
  But I keep hearing the talk about seniors here. We want to make sure 
that they have complete access to their health care, but I have to 
point out the irony that at 11, 11:30 a week ago last Saturday, they 
took a vote to cut half a trillion dollars out of Medicare and move it 
to a new plan away from seniors. I think we need to talk about the 
irony here and who is really standing up for the seniors.

                              {time}  1430

  Mr. WAXMAN. Mr. Speaker, I yield myself 1 minute.
  I want to point out to my colleagues while we're blaming each other 
on a partisan basis that the reason we got into this situation is in 
1997 with a Republican Congress and a Democratic President, there was a 
so-called balanced budget proposal adopted, and the way it was funded 
for tax cuts was to make future cuts in Medicare, especially in the 
physician payment side. We are paying the price of that poorly thought-
through approach, which was the reason I voted against that bill in 
1997.
  The gentleman from Texas made some points about the situation we're 
in. What he did not point out is that this bill is part of a 
comprehensive improvement in our health care system. It would reward 
primary care. It would provide for accountability care organizations, 
which would be a better delivery mechanism. This ought to be looked at 
in a more comprehensive way.
  That's why I'm pleased to support this bill today and the health care 
reform bill that the House passed a week or so ago, and we hope to 
complete our actions with the Senate later this year.
  Mr. Speaker, I yield the balance of my time to the Ways and Means 
Committee chairman, the gentleman from New York (Mr. Rangel), and I ask 
unanimous consent that he be allowed to control that time.
  The SPEAKER pro tempore. Is there objection to the request of the 
gentleman from California?
  There was no objection.


                             General Leave

  Mr. WAXMAN. Mr. Speaker, I ask unanimous consent that all Members may 
have 5 legislative days in which to revise and extend their remarks and 
include extraneous material on H.R. 3961.
  The SPEAKER pro tempore. Is there objection to the request of the 
gentleman from California?
  There was no objection.
  Mr. BARTON of Texas. Mr. Speaker, I yield 1 minute to the 
distinguished minority leader from the great State of Ohio (Mr. 
Boehner).
  Mr. BOEHNER. I thank my colleague for yielding.
  I tell my colleagues that during this debate over health care that's 
gone on for most of this year, Republicans have been listening to the 
American people; and what the American people want is they want to 
lower the cost of health care so that it's more affordable for more 
Americans.
  When it comes to this issue of fixing the doctors' payment 
reimbursement system in Medicare, there's no dispute on either side of 
the aisle about the need to address it. Republicans addressed it when 
we were in the majority; and when we did, we made sure that there were 
offsets in spending elsewhere or some other types of revenue to make 
sure that it was paid for and not added to the budget deficit.
  The issue here is twofold. One is that the proposal will not fix the 
problems that docs have in terms of their reimbursements down the road. 
It's a flawed formula that is not eliminated in this proposal. 
Secondly, it's going to add some $250 billion worth of debt put onto 
the backs of our kids and grandkids.
  Now, I have listened to Democrats. The President, the President's 
Chief of Staff, Democrat leaders over the last couple of weeks talk 
about the fact that we need to do something about the budget deficit. 
Well, give me a break. Why don't we start right now. Right now and say 
that we're not going to do this, that we're not going to pass this bill 
that has no chance of becoming law. The Senate has already rejected it.
  Why don't we just work together to come up with something that we can 
afford to cover the next 2, 3, 4 years so the doctors will have some 
idea of what their payments will be from us and get serious about 
working together for a long-term fix that doesn't put this 
responsibility on the backs of our kids and our grandkids.
  That's the real issue here, the fact that there is no pay-for here. 
There is no offsetting other types of spending. There are no increases 
in revenue somewhere to cover this. It's just going to be dumped onto 
the backs of our kids and grandkids.
  The American people want us to relearn fiscal responsibility. My 
colleagues on my side of the aisle over the course of this year have 
stood up, I believe, for fiscal responsibility. And if we're going to 
get our economy going again, we'd better get our fiscal house in order 
as well.
  Mr. RANGEL. Mr. Speaker, I yield myself such time as I may consume.
  Mr. Speaker, I rise in support of H.R. 3961, and I feel so proud that 
the Ways and Means Committee was able to make a contribution with the 
other two committees, Education and Labor as well as Energy and 
Commerce, to

[[Page H13296]]

bring the John Dingell medical reform bill before this House and before 
this country.
  What it does, really, is a new way to provide health care that is 
perfected in such a way that the patients are able to get medical care 
before they become patients, have preventative care, to provide for new 
doctors to be able to be made, and to get rid of a flawed physician 
payment system that, indeed, will strengthen the Medicare program.
  At the end of the day when you hear the opposition, most all of their 
comments are going to be negative and saying ``no.'' Even when we make 
our case as to why we should fulfill our obligation to the doctors, 
they will make some decisions here, procedure decisions, which my 
friend Mr. Barton gets fed up with, but I assume he will be leading the 
race and saying that there should be a way to resubmit this bill to the 
committees to do something all over again.
  If that is the case, I am certain that the American Medical 
Association as well as the older people and those people who need these 
doctors will not have to fear anything because their answer to this 
will be rejected, and once again we will be able to fulfill the promise 
that we made with the health bill by making certain they have doctors 
in order to support it.
  At this time, Mr. Speaker, I yield the balance of my time to Chairman 
Pete Stark, who has made such an important contribution over the years 
to reform our health system, and I ask unanimous consent that he be 
allowed to control that time.
  The SPEAKER pro tempore. Is there objection to the request of the 
gentleman from New York?
  There was no objection.
  Mr. BARTON of Texas. Mr. Speaker, could I inquire as to how much time 
I still control, please.
  The SPEAKER pro tempore. The gentleman has 3 minutes remaining.
  Mr. BARTON of Texas. I want to yield 1 of those 3 minutes to the 
gentlewoman from Nashville, Tennessee, a member of the Energy and 
Commerce Committee, Congresswoman Marsha Blackburn.
  Mrs. BLACKBURN. I thank the gentleman from Texas for yielding.
  Mr. Speaker, I would remind my colleagues here in the House that we 
know something is wrong with the piece of legislation when you have 
major media outlets talking about how off-track this is, and you also 
know something's wrong with it when you have our colleagues in the 
Senate who take up a bill, this bill, and they can't get to 50 votes in 
the Senate for the companion legislation. So it is with a real sense of 
regret that I think many of us look at this.
  Does the standard growth rate, SGR, need to be fixed? Absolutely. And 
there is agreement on that. It is an issue out of fairness to our 
Nation's physicians, the providers of health care. It is an issue of 
fairness to our Nation's seniors.
  Mr. Speaker, I think it has been really something that has been of 
concern to us as we have watched some of our colleagues in this House 
treat Medicare as a slush fund rather than recognizing that it is a 
trust fund and it's there for those seniors. We can do better. Our 
seniors and our physicians deserve better.
  Mr. STARK. Mr. Speaker, I yield myself 3 minutes.
  (Mr. STARK asked and was given permission to revise and extend his 
remarks.)
  Mr. STARK. Mr. Speaker, I would like to place in the Record a letter 
from the American Medical Association and a list of over 150 supporters 
of H.R. 3961, among which are the American College of Obstetricians and 
Gynecologists, the Iowa Medical Society, the Texas Medical Society, all 
of whom I think place Hippocrates ahead of Sarah Palin in terms of 
their assessment of what should be done.
  I would further begin in addressing my dear friend from Texas in some 
of his inquiry earlier by quoting from the ranking member of the Health 
Subcommittee on the Ways and Means Committee back last July when he 
said he believed Members on both sides of the aisle agree that there is 
a need for a long-term fix for the Medicare physician payment. All 15 
members, Republican members, of the Ways and Means Committee voted 
basically for the fix we're talking about today.
  Let me make no mistake about blame and where we are. It may come as a 
surprise to our side of the aisle we make mistakes. In 1997 we made a 
mistake in setting the formula by which we would automatically limit 
the increase that doctors get paid. Well, we're here today trying to 
correct that mistake.
  You've said so, correctly, that it's the same formula plus 2 percent 
for primary care, 1 percent for other physicians, some other plans to 
help encourage primary care doctors to come into practice. Hopefully, 
we've done it right, and recognizing if we don't correct it, we're 
talking about hundreds of billions of dollars by postponing. So we have 
postponed, whether on either side of the aisle, we have postponed 
correcting a mistake that we should have done earlier.
  That's where we are today. No place else. And I hope that we can get 
the continued support to do that. I hope we don't have to come back and 
keep addressing it. I see not correcting it increases the amount we 
will have to pay in the future.
  So there is plenty of blame, as the gentleman suggested, to go 
around. We could have fought harder to correct it earlier. We didn't 
and that's where we are today.
  Literally every major medical society in the country has suggested 
that we do it this way, and I urge my colleagues to join with me, 
hopefully with my 15 colleagues on the Ways and Means Committee who 
haven't changed their mind, and support H.R. 3961 today so we can put 
this behind us. Then we can go on and have some really spirited debate 
about whether they do a better job in Texas or California of reforming 
medical care. That will be more fun.
  But today let's fix this. Pass H.R. 3961, go home and have a 
wonderful Thanksgiving holiday, and come back to work on health care 
reform.

                                 American Medical Association,

                                   Chicago, IL, November 19, 2009.
     Hon. Dave Camp,
     Ranking Member, House of Representatives,
     Washington, DC.
       Dear Representative Camp: Thank you for your letter of 
     November 18, 2009, regarding the pending Congressional 
     consideration of H.R. 3961, the Medicare Physician Payment 
     Reform Act of 2009. We appreciate your agreement that having 
     physicians face annual cuts due to the flawed SGR is 
     unacceptable and your support for the intent of the 
     legislation. As you know, it is the same policy supported by 
     every Republican on the Ways and Means Committee during the 
     mark-up of H.R. 3200.
       We are disappointed, however, that you and your colleagues 
     do not support the bill. As you know, the SGR was put into 
     place by the Balanced Budget Act of 1997, which originated in 
     your committee. At that time, the AMA wrote numerous letters 
     to Speaker Gingrich and your committee leadership warning 
     that limiting growth in physician services to GDP would 
     inevitably lead to sharp cuts in physician reimbursement and 
     a crisis in access to care for our nation's seniors. 
     Previously we had supported legislation that would have 
     allowed growth at a rate above GDP.
       As predicted, the SGR did result in a 4.8% cut to 
     physicians for the year 2002. Congress declined to intervene 
     and that cut went into effect. In subsequent years, Congress 
     did step in to prevent additional cuts from occurring. The 
     Consolidated Appropriations Resolution of 2003, the Medicare 
     Modernization Act of 2003, the Deficit Reduction Act of 2005, 
     the Tax Relief and Health Care Act of 2006, the Medicare, 
     Medicaid, and SCHIP Extension Act of 2007, and the Medicare 
     Improvement for Patients and Providers Act of 2008 each 
     provided temporary relief for seniors and their physicians 
     from pending cuts.
       What these bills did not do, however, was make any progress 
     toward fixing the problem. Instead, Congress fell into a 
     comfortable rhythm of kicking the can down the road and 
     putting off real reform to some unspecified point in the 
     future. In 2005, physicians faced a cut of 3.3% which was 
     averted by the MMA. At that time, the Congressional Budget 
     Office reported that the cost of just a ten-year freeze in 
     physician rates was $48.6 billion. Just four years later, the 
     pending cut stood at 21.5% and the cost of a ten year freeze 
     stood at $285 billion. The AMA believes that this cycle must 
     come to an end. Anything short of permanent reform will not 
     be supported by the AMA. Every year that Congress ``pays-
     for'' a temporary solution, the cost of permanent reform 
     climbs higher still. These are obligations to our seniors 
     which the Medicare program has already made. To pretend that 
     they will not be incurred is unrealistic. To continue to grow 
     the size of the problem is irresponsible.
       As for the implication that the recent action by the 
     Administration to remove drugs from the SGR are ``budget 
     gimmicks to hide the true deficit impact,'' we are reminded 
     of a letter you signed on May 21, 2004, to the Bush 
     administration calling the policy of including drugs in the 
     formula ``our greatest concern'' regarding the magnitude of 
     the

[[Page H13297]]

     SGR problem. That letter was also signed by other members of 
     your committee. On June 16, 2004, Representative Cantor sent 
     a similar letter with Representative Pryce urging that CMS 
     ``remove prescription drug expenditures from the Sustainable 
     Growth Rate (SGR) determination.''
       The Congressional Record is replete with statements by 
     members from both sides of the aisle calling for permanent 
     reform. What is missing, however, is the result. The record 
     shows temporary patches and a ballooning problem.
       The AMA does not support any motion to recommit that would 
     have a temporary fix. How steep will cuts be after those four 
     years? How many hundreds of billions of dollars will it then 
     cost to fix this problem? Medical liability reform remains 
     among the highest priorities of the AMA and all physicians. 
     However, when Republicans controlled both chambers of 
     Congress and the White House, capping damages could not be 
     accomplished. We fail to see why you believe it is possible 
     today. With less than seven weeks before Medicare rates are 
     cut more than 21%, we need solutions that can be achieved 
     quickly.
       This should not be a partisan issue. Both sides of the 
     aisle have professed a desire to permanently address this 
     issue. The opportunity to advance permanent reform through 
     passage of H.R. 3961 cannot be missed. We urge all members to 
     vote for H.R. 3961.
           Sincerely,
                                                  J. James Rohack.
       H.R. 3961 is supported by a wide range of organizations 
     representing patients, doctors and other providers, 
     including: AARP; Air Force Association; Air Force Sergeants 
     Association; Air Force Women Officers Associated; Alliance 
     for Retired Americans; AMDA--Dedicated to Long Term Care 
     Medicine; American Academy of Allergy, Asthma and Immunology; 
     American Academy of Child and Adolescent Psychiatry; American 
     Academy of Cosmetic Surgery; American Academy of Dermatology 
     Association; American Academy of Facial Plastic and 
     Reconstructive Surgery; American Academy of Family 
     Physicians; American Academy of Hospice and Palliative 
     Medicine; American Academy of Neurology Professional 
     Association.
       American Academy of Ophthalmology; American Academy of Pain 
     Medicine; American Academy of Pediatrics; American Academy of 
     Sleep Medicine; American Association of Clinical Urologists; 
     American Association of Hip and Knee Surgeons; American 
     Association of Neurological Surgeons; American Association of 
     Neuromuscular and Electrodiagnostic Medicine; American 
     Association of Orthopaedic Surgeons; American College of 
     Allergy, Asthma and Immunology; American College of 
     Cardiology; American College of Chest Physicians; American 
     College of Emergency Physicians; American College of 
     Gastroenterology.
       American College of Obstetricians and Gynecologists; 
     American College of Osteopathic Internists; American College 
     of Osteopathic Surgeons; American College of Physicians; 
     American College of Radiation Oncology; American College of 
     Radiology; American College of Rheumatology; American College 
     of Surgeons; American Gastroenterological Association; 
     American Geriatrics Society; American Logistics Association; 
     American Medical Association; American Medical Group 
     Association; American Osteopathic Academy of Orthopedics; 
     American Osteopathic Association.
       American Psychiatric Association; American Society for 
     Clinical Pathology; American Society for Gastrointestinal 
     Endoscopy; American Society for Metabolic and Bariatric 
     Surgery; American Society for Radiation Oncology; American 
     Society for Reproductive Medicine; American Society for 
     Surgery of the Hand; American Society of Addiction Medicine; 
     American Society of Anesthesiologists; American Society of 
     Cataract and Refractive Surgery; American Society of Clinical 
     Oncology; American Society of Hematology; American Society 
     of Nephrology; American Society of Ophthalmic Plastic and 
     Reconstructive Surgery; American Society of Plastic 
     Surgeons.
       American Society of Transplant Surgeons; American Thoracic 
     Society; American Urological Association; AMVETS; Arizona 
     Medical Association; Arkansas Medical Society; Army Aviation 
     Association of America; Association of American Medical 
     Colleges; Association of Military Surgeons of the United 
     States; Association of the United States Army; Association of 
     the United States Navy; California Medical Association; Chief 
     Warrant Officer and Warrant Officer Association of the U.S. 
     Coast Guard; College of American Pathologists; Colorado 
     Medical Society.
       Commissioned Officers Association of the U.S. Public Health 
     Service, Inc.; Congress of Neurological Surgeons; Connecticut 
     State Medical Society; Contact Lens Association of 
     Ophthalmologists; Emergency Department Practice Management 
     Association; Enlisted Association of the National Guard of 
     the United States; Fleet Reserve Association; Florida Medical 
     Association Inc.; Gold Star Wives of America; Hawaii Medical 
     Association; Heart Rhythm Society; Idaho Medical Association; 
     Illinois State Medical Society; Indiana State Medical 
     Association; Infectious Diseases Society of America.
       International Society for Clinical Densitometry; 
     International Spine Intervention Society; Iowa Medical 
     Society; Iraq and Afghanistan Veterans of America; Jewish War 
     Veterans of the United States of America; Joint Council of 
     Allergy, Asthma and Immunology; Kansas Medical Society; 
     Kentucky Medical Association; Louisiana State Medical 
     Society; Maine Medical Association; Marine Corps League; 
     Marine Corps Reserve Association; Massachusetts Medical 
     Society; MedChi, The Maryland State Medical Society; Medical 
     Association of Georgia.
       Medical Association of the State of Alabama; Medical Group 
     Management Association; Medical Society of Delaware; Medical 
     Society of the District of Columbia; Medical Society of the 
     State of New York; Medical Society of Virginia; Michigan 
     State Medical Society; Military Chaplains Association of 
     the United States of America; Military Officers 
     Association of America; Military Order of the Purple 
     Heart; Minnesota Medical Association; Mississippi State 
     Medical Association; Missouri State Medical Association; 
     Montana Medical Association; National Association for 
     Uniformed Services.
       National Committee to Preserve Social Security and 
     Medicare; National Guard Association of the United States; 
     National Medical Association; National Military Family 
     Association; National Order of Battlefield Commissions; Naval 
     Enlisted Reserve Association; Nebraska Medical Association; 
     Nevada State Medical Association; New Hampshire Medical 
     Society; New Mexico Medical Society; Non Commissioned 
     Officers Association; North Carolina Medical Society; North 
     Dakota Medical Association; Ohio State Medical Association; 
     Oklahoma State Medical Association.
       Oregon Medical Association; Pennsylvania Medical Society; 
     Renal Physicians Association; Reserve Enlisted Association; 
     Reserve Officers Association; Rhode Island Medical Society; 
     Society for Cardiovascular Angiography and Interventions; 
     Society for Maternal-Fetal Medicine; Society for Vascular 
     Surgery; Society of Critical Care Medicine; Society of 
     Gastrointestinal and Endoscopic Surgeons; Society of 
     Gynecologic Oncologists; Society of Hospital Medicine; 
     Society of Interventional Radiology; Society of Medical 
     Consultants to the Armed Forces.
       South Carolina Medical Association; South Dakota State 
     Medical Association; Tennessee Medical Association; Texas 
     Medical Association; The Endocrine Society; The Retired 
     Enlisted Association; The Society of Thoracic Surgeons; 
     United States Army Warrant Officers Association; USCG Chief 
     Petty Officers Association; Utah Medical Association; Vermont 
     Medical Society; Veterans of Foreign Wars; Washington State 
     Medical Association; West Virginia State Medical Association; 
     Wisconsin Medical Society; Wyoming Medical Society.

  Mr. Speaker, I reserve the balance of my time.


                Announcement by the Speaker Pro Tempore

  The SPEAKER pro tempore. The Chair reminds Members on both sides of 
the aisle to direct their remarks to the Chair.
  Mr. BARTON of Texas. Mr. Speaker, I'm not used to dealing with a warm 
and fuzzy Pete Stark. I have to admit that was a very good speech.
  Mr. Speaker, I yield 1 minute to my good friend from Michigan from 
the Energy and Commerce Committee, Mr. Rogers.
  Mr. ROGERS of Michigan. Mr. Speaker, the SGR fix is incredibly 
important, but this approach is disingenuous at best. Let's go back 
quickly.
  In 2008 the Medicare Improvement for Patient and Providers Act, 
sponsored by my friends on the other side of the aisle, had a 21 
percent cut to go into effect for doctors this year. Your bill, your 
issue, your 21 percent. And you come here today knowing full well this 
bill will go nowhere.
  Why this is disingenuous is because 2 weeks ago, you added about 16 
million people to Medicaid that shorts doctors hundreds of millions of 
dollars in reimbursement every single year. And, oh, by the way, you 
tax doctors, and everything in their operation; their costs go up. And 
here's the thing: you cut a half trillion dollars out of Medicare, 
hospitals, home health services, nursing homes, hospice care. You cut 
Medicare a half trillion dollars. You know this bill will go nowhere.
  This is an easy fix. Let's work together. Let's find some offsets. 
Let's fix it for doctors. And, by the way, let's go back and take back 
that money that you have cut, a half trillion dollars, out of Medicare 
for the lives and betterment of seniors.


                Announcement by the Speaker Pro Tempore

  The SPEAKER pro tempore. The Chair reminds Members on both sides of 
the aisle to address their remarks to the Chair.
  Mr. STARK. Mr. Speaker, at this time I'm delighted to yield 1 minute 
to the gentleman from Texas (Mr. Doggett).
  Mr. DOGGETT. This bill is about more than the reasonable desire of 
physicians for reimbursement rates that cover their actual cost and 
fairly compensate their work. It is about access

[[Page H13298]]

to quality health care and your ability to choose the doctor best for 
you.
  When accepting new Medicare patients means losing money, fewer 
physicians can accept new patients. In 1997, a Republican Congress 
enacted a payment formula that never worked, and then they kept 
everyone guessing year after year as to what kind of gimmick they would 
come up with in lieu of the next year's payment cut.
  Now we have revised their flawed formula and prevented what could be 
up to a 40 percent cut for physicians. Our bill will not only help 
seniors and the disabled, but it will help many members of the active 
duty military and our veterans who rely on TRICARE. Our troops should 
never have to worry whether their family can get the care and the 
doctor that they need.
  Instead of another Republican Band-Aid, we offer a cure for what ails 
the Medicare-TRICARE formula. Today is one time that the ``just say 
no'' party ought to say ``yes'' to good public policy, which is 
supported by the Texas Medical Association and medical societies across 
the country.

                              {time}  1445

  The SPEAKER pro tempore. The gentleman from Texas (Mr. Barton) has 1 
minute remaining.
  Mr. BARTON of Texas. Mr. Speaker, I yield myself the balance of the 
time.
  I'd like to put into the Record a statement from the vice chairman of 
the American Medical Association on March 20, 1997, where they went on 
record before the Ways and Means Committee subcommittee supporting the 
current system. And now, I understand and I accept what Subcommittee 
Chairman Stark said, that mistakes have been made, and I think, in 
hindsight, both sides can agree that a mistake has been made.
  It is my opinion, and I think most of the Republicans would share 
this opinion, that this is not the solution. When all you do is change 
which formula gets reimbursed, either primary care or specialist, but 
you use the same underlying formula, the same lack of enforcement, 
that's not, in my opinion, a fix. So respectfully, I believe that we 
should defeat this bill and then work together.
  I do sense some bipartisanship on this floor. Let's work together to 
come up with a real fix. It will not be easy. It's not easy to come up 
with $350 billion. It's not easy to allocate that. It's not easy to 
change the formula to something that more accurately reflects the costs 
of practicing medicine in the modern era. But, we can do it. This is 
not the solution. I hope we'll vote this down.
  As has been pointed out, this bill isn't going anywhere in the 
Senate. This is an act, in my opinion, of paying off a political debt 
to the American Medical Association for endorsing the larger health 
care bill several weeks ago. Please vote ``no.''

  Statement of Thomas R. Reardon, M.D., Vice Chair, American Medical 
                              Association

       Mr. Chairman, my name is Thomas R. Reardon, M.D. I am a 
     general practitioner from Boring, Oregon, and a member of the 
     Board of Trustees for the American Medical Association (AMA). 
     On behalf of the 300,000 physician and medical student 
     members of the AMA, I thank you for this opportunity to 
     testify before the Subcommittee today regarding Medicare 
     physician payment issues.
       A wide range of experts have independently concluded that, 
     despite Medicare's clear success in improving the health 
     status of our elderly and disabled citizens, the program 
     cannot be sustained without fundamental restructuring. The 
     Hospital Insurance Trust Fund faces bankruptcy in five years 
     or less, and Medicare's current overall expenditure growth 
     cannot be sustained. Medicare faces a much more serious long-
     term problem as the ``baby boom'' generation ages and the 
     number of workers paying taxes for every Medicare 
     beneficiaries will decline from 3.9 currently to only 2.2 in 
     the year 2030.
       The high growth rates for many of the services are due to a 
     combination of factors, including increased beneficiary 
     demand for new services, flaws in payment rules which 
     encourage high volume growth in some categories of service, 
     insulation of most beneficiaries from cost considerations, 
     and ineffective approaches to cost control. However, as the 
     chart below indicates, physician spending growth is well 
     below the rate for any other major sector of Medicare, and 
     well below overall Medicare growth. The AMA is pleased that 
     the President's 1998 budget proposal explicitly recognizes 
     this fact.
       We are also pleased that the Administration's budget 
     supports the development of innovative provider sponsored 
     organizations in order to offer greater choice to Medicare 
     beneficiaries. We believe these types of options hold the 
     promise of enhancing beneficiary choice while controlling 
     Medicare's costs. The AMA also supports the President's 
     investment in preventive health care to improve seniors' 
     health status by covering colorectal screening, diabetes 
     management, and annual mammograms without copayments, and by 
     increasing reimbursement rates for immunizations to ensure 
     that Medicare beneficiaries are protected from pneumonia, 
     influenza and hepatitis.
       Unfortunately, the Administration's budget primarily adopts 
     the strategy of cutting physician and other provider payments 
     in hopes of getting more services for less money. We believe 
     this approach will ultimately divorce the Medicare system and 
     its beneficiaries from the mainstream of American medical 
     care, while postponing the major restructuring needed for 
     Medicare's long-term survival. In the meantime, the long-term 
     problems will only grow larger, requiring more draconian and 
     expensive solutions.


               AMA's Proposal For Medicare Transformation

       The AMA has a plan which addresses both the short and long-
     term problems with Medicare, while preserving the bond of 
     trust between a patient and physician that makes medicine 
     unique. The AMA's Transforming Medicare proposal is based on 
     the idea of a competitive market-driven system as the best 
     option for the future of the Medicare program because it 
     offers more choice to senior citizens and the disabled. We 
     must give the patient both the opportunity and the 
     responsibility to make wise prospective choices of physician 
     and health plan, with the reasonable opportunity to change 
     either if they prove unsatisfactory.
       Our plan would modernize traditional Medicare, eliminating 
     the need for Medigap, while preserving the security and 
     quality of care beneficiaries now receive. It would create a 
     new MediChoice option, which would provide a broad menu of 
     health plan choices for Medicare beneficiaries to choose 
     from, including medical savings accounts and provider 
     sponsored organizations. And finally, it would ensure that a 
     healthy Medicare is available for future generations. The AMA 
     would welcome the opportunity to discuss our Transforming 
     Medicare proposal with the Subcommittee in greater detail at 
     an appropriate forum.


                 Improving the Physician Payment System

       The Administration's 1998 budget proposal targets $5 
     billion in savings over five years from refinements to the 
     Medicare physician payment schedule. In particular, the 
     Administration proposes moving to a single conversion factor 
     (CF) for the payment schedule, and replacing the current 
     Medicare Volume Performance Standard (MVPS) update formula 
     with a Sustainable Growth Rate (SGR) formula.
       Under the Administration's budget proposal, the overall 
     payment update for 1998 would be set at 1.9%, yielding an 
     overall CF of $36.63 in 1998. With the move to a single CF of 
     $36.63, surgical service payments would fall by 10.6% 
     compared to 1997 levels, while primary care payments would 
     increase by 2.4% and other service payments would increase by 
     8.2%. The payment reductions for surgical services are 
     further exacerbated by the implementation of resource-based 
     practice expense relative value units scheduled for 1998, as 
     discussed below.
       The AMA has consistently sought a return to a single growth 
     standard and conversion factor for physician services. We 
     adopted this position well before any indication of which 
     services would benefit from multiple standards. At our Annual 
     House of Delegates meeting in 1996, AMA policy was modified 
     to adopt a compromise that responds to two realties. First, 
     because moving to a single conversion factor could lead to 
     large single year cuts for some services and specialties, we 
     support a transition of as close to three years as possible. 
     Second, because we also recognize that one of the purposes of 
     a transition is to allow those who face cuts time to adjust, 
     and that there has been ``fair notice'' of a shift to a 
     single conversion factor, our House of Delegates voted that 
     the ``clock should start running'' on such a transition on 
     January 1, 1997.
       In addition to moving to a single conversion factor, the 
     AMA supports replacing the MVPS system of updating physician 
     payments. There is widespread agreement that the current 
     method of updating physician payments, the MVPS system, is 
     fundamentally flawed. The Congress, the Administration, and 
     the Physician Payment Review Commission (PPRC) have all 
     proposed replacing the current MVPS update formula with a 
     sustainable growth rate (SGR) formula, which uses real per 
     capita gross domestic product (GDP) to adjust for volume and 
     intensity.
       The Administration's fiscal year 1998 budget proposes 
     implementing an SGR formula, with the volume target in the 
     SGR formula initially set at growth in real per-capita GDP 
     plus one percentage point. However, the Congressional Budget 
     Office (CBO) scoring of the proposal apparently failed to 
     yield the targeted savings of $5 billion in savings from the 
     Medicare fee schedule, and the volume allowance in the SGR 
     was reportedly reduced to GDP+0.
       In general, the AMA supports implementing the SGR approach 
     as a needed correction for the MVPS. Fundamentally, the 
     question for policymakers is determining the level of annual 
     spending growth for physician services that best balances 
     patient care

[[Page H13299]]

     needs and the federal budget. Under the current MVPS 
     physician update formula, the projected Medicare payment 
     level for physicians is a steep actual decline, while 
     hospital and other provider payment rates go up, as the chart 
     below indicates. Although these non-physician services are 
     unlikely to see their full projected increases, their 
     budget savings will be charged against this rising 
     baseline, while further savings from physicians require 
     even steeper cuts.
       Budget reconciliation for Medicare should reflect the fact 
     that physician spending is under better control than any 
     other major Medicare segment, and that the budget baseline 
     already assumes steep annual payment cuts. Physician practice 
     costs, as measured by the Medicare Economic Index (MEI), 
     continue to rise while physician reimbursement under Medicare 
     is projected to fall. Physicians are only asking for the 
     opportunity to have Medicare payments keep up with the costs 
     of providing care to Medicare beneficiaries, and are willing 
     to accept the challenge of maintaining volume growth at 
     current low levels.
       While we believe that MEI is the appropriate goal for 
     physician updates, we understand that budgetary constraints 
     may not presently allow for a full MEI update for physicians. 
     Physicians are willing to do their part to put Medicare's 
     fiscal house in order, as we have repeatedly done in the 
     past. Physicians, who accounted for 32% of combined physician 
     and hospital Medicare spending from 1987 to 1993, absorbed 
     43% of Medicare provider cuts over the same time. We would be 
     willing to accept GDP+2 under an SGR system as a temporary 
     measure, if there were assurances that this could be 
     increased to cover MEI once the necessary Medicare savings 
     were obtained. In contrast, under GDP+O as the Administration 
     proposes, physician payments would continue to fall well 
     below MEI, as they are projected to do under the current MVPS 
     system.
       Given a new SGR, with a realistic growth allowance, we 
     could also support a new ceiling on positive MVPS 
     adjustments, which would provide direct financial benefits to 
     the federal budget if actual volume is below target. 
     Moreover, the federal government receives a very real 
     additional benefit--the ability to pay for the payment rates 
     needed to maintain the viability of Medicare fee-for-
     service out of reduced service volume. At the same time, 
     like the PPRC, we believe it essential to maintain the 
     current 5% maximum payment reduction from the MEI 
     (increased from 3% by OBRA 93) and to reject 
     Administration proposals to lower the floor to MEI minus 
     8.25%.


                    Resource-Based Practice Expense

       As mentioned above, many physicians face additional extreme 
     payment reductions due to the implementation of the resource-
     based practice expense in 1998. The Social Security Act 
     Amendments of 1994 requires the Health Care Financing 
     Administration (HCFA) to implement a ``resource-based'' 
     practice expense component of the Medicare fee schedule by 
     January 1, 1998. That is, the payment for this component--
     which represents over 40 percent of the payment for physician 
     services--is to be based on the actual expenses incurred in 
     delivering each service. Currently, the practice expense 
     allowance is derived from a formula based on the prior 
     reasonable charge payment system.
       The AMA supports resource-based practice expenses so long 
     as they reflect actual practice expenses, but is seeking a 
     one-year extension of the implementation date. The 1994 
     legislation said that HCFA should ``recognize the staff, 
     equipment, and supplies used in the provision of various 
     medical and surgical services in various settings.'' HCFA 
     contracted with Abt Associates to conduct a two-part study of 
     3,000 physician practices expenses. When the survey was 
     pulled back due to poor response rates, HCFA was left without 
     adequate data to meet the intent of the law.
       HCFA is relying primarily on data derived from clinical 
     practice expert panels, or CPEPs. Early review of the 
     recently-released CPEP findings suggest that they contain a 
     number of errors. HCFA has even rejected certain direct costs 
     that its expert panels found were part of the cost of surgery 
     when doctors supply their own staff and supplies in hospital 
     operating rooms. The AMA and medical specialties are working 
     to identify and correct those flaws but more time is needed.
       Those who want to adhere to the current January 1, 1998, 
     deadline argue that any problems can be corrected later 
     through a refinement process similar to the one used when new 
     work values were implemented in 1992. The AMA believes this 
     is an inappropriate comparison. HCFA invested nearly three 
     times as much time and money on the design of new work values 
     as it has spent to revise practice expense values. Whereas 
     thousands of doctors were surveyed to come up with the work 
     values, in the end, there was no broad survey of practice 
     expenses. Simply put, with work values, the product being 
     tested was much further along in the development process than 
     is now the case with practice expense values.
       Opponents of an extension also maintain that there is no 
     point in waiting another year because the demise of the 
     indirect cost survey shows that it will never be possible to 
     collect this information independently. We believe that with 
     another year, HCFA could develop alternative relative values 
     that bear some relationship to actual practice expenses. 
     There would be adequate time to validate and correct the CPEP 
     data. Better indirect cost allocation methodologies could be 
     developed and tested. Missing data could be collected, 
     perhaps through an expansion of existing surveys.
       The cuts HCFA projected in January are so extreme that they 
     would nearly eliminate practice cost reimbursement for some 
     procedures and specialties. Many inpatient surgical 
     procedures and two specialties could suffer cuts of more than 
     80% in their practice expense values, and at least 40% in 
     their total payments. Under HCFA's projections, payments for 
     many surgical procedures would fall below Medicaid levels. 
     Thus, there is good reason to fear that if Medicare makes 
     deep cuts in its payments for complex procedures, doctors 
     performing these services may find that they can no longer 
     afford to accept Medicare patients.
       In addition, even some of the specialties which seem 
     relatively unscathed in HCFA's projections could actually 
     experience significant cuts if other payers pick up the new 
     Medicare values because the projections do not show the 
     impact of cuts in procedures usually done on patients under 
     age 65. To impose such deep payment cuts based on such spotty 
     research seems certain to undermine physician support for the 
     RBRVS.
       The AMA urges Congress to: (1) extend the resource-based 
     practice expense implementation date by one year to January 
     1, 1999, in order for HCFA to incorporate data on physicians' 
     actual practice expenses into the new relative values; (2) 
     direct HCFA to give physicians the opportunity to review the 
     practice expense data and assumptions six months prior to 
     issuing the proposed rule; and (3) instruct HCFA to take 
     whatever steps may be necessary to ensure that implementation 
     of the new values will not have a negative effect on 
     physicians' ability to provide high quality medical services 
     to Medicare beneficiaries.


                     Other Physician Payment Issues

     Assistants at Surgery
       The Administration is proposing to save $400 million over 
     the next five years by making a single payment for surgery. 
     This means that the additional payment Medicare now makes for 
     a physician assisting the principal surgeon in performing an 
     operation would no longer be made. Instead, the payment 
     amount for the operation would have to be split between the 
     principal surgeon and the assistant at surgery. We believe 
     this provision dangerously imposes financial disincentives 
     for the use of an assistant at surgery. The AMA supports 
     efforts to develop guidelines for the appropriate use of 
     assistants at surgery, but believes that patient care should 
     not be compromised in search of Medicare savings. The 
     professional judgment of surgeons regarding the need for an 
     assistant at surgery for a specific patient must be 
     recognized, even for operations in which an assistant 
     ordinarily may not be required. Congress has considered and 
     rejected this proposal in the past, and we urge the 
     Subcommittee to reject it again.
     High Cost Medical Staff
       The Administration proposes to reduce Medicare payments for 
     so-called high cost hospital medical staffs. This proposal is 
     not new. In its 1994 Annual Report to Congress, the PPRC 
     concluded that such a ``provision's disadvantages . . . 
     outweigh its advantages.'' The Commission went on to note 
     that such a provision: ``may have unintended effects on 
     physician behavior, including a shifting of admissions away 
     from hospitals with the high-cost designation. The provision 
     would also increase the cost and complexity [of] 
     administering the Medicare program.''
       In some cases, the physicians responsible for a hospital's 
     medical staff being designated ``high cost'' for a given year 
     might simply take their patients elsewhere, leaving the 
     remaining physicians on staff to bear the financial 
     consequences, with potentially serious repercussions for the 
     affected hospital. Finally, the proposal could have the 
     effect of inappropriately reducing payments to physicians who 
     treat a sicker patient population. In the absence of a sound 
     methodology to measure differences in the severity of illness 
     of the patient population being treated by the medical staff, 
     it is too risky to put in place a formula-driven process that 
     could inappropriately lower payments for treating patients 
     who are more expensive to treat because they are sicker.
     Centers of Excellence
       The Administration proposes to expand what it calls the 
     ``Centers of Excellence'' demonstration project, under which 
     Medicare makes a bundled payment to participating entities 
     covering both physician and facility services for selected 
     conditions, such as coronary artery bypass operations. We are 
     concerned that these demonstration projects do not offer a 
     potential increase in quality and cost-effectiveness, and 
     that these ``centers of excellence'' in fact emphasize cost-
     cutting rather than excellence. We also find the name 
     ``centers of excellence'' inappropriate in that it implies 
     that institutions participating in this payment arrangement 
     provide higher quality services than non-participating 
     institutions.


                            Fraud and Abuse

       The AMA strongly opposes the Administration's efforts to 
     repeal the fraud and abuse safeguards included in the Health 
     Insurance Portability and Accountability Act of 1996 (HIPAA), 
     which would eliminate the obligation of the Departments of 
     Justice and Health and Human Services to issue advisory 
     opinions on the anti-kickback statute, reduce the 
     government's burden of proof for

[[Page H13300]]

     civil monetary penalties, and repeal the risk sharing 
     exception to the anti-kickback statute.
       Fraud and abuse has no place in medical practice and the 
     AMA is committed to setting the highest ethical standards for 
     the profession. For those who wish to comply with the law, 
     the incidence of misconduct can be greatly reduced by setting 
     standards of appropriate behavior, disseminating this 
     information widely, and designing and implementing programs 
     to facilitate compliance. HIPAA provides new and much needed 
     guidance by requiring HHS to establish mechanisms to modify 
     existing safe harbors, create new safe harbors, issue 
     advisory opinions, and issue special fraud alerts. This 
     guidance will allow physicians, hospitals and insurers to 
     develop efficient and effective integrated delivery systems 
     that will benefit Medicare, Medicaid and the private health 
     care marketplace.
       In the area of civil monetary penalties (CMPs), HIPAA 
     requires that the Inspector General establish that the 
     physician either acted ``in deliberate ignorance of the truth 
     or falsity of the information,'' or acted ``in reckless 
     disregard of the truth or falsity of the information.'' The 
     AMA fought long and hard to preserve this clarified standard 
     in the face of huge opposition. This standard makes the 
     burden of proof for imposing CMPs under HIPAA identical to 
     the standard used in the Federal False Claims Act, and there 
     is no reason that two enforcement tools designed to address 
     the same fraudulent behavior should have different standards 
     of proof. Moreover, this section provides important 
     protection for physicians who may unwittingly engage in 
     behavior that is impermissible.
       Finally, the AMA strongly opposes the Administration's 
     proposal to eliminate the new risk sharing exception to the 
     anti-kickback law provided in HIPAA. The expansion of managed 
     care in today's health care market requires additional 
     exceptions to the anti-kickback laws so that more flexibility 
     in marketing practices and contractual arrangements is 
     afforded. The future of the Medicare and Medicaid programs 
     depends upon the ability of competing plans to offer quality 
     alternatives to the existing program. HIPAA provides a much 
     needed exception to the anti-kickback law for certain risk-
     sharing arrangements which will facilitate the development of 
     innovative and cost-effective integrated delivery systems.


                               Conclusion

       Americans can no longer postpone tackling fundamental 
     reform of the Medicare program. Failure to do so is certain 
     to prove even more costly for the millions of Americans who 
     expect to be able to rely on this program in the future, as 
     well as those working Americans who are called upon to help 
     finance it. Simplistic budget-cutting has not resulted in 
     cost-control over recent years; on the contrary, price 
     controls have had the perverse effect of exacerbating 
     Medicare's fiscal crisis and severely threatening the 
     promised access of beneficiaries to medical care.
       However Medicare is reformed, it will be our overriding 
     goal to ensure that the change not damage the essential 
     elements of the patient-physician relationship. Above all, 
     reform should not break the bond of trust between a patient 
     and physician that makes medicine unique. By that we mean:
       All patients must remain free to choose the physician they 
     feel is best qualified to treat them or individually elect 
     any restrictions on choice;
       All patients, including those with chronic conditions and 
     special health or financial needs, must have access to any 
     needed service covered by Medicare;
       No restrictions on information about treatment options and 
     no financial incentive program can be allowed to interfere 
     with the physician's role as patient advocate;
       Both patients and physicians must have complete, easily 
     understood information about the Medicare program, and a 
     right to raise questions, voice grievances, and to have them 
     responded to in a fair, effective process; and
       Patients must be protected from unscrupulous or inept 
     health plans, physicians, and other providers.
       Americans who depend on the Medicare program for their 
     medical and health care, as well as those who will rely on it 
     in the future, should not have to worry about whether 
     benefits promised them will be forthcoming. The AMA looks 
     forward to working with the Subcommittee and the 105th 
     Congress in protecting Medicare for our seniors and saving it 
     for our children.

  Mr. STARK. Mr. Speaker, I am pleased at this time to recognize a 
distinguished member of the Ways and Means Committee, Mr. Neal of 
Massachusetts, for 1 minute.
  Mr. NEAL of Massachusetts. Mr. Speaker, I rise in support of this 
Medicare Physician Payment Reform Act, and remind our friends on the 
other side that this is similar to the 2-minute drill. We do this every 
year. It's like the 2-minute warning in professional football. H.R. 
3961 is about preserving patient choice, which is a fundamental element 
of our health care system, and very important to the reform measure 
that we passed about a week ago.
  This legislation will ensure that seniors on Medicare and TRICARE 
across America continue to have access to care and to the physician of 
their choice. But conversely, this bill also provides physicians with 
the certainty they need and have been missing to operate their offices 
in a predictable way and to continue to serve Medicare patients.
  It eliminates the steep payment cut scheduled for next year, a cut 
that, if it were allowed to happen, could reduce physician access 
across the country. H.R. 3961 is a good piece of legislative work. It 
increases payments to primary care providers for office visits, and it 
encourages the formation of accountable health care organizations. It 
goes a long way in preserving the vital patient-doctor trust contract 
and to strengthening that relationship.
  I urge support of this legislation.
  Mr. CAMP. Mr. Speaker, I yield myself 2\1/2\ minutes.
  The Medicare system paying for doctors is broken. It's broken badly, 
and on that, I don't think there's any disagreement. The question 
before us today is not whether to fix the so-called ``sustainable 
growth rate formula,'' but how.
  Time and time again, Republicans have supported America's doctors, 
while always paying for a so-called doctor fix. And the fact remains 
true today. It's irresponsible for the Speaker to force this House to 
choose between protecting doctors and seniors today and protecting our 
children's future. The bill before us directly adds at least $210 
billion to the deficit, plus another 50 billion in added debt payment, 
and as The Washington Post noted, the budget gimmicks mask the true 
costs, which are closer to $300 billion. So much for health care reform 
not adding one dime to the deficit.
  Adding insult to injury, the bill before us doesn't even solve the 
underlying problem with the SGR. The Democrats' new ``targeted growth 
rate'' would allow doctors to face cuts again as soon as 2011. We can 
and should do better by our doctors, our seniors and our children.
  Republicans are offering a better alternative, a 2 percent increase 
in doctor and Medicare payments in each of the next 4 years that is 
fully paid for, primarily by implementing real medical liability 
reform, a proven way to cut wasteful health care spending.
  It's telling that our colleagues on the other side prefer to pile up 
hundreds of billions of dollars in new debt on our children, instead of 
standing up to their friends in the trial lawyer lobby. For all of the 
talk about PAYGO, this bill makes a mockery of the majority's so-called 
commitment to fiscal responsibility. This is new spending and lots of 
it. It should be paid for, it must be paid for, and Republicans are 
offering a way to pay for it.
  I reserve the balance of my time.
  Mr. STARK. I'd like to recognize Mr. Blumenauer from Oregon for 1 
minute, but pending that, I yield myself 30 seconds to respond to my 
distinguished colleague and ranking member of the Ways and Means 
Committee that we debated this back in July, and that all of us agreed 
and voted for the fix that we're talking about today. And I hope that 
we could continue that. It was done on a bipartisan basis at that time. 
It was probably the only part of the bill that was bipartisan, but we 
did all vote for it and voted for exactly what we're talking about 
today, and I hope we could get those votes again.
  I yield to the gentleman from Oregon (Mr. Blumenauer).
  Mr. BLUMENAUER. I appreciate the gentleman's courtesy. This is a 
necessary budget adjustment, the consequence of the Republican gimmick 
that I voted against in 1993 because it was an artificial attempt that 
nobody had an expectation we were actually going to do. Indeed, every 
single year, except one, the Republicans blinked and kicked the can 
down the road.
  We are facing up to the problem today in a comprehensive way, not 
holding doctors and their patients hostage. Health care reform actually 
moves us in the direction to be able to reduce costs in the long term, 
and I'm optimistic that what the House has already done will move us in 
that direction.
  But whether or not reform is enacted, failure to pass this inflicts 
unacceptable damage on our constituents. This legislation gets us off 
the merry-go-round. I would strongly urge my colleagues to vote with 
us, my Republican friends not to vote ``no,'' but

[[Page H13301]]

work with us with a strong, resounding vote of support, and then work 
with the Senate to adopt this reasonable long-term adjustment.
  Mr. CAMP. I yield 2 minutes to the ranking member of the Health 
Subcommittee, the distinguished gentleman from California (Mr. Herger).
  Mr. HERGER. Mr. Speaker, while I rise today in support of reversing 
the devastating Medicare cuts for physicians, I also rise in opposition 
to passing the buck to our children and grandchildren.
  Mr. Speaker, our government is facing a severe and unprecedented debt 
crisis. Yet, despite the President's pledge that health care 
legislation won't add one dime to the deficit, we're voting today on a 
health care bill that adds 2 trillion dimes to the debt, while piling 
trillions of dollars more onto Medicare's unfunded liabilities.
  Mr. Speaker, the American people are tired of these budget games. Two 
weeks ago, 219 Members of the Democratic majority voted to cut Medicare 
by $500 billion. We could have taken a fraction of those savings and 
kept them within Medicare to pay for this much-needed relief for 
physicians. It would have passed with a huge bipartisan vote. But, 
instead, the majority decided to raid Medicare and spend the money on a 
new government-run health program.
  Republicans will be offering an alternative to ensure that doctors in 
Medicare are paid appropriately, and protect them from frivolous 
medical lawsuits, all without adding to the debt.
  I urge the Speaker to stop the political games and allow the House to 
vote on our responsible solution. It's the right thing to do for our 
doctors, it's the right thing to do for our seniors, and it's the right 
thing to do for the future of our country.
  Mr. STARK. Mr. Speaker, could I inquire as to the remaining time on 
either side?
  The SPEAKER pro tempore. The gentleman from California has 7 minutes 
and the gentleman from Michigan has 11\1/2\ minutes.
  Mr. STARK. At this time, Mr. Speaker, I'm delighted to yield 1 minute 
to the distinguished gentleman from New Jersey (Mr. Pascrell).
  Mr. PASCRELL. First thing we have to get straight here is that the 
past administration masked the costs of our one-sided tax cuts in 2001 
and 2003, unpaid for; masked the costs of two wars, never in the base 
budget; masked the costs of taking care of our returning brave 
soldiers. You have been the masters of masks. And now you're advising 
Democrats? Case closed.
  Mr. Speaker, today we have the opportunity to vote on legislation for 
which many of us here have hoped for years, a permanent solution to the 
flawed Medicare physician payment formula. I implore my colleagues to 
set aside partisan bickering. Each year for the past 7 years, both 
Republican Congresses and Democratic Congresses have stepped in to 
preserve seniors' access to care by preventing steep cuts to physician 
payments. Each year.
  The sustainable solution before us today deserves bipartisan support. 
If we're truly serious about enacting comprehensive health reform then 
we will pass this vital legislation. Providing a realistic, long-term 
solution that embraces a legitimate effort to rein in spending while 
recognizing--
  The SPEAKER pro tempore. The time of the gentleman has expired.
  Mr. STARK. I yield the gentleman an additional 15 seconds.
  Mr. PASCRELL. To rein in spending while recognizing the value of 
primary care is a necessary foundation to true reform. Without it, it's 
like building our house on a foundation of sand that not only 
jeopardizes access to care for 45 million seniors and individuals with 
disabilities but also has important consequences for our entire 
physician workforce.
  Mr. CAMP. I yield 2 minutes to a distinguished member of the Ways and 
Means Committee, the gentleman from Texas (Mr. Brady).
  Mr. BRADY of Texas. Mr. Speaker, unfortunately, this conversation is 
not about doctors. It's about a budget gimmick to try to hide the true 
cost of Nancy Pelosi's health care takeover. There is a right way and 
there is a wrong way to help our doctors get paid fairly under 
Medicare. But because not one dime of this bill is paid for, it forces 
Americans to borrow another $279 billion from China and pass the bill 
of debt down to our grandchildren to pay, all to hide the cost of this 
health care reform in Washington.
  This is irresponsible, and it's the wrong way. I support the 
Republican alternative. We give our doctors cost-of-living increases, 
but we pay for them by chasing frivolous lawsuits that drive up the 
costs of medicine out of our system. So we help our doctors and we help 
the patients at the same time.
  And I want to finish with this: This Medicare, the way we pay our 
doctors, it's a great taste, sort of a look into the future of what 
happens when the government is going to run your health care decisions. 
Not paying doctors fairly is how Medicare rations care today, and it's 
the main reason seniors have difficulty finding a doctor. This is a 
peek into the future when Medicare makes budget decisions about your 
life and death medical decisions. This is the future, and it's 
frightening.

                              {time}  1500

  Mr. STARK. I reserve the balance of my time.
  Mr. CAMP. At this time, Mr. Speaker, I yield 2 minutes to the ranking 
member of the Budget Committee and a distinguished member of the Ways 
and Means Committee, the gentleman from Wisconsin (Mr. Ryan).
  Mr. RYAN of Wisconsin. Mr. Speaker, there is so much irony 
surrounding this bill here.
  First of all, everybody knows this bill is not going anywhere because 
the Senate already defeated a cheaper version because it created a huge 
deficit.
  I have a score from the Congressional Budget Office which I will 
insert into the Record that says this thing raises the deficit by $210 
billion. What's more ironic is that the majority, which put in this 
huge PAYGO system, has just swept it aside and decided to say, No, the 
CBO is wrong, this doesn't increase the deficit. It costs nothing.
  Why did they do that? They did that because they're trying to pass 
this health care bill and suggest that it doesn't cost anything.
  I have a letter from the CBO today that simply says when you merge 
these bills together--because they are together; in fact, this doc fix 
bill was in the original bill in the first place--that it raises the 
deficit, now and into the future. It adds more than many dimes to the 
deficit now and into the future. It breaks the President's pledge and 
promise on how health care reform will be conducted.
  What is even more ironic are the doctors who are telling us to fix 
this--and we all want to fix this--is that we can't even bring a bill 
to the floor to fix it without raising the deficit. That's irony.
  What I also find especially ironic are that some physicians say fix 
this but then create this new system, which is basically to have 
Medicare for everybody else. So if they think the SGR is a problem now, 
just wait until you see this system writ large throughout all of 
American health care. That is a mistake.
  We should do this in a bipartisan way, fix it without cranking a huge 
hole in the deficit, and if the majority would have allowed us to bring 
a bill to do that, we could have done just that. It's cynical. We know 
this bill is not going anywhere. So let's get back to work and fix this 
problem without cranking up a huge hole in the deficit.
  Mr. STARK. I yield myself 30 seconds, Mr. Speaker, just to remind the 
distinguished gentleman from Wisconsin that he and 14 of his colleagues 
voted for this bill in the Ways and Means Committee last July.
  I don't mind mixing it up with the health care reform, but it's not. 
It's the doctor fix.
  Mr. RYAN of Wisconsin. Will the gentleman yield?
  Mr. STARK. In just a moment, yes.
  The important thing is that if we move this aside, we're correcting 
the mistake that was made. Let's forget about who made it. It was 
there.
  Now this may not be the end-all correction, but there is no reason 
that we couldn't come back next year if we find that the formula 
doesn't work.
  The SPEAKER pro tempore. The time of the gentleman has expired.
  Mr. STARK. I will yield myself an additional 30 seconds.
  If we don't do it and we do the 4-year fix that you, Mike, suggested, 
or the 3-year, and then it doesn't work, we will have $400 billion to 
correct.

[[Page H13302]]

  My point is this. If we could remove it for a moment from the 
discussion on the overall health reform bill--which we can have a 
spirited discussion on--this is a technical fix which all of your 
members supported on a bipartisan basis.
  Mr. RYAN of Wisconsin. Will the gentleman yield?
  Mr. STARK. I yield to the gentleman from Wisconsin.
  Mr. RYAN of Wisconsin. If you recall during the debate, at the time 
we said we should be paying for this and let's come together to find a 
solution to fix this without raising the deficit. This was inside of 
your health care bill to begin with. So it's difficult to say that 
these two things aren't connected.
  Mr. STARK. Well, as I say, the gentleman supported it a few months 
ago.
  At this point, Mr. Speaker, I'd like to yield 1 minute to the 
gentlelady from Nevada (Ms. Berkley).
  Ms. BERKLEY. I thank the gentleman from California for yielding me 
the time.
  I have had the fastest growing senior population in the United States 
for many decades in a row. My seniors need health care and they need to 
be able to see a doctor. But every year when we get to the end of the 
year, we play this ridiculous game of whether or not we're going to 
provide a doctors fix and be able to reimburse the doctors for seeing 
our senior patients under the Medicare program. And every year I 
receive telephone calls from doctors in the Las Vegas area telling me 
that if in fact they don't get reimbursed as they should, that they 
will not be able to continue seeing Medicare patients.
  Now, short of me going to medical school so I could go home and take 
care of the seniors in my district when I go home on the weekends, we 
better figure out a way of adequately reimbursing the doctors--not 
doing it on a year-to-year basis which gives them an accounting 
nightmare--and being able to provide stability for the Medicare system 
so that the millions of seniors in this country that depend on the 
Medicare program for their health care needs to be met, that we are 
able to meet them. I urge that we support this bill.
  Mr. CAMP. Mr. Speaker, I yield 1 minute to a distinguished member of 
the Ways and Means Committee, the gentlewoman from Florida (Ms. Brown-
Waite).
  Ms. GINNY BROWN-WAITE of Florida. Mr. Speaker, I rise today in 
opposition to the Medicare Physician Payment Reform Act.
  Let me be clear. We all want to fix the flawed physician 
reimbursement rate. Without a fix, physicians around this country may 
be closing their practices and turning seniors away. This is an 
extremely serious matter. However, Democrats are using physicians and 
seniors as political pawns and playing games with people's livelihoods. 
It's unconscionable that the AMA traded their support for $210 billion.
  The Congressional Budget Office has said that this bill will increase 
Medicare part B premiums to our Nation's seniors by $50 billion. This 
bill will add nearly a quarter of a trillion dollars to our Nation's 
exploding deficit. My constituents want to know how in God's name are 
we ever going to pay this debt down. I am one of the few Republicans 
who voted for PAYGO, and I'd like to see it being used instead of 
regularly waived as it is here.
  This bill is fatally flawed, and I urge my colleagues to follow the 
lead of the Senate and reject this bill so we can work together on a 
solution.
  Mr. STARK. Mr. Speaker, I reserve the balance of my time.
  Mr. CAMP. I yield 1\1/2\ minutes to the gentleman from Illinois (Mr. 
Roskam), a distinguished member of the Ways and Means Committee.
  Mr. ROSKAM. I thank the gentleman for yielding.
  Can you imagine what it would be like if this House at this time took 
President Obama's admonition seriously? A couple days ago he said this 
on his trip to China:
  It's important, though, to recognize that if we keep on adding to the 
debt, even in the midst of this recovery, that at some point people 
could lose confidence in the U.S. economy in a way that could actually 
lead to a double dip recession.
  Can you imagine what would happen if this House came together and 
said, No, no, no, no, no. We're actually going to take this seriously. 
We're going to deal with this debt question, and we're going to lean 
into it in such a way that gives, what, a buoyancy to the American 
economy as opposed to continuing to drag down.
  With all due respect to the majority leader when he was on the House 
floor a bit ago, he argued, in essence, don't worry about it because 
it's in the President's budget. Well, think about where that takes you. 
The President's budget is the problem. The President's budget doubled 
our national debt in 5 years and will triple that debt in 10 years, 
which is one of the reasons why Americans are so increasingly 
concerned.
  Look, we all come together and we know the physicians need to be 
compensated fairly. We know that seniors ought not bear this burden. 
But why not work together to take the President's admonition seriously 
to take the debt question seriously and come up with a real fix?
  Mr. STARK. I reserve the balance of my time.
  The SPEAKER pro tempore. The gentleman from California has 3\3/4\ 
minutes, and the gentleman from Michigan has 5\1/2\ minutes.
  Mr. CAMP. Mr. Speaker, I yield 2 minutes to a distinguished member of 
the Ways and Means Committee, the gentleman from Louisiana, Dr. 
Boustany.
  Mr. BOUSTANY. Mr. Speaker, as a physician I know directly about 
access problems that our seniors are having. Clearly we must protect 
seniors' access to physicians of their choice. I also know directly 
about the flawed formula for physician reimbursement. We all want to 
deal with it.
  What we need to do is repeal the flawed SGR formula and replace it 
with a more equitable reimbursement for physicians that is paid for. 
This bill ignores over $200 billion in added deficit spending. It 
continues the same price-controlled formula for physicians. And it does 
not eliminate--let me repeat--it does not eliminate the tendency for 
physician cuts. Instead of providing a realistic, long-term solution, 
this bill spends borrowed money and basically increases the Medicare 
shortfall by $1.9 trillion.
  I urge my colleagues, let's get real about this. I urge my colleagues 
to vote ``no'' on this bill. Let's support a real solution that 
protects patient access to a physician of their choice. Let's support a 
real solution that's honest with physicians and treats them fairly, and 
a solution that avoids massive debt passed on to our children and 
grandchildren.
  Vote ``no'' on this bill.
  Mr. STARK. I yield myself such time as I may consume, Mr. Speaker, to 
remind my distinguished friend from Louisiana that the American College 
of Cardiology, the Louisiana Medical Association, and most every 
medical association in the United States has endorsed the legislation.
  I reserve the balance of my time.


                         Parliamentary Inquiry

  Mr. RYAN of Wisconsin. Parliamentary inquiry, Mr. Speaker.
  The SPEAKER pro tempore. The gentleman will state his parliamentary 
inquiry.
  Mr. RYAN of Wisconsin. Mr. Speaker, clause 10 of rule XXI, what is 
known as the pay-as-you-go or PAYGO rule, provides a point of order 
against direct spending or revenue legislation that would increase the 
deficit, and the bill before us today increases the deficit by $209.6 
billion according to the Congressional Budget Office. While there is no 
authority to reduce the estimated cost of legislation in the rules 
adopted by the House at the beginning of the 111th Congress, am I 
correct that the House has effectively modified the application of this 
rule on two separate occasions with respect to its application to 
Medicare legislation?
  The SPEAKER pro tempore. In addition to its adoption of standing 
rules on January 6, 2009, the House has further exercised its 
rulemaking authority in section 421 of the current budget resolution, 
Senate Concurrent Resolution 13, and in section 2 of House Resolution 
665.
  Mr. RYAN of Wisconsin. Further parliamentary inquiry, Mr. Speaker.
  The SPEAKER pro tempore. The gentleman will state his inquiry.
  Mr. RYAN of Wisconsin. The first modification was made by the 
conference report on the FY 2010 budget

[[Page H13303]]

resolution adopted on April 29, 2009. Am I correct that the budget 
resolution provided authority to reduce CBO's deficit estimate of this 
legislation by up to $38 billion?
  The SPEAKER pro tempore. The gentleman alludes to section 
421(a)(2)(A) of the budget resolution, which the Chair will not 
characterize. The text speaks for itself and may be addressed by 
Members in debate.
  Mr. RYAN of Wisconsin. Further parliamentary inquiry.
  The SPEAKER pro tempore. The gentleman will state his parliamentary 
inquiry.
  Mr. RYAN of Wisconsin. My understanding is that on July 22, in 
passage of that PAYGO bill, that the budget resolution was modified to 
allow the CBO estimate of the cost of the legislation to go up to $284 
billion which could not be counted. Am I correct that even though the 
Congressional Budget Office says that this bill raises the deficit by 
$209.6 billion, the rule in place right now gives the chairman of the 
Budget Committee the ability to simply say that this costs nothing, 
that the score is zero.
  Am I correct in saying that?
  The SPEAKER pro tempore. This is not a parliamentary inquiry. Such 
commentary may be presented by the gentleman in his own voice by 
remarks in debate.
  Mr. RYAN of Wisconsin. I thank the Chair.
  Mr. STARK. Mr. Speaker, at this time I am pleased to yield 1\1/2\ 
minutes to the distinguished gentleman from North Carolina (Mr. 
Etheridge).
  (Mr. ETHERIDGE asked and was given permission to revise and extend 
his remarks.)
  Mr. ETHERIDGE. Mr. Speaker, I thank the gentleman for yielding time 
and for this bill.
  You know, folks, Medicare is a vital lifeline for our seniors, but 
it's worthless if doctors can't afford to see Medicare patients. 
Seniors should be able to see the doctors they prefer, and fixing the 
doctor payment system will make sure that they have access to high 
quality care from people that they trust.
  Countless doctors in my district have told me that they're happy to 
treat seniors, but they risk going out of business with current 
Medicare payments. We must make sure that they continue to be able to 
treat patients.
  By fixing the doctor payment issue and including PAYGO, Congress is 
ending budget gimmicks and the reckless borrow-and-spend policies of 
the last decade.
  I strongly support this bill, and I urge my colleagues to join me in 
strong support of our seniors and the physicians who keep them healthy.
  Mr. Speaker, this bill deserves every Member's support.
  Mr. CAMP. Mr. Speaker, I yield myself the balance of my time.

                              {time}  1515

  When we reviewed this debate on this physician payment formula fix, 
clearly, this is something that we, both sides, agree needs to be 
addressed. But as you look at how this has evolved, initially this 
provision was part of the Pelosi-Obama health care bill. But when that 
2,000-page bill came in at $1 trillion, this was pulled out, and then 
it was made a separate bill that be will magically merged into 
ObamaCare as that moves over to the Senate. And we have experts who 
have said this provision alone, without being paid for, could add to 
Medicare's unfunded liability as much as $1.9 trillion over a 75-year 
period. And obviously, with Medicare, we are looking at the long term. 
Given that there is already a $39 trillion hole in Medicare, this ends 
up making a commitment that will be borne by our children and 
grandchildren.
  We believe that we should have the opportunity to offer an 
alternative that would be paid for, as every alternative over the years 
has been. And I know the other side has cited this vote in committee. 
That vote was simply, in the context of full health care reform, saying 
that health care reform needed to be paid for and we needed to be 
fiscally responsible.
  We think this is a very important issue. Certainly, the public has 
weighed in on this incredible explosion in the debt over these last few 
months. And we believe that it is irresponsible to bring this bill to 
the floor, to make us choose between doctors and seniors and our 
children, and we believe that an alternative that is fully paid for is 
the right way to go.
  With that, I yield back the balance of my time.
  Mr. STARK. Mr. Speaker, I yield to the gentlewoman from Texas (Ms. 
Jackson-Lee) for a unanimous consent request.
  (Ms. JACKSON-LEE of Texas asked and was given permission to revise 
and extend her remarks.)
  Ms. JACKSON-LEE of Texas. Thank you very much, Mr. Stark.
  I rise to support H.R. 3961 because it provides a payment for our 
doctors, allows seniors to keep their doctors, and is paid for.
  Mr. Speaker, I am pleased to stand before you today in support of the 
Medicare Physician Payment Reform Act. This bill, which will finally 
put an end to the cycle of threats of larger and larger fee-cuts 
followed by short-term fixes, is long overdue. This bill will repeal a 
21 percent fee reduction that currently scheduled right around the 
corner, January 2010.
  Given the fact that Healthcare reform has been, and still is, a very 
lively and relevant topic over the recent months, the timing of this 
bill is apropos in that is intended to make our nations healthcare 
system more efficient. The importance of this bill is evidenced by its 
widespread support from a range of organizations representing both 
patients and doctors, including the American Medical Association, AARP, 
and the American Academy of Family Physicians just to name a few. Their 
support shows that there has been a need for better management of the 
Medicare system, and this bill presents the sustainable solution that 
physicians and patients alike have been looking for.
  Proper management of Medicare funding ensures that the Medicare 
system will be able to properly support the medical needs of its 
intended beneficiaries. This bill will help promote the use of primary 
care and give access to the use of primary care practitioners in 
Medicare and throughout the healthcare system. By providing incentives 
to physicians, this bill will also encourage integrated care and 
increased communications amongst doctors on the care of their specific 
patients. These improvements to the Medicare system will result in a 
higher quality of care and ultimately, a healthier population of 
patients.
  With so many Americans currently uninsured or receiving inadequate 
healthcare, it is paramount that the funds set aside to support 
Medicare are used wisely to provide the best possible care for 
patients.
  In my home state of Texas, the need for a more efficient healthcare 
is more prevalent now than ever. One in four Texans, about 5.7 million 
people, or 24.5 percent of the state's population, has no health 
insurance coverage. An estimated 1,339,550 Texas children--20.2 percent 
of Texas children--are uninsured. According to the U.S. Census Bureau, 
Texas has the nation's highest percentage of uninsured residents. This 
poses consequences for every person, business and local government in 
the state who bear extra costs to pay for uncompensated care. If 
Medicare funding is allowed to be cut or capped, the number of 
uninsured will grow dramatically.
  I realize that we must consider budgetary concerns while we champion 
the push for better quality healthcare, and the Medicare Physician 
Payment Reform Act does just that. It was drafted with fiscal 
responsibility in mind. We want to protect both the medical and fiscal 
health of our people and this bill takes steps to do just that. The 
cost of the bill is already included in the House-passed and 
President's budgets. This money represents the ongoing care and 
maintenance of the Medicare program. The legislation fully complies 
with the House-passed PAYGO requirements because the PAYGO legislation 
explicitly accommodates physician reform legislation that is designed 
to maintain current spending. As such, the bill, while it contains new 
reforms, represents continuation of an existing policy rather than new 
spending. H.R. 3961 will be coupled with Statutory PAYGO legislation 
when it is sent to the Senate.
  The cost of addressing this problem will only grow in the future. In 
2005 a permanent freeze for physician payments was scored as costing 
$48.6 billion; today, a policy with a similar score costs $210 billion. 
Delays today mean larger and larger price tags in the future and 
continuing damage to the Medicare program. Therefore prompt action on 
this issue is necessary and must be taken.
  As we talk about fixing the issue of Medicare payments to physicians, 
this raises similar fixes that I proposed in H.R. 3962--The America's 
Affordable Health Choices Act of 2009. Specifically, I proposed two 
changes to Section 1156 of H.R. 3962, to prevent existing physician-
owned hospitals from being forced out of business, amendments that 
enjoyed bi-partisan support. First, to avoid harming existing 
physician-owned hospital projects, I proposed extending the date of the 
grandfathering provision of Section 1156 to

[[Page H13304]]

January 1, 2011 and by strengthening the requirements for Hospitals to 
qualify for an extension. Next, I suggested that we extend the cut-off 
date for determining the baseline number of beds and procedure rooms 
for purposes of the expansion prohibition (currently, date of 
enactment) to the same date proposed or the grandfathering provision.
  Along with this, I share the concerns of health advocates that, as 
is, the public option in H.R. 3962 is not equipped to provide real 
competition to large mega insurance plans. As such, I proposed that 
H.R. 3962 incorporate Congressman Kucinich's proposal to allow states 
to choose public insurance options more robust than the Federal plan.
  I look forward to working with the leadership going forward to fix 
these items along with a system that each year cuts Medicare 
reimbursements to Physicians.
  Mr. STARK. Mr. Speaker, I yield myself the balance of the time.
  I again encourage my friends on the other side of the aisle to 
support this fix for the physician reimbursement. It was correct 
originally in our major health reform bill. The reason it was 
separated, I would have to admit, was purely political. We had to abide 
by the President's request that we did not exceed certain costs, and we 
separated it for that.
  For those of you who suggest that the Senate may do nothing with 
this, I'm afraid we have to leave that to the American Medical 
Association and America's physicians. They will have to pressure the 
Senate to add this at some point in their deliberations. I think it's 
beyond us to do that, and my suspicion is that with the more than 150 
medical societies around the country, they will be able to importune 
our friends on the other side of the Capitol.
  Mr. Speaker, I believe that we will see a format of this bill facing 
us from the other side. I hope we do. We are talking about postponing 
any length of time increases, whether it's 4 years and we get $400 
billion, whether it's a couple of years and we get $200 billion, there 
was a mistake made. The distinguished gentleman whom the current 
ranking member and I know so well is no longer with us. He is probably 
chuckling up his sleeve at the angst he has caused us.
  But we recognize the mistake. We did try to fix it. We did try to fix 
it on a bipartisan basis. I know there are other issues that are 
tangential to this. I hope we can put these aside today. Take care of 
the physician fix. Hopefully we've got the formula right. As I said 
earlier to the distinguished gentleman from Wisconsin, we might not 
have it perfect, but we have some time in the next year or 2 to make 
those adjustments. I commit to you that we certainly will, and I hope 
that you would work with us to help correct it if that comes in the 
future so we can set this aside. It's a separate debate.
  We are going to have a long and strenuous debate on health care 
reform as we go down toward the end of the year and into next year. And 
I look forward to that. But I would like to see this set aside so that 
we can see that the physician payment fix, which we all know has been 
facing us for years, is ended today and that we pass this bill.
  I thank my friends on the minority side for their kindness in this 
debate and, Mr. Speaker, I urge passage of the bill.
  Mr. REYES. Mr. Speaker, I rise today in strong support of H.R. 3961, 
the Medicare Physician Payment Reform Act of 2009. Over this past 
summer, physicians in my district consistently stressed the need to 
reform our flawed Medicare reimbursement formula to ensure continued 
access to care for our Medicare beneficiaries. I could not agree more. 
For the last several years, Congress has had to act to reverse 
reimbursement reductions that would have prompted many doctors to close 
their doors or refuse to see more Medicare beneficiaries. If we do not 
act today, physicians serving Medicare patients will see a 21 percent 
reduction in their reimbursements next year. A cut of this magnitude 
will reduce access to physicians for Medicare beneficiaries throughout 
the country. Today, we in the House of Representatives are 
demonstrating our commitment to permanently fixing this problem.
  I am pleased that H.R. 3961 will eliminate this steep payment cut 
scheduled for 2010 and protect access to care for seniors and people 
with disabilities into the future. It will also help protect access for 
our men and women in uniform and their families, since physician 
payment rates in TRICARE are tied to those used by Medicare. By 
providing a boost to primary care providers through increased payments 
for evaluation and management services, such as routine office visits, 
we help our physicians and patients focus on preventive measures and 
general wellness. Above all, this important legislation will ensure 
fair and adequate payment for physicians who participate in Medicare.
  The American Medical Association, AARP, the Military Officers 
Association of America, the American Academy of Family Physicians, the 
American College of Physicians, the American College of Surgeons, the 
Center for Medicare Advocacy, the Medicare Rights Center, and the 
National Committee to Preserve Social Security and Medicare support 
this legislation. Like them and many of my colleagues, I too support 
comprehensive reforms to Medicare physician payments that enhance 
efficient and high-quality care for beneficiaries that protect their 
choice of physicians. For these reasons, I urge my colleagues to vote 
in favor of H.R. 3961.
  Mr. GENE GREEN of Texas. Mr. Speaker, I rise today in support of H.R. 
3961, the Medicare Physician Payment Reform Act of 2009.
  This important piece of legislation will repeal the 21 percent 
physician payment cut, which is scheduled to go into effect on January 
1 and replace it with a 1.2 percent increase for next year.
  It has been over a decade since the physician fee schedule was put in 
place to help control increases in Medicare payments to physicians. The 
Medicare program reimburses physicians who treat seniors using a 
complex formula that is based on a number of factors.
  Unfortunately, payments for physician services matched the SGR and 
expenditure targets for only the first 5 years. Since then, the actual 
expenditures have exceeded the target by so much that the system is no 
longer realistic.
  As we have learned in recent years the formula reduces payments to 
physicians when the economy goes down--a time when doctors are least 
able to absorb the extra costs. These payment reductions have caused 
many physicians to hold off on accepting new Medicare patients, 
withdraw from the program, or retire altogether.
  In areas like mine that rely heavily on Medicare and Medicaid, we 
probably will not be in a situation where doctors stop taking Medicare. 
Rather, we will see access problems created by gap from physician 
retirements that is not filled by new crops of doctors willing to take 
Medicare patients. If we reach that point, Medicare will have failed in 
its mission to provide equality in access to health care for our senior 
citizens.
  We passed H.R. 3962, the Affordable Health Care for America Act a 
couple of weeks ago, but we cannot successfully implement health care 
reform if we do not reimburse our physicians correctly. It is time for 
Congress to intervene and revamp the SGR formula and pass H.R. 3961.
  Mr. KLEIN of Florida. Mr. Speaker, I rise in strong support of H.R. 
3961, the Medicare Physician Payment Reform Act. This vital component 
to health care reform will finally eliminate the widely criticized 
Sustainable Growth Rate, or SGR, and implement a new, fairer system to 
pay our doctors and protect and strengthen Medicare for all our 
seniors.
  Originally enacted in 1997, the SGR has been, in my opinion, an 
attempt to balance the budget on the backs of doctors and other 
providers, and this is not acceptable. Not only has the SGR failed to 
curtail spending, but in some cases it incentivizes volume of services 
instead of quality of care, and it may be expediting the shift from 
primary care services to specialty and sub-specialty services. As you 
well know, Mr. Speaker, the alarming shortage of primary care 
physicians remains one of the most pressing challenges to our health 
care system.
  Make no mistake: passing this bill today is of the utmost importance 
for our seniors and our physicians. Since 2001, doctors have faced cut 
after cut in their Medicare reimbursements due to the flawed SGR. Each 
time, Congress stepped in at the 11th hour to block the cuts and 
provide increases to their pay to ensure that seniors can continue to 
see the doctors of their choice under Medicare.
  We are facing the same alarming situation now due to the SGR. Doctors 
are facing a crippling cut of 21 percent in January 2010. Let me repeat 
that number so all my colleagues who intend to vote against this bill 
can hear this loud and clear. Doctors who care for our seniors are 
facing a 21 percent cut in their pay. It doesn't take an economist to 
know that if doctors face a 21 percent cut in their salary, they will 
stop taking Medicare patients.
  I can't speak for my colleagues, but I will say this. When I came to 
Congress 3 years ago, I vowed to strengthen and protect Medicare for my 
seniors, and that means fixing once and for all the way we pay our 
doctors under Medicare. By passing this bill, seniors will not have to 
lose another night of sleep over whether they can be treated by the 
doctor of their choice. This bill will bring peace of

[[Page H13305]]

mind to thousands of seniors and health care professionals in South 
Florida.
  This important legislation builds on the critical reforms that we 
passed in H.R. 3962, the Affordable Health Care for America Act, which 
will finally close the donut hole for seniors enrolled in Part D, allow 
for drug price negotiation in Medicare, and eliminate copayments for 
vital preventive services to our seniors. Combined with this permanent 
fix to the way we pay doctors, this Congress is following through on 
our promises to our seniors and strengthening Medicare for years to 
come.
  This bill will also include an important component to reducing the 
federal deficit. The ``pay as you go'' principle of budget discipline 
requires Congress to offset any new spending with either cuts to 
existing programs or increases in revenue. It was in place during the 
1990s when Congress balanced the budget and actually ran a budget 
surplus. Pay-Go was allowed to expire and now we have the situation we 
are in now.
  As a deficit hawk, I am absolutely committed to balanced budgets and 
reducing our deficit. I am a very strong supporter of writing pay-as-
you-go requirements into law. This is a common-sense principle that 
families follow around their kitchen tables every day, and the 
government should be no different. We can only buy what we can afford, 
and nothing more.
  I urge my colleagues to support H.R. 3961.
  Mr. VAN HOLLEN. Mr. Speaker, I rise in support of this legislation. 
The bill before us today would accomplish two very important things--
provide a long-term fix to the Medicare physician reimbursement problem 
and implement statutory pay-as-you-go, PAYGO, rules will promote long-
term fiscal responsibility for our nation.
  Permanent reform of the flawed Medicare physician payment formulas is 
necessary to ensure that beneficiaries can see their doctor of choice 
and protect access to care. Consistent with the House Budget Resolution 
and President Obama's recommendation, this bill uses realistic and 
responsible assumptions about future Medicare spending on physician 
services. The choice is clear: We need to fix this problem honestly 
today and not continue to kick the can down the down the road.
  As we put Medicare physician payments on a sustainable path, so must 
we tend to the fiscal health of our Nation. The day President Obama was 
sworn into office, he inherited huge deficits and exploding debt in 
this country. The previous administration wanted to put everything on 
our national credit card and ask future generations to pay for it. It 
is the legacy of this irresponsible spending that has left us with 
today's historic Federal debt.
  Fortunately, there is a time-tested solution for bringing our budget 
back into balance: PAYGO budget rules. We have had the benefit of PAYGO 
in the past. For example, when the PAGYO rule was in place in the 
1990s, our Federal budget went from record deficits to record surplus. 
In fact, when President Clinton left office, CBO projected that America 
would have an $800 billion surplus this year. However, when Congress 
abandoned PAYGO in 2002, the Federal debt exploded. Today, we are 
saddled with a $1.4 trillion deficit.
  Digging out of this economic ditch will take time, but it is 
important that we put our economy on a long-term, sustainable path. 
PAYGO will do that by requiring policies that result in revenue 
reduction or increased mandatory spending be offset over the next 5 and 
10 years. It will force Congress to evaluate the tradeoffs inherent in 
its financial decisions and make hard choices, just like any family in 
America.
  Mr. Speaker, with this legislation, we will be putting our country on 
a path of fiscal responsibility. Let's tell our children and 
grandchildren that we're going to take some responsibility. I urge my 
colleagues to support this important legislation.
  Mr. LANGEVIN. Mr. Speaker, I rise today in support of H.R. 3961, the 
Medicare Physician Payment Reform Act of 2009. This legislation will 
prevent a scheduled 21 percent Medicare payment cut to physicians, 
while providing a long-term fix to the flawed Medicare reimbursement 
formula that has threatened access to care for over a decade.
  Congress has made unprecedented strides this year in the fight to 
reform our nation's health insurance system. On November 7, I was proud 
to support the first comprehensive health reform bill to pass the House 
in several decades. This was an historic achievement, but we have more 
work to do. Low Medicare reimbursement rates have made it difficult to 
retain qualified doctors in Rhode Island, particularly those who 
practice primary care. This is not just a problem for Rhode Island's 
seniors; it is an issue that affects every patient in Rhode Island and 
throughout the country.
  The Medicare Sustainable Growth Rate formula, or SGR, was a cost 
control measure instituted in 1997 that has required repeated cuts in 
physician reimbursements that don't reflect the true costs of care. 
Since 2002, Congress has recognized this fact and passed yearly fixes 
to prevent these cuts from taking effect. If left unresolved, this 
problem will result in a total reimbursement cut of 40 percent to 
doctors by 2016, the same time period during which we will see even 
more baby boomers entering the Medicare program.
  H.R. 3961 replaces the pending 21 percent fee cut with an update for 
2010 based on the Medicare economic index, estimated at 1.2 percent. 
Beginning in 2011, the update adjustment factor would be based on 
spending for each category of service since 2009, wiping the slate 
clean from the onerous accrual of cuts that have loomed over doctors 
for years. In addition, it provides an extra growth allowance for 
primary care services to promote access to primary care practitioners 
in Medicare and throughout the health care system.
  Successful health reform must include a Medicare payment structure 
that ensures fair reimbursement for doctors and continued access for 
seniors. H.R. 3961 is a necessary step toward achieving that goal, and 
I urge my colleagues to support its passage.
  Mr. BACA. Mr. Speaker, I rise today in strong support of H.R. 3961, 
the Medicare Physician Payment Reform Act.
  Congress is only a few steps away from passing a healthcare reform 
bill and sending it to the President's desk for a signature.
  However the 21% cut to physician payments under Medicare scheduled to 
go into effect on January 1st is just around the corner.
  We must act now to protect Medicare patient's access to their 
doctors. We must act now to protect military and their families under 
TRICARE the access to their doctors. The status quo is not an option; 
we must not let these cuts go through. Let's stop the cuts and short-
term patches once and for all; this is real reform with a real 
solution.
  Today I will vote for the 194,510 Medicare patients in my District. 
Access to healthcare is not a privilege, it is a human right. I urge my 
colleagues vote for H.R. 3961 and preserve the access of Americans to 
see their doctor.
  Ms. RICHARDSON. Mr. Speaker, I rise today in strong support of H.R. 
3961, the ``Medicare Physician Payment Reform Act of 2009.'' Our 
seniors and veterans have worked for affordable, quality, and 
accessible health care. The bill before us, H.R. 3961, ensures that 
Medicare payments fairly compensate physicians for their services. This 
legislation will ensure that doctors will be available to treat their 
Medicare patients.
  Over the last five years, Medicare payment rates to doctors were set 
artificially low just to keep the system from becoming insolvent. That 
was the wrong approach. Instead of saving money, the system had the 
unintended consequence of discouraging doctors from accepting Medicare 
patients. Under the ``Sustainable Growth Rate'' formula, or ``SGR,'' 
employed by the previous Administration and Congresses, the rate of 
physicians' reimbursement steadily decreased in order to restrain the 
growth of overall Medicare spending. So while aggregate spending was 
balanced, payments to individual doctors provided minimal incentive for 
them to continue treating Medicare patients.
  Indeed, if this flawed SGR formula were implemented in its current 
form, Medicare physicians would suffer a 21 percent fee reduction in 
January 2010. This would be disastrous for Medicare patients because 
many of their doctors would no longer be able to afford to provide them 
with the quality care they need.
  H.R. 3961 will allow doctors to keep their doors open to their 
Medicare and TRICARE patients. Rather than being reimbursed based on 
some externally constructed, faulty measure such as the SGR, doctors 
will be reimbursed based on a new measure, one that reflects the actual 
cost of the services they provide to their patients. H.R. 3961 also 
sets 2009 as the baseline for years to come. This means that, rather 
than a steadily declining reimbursement, doctors will experience a 
reimbursement rate that either matches or slightly exceeds what they 
received the year before. This bill ends the cycle of fee reductions 
based on an artificially constructed formula and replaces it with a 
stable system that reflects the valuable relationship between seniors 
and their doctors.
  In my district alone, there are more than 60,000 seniors on Medicare. 
For them, this bill means access to the quality care provided by their 
doctor. Since doctors know they will be reimbursed fairly for their 
services, they will not feel compelled to close their doors to the 
Medicare and TRICARE patients in my district.
  This bill also establishes more moderate target growth rates for 
Medicare spending. These target growth rates are much more realistic 
than the SGR and they will not result in the types of fee reductions 
like the 21 percent reduction that is currently threatening physicians. 
Finally, this bill encourages integrated care so that providers can 
communicate and develop a comprehensive wellness plan that meets the 
needs of each patient.
  Mr. Speaker, it is not surprising that President Obama strongly 
supports H.R. 3961. He understands the relationship between reasonable 
reimbursement rates and availability of

[[Page H13306]]

quality care for Medicare beneficiaries. Likewise, the American Medical 
Association supports this bill because it provides physicians with the 
financial stability they need to invest in the infrastructure needed to 
build a health care system that works. The AARP supports this bill 
because it represents meaningful, sustainable reform for the 40 million 
seniors it represents.
  I support this bill because it continues the work we began this month 
when we passed the historic Affordable Health Care for America Act. 
This necessary and timely reform benefits our seniors and our veterans. 
As we approach the Thanksgiving holiday, the security and peace of mind 
that this legislation will bring to our seniors and veterans is 
something for which we can all be thankful. I urge my colleagues to 
support H.R. 3961.
  Mr. POSEY. Mr. Speaker, I rise in strong support of legislation to 
fix the physician fee cut. This system has been broken for more than 
six years and rather than fix the problem, previous Congresses have 
simply kicked the can down the road and now physicians are facing more 
than a 20 percent reduction in payments come January 1, 2010. This is 
unacceptable.
  Stopping the cut and putting physician payments on a realistic 
payment formula should have been a higher priority for this Congress. 
Here we are, less than one month away from the January 1 deadline, and 
the Speaker finally decides to bring legislation to the floor for a 
vote. Unfortunately, the bill she has brought to the floor has many of 
the same shortcomings in it that S. 1776 did when the Senate rejected 
that bill on October 21, 2009. That bill fell 13 votes short of the 
number needed for passage, principally, because it was not paid for and 
simply added hundreds of billions of dollars to the record level 
national debt.
  On November 7, 2009, the House passed comprehensive health care 
reform legislation (H.R. 3962) on a 220-215 vote. That bill creates a 
new unsustainable health care program that the federal government has 
no way to pay for long-term. Rather than making H.R. 3962 a priority, 
the Congress should have first considered legislation to fix the 
physician payment problem by replacing the inherently flawed 
sustainable growth rate (SGR) formula. Sadly, the majority chose the 
opposite path. Congress should, in my view, fix the problems with the 
current programs--Medicare, Medicaid, and the State Children's Health 
Insurance Program (SCHIP)--before creating new programs that we cannot 
afford.
  In states such as Florida, which have large numbers of seniors, the 
erosion of payments under Medicare has had an adverse impact on the 
ability of some seniors to have access to good medical providers, and 
it makes it difficult for Florida to attract new providers.
  The only reason that this bill (H.R. 3961) has been separated out 
from H.R. 3962, which passed the House two weeks ago, is because 
Congressional leaders want to make the cost of overall comprehensive 
health care reform (H.R. 3962) appear less expensive.
  The American people deserve better. The most appropriate approach is 
to end the budget games, acknowledge the realistic costs of 
legislation, and find the appropriate ways to pay the costs of the bill 
without adding further to our Nation's record debt.
  Fixing the payment formula should be the top priority for the 
Congress at this time, not an afterthought. The good news is that there 
are appropriate and sufficient ways to fund the cost of averting the 21 
percent payment cut. The question before Congress is whether the 
Leaders in Congress will switch gears and put the SGR fix at the top of 
the legislative agenda and use these offsets to fix what is broken with 
Medicare, rather than playing politics and budget games.
  I will be voting for the alternative to the Speaker's bill. This 
alternative will increase physician payments by 2 percent in each of 
the next four years, enact liability reforms, and implement insurance 
administrative simplification reforms to cut physicians' administrative 
costs. Overall, this is a much better and more certain approach for 
physicians.
  Our physicians and seniors deserve a quick fix to this problem. Let's 
pass a bill that has a chance in the Senate, rather than passing a bill 
that has the same fatal flaws as a bill they have already voted down.
  Mr. THOMPSON of California. Mr. Speaker, I rise today in strong 
support of H.R. 3961, the Medicare Physician Payment Reform Act.
  We've all heard from our constituents how important their 
relationship is with their doctor. We have a system that works--over 45 
million people across the country depend on Medicare for that doctor-
patient relationship.
  Yet every year this doctor-patient relationship is threatened by 
excessive cuts to Medicare reimbursement rates. Every year we wait 
until the last minute to address it in Congress. Meanwhile, patients 
worry that they will lose access to their doctors. And doctors worry 
about how they will be able to continue to serve their patients.
  This bill will permanently fix this problem--so that we don't have to 
put patients and their doctors through this yearly ritual, and Medicare 
recipients will have continuous access to their doctors. I urge my 
colleagues to vote yes on this legislation.
  Mr. FRELINGHUYSEN. Mr. Speaker, I rise in opposition to H.R. 3961.
  It goes without saying that I recognize that doctors are the backbone 
of Medicare and our health care system in general. As such, they must 
be compensated by the federal government in a manner that allows them 
to recover their expenses at the very least. I have been very 
supportive of providing doctors with a fair and equitable reimbursement 
for their services.
  I recognize that an increasing number of physicians are finding it 
financially impossible to treat Medicare patients and another reduction 
in reimbursement levels would encourage more doctors to drop Medicare 
patients, endangering the health of the most vulnerable of our 
society--the frail elderly.
  I have also been informed that nearly one-third of physicians in 
America are near or have actually achieved retirement age.
  It would not take much in terms of lower reimbursements or additional 
bureaucratic red tape to encourage them to close their practices, 
further limiting access to quality health care for many older 
Americans.
  I have supported Medicare fee ``fix'' legislation over the years. 
However, this bill is different. It is not ``paid for'' and presents 
another unnecessary blow to our embattled taxpayers and future 
generations of Americans.
  Enough is enough! We have to stop spending borrowed federal dollars 
like there is no tomorrow!
  As I stated earlier, I understand that we must prevent the Medicare 
physician reimbursement level from being slashed by a catastrophic 21 
percent. But the $285 billion cost of this legislation can and must be 
offset.
  I suggest that the unspent balance of the failed economic stimulus 
bill is a great place to start.
  Mr. Speaker, I urge defeat of the bill.
  Mrs. MALONEY. Mr. Speaker, I rise in strong support of H.R. 3961, the 
Medicare Physician Payment Reform Act, also known as the Doc Fix. I am 
proud to represent thousands of doctors who both live and work in New 
York's 14th Congressional District. Each year, I am visited by hundreds 
of them and hear from hundreds more, who are concerned about their 
patient's access to care due to a scheduled annual cut to their 
Medicare payments. Under the current system, when Medicare utilization 
of physicians' services exceeds the Sustainable Growth Rate, SGR, 
target, physicians are unfairly penalized with steep cuts in their 
payment update. With this bill, we are averting a 21-percent cut in 
Medicare rates while saving patient access to care by working toward a 
permanent fix of the SGR. After all, a stable and predictable payment 
system for physician service delivery is critical to preserving 
patient-centered care and investing in health care for the 21st 
century.
  H.R. 3961 finally addresses the problem with the SGR formula that 
plagues Congress each year when we are forced to do a quick fix to 
prevent drastic cuts to doctor payments. This important legislation 
makes a critical first step toward physician payment reform by 
establishing distinct growth rates and spending targets. It establishes 
fairer growth targets to keep doctors' pay steady and erases the debt 
that was produced by the short-term patches that stopped cuts from 
going into effect over the past 7 years. At the same time, it holds 
physicians accountable for spending growth. H.R. 3961 promotes primary 
care that can keep Americans healthier longer by providing an extra 
growth allowance for primary care services to promote access to primary 
care practitioners in Medicare and throughout the health care system.
  H.R. 3961 encourages integrated care to ensure our doctors are 
communicating with one another. When doctors speak about our care, 
mistakes are avoided and quality improves.
  Finally, H.R. 3961 is fiscally responsible and is paid for. This bill 
will not increase total payments to physicians above what they are 
today and is paygo neutral.
  The old system is broken, and this bill fixes it. With the lack of 
predictability in Medicare payments, older doctors with older patients 
retire early and younger doctors are discouraged from entering 
specialties that treat predominately Medicare patients. Fixing the SGR 
is critical to preserving Medicare patients' access to care and passage 
of this bill is a crucial part of health care reform. I urge my 
colleagues to vote in favor of this important legislation.
  Mr. KUCINICH. Mr. Speaker, I rise in support of H.R. 3961, the 
Medicare Physician Payment Reform Act. Unfortunately, the bill includes 
statutory-pay-as-you-go requirements. Our country's economy continues 
to flounder in the worst downturn since the Great Depression, yet 
Congress insists on passing legislation that will constrain our ability 
to respond appropriately to our economic circumstances.

[[Page H13307]]

  The Nation's unemployment rate is over 10 percent, and is likely to 
remain high well into the next year. The private sector is slashing 
payrolls and squeezing productivity out of the employees who remain, 
stubbornly refusing to contribute to an economic recovery. The 
government must be the spender of last resort to get Americans working 
again. While the Recovery Act has certainly helped to stave off a more 
severe economic downturn, it is obviously insufficient. We have more 
work to do, but pay-as-you-go requirements will only inhibit our 
ability to help our constituents.
  However, Medicare is one of the most popular government programs in 
part because, in contrast to private insurance plans, seniors and 
people with certain disabilities can have access to their doctor of 
choice. Doctors will be less willing to participate, however, if they 
are not sufficiently paid, as is the case now. I have met with doctors 
and doctor representatives in the Cleveland area to discuss the issue 
and the urgency is clear. We must maintain incentives that lead to a 
high standard of care. I am especially supportive of the extra growth 
allowance for primary care services as a small down payment toward 
addressing a severe shortage of primary care physicians. For those 
reasons, I support the Medicare Physician Payment Reform Act.
  Mr. ETHERIDGE. Mr. Speaker, I rise today in strong support of H.R. 
3961, the Medicare Physician Payment Reform Act of 2009.
  H.R. 3961 repeals the irresponsible budget gimmicks of the last 
decade, replacing a scheduled 21 percent fee reduction for doctors who 
accept Medicare with a more rational and stable system. The new payment 
formula will support primary care and encourage coordination among 
providers, while holding physicians accountable for spending growth. 
H.R. 3961 builds on the historic health insurance reform bill the House 
passed two weeks ago, which will lower premiums, extend the solvency of 
Medicare by 5 years, and close the ``donut hole'' drug coverage gap.
  Medicare is a vital lifeline for seniors, but it is worthless if 
doctors cannot afford to see Medicare patients. Seniors should be able 
to see the doctors they prefer, and fixing the doctor payment system 
will make sure they have access to high-quality care from people they 
trust. Countless doctors in my district have told me that they are 
happy to treat seniors, but that they risk going out of business with 
current Medicare payments. We must make sure that they continue to be 
able to provide high-quality health care to Medicare beneficiaries.
  H.R. 3961 will replace the flawed physician payment system that 
continually threatens access to care for our Nation's elderly and 
disabled patients. Since TRICARE rates are tied to Medicare, the 
current system also threatens the health of our military families 
covered by TRICARE. Fixing the system will provide physician practices 
with financial stability and predictability and enable them to invest 
in the infrastructure needed to build a health care system for the 21st 
century.
  Without Medicare physician payment reform, the goals of health system 
reform will remain out of reach. Another short-term ``patch'' would 
only increase the severity of future cuts and raise the costs of 
permanently repealing the sustainable growth rate. Medicine can no 
longer support the sort of short-term patches that have been used in 
the past to postpone true payment reform. By fixing the doctor payment 
issue and including PAYGO, Congress is replacing the reckless borrow-
and-spend policies of the last decade with responsible and reliable 
budget planning.
  Mr. Speaker, H.R. 3961 is fiscally responsible and will improve the 
health and health care of people across my district, North Carolina, 
and the country. I urge my colleagues to join me in strong support of 
our seniors and the physicians who keep them healthy.
  Mr. GOODLATTE. Mr. Speaker, I rise in opposition to H.R. 3961.
  Under current law, Medicare physician reimbursement rates are 
expected to be cut by 21 percent next year and by roughly 5 percent for 
each of the next several years thereafter, according to the 2009 
Medicare Trustees Report.
  While we can all agree that our current physician reimbursement rate 
is flawed, Republicans and Democrats have many different ideas about 
how to fix it.
  Since 2003, Congress has offset the cost of averting physician 
payment cuts. Unfortunately, today's legislation's further exacerbates 
the Democratic majority's infatuation with deficit spending.
  According to CBO, the full cost of H.R. 3961 is $260 billion, $210 
billion of which is deficit spending by the federal government. 
Furthermore $50 billion will be paid for by Medicare beneficiaries in 
the form of higher Part B premiums.
  The Democrats' health care takeover already costs over $1 trillion. 
In order to hide the additional costs of that bill, the Democrats 
separated this physician reimbursement rate legislation from the larger 
health care bill.
  It is clear that this procedural move is simply a budget gimmick by 
Democrats to avoid including the full cost of this Medicare physician 
fix in their health care reform bill. This trickery is insulting to 
Americans who are tired of politics as usual and who are demanding 
straight answers about our nation's deteriorating fiscal situation.
  This legislation also breaks President Obama's promise that health 
care reform would not cost more than $900 billion. Taking CBO's 10-year 
score of the health care overhaul, $1.055 trillion, and adding the cost 
of this physician reimbursement fix, the total cost of the Democrats' 
health care reform would be at least $1.3 trillion.
  Mr. Speaker, I cannot support the deficit spending in this 
legislation. As I stated previously, according to the Congressional 
Budget Office, CBO, this bill would increase the Federal deficit by 
more than $210 billion with this one bill alone.
  The American people know that we can't borrow and spend our way back 
to prosperity. The path to our economic recovery starts with fiscal 
responsibility in Washington. The Federal Government must follow the 
example set by our Nation's families.
  Unfortunately, Democrats continue to ignore this reality. We have 
accumulated a 2009 deficit of $1.42 trillion and a national debt of 
over $12 trillion and Democrats seem determined to dig us deeper into 
this debt hole.
  While my colleagues on the other side of the aisle may have concocted 
a scheme to enable this bill to pass today, I hope they realize that 
the Senate has already rejected a bill substantially similar to this 
one, almost identical in cost, because of its crippling deficit impact. 
In fact, 13 Democrat Senators opposed it.
  Mr. Speaker, the Rules Committee is a very powerful committee--one 
that determines under what rules every bill will be brought to the 
House floor. In yet another strong-armed tactic, the majority has used 
yet another rule to limit discussion and amendments offered by 
Republicans. Instead of having an honest debate, the Democratic 
majority has decided they didn't like the discussion, so they have 
effectively decided to stifle alternative ideas and debate. This 
doesn't seem very democratic to me.
  House Republicans have a better alternative. Our proposal, which was 
not given the light of day, much less a vote, would provide: $54 
billion in savings from medical liability reform that would enact caps 
on noneconomic damages and lawyers' fees, encouraging speedy 
resolutions of claims, and limit punitive damages. This will reduce 
defensive medicine, protect doctors from frivolous lawsuits, and bring 
down the cost of health care; $5.7 billion in savings from the creation 
of a pathway for approval at the Food and Drug Administration for bio-
similar products, with appropriate protections that continue to promote 
innovation while providing access to affordable drugs; and $19 billion 
in savings through enacting health insurance administrative 
simplification policies such as the creation of standardized forms and 
transactions.
  Mr. Speaker, there is a fiscally responsible way to solve this 
physician reimbursement problem. I urge my colleagues to oppose H.R. 
3961.
  Mr. TIAHRT. Mr. Speaker, I rise today in reluctant opposition to H.R. 
3961. I say reluctant because we desperately need a real physician 
reimbursement rate fix. The future of medicine and the health of 
Americans, especially seniors, depends on a cost-based formula to 
reimburse providers for medical expenses. This bill, however, is not a 
real fix but yet another political and budget gimmick.
  The issue known as the ``doctor fix'' is familiar to us all, but I 
don't think that the majority fully understands who suffers under 
inadequate physician pay--the American people. CMS reimbursement rates 
to providers is anywhere from 30-70 percent of actual cost, based on 
the specific procedure. Even the highest CMS reimbursement is still 
loss to providers. It isn't just the doctors who suffer but also the 
patients. Many doctors have to close their door to new Medicare and 
Medicaid patients or face bankruptcy. This is especially troubling in 
rural areas where there are limited providers and seniors face a 
serious medical accessibility problem. In Kansas, between 20-30 percent 
of physicians say they will no longer accept new Medicare patients. 
These doctors, especially in rural areas, go into their profession to 
help people and having to turn away patients is a measure of absolute 
last resort.
  The current formula for physician reimbursement is known as the 
sustainable growth rate, SGR, and has little if anything to do with 
actual costs. That is why year after year Congress passes adjustments 
to prevent cuts in reimbursement rate. These adjustments are the bare 
minimum that we can do, even staving off cuts for one year does not 
allow for certainty in the system.
  For that reason, for years several of us have been trying to get CMS 
to get rid of the SGR and instead base reimbursement rates on actual 
medical costs. I brought data to

[[Page H13308]]

then-Chairman Bill Thomas showing that more and more Kansas doctors 
were refusing new Medicare patients. Due to the overwhelming evidence 
that this is a real problem, the House version of the Medicare 
Modernization Act, the prescription drug bill, included language 
directing CMS to scrap the SGR and come up with a real reimbursement 
rate formula. Unfortunately, the Senate stripped that provision and 
subsequent efforts to enact real SGR reform have failed.
  H.R. 3961 is not real SGR reform, but rather putting lipstick on a 
pig. As the Association of American Physicians and Surgeons asserts, 
``It just trades one complicated federal formula for another, and still 
leaves physician pay subject to Congressional whim in the future.'' The 
Democrat proposal uses GDP and other factors instead of actual cost to 
calculate reimbursement rates and does nothing to prevent the need for 
further congressional 1-year adjustments to the rate.
  The Democrat health care proposals, including H.R. 3961, do nothing 
to address the rising cost of health care, and indeed will cause costs 
to rise faster than they do today. There are several things we need to 
do to improve access to and quality of health care, including 
addressing physician reimbursement rates. Real health reform requires 
addressing the cost centers that are driving insurance costs up, 
reducing provider services, and discouraging professionals from 
entering medicine. For this reason, a recent IB/TIPP Poll revealed that 
two-thirds of physicians oppose the Democrat bills, and furthermore 
warn of dire consequences should they be enacted. In addition, 45 
percent of physicians said that they would consider leaving their 
practice or take early retirement.
  I am hopeful that the Democrat leadership will abandon this political 
gimmick and work with us to address physician reimbursement rates. This 
is no ``Chicken Little'' story. Without congressional action, the sky 
will fall in, doctors will be unable to participate in Medicare and our 
seniors will be left without care--regardless of Obamacare reforms.
  Ms. ESHOO. Mr. Speaker, I rise today in support of H.R. 3961, the 
Medicare Physician Payment Reform Act.
  H.R. 3961 would repeal the current Medicare Sustainable Growth Rate, 
SGR, formula and save our physicians from a looming 21 percent 
reimbursement cut. Instead of temporarily overriding the cut as 
Congress has done before, H.R. 3961 will replace the broken SGR formula 
with a sustainable solution.
  This bill is essential, not only for the doctors who deserve adequate 
reimbursement for services, but for the millions of Medicare 
beneficiaries and members of the military and their families, since 
physician payment rates in TRICARE are tied to those used by Medicare. 
With comprehensive healthcare reform on the horizon, it's our 
responsibility to ensure physicians are reimbursed appropriately.
  H.R. 3961 is supported by a wide range of organizations representing 
patients, doctors and other providers, including the American Medical 
Association, AARP, the Military Officers Association of America, the 
American Academy of Family Physicians, the American College of 
Physicians, the American College of Surgeons, the Center for Medicare 
Advocacy, the Medicare Rights Center, and the National Committee to 
Preserve Social Security and Medicare.
  This is critically needed and sound legislation and I look forward to 
voting in favor of H.R. 3961 and ask my colleagues to do the same.
  Mr. STARK. I yield back the balance of my time.
  The SPEAKER pro tempore. All time for debate has expired.
  Pursuant to House Resolution 903, the previous question is ordered on 
the bill.


          Motion To Recommit Offered by Mr. Gingrey of Georgia

  Mr. GINGREY of Georgia. Mr. Speaker, I have a motion to recommit at 
the desk.
  The SPEAKER pro tempore. Is the gentleman opposed to the bill?
  Mr. GINGREY of Georgia. In its present form, I am.
  Mr. WAXMAN. Mr. Speaker, I reserve a point of order.
  The SPEAKER pro tempore. A point of order is reserved.
  The Clerk will report the motion to recommit.
  The Clerk read as follows:

       Mr. Gingrey of Georgia moves to recommit the bill, H.R. 
     3961, to the Committee on Energy and Commerce with 
     instructions to report the same back to the House forthwith 
     with the following amendment:
       Strike all after the enacting clause and insert the 
     following:

     SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

       (a) Short Title.--This Act may be cited as the ``Medicare 
     SGR Improvement and Reform Act of 2009''.
       (b) Table of Contents.--The table of contents of this Act 
     is as follows:

Sec. 1. Short title; table of contents.

      TITLE I--ENSURING CONTINUED ACCESS TO PHYSICIANS IN MEDICARE

Sec. 101. Improving Medicare physician payments.
Sec. 102. Statement of policy.

         TITLE II--DEFICIT PROTECTION AND FISCAL RESPONSIBILITY

           Subtitle A--Enacting Real Medical Liability Reform

Sec. 201. Encouraging speedy resolution of claims.
Sec. 202. Compensating patient injury.
Sec. 203. Maximizing patient recovery.
Sec. 204. Additional health benefits.
Sec. 205. Punitive damages.
Sec. 206. Authorization of payment of future damages to claimants in 
              health care lawsuits.
Sec. 207. Definitions.
Sec. 208. Effect on other laws.
Sec. 209. State flexibility and protection of states' rights.
Sec. 210. Applicability; effective date.

          Subtitle B--Application of Medicare Improvement Fund

Sec. 211. Application of Medicare Improvement Fund.

         Subtitle C--Pathway for Biosimilar Biological Products

Sec. 221. Licensure pathway for biosimilar biological products.
Sec. 222. Fees relating to biosimilar biological products.
Sec. 223. Amendments to certain patent provisions.

               Subtitle D--Administrative Simplification

Sec. 231. Administrative simplification.

      TITLE I--ENSURING CONTINUED ACCESS TO PHYSICIANS IN MEDICARE

     SEC. 101. IMPROVING MEDICARE PHYSICIAN PAYMENTS.

       Section 1848(d) of the Social Security Act (42 U.S.C. 
     1395w-4(d)) is amended by adding at the end the following new 
     paragraphs:
       ``(10) 2 percent annual update for years 2010 through 
     2013.--
       ``(A) In general.--Subject to paragraphs (7)(B), (8)(B), 
     and (9)(B) and subparagraph (B), in lieu of the update to the 
     single conversion factor established in paragraph (1)(C) that 
     would otherwise apply for each of 2010, 2011, 2012, and 2013, 
     the update to the single conversion factor shall be 2 
     percent.
       ``(B) No effect on computation of conversion factor for 
     2014 and subsequent years.--The conversion factor under this 
     subsection shall be computed under paragraph (1)(A) for 2014 
     and subsequent years as if subparagraph (A) had never 
     applied, subject to paragraph (11).
       ``(11) Update for 2014 and possible subsequent years 
     through 2019.--
       ``(A) In general.--Subject to paragraphs (7)(B), (8)(B), 
     and (9)(B) and subparagraph (B), in lieu of the update to the 
     single conversion factor established in paragraph (1)(C) that 
     would otherwise apply for 2014 and, at the Secretary's 
     discretion, for subsequent years ending not later than 2019, 
     the update to the single conversion factor shall be such 
     percentage for each such year as the Secretary determines 
     will result in additional expenditures under this title in 
     the aggregate for all such years of $26,400,000,000. Not 
     later than October 1, 2013, the Secretary shall establish by 
     regulation the method the Secretary will use in allocating 
     the $26,400,000,000 under the previous sentence between 2014 
     and subsequent years. Such allocation shall be designed in a 
     manner so that the single conversion factor for a year is not 
     less than 79 percent of the conversion factor for the 
     previous year.
       ``(B) Limited effect on computation of conversion factor 
     for subsequent years.--The conversion factor under this 
     subsection shall be computed under paragraph (1)(A) for 
     subsequent years as if subparagraph (A) had never applied, 
     but taking into account the aggregate additional increase in 
     expenditures permitted under such subparagraph.''.

     SEC. 102. STATEMENT OF POLICY.

       It is the policy of the Federal Government that the 
     sustainable growth rate formula, upon which physician 
     payments are based for the Medicare program, should be 
     permanently repealed and replaced with a reimbursement policy 
     that pays doctors an amount reflecting the true cost of 
     services provided in a high-quality and efficient manner and 
     uses a fiscally responsibly funding mechanism.

         TITLE II--DEFICIT PROTECTION AND FISCAL RESPONSIBILITY

           Subtitle A--Enacting Real Medical Liability Reform

     SEC. 201. ENCOURAGING SPEEDY RESOLUTION OF CLAIMS.

       The time for the commencement of a health care lawsuit 
     shall be 3 years after the date of manifestation of injury or 
     1 year after the claimant discovers, or through the use of 
     reasonable diligence should have discovered, the injury, 
     whichever occurs first. In no event shall the time for 
     commencement of a health care lawsuit exceed 3 years after 
     the date of manifestation of injury unless tolled for any of 
     the following--
       (1) upon proof of fraud;
       (2) intentional concealment; or
       (3) the presence of a foreign body, which has no 
     therapeutic or diagnostic purpose or effect, in the person of 
     the injured person.

[[Page H13309]]

     Actions by a minor shall be commenced within 3 years from the 
     date of the alleged manifestation of injury except that 
     actions by a minor under the full age of 6 years shall be 
     commenced within 3 years of manifestation of injury or prior 
     to the minor's 8th birthday, whichever provides a longer 
     period. Such time limitation shall be tolled for minors for 
     any period during which a parent or guardian and a health 
     care provider or health care organization have committed 
     fraud or collusion in the failure to bring an action on 
     behalf of the injured minor.

     SEC. 202. COMPENSATING PATIENT INJURY.

       (a) Unlimited Amount of Damages for Actual Economic Losses 
     in Health Care Lawsuits.--In any health care lawsuit, nothing 
     in this subtitle shall limit a claimant's recovery of the 
     full amount of the available economic damages, 
     notwithstanding the limitation in subsection (b).
       (b) Additional Noneconomic Damages.--In any health care 
     lawsuit, the amount of noneconomic damages, if available, may 
     be as much as $250,000, regardless of the number of parties 
     against whom the action is brought or the number of separate 
     claims or actions brought with respect to the same injury.
       (c) No Discount of Award for Noneconomic Damages.--For 
     purposes of applying the limitation in subsection (b), future 
     noneconomic damages shall not be discounted to present value. 
     The jury shall not be informed about the maximum award for 
     noneconomic damages. An award for noneconomic damages in 
     excess of $250,000 shall be reduced either before the entry 
     of judgment, or by amendment of the judgment after entry of 
     judgment, and such reduction shall be made before accounting 
     for any other reduction in damages required by law. If 
     separate awards are rendered for past and future noneconomic 
     damages and the combined awards exceed $250,000, the future 
     noneconomic damages shall be reduced first.
       (d) Fair Share Rule.--In any health care lawsuit, each 
     party shall be liable for that party's several share of any 
     damages only and not for the share of any other person. Each 
     party shall be liable only for the amount of damages 
     allocated to such party in direct proportion to such party's 
     percentage of responsibility. Whenever a judgment of 
     liability is rendered as to any party, a separate judgment 
     shall be rendered against each such party for the amount 
     allocated to such party. For purposes of this section, the 
     trier of fact shall determine the proportion of 
     responsibility of each party for the claimant's harm.

     SEC. 203. MAXIMIZING PATIENT RECOVERY.

       (a) Court Supervision of Share of Damages Actually Paid to 
     Claimants.--In any health care lawsuit, the court shall 
     supervise the arrangements for payment of damages to protect 
     against conflicts of interest that may have the effect of 
     reducing the amount of damages awarded that are actually paid 
     to claimants. In particular, in any health care lawsuit in 
     which the attorney for a party claims a financial stake in 
     the outcome by virtue of a contingent fee, the court shall 
     have the power to restrict the payment of a claimant's damage 
     recovery to such attorney, and to redirect such damages to 
     the claimant based upon the interests of justice and 
     principles of equity. In no event shall the total of all 
     contingent fees for representing all claimants in a health 
     care lawsuit exceed the following limits:
       (1) 40 percent of the first $50,000 recovered by the 
     claimant(s).
       (2) 33\1/3\ percent of the next $50,000 recovered by the 
     claimant(s).
       (3) 25 percent of the next $500,000 recovered by the 
     claimant(s).
       (4) 15 percent of any amount by which the recovery by the 
     claimant(s) is in excess of $600,000.
       (b) Applicability.--The limitations in this section shall 
     apply whether the recovery is by judgment, settlement, 
     mediation, arbitration, or any other form of alternative 
     dispute resolution. In a health care lawsuit involving a 
     minor or incompetent person, a court retains the authority to 
     authorize or approve a fee that is less than the maximum 
     permitted under this section. The requirement for court 
     supervision in the first two sentences of subsection (a) 
     applies only in civil actions.

     SEC. 204. ADDITIONAL HEALTH BENEFITS.

       In any health care lawsuit involving injury or wrongful 
     death, any party may introduce evidence of collateral source 
     benefits. If a party elects to introduce such evidence, any 
     opposing party may introduce evidence of any amount paid or 
     contributed or reasonably likely to be paid or contributed in 
     the future by or on behalf of the opposing party to secure 
     the right to such collateral source benefits. No provider of 
     collateral source benefits shall recover any amount against 
     the claimant or receive any lien or credit against the 
     claimant's recovery or be equitably or legally subrogated to 
     the right of the claimant in a health care lawsuit involving 
     injury or wrongful death. This section shall apply to any 
     health care lawsuit that is settled as well as a health care 
     lawsuit that is resolved by a fact finder. This section shall 
     not apply to section 1862(b) (42 U.S.C. 1395y(b)) or section 
     1902(a)(25) (42 U.S.C. 1396a(a)(25)) of the Social Security 
     Act.

     SEC. 205. PUNITIVE DAMAGES.

       (a) In General.--Punitive damages may, if otherwise 
     permitted by applicable State or Federal law, be awarded 
     against any person in a health care lawsuit only if it is 
     proven by clear and convincing evidence that such person 
     acted with malicious intent to injure the claimant, or that 
     such person deliberately failed to avoid unnecessary injury 
     that such person knew the claimant was substantially certain 
     to suffer. In any health care lawsuit where no judgment for 
     compensatory damages is rendered against such person, no 
     punitive damages may be awarded with respect to the claim in 
     such lawsuit. No demand for punitive damages shall be 
     included in a health care lawsuit as initially filed. A court 
     may allow a claimant to file an amended pleading for punitive 
     damages only upon a motion by the claimant and after a 
     finding by the court, upon review of supporting and opposing 
     affidavits or after a hearing, after weighing the evidence, 
     that the claimant has established by a substantial 
     probability that the claimant will prevail on the claim for 
     punitive damages. At the request of any party in a health 
     care lawsuit, the trier of fact shall consider in a separate 
     proceeding--
       (1) whether punitive damages are to be awarded and the 
     amount of such award; and
       (2) the amount of punitive damages following a 
     determination of punitive liability.
     If a separate proceeding is requested, evidence relevant only 
     to the claim for punitive damages, as determined by 
     applicable State law, shall be inadmissible in any proceeding 
     to determine whether compensatory damages are to be awarded.
       (b) Determining Amount of Punitive Damages.--
       (1) Factors considered.--In determining the amount of 
     punitive damages, if awarded, in a health care lawsuit, the 
     trier of fact shall consider only the following--
       (A) the severity of the harm caused by the conduct of such 
     party;
       (B) the duration of the conduct or any concealment of it by 
     such party;
       (C) the profitability of the conduct to such party;
       (D) the number of products sold or medical procedures 
     rendered for compensation, as the case may be, by such party, 
     of the kind causing the harm complained of by the claimant;
       (E) any criminal penalties imposed on such party, as a 
     result of the conduct complained of by the claimant; and
       (F) the amount of any civil fines assessed against such 
     party as a result of the conduct complained of by the 
     claimant.
       (2) Maximum award.--The amount of punitive damages, if 
     awarded, in a health care lawsuit may be as much as $250,000 
     or as much as two times the amount of economic damages 
     awarded, whichever is greater. The jury shall not be informed 
     of this limitation.

     SEC. 206. AUTHORIZATION OF PAYMENT OF FUTURE DAMAGES TO 
                   CLAIMANTS IN HEALTH CARE LAWSUITS.

       (a) In General.--In any health care lawsuit, if an award of 
     future damages, without reduction to present value, equaling 
     or exceeding $50,000 is made against a party with sufficient 
     insurance or other assets to fund a periodic payment of such 
     a judgment, the court shall, at the request of any party, 
     enter a judgment ordering that the future damages be paid by 
     periodic payments. In any health care lawsuit, the court may 
     be guided by the Uniform Periodic Payment of Judgments Act 
     promulgated by the National Conference of Commissioners on 
     Uniform State Laws.
       (b) Applicability.--This section applies to all actions 
     which have not been first set for trial or retrial before the 
     effective date of this subtitle.

     SEC. 207. DEFINITIONS.

       In this subtitle:
       (1) Alternative dispute resolution system; adr.--The term 
     ``alternative dispute resolution system'' or ``ADR'' means a 
     system that provides for the resolution of health care 
     lawsuits in a manner other than through a civil action 
     brought in a State or Federal court.
       (2) Claimant.--The term ``claimant'' means any person who 
     brings a health care lawsuit, including a person who asserts 
     or claims a right to legal or equitable contribution, 
     indemnity, or subrogation, arising out of a health care 
     liability claim or action, and any person on whose behalf 
     such a claim is asserted or such an action is brought, 
     whether deceased, incompetent, or a minor.
       (3) Collateral source benefits.--The term ``collateral 
     source benefits'' means any amount paid or reasonably likely 
     to be paid in the future to or on behalf of the claimant, or 
     any service, product, or other benefit provided or reasonably 
     likely to be provided in the future to or on behalf of the 
     claimant, as a result of the injury or wrongful death, 
     pursuant to--
       (A) any State or Federal health, sickness, income-
     disability, accident, or workers' compensation law;
       (B) any health, sickness, income-disability, or accident 
     insurance that provides health benefits or income-disability 
     coverage;
       (C) any contract or agreement of any group, organization, 
     partnership, or corporation to provide, pay for, or reimburse 
     the cost of medical, hospital, dental, or income-disability 
     benefits; and
       (D) any other publicly or privately funded program.
       (4) Compensatory damages.--The term ``compensatory 
     damages'' means objectively verifiable monetary losses 
     incurred as a result of the provision of, use of, or payment 
     for (or failure to provide, use, or pay for) health care 
     services or medical products, such as past and future medical 
     expenses, loss of past and future earnings, cost of obtaining 
     domestic services, loss of employment, and loss of business 
     or employment opportunities, damages for physical and 
     emotional pain, suffering, inconvenience,

[[Page H13310]]

     physical impairment, mental anguish, disfigurement, loss of 
     enjoyment of life, loss of society and companionship, loss of 
     consortium (other than loss of domestic service), hedonic 
     damages, injury to reputation, and all other nonpecuniary 
     losses of any kind or nature. The term ``compensatory 
     damages'' includes economic damages and noneconomic damages, 
     as such terms are defined in this section.
       (5) Contingent fee.--The term ``contingent fee'' includes 
     all compensation to any person or persons which is payable 
     only if a recovery is effected on behalf of one or more 
     claimants.
       (6) Economic damages.--The term ``economic damages'' means 
     objectively verifiable monetary losses incurred as a result 
     of the provision of, use of, or payment for (or failure to 
     provide, use, or pay for) health care services or medical 
     products, such as past and future medical expenses, loss of 
     past and future earnings, cost of obtaining domestic 
     services, loss of employment, and loss of business or 
     employment opportunities.
       (7) Health care lawsuit.--The term ``health care lawsuit'' 
     means any health care liability claim concerning the 
     provision of health care goods or services or any medical 
     product affecting interstate commerce, or any health care 
     liability action concerning the provision of health care 
     goods or services or any medical product affecting interstate 
     commerce, brought in a State or Federal court or pursuant to 
     an alternative dispute resolution system, against a health 
     care provider, a health care organization, or the 
     manufacturer, distributor, supplier, marketer, promoter, or 
     seller of a medical product, regardless of the theory of 
     liability on which the claim is based, or the number of 
     claimants, plaintiffs, defendants, or other parties, or the 
     number of claims or causes of action, in which the claimant 
     alleges a health care liability claim. Such term does not 
     include a claim or action which is based on criminal 
     liability; which seeks civil fines or penalties paid to 
     Federal, State, or local government; or which is grounded in 
     antitrust.
       (8) Health care liability action.--The term ``health care 
     liability action'' means a civil action brought in a State or 
     Federal court or pursuant to an alternative dispute 
     resolution system, against a health care provider, a health 
     care organization, or the manufacturer, distributor, 
     supplier, marketer, promoter, or seller of a medical product, 
     regardless of the theory of liability on which the claim is 
     based, or the number of plaintiffs, defendants, or other 
     parties, or the number of causes of action, in which the 
     claimant alleges a health care liability claim.
       (9) Health care liability claim.--The term ``health care 
     liability claim'' means a demand by any person, whether or 
     not pursuant to ADR, against a health care provider, health 
     care organization, or the manufacturer, distributor, 
     supplier, marketer, promoter, or seller of a medical product, 
     including, but not limited to, third-party claims, cross-
     claims, counter-claims, or contribution claims, which are 
     based upon the provision of, use of, or payment for (or the 
     failure to provide, use, or pay for) health care services or 
     medical products, regardless of the theory of liability on 
     which the claim is based, or the number of plaintiffs, 
     defendants, or other parties, or the number of causes of 
     action.
       (10) Health care organization.--The term ``health care 
     organization'' means any person or entity which is obligated 
     to provide or pay for health benefits under any health plan, 
     including any person or entity acting under a contract or 
     arrangement with a health care organization to provide or 
     administer any health benefit.
       (11) Health care provider.--The term ``health care 
     provider'' means any person or entity required by State or 
     Federal laws or regulations to be licensed, registered, or 
     certified to provide health care services, and being either 
     so licensed, registered, or certified, or exempted from such 
     requirement by other statute or regulation.
       (12) Health care goods or services.--The term ``health care 
     goods or services'' means any goods or services provided by a 
     health care organization, provider, or by any individual 
     working under the supervision of a health care provider, that 
     relates to the diagnosis, prevention, or treatment of any 
     human disease or impairment, or the assessment or care of the 
     health of human beings.
       (13) Malicious intent to injure.--The term ``malicious 
     intent to injure'' means intentionally causing or attempting 
     to cause physical injury other than providing health care 
     goods or services.
       (14) Medical product.--The term ``medical product'' means a 
     drug, device, or biological product intended for humans, and 
     the terms ``drug'', ``device'', and ``biological product'' 
     have the meanings given such terms in sections 201(g)(1) and 
     201(h) of the Federal Food, Drug and Cosmetic Act (21 U.S.C. 
     321(g)(1) and (h)) and section 351(a) of the Public Health 
     Service Act (42 U.S.C. 262(a)), respectively, including any 
     component or raw material used therein, but excluding health 
     care services.
       (15) Noneconomic damages.--The term ``noneconomic damages'' 
     means damages for physical and emotional pain, suffering, 
     inconvenience, physical impairment, mental anguish, 
     disfigurement, loss of enjoyment of life, loss of society and 
     companionship, loss of consortium (other than loss of 
     domestic service), hedonic damages, injury to reputation, and 
     all other nonpecuniary losses of any kind or nature.
       (16) Punitive damages.--The term ``punitive damages'' means 
     damages awarded, for the purpose of punishment or deterrence, 
     and not solely for compensatory purposes, against a health 
     care provider, health care organization, or a manufacturer, 
     distributor, or supplier of a medical product. Punitive 
     damages are neither economic nor noneconomic damages.
       (17) Recovery.--The term ``recovery'' means the net sum 
     recovered after deducting any disbursements or costs incurred 
     in connection with prosecution or settlement of the claim, 
     including all costs paid or advanced by any person. Costs of 
     health care incurred by the plaintiff and the attorneys' 
     office overhead costs or charges for legal services are not 
     deductible disbursements or costs for such purpose.
       (18) State.--The term ``State'' means each of the several 
     States, the District of Columbia, the Commonwealth of Puerto 
     Rico, the Virgin Islands, Guam, American Samoa, the Northern 
     Mariana Islands, the Trust Territory of the Pacific Islands, 
     and any other territory or possession of the United States, 
     or any political subdivision thereof.

     SEC. 208. EFFECT ON OTHER LAWS.

       (a) Vaccine Injury.--
       (1) To the extent that title XXI of the Public Health 
     Service Act establishes a Federal rule of law applicable to a 
     civil action brought for a vaccine-related injury or death--
       (A) this subtitle does not affect the application of the 
     rule of law to such an action; and
       (B) any rule of law prescribed by this subtitle in conflict 
     with a rule of law of such title XXI shall not apply to such 
     action.
       (2) If there is an aspect of a civil action brought for a 
     vaccine-related injury or death to which a Federal rule of 
     law under title XXI of the Public Health Service Act does not 
     apply, then this subtitle or otherwise applicable law (as 
     determined under this subtitle) will apply to such aspect of 
     such action.
       (b) Other Federal Law.--Except as provided in this section, 
     nothing in this subtitle shall be deemed to affect any 
     defense available to a defendant in a health care lawsuit or 
     action under any other provision of Federal law.

     SEC. 209. STATE FLEXIBILITY AND PROTECTION OF STATES' RIGHTS.

       (a) Health Care Lawsuits.--The provisions governing health 
     care lawsuits set forth in this subtitle preempt, subject to 
     subsections (b) and (c), State law to the extent that State 
     law prevents the application of any provisions of law 
     established by or under this subtitle. The provisions 
     governing health care lawsuits set forth in this subtitle 
     supersede chapter 171 of title 28, United States Code, to the 
     extent that such chapter--
       (1) provides for a greater amount of damages or contingent 
     fees, a longer period in which a health care lawsuit may be 
     commenced, or a reduced applicability or scope of periodic 
     payment of future damages, than provided in this subtitle; or
       (2) prohibits the introduction of evidence regarding 
     collateral source benefits, or mandates or permits 
     subrogation or a lien on collateral source benefits.
       (b) Protection of States' Rights and Other Laws.--(1) Any 
     issue that is not governed by any provision of law 
     established by or under this subtitle (including State 
     standards of negligence) shall be governed by otherwise 
     applicable State or Federal law.
       (2) This subtitle shall not preempt or supersede any State 
     or Federal law that imposes greater procedural or substantive 
     protections for health care providers and health care 
     organizations from liability, loss, or damages than those 
     provided by this subtitle or create a cause of action.
       (c) State Flexibility.--No provision of this subtitle shall 
     be construed to preempt--
       (1) any State law (whether effective before, on, or after 
     the date of the enactment of this Act) that specifies a 
     particular monetary amount of compensatory or punitive 
     damages (or the total amount of damages) that may be awarded 
     in a health care lawsuit, regardless of whether such monetary 
     amount is greater or lesser than is provided for under this 
     subtitle, notwithstanding section 202(a); or
       (2) any defense available to a party in a health care 
     lawsuit under any other provision of State or Federal law.

     SEC. 210. APPLICABILITY; EFFECTIVE DATE.

       This subtitle shall apply to any health care lawsuit 
     brought in a Federal or State court, or subject to an 
     alternative dispute resolution system, that is initiated on 
     or after the date of the enactment of this Act, except that 
     any health care lawsuit arising from an injury occurring 
     prior to the date of the enactment of this Act shall be 
     governed by the applicable statute of limitations provisions 
     in effect at the time the injury occurred.

          Subtitle B--Application of Medicare Improvement Fund

     SEC. 211. APPLICATION OF MEDICARE IMPROVEMENT FUND.

       Section 1898(b)(1) of the Social Security Act (42 U.S.C. 
     1395iii(b)(1)) is amended by striking ``for services 
     furnished'' and all that follows and inserting ``for services 
     furnished on or after January 1, 2010, $0.''.

[[Page H13311]]

         Subtitle C--Pathway for Biosimilar Biological Products

     SEC. 221. LICENSURE PATHWAY FOR BIOSIMILAR BIOLOGICAL 
                   PRODUCTS.

       (a) Licensure of Biological Products as Biosimilar or 
     Interchangeable.--Section 351 of the Public Health Service 
     Act (42 U.S.C. 262) is amended--
       (1) in subsection (a)(1)(A), by inserting ``under this 
     subsection or subsection (k)'' after ``biologics license''; 
     and
       (2) by adding at the end the following:
       ``(k) Licensure of Biological Products as Biosimilar or 
     Interchangeable.--
       ``(1) In general.--Any person may submit an application for 
     licensure of a biological product under this subsection.
       ``(2) Content.--
       ``(A) In general.--
       ``(i) Required information.--An application submitted under 
     this subsection shall include information demonstrating 
     that--

       ``(I) the biological product is biosimilar to a reference 
     product based upon data derived from--

       ``(aa) analytical studies that demonstrate that the 
     biological product is highly similar to the reference product 
     notwithstanding minor differences in clinically inactive 
     components;
       ``(bb) animal studies (including the assessment of 
     toxicity); and
       ``(cc) a clinical study or studies (including the 
     assessment of immunogenicity and pharmacokinetics or 
     pharmacodynamics) that are sufficient to demonstrate safety, 
     purity, and potency in 1 or more appropriate conditions of 
     use for which the reference product is licensed and intended 
     to be used and for which licensure is sought for the 
     biological product;

       ``(II) the biological product and reference product utilize 
     the same mechanism or mechanisms of action for the condition 
     or conditions of use prescribed, recommended, or suggested in 
     the proposed labeling, but only to the extent the mechanism 
     or mechanisms of action are known for the reference product;
       ``(III) the condition or conditions of use prescribed, 
     recommended, or suggested in the labeling proposed for the 
     biological product have been previously approved for the 
     reference product;

       ``(IV) the route of administration, the dosage form, and 
     the strength of the biological product are the same as those 
     of the reference product; and
       ``(V) the facility in which the biological product is 
     manufactured, processed, packed, or held meets standards 
     designed to assure that the biological product continues to 
     be safe, pure, and potent.

       ``(ii) Determination by secretary.--The Secretary may 
     determine, in the Secretary's discretion, that an element 
     described in clause (i)(I) is unnecessary in an application 
     submitted under this subsection.
       ``(iii) Additional information.--An application submitted 
     under this subsection--

       ``(I) shall include publicly available information 
     regarding the Secretary's previous determination that the 
     reference product is safe, pure, and potent; and
       ``(II) may include any additional information in support of 
     the application, including publicly available information 
     with respect to the reference product or another biological 
     product.

       ``(B) Interchangeability.--An application (or a supplement 
     to an application) submitted under this subsection may 
     include information demonstrating that the biological product 
     meets the standards described in paragraph (4).
       ``(3) Evaluation by secretary.--Upon review of an 
     application (or a supplement to an application) submitted 
     under this subsection, the Secretary shall license the 
     biological product under this subsection if--
       ``(A) the Secretary determines that the information 
     submitted in the application (or the supplement) is 
     sufficient to show that the biological product--
       ``(i) is biosimilar to the reference product; or
       ``(ii) meets the standards described in paragraph (4), and 
     therefore is interchangeable with the reference product; and
       ``(B) the applicant (or other appropriate person) consents 
     to the inspection of the facility that is the subject of the 
     application, in accordance with subsection (c).
       ``(4) Safety standards for determining 
     interchangeability.--Upon review of an application submitted 
     under this subsection or any supplement to such application, 
     the Secretary shall determine the biological product to be 
     interchangeable with the reference product if the Secretary 
     determines that the information submitted in the application 
     (or a supplement to such application) is sufficient to show 
     that--
       ``(A) the biological product--
       ``(i) is biosimilar to the reference product; and
       ``(ii) can be expected to produce the same clinical result 
     as the reference product in any given patient; and
       ``(B) for a biological product that is administered more 
     than once to an individual, the risk in terms of safety or 
     diminished efficacy of alternating or switching between use 
     of the biological product and the reference product is not 
     greater than the risk of using the reference product without 
     such alternation or switch.
       ``(5) General rules.--
       ``(A) One reference product per application.--A biological 
     product, in an application submitted under this subsection, 
     may not be evaluated against more than 1 reference product.
       ``(B) Review.--An application submitted under this 
     subsection shall be reviewed by the division within the Food 
     and Drug Administration that is responsible for the review 
     and approval of the application under which the reference 
     product is licensed.
       ``(C) Risk evaluation and mitigation strategies.--The 
     authority of the Secretary with respect to risk evaluation 
     and mitigation strategies under the Federal Food, Drug, and 
     Cosmetic Act shall apply to biological products licensed 
     under this subsection in the same manner as such authority 
     applies to biological products licensed under subsection (a).
       ``(D) Restrictions on biological products containing 
     dangerous ingredients.--If information in an application 
     submitted under this subsection, in a supplement to such an 
     application, or otherwise available to the Secretary shows 
     that a biological product--
       ``(i) is, bears, or contains a select agent or toxin listed 
     in section 73.3 or 73.4 of title 42, section 121.3 or 121.4 
     of title 9, or section 331.3 of title 7, Code of Federal 
     Regulations (or any successor regulations); or

       ``(ii) is, bears, or contains a controlled substance in 
     schedule I or II of section 202 of the Controlled Substances 
     Act, as listed in part 1308 of title 21, Code of Federal 
     Regulations (or any successor regulations);
     the Secretary shall not license the biological product under 
     this subsection unless the Secretary determines, after 
     consultation with appropriate national security and drug 
     enforcement agencies, that there would be no increased risk 
     to the security or health of the public from licensing such 
     biological product under this subsection.
       ``(6) Exclusivity for first interchangeable biological 
     product.--Upon review of an application submitted under this 
     subsection relying on the same reference product for which a 
     prior biological product has received a determination of 
     interchangeability for any condition of use, the Secretary 
     shall not make a determination under paragraph (4) that the 
     second or subsequent biological product is interchangeable 
     for any condition of use until the earlier of--
       ``(A) 1 year after the first commercial marketing of the 
     first interchangeable biosimilar biological product to be 
     approved as interchangeable for that reference product;
       ``(B) 18 months after--
       ``(i) a final court decision on all patents in suit in an 
     action instituted under subsection (l)(5) against the 
     applicant that submitted the application for the first 
     approved interchangeable biosimilar biological product; or
       ``(ii) the dismissal with or without prejudice of an action 
     instituted under subsection (l)(5) against the applicant that 
     submitted the application for the first approved 
     interchangeable biosimilar biological product; or
       ``(C)(i) 42 months after approval of the first 
     interchangeable biosimilar biological product if the 
     applicant that submitted such application has been sued under 
     subsection (l)(5) and such litigation is still ongoing within 
     such 42-month period; or
       ``(ii) 18 months after approval of the first 
     interchangeable biosimilar biological product if the 
     applicant that submitted such application has not been sued 
     under subsection (l)(5).

     For purposes of this paragraph, the term `final court 
     decision' means a final decision of a court from which no 
     appeal (other than a petition to the United States Supreme 
     Court for a writ of certiorari) has been or can be taken.
       ``(7) Exclusivity for reference product.--
       ``(A) Effective date of biosimilar application approval.--
     Approval of an application under this subsection may not be 
     made effective by the Secretary until the date that is 12 
     years after the date on which the reference product was first 
     licensed under subsection (a).
       ``(B) Filing period.--An application under this subsection 
     may not be submitted to the Secretary until the date that is 
     4 years after the date on which the reference product was 
     first licensed under subsection (a).
       ``(C) First licensure.--Subparagraphs (A) and (B) shall not 
     apply to a license for or approval of--
       ``(i) a supplement for the biological product that is the 
     reference product; or
       ``(ii) a subsequent application filed by the same sponsor 
     or manufacturer of the biological product that is the 
     reference product (or a licensor, predecessor in interest, or 
     other related entity) for--

       ``(I) a change (not including a modification to the 
     structure of the biological product) that results in a new 
     indication, route of administration, dosing schedule, dosage 
     form, delivery system, delivery device, or strength; or
       ``(II) a modification to the structure of the biological 
     product that does not result in a change in safety, purity, 
     or potency.

       ``(8) Pediatric studies.--
       ``(A) Exclusivity.--If, before or after licensure of the 
     reference product under subsection (a) of this section, the 
     Secretary determines that information relating to the use of 
     such product in the pediatric population may produce health 
     benefits in that population, the Secretary makes a written 
     request for pediatric studies (which shall include a 
     timeframe for completing such studies), the applicant or 
     holder of the approved application agrees to the request, 
     such studies are completed using appropriate formulations for 
     each age group for which the study is requested within any 
     such timeframe, and

[[Page H13312]]

     the reports thereof are submitted and accepted in accordance 
     with section 505A(d)(3) of the Federal Food, Drug, and 
     Cosmetic Act the period referred to in paragraph (7)(A) of 
     this subsection is deemed to be 12 years and 6 months rather 
     than 12 years.
       ``(B) Exception.--The Secretary shall not extend the period 
     referred to in subparagraph (A) of this paragraph if the 
     determination under section 505A(d)(3) of the Federal Food, 
     Drug, and Cosmetic Act is made later than 9 months prior to 
     the expiration of such period.
       ``(C) Application of certain provisions.--The provisions of 
     subsections (a), (d), (e), (f), (h), (j), (k), and (l) of 
     section 505A of the Federal Food, Drug, and Cosmetic Act 
     shall apply with respect to the extension of a period under 
     subparagraph (A) of this paragraph to the same extent and in 
     the same manner as such provisions apply with respect to the 
     extension of a period under subsection (b) or (c) of section 
     505A of the Federal Food, Drug, and Cosmetic Act.
       ``(9) Guidance documents.--
       ``(A) In general.--The Secretary may, after opportunity for 
     public comment, issue guidance in accordance, except as 
     provided in subparagraph (B)(i), with section 701(h) of the 
     Federal Food, Drug, and Cosmetic Act with respect to the 
     licensure of a biological product under this subsection. Any 
     such guidance may be general or specific.
       ``(B) Public comment.--
       ``(i) In general.--The Secretary shall provide the public 
     an opportunity to comment on any proposed guidance issued 
     under subparagraph (A) before issuing final guidance.
       ``(ii) Input regarding most valuable guidance.--The 
     Secretary shall establish a process through which the public 
     may provide the Secretary with input regarding priorities for 
     issuing guidance.
       ``(C) No requirement for application consideration.--The 
     issuance (or non-issuance) of guidance under subparagraph (A) 
     shall not preclude the review of, or action on, an 
     application submitted under this subsection.
       ``(D) Requirement for product class-specific guidance.--If 
     the Secretary issues product class-specific guidance under 
     subparagraph (A), such guidance shall include a description 
     of--
       ``(i) the criteria that the Secretary will use to determine 
     whether a biological product is highly similar to a reference 
     product in such product class; and
       ``(ii) the criteria, if available, that the Secretary will 
     use to determine whether a biological product meets the 
     standards described in paragraph (4).
       ``(E) Certain product classes.--
       ``(i) Guidance.--The Secretary may indicate in a guidance 
     document that the science and experience, as of the date of 
     such guidance, with respect to a product or product class 
     (not including any recombinant protein) does not allow 
     approval of an application for a license as provided under 
     this subsection for such product or product class.
       ``(ii) Modification or reversal.--The Secretary may issue a 
     subsequent guidance document under subparagraph (A) to modify 
     or reverse a guidance document under clause (i).
       ``(iii) No effect on ability to deny license.--Clause (i) 
     shall not be construed to require the Secretary to approve a 
     product with respect to which the Secretary has not indicated 
     in a guidance document that the science and experience, as 
     described in clause (i), does not allow approval of such an 
     application.
       ``(10) Naming.--The Secretary shall ensure that the 
     labeling and packaging of each biological product licensed 
     under this subsection bears a name that uniquely identifies 
     the biological product and distinguishes it from the 
     reference product and any other biological products licensed 
     under this subsection following evaluation against such 
     reference product.
       ``(l) Patent Notices; Relationship to Final Approval.--
       ``(1) Definitions.--For the purposes of this subsection, 
     the term--
       ``(A) `biosimilar product' means the biological product 
     that is the subject of the application under subsection (k);
       ``(B) `relevant patent' means a patent that--
       ``(i) expires after the date specified in subsection 
     (k)(7)(A) that applies to the reference product; and
       ``(ii) could reasonably be asserted against the applicant 
     due to the unauthorized making, use, sale, or offer for sale 
     within the United States, or the importation into the United 
     States of the biosimilar product, or materials used in the 
     manufacture of the biosimilar product, or due to a use of the 
     biosimilar product in a method of treatment that is indicated 
     in the application;
       ``(C) `reference product sponsor' means the holder of an 
     approved application or license for the reference product; 
     and
       ``(D) `interested third party' means a person other than 
     the reference product sponsor that owns a relevant patent, or 
     has the right to commence or participate in an action for 
     infringement of a relevant patent.
       ``(2) Handling of confidential information.--Any entity 
     receiving confidential information pursuant to this 
     subsection shall designate one or more individuals to receive 
     such information. Each individual so designated shall execute 
     an agreement in accordance with regulations promulgated by 
     the Secretary. The regulations shall require each such 
     individual to take reasonable steps to maintain the 
     confidentiality of information received pursuant to this 
     subsection and use the information solely for purposes 
     authorized by this subsection. The obligations imposed on an 
     individual who has received confidential information pursuant 
     to this subsection shall continue until the individual 
     returns or destroys the confidential information, a court 
     imposes a protective order that governs the use or handling 
     of the confidential information, or the party providing the 
     confidential information agrees to other terms or conditions 
     regarding the handling or use of the confidential 
     information.
       ``(3) Public notice by secretary.--Within 30 days of 
     acceptance by the Secretary of an application filed under 
     subsection (k), the Secretary shall publish a notice 
     identifying--
       ``(A) the reference product identified in the application; 
     and
       ``(B) the name and address of an agent designated by the 
     applicant to receive notices pursuant to paragraph (4)(B).
       ``(4) Exchanges concerning patents.--
       ``(A) Exchanges with reference product sponsor.--
       ``(i) Within 30 days of the date of acceptance of the 
     application by the Secretary, the applicant shall provide the 
     reference product sponsor with a copy of the application and 
     information concerning the biosimilar product and its 
     production. This information shall include a detailed 
     description of the biosimilar product, its method of 
     manufacture, and the materials used in the manufacture of the 
     product.
       ``(ii) Within 60 days of the date of receipt of the 
     information required to be provided under clause (i), the 
     reference product sponsor shall provide to the applicant a 
     list of relevant patents owned by the reference product 
     sponsor, or in respect of which the reference product sponsor 
     has the right to commence an action of infringement or 
     otherwise has an interest in the patent as such patent 
     concerns the biosimilar product.
       ``(iii) If the reference product sponsor is issued or 
     acquires an interest in a relevant patent after the date on 
     which the reference product sponsor provides the list 
     required by clause (ii) to the applicant, the reference 
     product sponsor shall identify that patent to the applicant 
     within 30 days of the date of issue of the patent, or the 
     date of acquisition of the interest in the patent, as 
     applicable.
       ``(B) Exchanges with interested third parties.--
       ``(i) At any time after the date on which the Secretary 
     publishes a notice for an application under paragraph (3), 
     any interested third party may provide notice to the 
     designated agent of the applicant that the interested third 
     party owns or has rights under 1 or more patents that may be 
     relevant patents. The notice shall identify at least 1 patent 
     and shall designate an individual who has executed an 
     agreement in accordance with paragraph (2) to receive 
     confidential information from the applicant.
       ``(ii) Within 30 days of the date of receiving notice 
     pursuant to clause (i), the applicant shall send to the 
     individual designated by the interested third party the 
     information specified in subparagraph (A)(i), unless the 
     applicant and interested third party otherwise agree.
       ``(iii) Within 90 days of the date of receiving information 
     pursuant to clause (ii), the interested third party shall 
     provide to the applicant a list of relevant patents which the 
     interested third party owns, or in respect of which the 
     interested third party has the right to commence or 
     participate in an action for infringement.
       ``(iv) If the interested third party is issued or acquires 
     an interest in a relevant patent after the date on which the 
     interested third party provides the list required by clause 
     (iii), the interested third party shall identify that patent 
     within 30 days of the date of issue of the patent, or the 
     date of acquisition of the interest in the patent, as 
     applicable.
       ``(C) Identification of basis for infringement.--For any 
     patent identified under clause (ii) or (iii) of subparagraph 
     (A) or under clause (iii) or (iv) of subparagraph (B), the 
     reference product sponsor or the interested third party, as 
     applicable--
       ``(i) shall explain in writing why the sponsor or the 
     interested third party believes the relevant patent would be 
     infringed by the making, use, sale, or offer for sale within 
     the United States, or importation into the United States, of 
     the biosimilar product or by a use of the biosimilar product 
     in treatment that is indicated in the application;
       ``(ii) may specify whether the relevant patent is available 
     for licensing; and
       ``(iii) shall specify the number and date of expiration of 
     the relevant patent.
       ``(D) Certification by applicant concerning identified 
     relevant patents.--Not later than 45 days after the date on 
     which a patent is identified under clause (ii) or (iii) of 
     subparagraph (A) or under clause (iii) or (iv) of 
     subparagraph (B), the applicant shall send a written 
     statement regarding each identified patent to the party that 
     identified the patent. Such statement shall either--
       ``(i) state that the applicant will not commence marketing 
     of the biosimilar product and has requested the Secretary to 
     not grant final approval of the application before the date 
     of expiration of the noticed patent; or
       ``(ii) provide a detailed written explanation setting forth 
     the reasons why the applicant believes--

       ``(I) the making, use, sale, or offer for sale within the 
     United States, or the importation into the United States, of 
     the biosimilar product, or the use of the biosimilar product

[[Page H13313]]

     in a treatment indicated in the application, would not 
     infringe the patent; or
       ``(II) the patent is invalid or unenforceable.

       ``(5) Action for infringement involving reference product 
     sponsor.--If an action for infringement concerning a relevant 
     patent identified by the reference product sponsor under 
     clause (ii) or (iii) of paragraph (4)(A), or by an interested 
     third party under clause (iii) or (iv) of paragraph (4)(B), 
     is brought within 60 days of the date of receipt of a 
     statement under paragraph (4)(D)(ii), and the court in which 
     such action has been commenced determines the patent is 
     infringed prior to the date applicable under subsection 
     (k)(7)(A) or (k)(8), the Secretary shall make approval of the 
     application effective on the day after the date of expiration 
     of the patent that has been found to be infringed. If more 
     than one such patent is found to be infringed by the court, 
     the approval of the application shall be made effective on 
     the day after the date that the last such patent expires.
       ``(6) Notification of agreements.--
       ``(A) Requirements.--
       ``(i) Agreement between biosimilar product applicant and 
     reference product sponsor.--If a biosimilar product applicant 
     under subsection (k) and the reference product sponsor enter 
     into an agreement described in subparagraph (B), the 
     applicant and sponsor shall each file the agreement in 
     accordance with subparagraph (C).
       ``(ii) Agreement between biosimilar product applicants.--If 
     2 or more biosimilar product applicants submit an application 
     under subsection (k) for biosimilar products with the same 
     reference product and enter into an agreement described in 
     subparagraph (B), the applicants shall each file the 
     agreement in accordance with subparagraph (C).
       ``(B) Subject matter of agreement.--An agreement described 
     in this subparagraph--
       ``(i) is an agreement between the biosimilar product 
     applicant under subsection (k) and the reference product 
     sponsor or between 2 or more biosimilar product applicants 
     under subsection (k) regarding the manufacture, marketing, or 
     sale of--

       ``(I) the biosimilar product (or biosimilar products) for 
     which an application was submitted; or
       ``(II) the reference product;

       ``(ii) includes any agreement between the biosimilar 
     product applicant under subsection (k) and the reference 
     product sponsor or between 2 or more biosimilar product 
     applicants under subsection (k) that is contingent upon, 
     provides a contingent condition for, or otherwise relates to 
     an agreement described in clause (i); and
       ``(iii) excludes any agreement that solely concerns--

       ``(I) purchase orders for raw material supplies;
       ``(II) equipment and facility contracts;
       ``(III) employment or consulting contracts; or
       ``(IV) packaging and labeling contracts.

       ``(C) Filing.--
       ``(i) In general.--The text of an agreement required to be 
     filed by subparagraph (A) shall be filed with the Assistant 
     Attorney General and the Federal Trade Commission not later 
     than--

       ``(I) 10 business days after the date on which the 
     agreement is executed; and
       ``(II) prior to the date of the first commercial marketing 
     of, for agreements described in subparagraph (A)(i), the 
     biosimilar product that is the subject of the application or, 
     for agreements described in subparagraph (A)(ii), any 
     biosimilar product that is the subject of an application 
     described in such subparagraph.

       ``(ii) If agreement not reduced to text.--If an agreement 
     required to be filed by subparagraph (A) has not been reduced 
     to text, the persons required to file the agreement shall 
     each file written descriptions of the agreement that are 
     sufficient to disclose all the terms and conditions of the 
     agreement.
       ``(iii) Certification.--The chief executive officer or the 
     company official responsible for negotiating any agreement 
     required to be filed by subparagraph (A) shall include in any 
     filing under this paragraph a certification as follows: `I 
     declare under penalty of perjury that the following is true 
     and correct: The materials filed with the Federal Trade 
     Commission and the Department of Justice under section 
     351(l)(6) of the Public Health Service Act, with respect to 
     the agreement referenced in this certification: (1) represent 
     the complete, final, and exclusive agreement between the 
     parties; (2) include any ancillary agreements that are 
     contingent upon, provide a contingent condition for, or 
     are otherwise related to, the referenced agreement; and 
     (3) include written descriptions of any oral agreements, 
     representations, commitments, or promises between the 
     parties that are responsive to such section and have not 
     been reduced to writing.'.
       ``(D) Disclosure exemption.--Any information or documentary 
     material filed with the Assistant Attorney General or the 
     Federal Trade Commission pursuant to this paragraph shall be 
     exempt from disclosure under section 552 of title 5, United 
     States Code, and no such information or documentary material 
     may be made public, except as may be relevant to any 
     administrative or judicial action or proceeding. Nothing in 
     this subparagraph prevents disclosure of information or 
     documentary material to either body of the Congress or to any 
     duly authorized committee or subcommittee of the Congress.
       ``(E) Enforcement.--
       ``(i) Civil penalty.--Any person that violates a provision 
     of this paragraph shall be liable for a civil penalty of not 
     more than $11,000 for each day on which the violation occurs. 
     Such penalty may be recovered in a civil action--

       ``(I) brought by the United States; or
       ``(II) brought by the Federal Trade Commission in 
     accordance with the procedures established in section 
     16(a)(1) of the Federal Trade Commission Act.

       ``(ii) Compliance and equitable relief.--If any person 
     violates any provision of this paragraph, the United States 
     district court may order compliance, and may grant such other 
     equitable relief as the court in its discretion determines 
     necessary or appropriate, upon application of the Assistant 
     Attorney General or the Federal Trade Commission.
       ``(F) Rulemaking.--The Federal Trade Commission, with the 
     concurrence of the Assistant Attorney General and by rule in 
     accordance with section 553 of title 5, United States Code, 
     consistent with the purposes of this paragraph--
       ``(i) may define the terms used in this paragraph;
       ``(ii) may exempt classes of persons or agreements from the 
     requirements of this paragraph; and
       ``(iii) may prescribe such other rules as may be necessary 
     and appropriate to carry out the purposes of this paragraph.
       ``(G) Savings clause.--Any action taken by the Assistant 
     Attorney General or the Federal Trade Commission, or any 
     failure of the Assistant Attorney General or the Commission 
     to take action, under this paragraph shall not at any time 
     bar any proceeding or any action with respect to any 
     agreement between a biosimilar product applicant under 
     subsection (k) and the reference product sponsor, or any 
     agreement between biosimilar product applicants under 
     subsection (k), under any other provision of law, nor shall 
     any filing under this paragraph constitute or create a 
     presumption of any violation of any competition laws.''.
       (b) Definitions.--Section 351(i) of the Public Health 
     Service Act (42 U.S.C. 262(i)) is amended--
       (1) by striking ``In this section, the term `biological 
     product' means'' and inserting the following: ``In this 
     section:
       ``(1) The term `biological product' means'';
       (2) in paragraph (1), as so designated, by inserting 
     ``protein (except any chemically synthesized polypeptide),'' 
     after ``allergenic product,''; and
       (3) by adding at the end the following:
       ``(2) The term `biosimilar' or `biosimilarity', in 
     reference to a biological product that is the subject of an 
     application under subsection (k), means--
       ``(A) that the biological product is highly similar to the 
     reference product notwithstanding minor differences in 
     clinically inactive components; and
       ``(B) there are no clinically meaningful differences 
     between the biological product and the reference product in 
     terms of the safety, purity, and potency of the product.
       ``(3) The term `interchangeable' or `interchangeability', 
     in reference to a biological product that is shown to meet 
     the standards described in subsection (k)(4), means that the 
     biological product may be substituted for the reference 
     product without the intervention of the health care provider 
     who prescribed the reference product.
       ``(4) The term `reference product' means the single 
     biological product licensed under subsection (a) against 
     which a biological product is evaluated in an application 
     submitted under subsection (k).''.
       (c) Products Previously Approved Under Section 505.--
       (1) Requirement to follow section 351.--Except as provided 
     in paragraph (2), an application for a biological product 
     shall be submitted under section 351 of the Public Health 
     Service Act (42 U.S.C. 262) (as amended by this Act).
       (2) Exception.--An application for a biological product may 
     be submitted under section 505 of the Federal Food, Drug, and 
     Cosmetic Act (21 U.S.C. 355) if--
       (A) such biological product is in a product class for which 
     a biological product in such product class is the subject of 
     an application approved under such section 505 not later than 
     the date of enactment of this Act; and
       (B) such application--
       (i) has been submitted to the Secretary of Health and Human 
     Services (referred to in this Act as the ``Secretary'') 
     before the date of enactment of this Act; or
       (ii) is submitted to the Secretary not later than the date 
     that is 10 years after the date of enactment of this Act.
       (3) Limitation.--Notwithstanding paragraph (2), an 
     application for a biological product may not be submitted 
     under section 505 of the Federal Food, Drug, and Cosmetic Act 
     (21 U.S.C. 355) if there is another biological product 
     approved under subsection (a) of section 351 of the Public 
     Health Service Act that could be a reference product with 
     respect to such application (within the meaning of such 
     section 351) if such application were submitted under 
     subsection (k) of such section 351.
       (4) Deemed approved under section 351.--An approved 
     application for a biological product under section 505 of the 
     Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355) shall be 
     deemed to be a license for the biological product under such 
     section 351 on the date that is 10 years after the date of 
     enactment of this Act.
       (5) Definitions.--For purposes of this subsection, the term 
     ``biological product'' has the meaning given such term under 
     section

[[Page H13314]]

     351 of the Public Health Service Act (42 U.S.C. 262) (as 
     amended by this Act).

     SEC. 222. FEES RELATING TO BIOSIMILAR BIOLOGICAL PRODUCTS.

       Subparagraph (B) of section 735(1) of the Federal Food, 
     Drug, and Cosmetic Act (21 U.S.C. 379g(1)) is amended by 
     inserting ``, including licensure of a biological product 
     under section 351(k) of such Act'' before the period at the 
     end.

     SEC. 223. AMENDMENTS TO CERTAIN PATENT PROVISIONS.

       (a) Section 271(e)(2) of title 35, United States Code is 
     amended--
       (1) in subparagraph (A), by striking ``or'' after 
     ``patent,'';
       (2) in subparagraph (B), by adding ``or'' after the comma 
     at the end;
       (3) by inserting the following after subparagraph (B):
       ``(C) a statement under section 351(l)(4)(D)(ii) of the 
     Public Health Service Act,''; and
       (4) in the matter following subparagraph (C) (as added by 
     paragraph (3)), by inserting before the period the following: 
     ``, or if the statement described in subparagraph (C) is 
     provided in connection with an application to obtain a 
     license to engage in the commercial manufacture, use, or sale 
     of a biological product claimed in a patent or the use of 
     which is claimed in a patent before the expiration of such 
     patent''.
       (b) Section 271(e)(4) of title 35, United States Code, is 
     amended by striking ``in paragraph (2)'' in both places it 
     appears and inserting ``in paragraph (2)(A) or (2)(B)''.

               Subtitle D--Administrative Simplification

     SEC. 231. ADMINISTRATIVE SIMPLIFICATION.

       (a) Operating Rules for Health Information Transactions.--
       (1) Definition of operating rules.--Section 1171 of the 
     Social Security Act (42 U.S.C. 1320d) is amended by adding at 
     the end the following:
       ``(9) Operating rules.--The term `operating rules' means 
     the necessary business rules and guidelines for the 
     electronic exchange of information that are not defined by a 
     standard or its implementation specifications as adopted for 
     purposes of this part.''.
       (2) Operating rules and compliance.--Section 1173 of the 
     Social Security Act (42 U.S.C. 1320d-2) is amended--
       (A) in subsection (a)(2), by adding at the end the 
     following new subparagraph:
       ``(J) Electronic funds transfers.''; and
       (B) by adding at the end the following new subsections:
       ``(g) Operating Rules.--
       ``(1) In general.--The Secretary shall adopt a single set 
     of operating rules for each transaction described in 
     subsection (a)(2) with the goal of creating as much 
     uniformity in the implementation of the electronic standards 
     as possible. Such operating rules shall be consensus-based 
     and reflect the necessary business rules affecting health 
     plans and health care providers and the manner in which they 
     operate pursuant to standards issued under Health Insurance 
     Portability and Accountability Act of 1996.
       ``(2) Operating rules development.--In adopting operating 
     rules under this subsection, the Secretary shall rely on 
     recommendations for operating rules developed by a qualified 
     nonprofit entity, as selected by the Secretary, that meets 
     the following requirements:
       ``(A) The entity focuses its mission on administrative 
     simplification.
       ``(B) The entity demonstrates an established multi-
     stakeholder and consensus-based process for development of 
     operating rules, including representation by or participation 
     from health plans, health care providers, vendors, relevant 
     Federal agencies, and other standard development 
     organizations.
       ``(C) The entity has established a public set of guiding 
     principles that ensure the operating rules and process are 
     open and transparent.
       ``(D) The entity coordinates its activities with the HIT 
     Policy Committee and the HIT Standards Committee (as 
     established under title XXX of the Public Health Service Act) 
     and complements the efforts of the Office of the National 
     Healthcare Coordinator and its related health information 
     exchange goals.
       ``(E) The entity incorporates national standards, including 
     the transaction standards issued under Health Insurance 
     Portability and Accountability Act of 1996.
       ``(F) The entity supports nondiscrimination and conflict of 
     interest policies that demonstrate a commitment to open, 
     fair, and nondiscriminatory practices.
       ``(G) The entity allows for public review and updates of 
     the operating rules.
       ``(3) Review and recommendations.--The National Committee 
     on Vital and Health Statistics shall--
       ``(A) review the operating rules developed by a nonprofit 
     entity described under paragraph (2);
       ``(B) determine whether such rules represent a consensus 
     view of the health care industry and are consistent with and 
     do not alter current standards;
       ``(C) evaluate whether such rules are consistent with 
     electronic standards adopted for health information 
     technology; and
       ``(D) submit to the Secretary a recommendation as to 
     whether the Secretary should adopt such rules.
       ``(4) Implementation.--
       ``(A) In general.--The Secretary shall adopt operating 
     rules under this subsection, by regulation in accordance with 
     subparagraph (C), following consideration of the rules 
     developed by the non-profit entity described in paragraph (2) 
     and the recommendation submitted by the National Committee on 
     Vital and Health Statistics under paragraph (3)(D) and having 
     ensured consultation with providers.
       ``(B) Adoption requirements; effective dates.--
       ``(i) Eligibility for a health plan and health claim 
     status.--The set of operating rules for transactions for 
     eligibility for a health plan and health claim status shall 
     be adopted not later than July 1, 2011, in a manner ensuring 
     that such rules are effective not later than January 1, 2013, 
     and may allow for the use of a machine readable 
     identification card.
       ``(ii) Electronic funds transfers and health care payment 
     and remittance advice.--The set of operating rules for 
     electronic funds transfers and health care payment and 
     remittance advice shall be adopted not later than July 1, 
     2012, in a manner ensuring that such rules are effective not 
     later than January 1, 2014.
       ``(iii) Other completed transactions.--The set of operating 
     rules for the remainder of the completed transactions 
     described in subsection (a)(2), including health claims or 
     equivalent encounter information, enrollment and 
     disenrollment in a health plan, health plan premium payments, 
     and referral certification and authorization, shall be 
     adopted not later than July 1, 2014, in a manner ensuring 
     that such rules are effective not later than January 1, 2016.
       ``(C) Expedited rulemaking.--The Secretary shall promulgate 
     an interim final rule applying any standard or operating rule 
     recommended by the National Committee on Vital and Health 
     Statistics pursuant to paragraph (3). The Secretary shall 
     accept public comments on any interim final rule published 
     under this subparagraph for 60 days after the date of such 
     publication.
       ``(h) Compliance.--
       ``(1) Health plan certification.--
       ``(A) Eligibility for a health plan, health claim status, 
     electronic funds transfers, health care payment and 
     remittance advice.--Not later than December 31, 2013, a 
     health plan shall file a statement with the Secretary, in 
     such form as the Secretary may require, certifying that the 
     data and information systems for such plan are in compliance 
     with any applicable standards (as described under paragraph 
     (7) of section 1171) and operating rules (as described under 
     paragraph (9) of such section) for electronic funds 
     transfers, eligibility for a health plan, health claim 
     status, and health care payment and remittance advice, 
     respectively.
       ``(B) Other completed transactions.--Not later than 
     December 31, 2015, a health plan shall file a statement with 
     the Secretary, in such form as the Secretary may require, 
     certifying that the data and information systems for such 
     plan are in compliance with any applicable standards and 
     operating rules for the remainder of the completed 
     transactions described in subsection (a)(2), including health 
     claims or equivalent encounter information, enrollment and 
     disenrollment in a health plan, health plan premium payments, 
     and referral certification and authorization, respectively. A 
     health plan shall provide the same level of documentation to 
     certify compliance with such transactions as is required to 
     certify compliance with the transactions specified in 
     subparagraph (A).
       ``(2) Documentation of compliance.--A health plan shall 
     provide the Secretary, in such form as the Secretary may 
     require, with adequate documentation of compliance with the 
     standards and operating rules described under paragraph (1). 
     A health plan shall not be considered to have provided 
     adequate documentation and shall not be certified as being in 
     compliance with such standards, unless the health plan--
       ``(A) demonstrates to the Secretary that the plan conducts 
     the electronic transactions specified in paragraph (1) in a 
     manner that fully complies with the regulations of the 
     Secretary; and
       ``(B) provides documentation showing that the plan has 
     completed end-to-end testing for such transactions with their 
     partners, such as hospitals and physicians.
       ``(3) Service contracts.--A health plan shall be required 
     to comply with any applicable certification and compliance 
     requirements (and provide the Secretary with adequate 
     documentation of such compliance) under this subsection for 
     any entities that provide services pursuant to a contract 
     with such health plan.
       ``(4) Certification by outside entity.--The Secretary may 
     contract with an independent, outside entity to certify that 
     a health plan has complied with the requirements under this 
     subsection, provided that the certification standards 
     employed by such entities are in accordance with any 
     standards or rules issued by the Secretary.
       ``(5) Compliance with revised standards and rules.--A 
     health plan (including entities described under paragraph 
     (3)) shall comply with the certification and documentation 
     requirements under this subsection for any interim final rule 
     promulgated by the Secretary under subsection (i) that amends 
     any standard or operating rule described under paragraph (1) 
     of this subsection. A health plan shall comply with such 
     requirements not later than the effective date of the 
     applicable interim final rule.

[[Page H13315]]

       ``(6) Audits of health plans.--The Secretary shall conduct 
     periodic audits to ensure that health plans (including 
     entities described under paragraph (3)) are in compliance 
     with any standards and operating rules that are described 
     under paragraph (1).
       ``(i) Review and Amendment of Standards and Rules.--
       ``(1) Establishment.--Not later than January 1, 2014, the 
     Secretary shall establish a review committee (as described 
     under paragraph (4)).
       ``(2) Evaluations and reports.--
       ``(A) Hearings.--Not later than April 1, 2014, and not less 
     than biennially thereafter, the Secretary, acting through the 
     review committee, shall conduct hearings to evaluate and 
     review the existing standards and operating rules established 
     under this section.
       ``(B) Report.--Not later than July 1, 2014, and not less 
     than biennially thereafter, the review committee shall 
     provide recommendations for updating and improving such 
     standards and rules. The review committee shall recommend a 
     single set of operating rules per transaction standard and 
     maintain the goal of creating as much uniformity as possible 
     in the implementation of the electronic standards.
       ``(3) Interim final rulemaking.--
       ``(A) In general.--Any recommendations to amend existing 
     standards and operating rules that have been approved by the 
     review committee and reported to the Secretary under 
     paragraph (2)(B) shall be adopted by the Secretary through 
     promulgation of an interim final rule not later than 90 days 
     after receipt of the committee's report.
       ``(B) Public comment.--
       ``(i) Public comment period.--The Secretary shall accept 
     public comments on any interim final rule published under 
     this paragraph for 60 days after the date of such 
     publication.
       ``(ii) Effective date.--The effective date of any amendment 
     to existing standards or operating rules that is adopted 
     through an interim final rule published under this paragraph 
     shall be 25 months following the close of such public comment 
     period.
       ``(4) Review committee.--
       ``(A) Definition.--For the purposes of this subsection, the 
     term `review committee' means a committee within the 
     Department of Health and Human services that has been 
     designated by the Secretary to carry out this subsection, 
     including--
       ``(i) the National Committee on Vital and Health 
     Statistics; or
       ``(ii) any appropriate committee as determined by the 
     Secretary.
       ``(B) Coordination of hit standards.--In developing 
     recommendations under this subsection, the review committee 
     shall consider the standards approved by the Office of the 
     National Coordinator for Health Information Technology.
       ``(j) Penalties.--
       ``(1) Penalty fee.--
       ``(A) In general.--Not later than April 1, 2014, and 
     annually thereafter, the Secretary shall assess a penalty fee 
     (as determined under subparagraph (B)) against a health plan 
     that has failed to meet the requirements under subsection (h) 
     with respect to certification and documentation of compliance 
     with the standards (and their operating rules) as described 
     under paragraph (1) of such subsection.
       ``(B) Fee amount.--Subject to subparagraphs (C), (D), and 
     (E), the Secretary shall assess a penalty fee against a 
     health plan in the amount of $1 per covered life until 
     certification is complete. The penalty shall be assessed per 
     person covered by the plan for which its data systems for 
     major medical policies are not in compliance and shall be 
     imposed against the health plan for each day that the plan is 
     not in compliance with the requirements under subsection (h).
       ``(C) Additional penalty for misrepresentation.--A health 
     plan that knowingly provides inaccurate or incomplete 
     information in a statement of certification or documentation 
     of compliance under subsection (h) shall be subject to a 
     penalty fee that is double the amount that would otherwise be 
     imposed under this subsection.
       ``(D) Annual fee increase.--The amount of the penalty fee 
     imposed under this subsection shall be increased on an annual 
     basis by the annual percentage increase in total national 
     health care expenditures, as determined by the Secretary.
       ``(E) Penalty limit.--A penalty fee assessed against a 
     health plan under this subsection shall not exceed, on an 
     annual basis--
       ``(i) an amount equal to $20 per covered life under such 
     plan; or
       ``(ii) an amount equal to $40 per covered life under the 
     plan if such plan has knowingly provided inaccurate or 
     incomplete information (as described under subparagraph (C)).
       ``(F) Determination of covered individuals.--The Secretary 
     shall determine the number of covered lives under a health 
     plan based upon the most recent statements and filings that 
     have been submitted by such plan to the Securities and 
     Exchange Commission.
       ``(2) Notice and dispute procedure.--The Secretary shall 
     establish a procedure for assessment of penalty fees under 
     this subsection that provides a health plan with reasonable 
     notice and a dispute resolution procedure prior to provision 
     of a notice of assessment by the Secretary of the Treasury 
     (as described under paragraph (4)(B)).
       ``(3) Penalty fee report.--Not later than May 1, 2014, and 
     annually thereafter, the Secretary shall provide the 
     Secretary of the Treasury with a report identifying those 
     health plans that have been assessed a penalty fee under this 
     subsection.
       ``(4) Collection of penalty fee.--
       ``(A) In general.--The Secretary of the Treasury, acting 
     through the Financial Management Service, shall administer 
     the collection of penalty fees from health plans that have 
     been identified by the Secretary in the penalty fee report 
     provided under paragraph (3).
       ``(B) Notice.--Not later than August 1, 2014, and annually 
     thereafter, the Secretary of the Treasury shall provide 
     notice to each health plan that has been assessed a penalty 
     fee by the Secretary under this subsection. Such notice shall 
     include the amount of the penalty fee assessed by the 
     Secretary and the due date for payment of such fee to the 
     Secretary of the Treasury (as described in subparagraph (C)).
       ``(C) Payment due date.--Payment by a health plan for a 
     penalty fee assessed under this subsection shall be made to 
     the Secretary of the Treasury not later than November 1, 
     2014, and annually thereafter.
       ``(D) Unpaid penalty fees.--Any amount of a penalty fee 
     assessed against a health plan under this subsection for 
     which payment has not been made by the due date provided 
     under subparagraph (C) shall be--
       ``(i) increased by the interest accrued on such amount, as 
     determined pursuant to the underpayment rate established 
     under section 6601 of the Internal Revenue Code of 1986; and
       ``(ii) treated as a past-due, legally enforceable debt owed 
     to a Federal agency for purposes of section 6402(d) of the 
     Internal Revenue Code of 1986.
       ``(E) Administrative fees.--Any fee charged or allocated 
     for collection activities conducted by the Financial 
     Management Service will be passed on to a health plan on a 
     pro-rata basis and added to any penalty fee collected from 
     the plan.''.
       (b) Promulgation of Rules.--
       (1) Unique health plan identifier.--The Secretary shall 
     promulgate a final rule to establish a unique health plan 
     identifier (as described in section 1173(b) of the Social 
     Security Act (42 U.S.C. 1320d-2(b))) based on the input of 
     the National Committee of Vital and Health Statistics. The 
     Secretary may do so on an interim final basis and such rule 
     shall be effective not later than October 1, 2012.
       (2) Electronic funds transfer.--The Secretary shall 
     promulgate a final rule to establish a standard for 
     electronic funds transfers (as described in section 
     1173(a)(2)(J) of the Social Security Act, as added by 
     subsection (a)(2)(A)). The Secretary may do so on an interim 
     final basis and shall adopt such standard not later than 
     January 1, 2012, in a manner ensuring that such standard is 
     effective not later than January 1, 2014.
       (c) Expansion of Electronic Transactions in Medicare.--
     Section 1862(a) of the Social Security Act (42 U.S.C. 
     1395y(a)) is amended--
       (1) in paragraph (23), by striking the ``or'' at the end;
       (2) in paragraph (24), by striking the period and inserting 
     ``; or''; and
       (3) by inserting after paragraph (24) the following new 
     paragraph:
       ``(25) not later than January 1, 2014, for which the 
     payment is other than by electronic funds transfer (EFT) or 
     an electronic remittance in a form as specified in ASC X12 
     835 Health Care Payment and Remittance Advice or subsequent 
     standard.''.
       (d) Medicare and Medicaid Compliance Reports.--Not later 
     than July 1, 2013, the Secretary of Health and Human Services 
     shall submit a report to the Chairs and Ranking Members of 
     the Committee on Ways and Means and the Committee on Energy 
     and Commerce of the House of Representatives and the Chairs 
     and Ranking Members of the Committee on Health, Education, 
     Labor, and Pensions and the Committee on Finance of the 
     Senate on the extent to which the Medicare program and 
     providers that serve beneficiaries under that program, and 
     State Medicaid programs and providers that serve 
     beneficiaries under those programs, transact electronically 
     in accordance with transaction standards issued under the 
     Health Insurance Portability and Accountability Act of 1996, 
     part C of title XI of the Social Security Act, and 
     regulations promulgated under such Acts.

  Mr. GINGREY of Georgia (during the reading). Mr. Speaker, I ask 
unanimous consent to dispense with the reading.
  Mr. WAXMAN. I object.
  The SPEAKER pro tempore. Objection is heard.
  The Clerk will read.
  The Clerk continued to read the motion to recommit.
  Mr. WAXMAN (during the reading). Mr. Speaker, I ask unanimous consent 
that we dispense with the reading.
  The SPEAKER pro tempore. Is there objection to the request of the 
gentleman from California?
  There was no objection.


                             Point of Order

  Mr. WAXMAN. Mr. Speaker, pursuant to clause 7 of House rule XVI, 
matters within the motion to recommit are not germane to the underlying 
bill, and I insist on my point of order.
  The SPEAKER pro tempore. Does any other Member wish to be heard on 
the point of order?

[[Page H13316]]

                         Parliamentary Inquiry

  Mr. GINGREY of Georgia. Parliamentary inquiry, Mr. Speaker.
  The SPEAKER pro tempore. The gentleman will state his parliamentary 
inquiry.
  Mr. GINGREY of Georgia. Mr. Speaker, the gentleman from California 
reserved a point of order. Does that not allow me the opportunity to 
speak to the point of order?
  The SPEAKER pro tempore. The Chair will hear the gentleman on the 
point of order.
  Mr. GINGREY of Georgia. Mr. Speaker, I rise today as an OB/GYN 
physician who knows very well the challenges that our doctors face with 
the current SGR system. I can say with 100 percent confidence as a 
physician Member of Congress that this bill, H.R. 3961, is a bad deal. 
It's a bad deal for doctors, it's a bad deal for patients, and it's a 
bad deal for the American people upon whom this majority seems content 
to simply pile another $210 billion worth of debt.
  Mr. WAXMAN. Mr. Speaker, I don't believe the gentleman's argument is 
pertinent to the point of order. I insist on my point of order.
  The SPEAKER pro tempore. The gentleman from Georgia must confine his 
remarks to the point of order.
  Mr. GINGREY of Georgia. Mr. Speaker, during his meeting earlier this 
week with Chinese President Hu Jintao, I hope that President Obama 
asked for that $210 billion, because that's how the majority plans to 
pay for this bill, by borrowing more money from the Chinese.
  The SPEAKER pro tempore. The gentleman must confine his remarks to 
the point of order.
  Mr. GINGREY of Georgia. Mr. Speaker, I will proceed.
  To make matters worse, and contrary to the assertions of this 
majority, this bill does not fix our physician reimbursement problem, 
but it simply replaces one flawed system for another.
  So, Mr. Speaker, my motion to recommit ensures that physicians are 
reimbursed fairly and that this reimbursement is fully paid for and 
would add not one cent to the deficit.
  The SPEAKER pro tempore. The Chair will remind the Member to confine 
his remarks to the point of order.
  Mr. GINGREY of Georgia. Allow me to explain, Mr. Speaker.
  This motion to recommit will provide physicians with a 2 percent 
Medicare payment rate increase in each of the next 4 years. The motion 
to recommit would erase the scheduled 21 percent cut in 2010----
  Mr. WAXMAN. Mr. Speaker, I insist on my point of order.
  The SPEAKER pro tempore. The Chair will remind the Member to confine 
his remarks to the point of order.
  The Chair is prepared to rule.
  Mr. GINGREY of Georgia. Mr. Speaker, am I allowed to continue?
  The SPEAKER pro tempore. The gentleman may continue on the point of 
order.
  Mr. GINGREY of Georgia. Mr. Speaker, the motion to recommit would 
erase the scheduled 21 percent cut in 2010 and the estimated 5 percent 
cuts in 2011, 2012, and 2013. The Democratic bill would only provide 
eight-tenths of 1 percent payment rate increase.
  The SPEAKER pro tempore. The gentleman must confine his remarks to 
the point of order.
  Mr. GINGREY of Georgia. Mr. Speaker, in this underlying bill, we 
actually pay for our plan by enacting legislation that will not only 
achieve savings, but will also----
  The SPEAKER pro tempore. The Chair reminds the gentleman that he must 
confine his remarks to the point of order.
  The Chair is prepared to rule.
  The gentleman from Georgia may proceed on the point of order.
  Mr. GINGREY of Georgia. Mr. Speaker, on the point of order, I would 
like to say that unlike the underlying bill, we actually pay for our 
plan by enacting legislation that will not only achieve savings, but it 
will also improve----
  The SPEAKER pro tempore. The gentleman must confine his remarks to 
the point of order.
  The Chair is ready to rule.
  Mr. GINGREY of Georgia. Mr. Speaker, I'm trying to confine my remarks 
to the point of order.
  The SPEAKER pro tempore. The gentleman must address why the amendment 
is germane.
  Mr. GINGREY of Georgia. In doing so, I say we simply prefer to pay 
for what we do without raising taxes.
  The SPEAKER pro tempore. The Chair will rule.
  The gentleman from California makes a point of order that the 
amendment proposed in the instructions included in the motion to 
recommit offered by the gentleman from Georgia is not germane.
  The bill, H.R. 3961, addresses the narrow topic of payments under the 
Medicare sustainable growth rate system. The bill adjusts the formulas 
for the SGR system to alter payments to physicians under that system.
  Among other topics, the motion to recommit addresses the subject of 
medical liability reform. It includes provisions on compensation, court 
procedure, and liability for damages.
  As recorded in section 934 of the House Rules and Manual, a general 
principle of germaneness is that an amendment must confine itself to 
the committee of jurisdiction over the subject matters contained in the 
bill. The bill, H.R. 3961, merited referral only to the Committee on 
Energy and Commerce and the Committee on Ways and Means. The motion to 
recommit, addressing the subject of medical liability reform, 
introduces subject matter properly within the jurisdiction of the 
Committee on the Judiciary.
  The motion is therefore not germane and the point of order is 
sustained.
  Mr. GINGREY of Georgia. Mr. Speaker, I appeal the ruling of the 
Chair.
  The SPEAKER pro tempore. The question is, Shall the decision of the 
Chair stand as the judgment of the House?
  Mr. WAXMAN. Mr. Speaker, I move to table the appeal of the ruling of 
the Chair.
  The SPEAKER pro tempore. The question is on the motion to table.
  The question was taken; and the Speaker pro tempore announced that 
the ayes appeared to have it.
  Mr. GINGREY of Georgia. Mr. Speaker, on that I demand the yeas and 
nays.
  The yeas and nays were ordered.
  The SPEAKER pro tempore. Pursuant to clause 8 and clause 9 of rule 
XX, this 15-minute vote on the motion to table will be followed by 5-
minute votes on passage of the bill, if arising without further 
proceedings in recommittal, and the motion to suspend the rules on H.R. 
1834.
  The vote was taken by electronic device, and there were--yeas 251, 
nays 177, not voting 6, as follows:

                             [Roll No. 907]

                               YEAS--251

     Abercrombie
     Ackerman
     Adler (NJ)
     Altmire
     Andrews
     Arcuri
     Baca
     Baird
     Baldwin
     Barrow
     Bean
     Becerra
     Berkley
     Berman
     Berry
     Bishop (GA)
     Bishop (NY)
     Blumenauer
     Boccieri
     Boren
     Boswell
     Boucher
     Boyd
     Brady (PA)
     Braley (IA)
     Brown, Corrine
     Butterfield
     Capps
     Capuano
     Cardoza
     Carnahan
     Carson (IN)
     Castor (FL)
     Chandler
     Childers
     Chu
     Clarke
     Clay
     Cleaver
     Clyburn
     Cohen
     Connolly (VA)
     Conyers
     Cooper
     Costa
     Costello
     Courtney
     Crowley
     Cuellar
     Cummings
     Dahlkemper
     Davis (AL)
     Davis (CA)
     Davis (IL)
     Davis (TN)
     DeFazio
     DeGette
     Delahunt
     DeLauro
     Dicks
     Dingell
     Doggett
     Donnelly (IN)
     Doyle
     Driehaus
     Edwards (MD)
     Edwards (TX)
     Ellison
     Ellsworth
     Engel
     Eshoo
     Etheridge
     Farr
     Fattah
     Filner
     Foster
     Frank (MA)
     Fudge
     Garamendi
     Giffords
     Gonzalez
     Gordon (TN)
     Grayson
     Green, Al
     Green, Gene
     Griffith
     Grijalva
     Gutierrez
     Hall (NY)
     Halvorson
     Hare
     Harman
     Hastings (FL)
     Heinrich
     Herseth Sandlin
     Higgins
     Hill
     Himes
     Hinchey
     Hinojosa
     Hirono
     Hodes
     Holden
     Holt
     Honda
     Hoyer
     Inslee
     Israel
     Jackson (IL)
     Jackson-Lee (TX)
     Johnson (GA)
     Johnson, E. B.
     Kagen
     Kanjorski
     Kaptur
     Kennedy
     Kildee
     Kilpatrick (MI)
     Kilroy
     Kind
     Kirkpatrick (AZ)
     Kissell
     Klein (FL)
     Kosmas
     Kratovil
     Kucinich
     Langevin
     Larsen (WA)
     Larson (CT)
     Lee (CA)
     Levin
     Lewis (GA)
     Lipinski
     Loebsack
     Lofgren, Zoe
     Lowey
     Lujan
     Lynch
     Maffei
     Maloney
     Markey (CO)
     Markey (MA)
     Marshall
     Massa
     Matheson
     Matsui
     McCarthy (NY)
     McCollum
     McDermott
     McGovern
     McIntyre
     McMahon
     McNerney
     Meek (FL)
     Meeks (NY)
     Michaud
     Miller (NC)
     Mitchell
     Mollohan
     Moore (KS)
     Moore (WI)
     Moran (VA)
     Murphy (CT)
     Murphy (NY)
     Murphy, Patrick
     Murtha
     Nadler (NY)
     Napolitano
     Neal (MA)
     Nye
     Oberstar
     Obey
     Olver
     Ortiz
     Owens
     Pallone
     Pascrell
     Pastor (AZ)
     Payne
     Perlmutter
     Perriello
     Peters
     Peterson
     Pingree (ME)
     Polis (CO)
     Pomeroy
     Price (NC)
     Quigley

[[Page H13317]]


     Rahall
     Rangel
     Reyes
     Richardson
     Rodriguez
     Ross
     Rothman (NJ)
     Roybal-Allard
     Ruppersberger
     Rush
     Ryan (OH)
     Salazar
     Sanchez, Linda T.
     Sanchez, Loretta
     Sarbanes
     Schakowsky
     Schauer
     Schiff
     Schrader
     Schwartz
     Scott (GA)
     Scott (VA)
     Serrano
     Sestak
     Shea-Porter
     Sherman
     Shuler
     Sires
     Skelton
     Slaughter
     Smith (WA)
     Snyder
     Space
     Speier
     Spratt
     Stark
     Stupak
     Sutton
     Tanner
     Taylor
     Teague
     Thompson (CA)
     Thompson (MS)
     Tierney
     Titus
     Tonko
     Towns
     Tsongas
     Van Hollen
     Velazquez
     Visclosky
     Walz
     Wasserman Schultz
     Waters
     Watson
     Watt
     Waxman
     Weiner
     Welch
     Wilson (OH)
     Woolsey
     Wu
     Yarmuth

                               NAYS--177

     Aderholt
     Akin
     Alexander
     Austria
     Bachmann
     Bachus
     Barrett (SC)
     Bartlett
     Barton (TX)
     Biggert
     Bilbray
     Bilirakis
     Bishop (UT)
     Blackburn
     Blunt
     Boehner
     Bonner
     Bono Mack
     Boozman
     Boustany
     Brady (TX)
     Bright
     Broun (GA)
     Brown-Waite, Ginny
     Buchanan
     Burgess
     Burton (IN)
     Buyer
     Calvert
     Camp
     Campbell
     Cantor
     Cao
     Capito
     Carney
     Cassidy
     Castle
     Chaffetz
     Coble
     Coffman (CO)
     Cole
     Conaway
     Crenshaw
     Culberson
     Davis (KY)
     Deal (GA)
     Dent
     Diaz-Balart, L.
     Diaz-Balart, M.
     Dreier
     Duncan
     Ehlers
     Emerson
     Fallin
     Flake
     Fleming
     Forbes
     Fortenberry
     Foxx
     Franks (AZ)
     Frelinghuysen
     Gallegly
     Garrett (NJ)
     Gerlach
     Gingrey (GA)
     Gohmert
     Goodlatte
     Granger
     Graves
     Guthrie
     Hall (TX)
     Harper
     Hastings (WA)
     Heller
     Hensarling
     Herger
     Hoekstra
     Hunter
     Inglis
     Issa
     Jenkins
     Johnson (IL)
     Johnson, Sam
     Jones
     Jordan (OH)
     King (IA)
     King (NY)
     Kingston
     Kirk
     Kline (MN)
     Lamborn
     Lance
     Latham
     LaTourette
     Latta
     Lee (NY)
     Lewis (CA)
     Linder
     LoBiondo
     Lucas
     Luetkemeyer
     Lummis
     Lungren, Daniel E.
     Mack
     Manzullo
     Marchant
     McCarthy (CA)
     McClintock
     McCotter
     McHenry
     McKeon
     McMorris Rodgers
     Mica
     Miller (FL)
     Miller (MI)
     Miller, Gary
     Minnick
     Moran (KS)
     Murphy, Tim
     Myrick
     Neugebauer
     Nunes
     Olson
     Paul
     Paulsen
     Pence
     Petri
     Pitts
     Platts
     Poe (TX)
     Posey
     Price (GA)
     Putnam
     Radanovich
     Rehberg
     Reichert
     Roe (TN)
     Rogers (AL)
     Rogers (KY)
     Rogers (MI)
     Rohrabacher
     Rooney
     Ros-Lehtinen
     Roskam
     Royce
     Ryan (WI)
     Scalise
     Schmidt
     Schock
     Sensenbrenner
     Sessions
     Shadegg
     Shimkus
     Shuster
     Simpson
     Smith (NE)
     Smith (NJ)
     Smith (TX)
     Souder
     Stearns
     Sullivan
     Terry
     Thompson (PA)
     Thornberry
     Tiahrt
     Tiberi
     Turner
     Upton
     Walden
     Wamp
     Westmoreland
     Whitfield
     Wilson (SC)
     Wittman
     Wolf
     Young (AK)
     Young (FL)

                             NOT VOTING--6

     Brown (SC)
     Carter
     McCaul
     Melancon
     Miller, George
     Wexler

                              {time}  1553

  Messrs. SESSIONS, LUETKEMEYER, WALDEN, CARNEY and GERLACH changed 
their vote from ``yea'' to ``nay.''
  Mr. WILSON of Ohio, Ms. KILPATRICK of Michigan, Messrs. ELLISON, 
RODRIGUEZ, JOHNSON of Georgia and Ms. McCOLLUM changed their vote from 
``nay'' to ``yea.''
  So the motion to table was agreed to.
  The result of the vote was announced as above recorded.


                           Motion to Recommit

  Mr. CANTOR. Mr. Speaker, I have a motion to recommit at the desk.
  The SPEAKER pro tempore. Is the gentleman opposed to the bill.
  Mr. CANTOR. In its current form, I am.
  The SPEAKER pro tempore. The Clerk will report the motion to 
recommit.
  The Clerk read as follows:

       Mr. Cantor moves to recommit the bill, H.R. 3961, to the 
     Committee on Energy and Commerce with instructions to report 
     the same back to the House forthwith with the following 
     amendment:
       Add at the end of the bill the following:

     SEC. 3. FINDINGS.

       Congress finds that the Secretary of Health and Human 
     Services has the authority to increase payments for services 
     under section 1848 of the Social Security Act (related to 
     payments for physician services) in an amount not to exceed 
     $22,300,000,000.

     SEC. 4. LIMITATIONS.

       (a) In General.--In executing the amendments made by 
     section 2(b) of this Act the Secretary of Health and Human 
     Services shall implement an adjustment in payments under 
     section 1848 of the Social Security Act under such amendments 
     for 2011 or any subsequent year only to the extent that the 
     Secretary determines that the cost of such adjustment when 
     added to the cost of the amendment made by section 2(a) does 
     not exceed $22,300,000,000. Such cost determinations shall be 
     calculated based on the difference between net expenditures 
     resulting from the provisions of this Act and anticipated net 
     expenditures for each year under the law as in effect before 
     the date of the enactment of this Act.
       (b) Contingency.--If the Secretary is prevented from 
     implementing an adjustment described in subsection (a) as a 
     result of such subsection, the Secretary shall implement 
     section 1848 of the Social Security Act as such section was 
     in effect before the date of the enactment of this Act.

  Mr. WAXMAN (during the reading). Mr. Speaker, I ask unanimous consent 
to dispense with the reading.
  The SPEAKER pro tempore. Is there objection to the request of the 
gentleman from California?
  There was no objection.
  The Chair recognizes the gentleman from Virginia for 5 minutes in 
support of his motion.
  Mr. CANTOR. Thank you. Mr. Speaker, we have tried to do everything 
possible to pay for this doctor fix, and it seems that the majority 
just refuses to do the fiscally responsible thing. We just offered a 
proposal that was a fully paid doctor fix that provided our doctors 
with 2 percent updates for 4 years. The majority blocked this House 
from even voting on that proposal because they object to paying for the 
costs of the doctor fix.
  It seems that the rules that the majority is using prevent us from 
paying for this bill simply because, Mr. Speaker, the majority doesn't 
pay for this bill. Seeing that that is the case, one has to ask how 
perverse is that? Because the majority is okay with adding $250 billion 
to our debt, the Republicans are prevented under the rules from trying 
to be responsible and pay for those costs. Is this what passes for 
fiscal responsibility in the majority party, I ask?
  So now we are offering a second motion to recommit that attempts to 
address the deficit costs while living under the rules imposed on us by 
the majority. What does this motion do? Very simply, it recognizes that 
there is a fund already in existing law that has $22.3 billion in it 
that can be used to pay for the doctor fix. It further limits spending 
under this bill to that same amount, $22.3 billion. That is enough to 
provide the doctor payment updates for all of 2010 and most, if not 
all, of 2011 envisioned under the Democratic bill.
  So we've identified, Mr. Speaker, an amount of money that is 
available to pay for 2 years' worth of a doctor fix and limited this 
bill to 2 years. A vote for this motion to recommit is a vote to 
recognize that we ought to help our doctors, but we ought to do it in a 
fiscally responsible manner, and this motion shows us how to do it. I 
wish we could do more, but the rules imposed on us by the majority 
simply won't permit it.
  So now is the time to choose: Do we want to plan for a fiscally 
responsible doctor fix or $250 billion in new debt? Mr. Speaker, I ask 
this House to vote for fiscal responsibility.
  I yield to the gentleman from Georgia, Dr. Price.
  Mr. PRICE of Georgia. Thank you. As a physician, I know that the SGR, 
the sustainable growth rate, is neither sustainable nor growing. It is, 
however, truly destroying the ability of doctors to provide the needed 
care for patients across our land. And though the underlying bill is an 
acknowledgement that there is a huge problem and may be a step in the 
right direction, it exacerbates the phenomenal fiscal recklessness of 
this administration and the majority party.
  As a physician, I know with every fiber of my being that the doctors 
of this land are sick and tired of being played for fools, duped into 
support of another nonsolution because there is not a commitment to a 
responsible revenue stream with a recognition of the care that they 
provide.

                              {time}  1600

  With this trick, the majority demeans our Nation's caring and 
compassionate physicians. So let's commit to solve this challenge 
together, positively, with a plan that respects those who have 
dedicated their lives to our health.
  Mr. Speaker, our Nation is at a fiscal tipping point. We can continue 
to march further and further to the liberal left and bankrupt our 
Nation's future, or we can restore fiscal sanity to an overgrown and 
unrestrained Federal budget. Our motion to recommit is a

[[Page H13318]]

step in the right direction, not another plan that further adds to our 
Nation's debt and contributes to the financial ruin of future 
generations.
  Mr. Speaker, the American people are demanding a stop to runaway 
debt. They reject this spending and they reject this trick. Let's stand 
up for fiscal responsibility and vote for the responsible Republican 
solution.
  Mr. CANTOR. Mr. Speaker, I yield back the balance of my time.
  Mr. WAXMAN. Mr. Speaker, I rise in opposition to the motion to 
recommit.
  The SPEAKER pro tempore. The gentleman from California is recognized 
for 5 minutes.
  Mr. WAXMAN. Mr. Speaker and my colleagues, this motion to recommit 
proposes to spend $22.3 billion for a $210 billion problem. It simply 
postpones the problem. It is the same old kicking the can down the 
road. There are no guarantees of cuts when this money runs out. The 
gentleman from Virginia says his proposal would mean no cuts for 2 
years. I am not convinced of that 2-year period. But whatever period of 
time it would allow for, there would be another cliff, and that is why 
the American Medical Association wrote to the Honorable Dave Camp, 
ranking member of the Ways and Means Committee, that they oppose 
anything short of permanent reform. They want us to deal with this 
problem now and not just kick it down the road. The AMA does not 
support any motion to recommit that would have a temporary fix.
  I want to yield at this time to the gentleman from California (Mr. 
Stark).
  Mr. STARK. I thank the gentleman for yielding only to suggest that 
being nice doesn't seem to get you much around here.
  This motion makes a mockery of the debate. My friends on the other 
side simply propose the same old same old. They can't even tell us or 
the American people how this will affect doctors or military families 
or others. It is legislating in the dark.
  The distinguished minority whip voted in committee enthusiastically 
for the bill that is before us, now seems to have forgotten and changed 
his mind. It is a continuation of the Republican history of 
mismanagement of Medicare and dishonest budget gimmicks, and I urge its 
opposition.
  Mr. WAXMAN. Mr. Speaker, I yield to the gentleman from Florida (Mr. 
Boyd).
  Mr. BOYD. Mr. Speaker, I appreciate the gentleman from California 
yielding.
  As we have seen so many times in the past, ladies and gentlemen, the 
minority party has again offered a very insincere proposal that does 
not fix the issue at hand. This proposal is a gimmick that would 
eventually lead to deep cuts in Medicare.
  In contrast, this underlying bill recognizes that the current 
baseline of physician spending is no longer useful in projecting 
obligations for providing physician services to Medicare beneficiaries.
  The underlying bill fundamentally addresses this issue that Congress 
has acted on six times in the last 6 years for a temporary patch that 
has only made the problem worse. That is what they want to do again.
  As my colleague, Ranking Member Paul Ryan, mentioned earlier, this 
issue should be resolved in a bipartisan way, but that is not 
forthcoming here today. In the meantime, we must ensure that our 
seniors have access to their doctors.
  In addition, this bill also addresses the pay-as-you-go rule. Under 
Republican rules, record surpluses were turned into record deficits as 
the pay-as-you-go rules expired. We cannot police ourselves with regard 
to fiscal discipline. That is why we have to have these rules in place. 
My Blue Dog colleagues and I have urged implementation of this policy 
for years.
  I urge a ``no'' vote on the MTR and a ``yes'' vote on the underlying 
bill.
  Mr. WAXMAN. Mr. Speaker, I urge a ``no'' vote on the motion to 
recommit and an ``aye'' vote on the underlying bill, and I yield back 
the balance of my time.


                        Parliamentary Inquiries

  Mr. CANTOR. Mr. Speaker, parliamentary inquiry.
  The SPEAKER pro tempore. The gentleman will state his parliamentary 
inquiry.
  Mr. CANTOR. Mr. Speaker, is it true that the Democrats' bill will add 
$210 billion to the deficit?
  The SPEAKER pro tempore. The Chair does not respond to commentary 
posed as a parliamentary inquiry.
  Mr. CANTOR. Further parliamentary inquiry, Mr. Speaker.
  The SPEAKER pro tempore. The gentleman will state his parliamentary 
inquiry.
  Mr. CANTOR. Mr. Speaker, my prior inquiry asked: Would the Democrats' 
bill add $210 billion to the deficit, and I would say even the Blue 
Dogs know that the Democrat bill adds $210 billion to the deficit.
  The SPEAKER pro tempore. The gentleman from Virginia has not stated a 
parliamentary inquiry.
  Without objection, the previous question is ordered on the motion to 
recommit.
  There was no objection.
  The SPEAKER pro tempore. The question is on the motion to recommit.
  The question was taken; and the Speaker pro tempore announced that 
the noes appeared to have it.


                             Recorded Vote

  Mr. CANTOR. Mr. Speaker, I demand a recorded vote.
  A recorded vote was ordered.
  The SPEAKER pro tempore. Pursuant to clause 8 and clause 9 of rule 
XX, this 15-minute vote on the motion to recommit will be followed by 
5-minute votes on passage of the bill, if ordered, and the motion to 
suspend the rules on H.R. 1834.
  The vote was taken by electronic device, and there were--ayes 177, 
noes 252, not voting 5, as follows:

                             [Roll No. 908]

                               AYES--177

     Aderholt
     Adler (NJ)
     Akin
     Alexander
     Altmire
     Austria
     Bachus
     Barrett (SC)
     Bartlett
     Barton (TX)
     Biggert
     Bilbray
     Bilirakis
     Bishop (UT)
     Blackburn
     Boehner
     Bonner
     Bono Mack
     Boozman
     Boustany
     Bright
     Brown-Waite, Ginny
     Buchanan
     Burgess
     Burton (IN)
     Buyer
     Calvert
     Camp
     Campbell
     Cantor
     Cao
     Capito
     Cassidy
     Castle
     Chaffetz
     Childers
     Coble
     Coffman (CO)
     Conaway
     Crenshaw
     Culberson
     Davis (KY)
     Deal (GA)
     Dent
     Diaz-Balart, L.
     Diaz-Balart, M.
     Dreier
     Duncan
     Ehlers
     Emerson
     Fallin
     Flake
     Fleming
     Forbes
     Fortenberry
     Foxx
     Franks (AZ)
     Frelinghuysen
     Gallegly
     Garrett (NJ)
     Gerlach
     Gingrey (GA)
     Gohmert
     Goodlatte
     Granger
     Graves
     Guthrie
     Hall (TX)
     Harper
     Hastings (WA)
     Heller
     Hensarling
     Herger
     Hoekstra
     Hunter
     Inglis
     Jenkins
     Johnson (IL)
     Johnson, Sam
     Jones
     Jordan (OH)
     King (IA)
     King (NY)
     Kingston
     Kirk
     Kosmas
     Lamborn
     Lance
     Latham
     LaTourette
     Latta
     Lee (NY)
     Lewis (CA)
     Linder
     Lipinski
     LoBiondo
     Lucas
     Luetkemeyer
     Lummis
     Lungren, Daniel E.
     Mack
     Manzullo
     Marchant
     McCarthy (CA)
     McClintock
     McCotter
     McHenry
     McKeon
     McMahon
     McMorris Rodgers
     Mica
     Miller (FL)
     Miller (MI)
     Miller, Gary
     Moran (KS)
     Murphy, Tim
     Myrick
     Neugebauer
     Nunes
     Olson
     Paul
     Paulsen
     Pence
     Peterson
     Petri
     Pitts
     Poe (TX)
     Posey
     Price (GA)
     Putnam
     Radanovich
     Rehberg
     Reichert
     Roe (TN)
     Rogers (AL)
     Rogers (KY)
     Rogers (MI)
     Rohrabacher
     Rooney
     Ros-Lehtinen
     Roskam
     Royce
     Ryan (WI)
     Sanchez, Loretta
     Scalise
     Schmidt
     Schock
     Sensenbrenner
     Sessions
     Shadegg
     Shimkus
     Shuster
     Simpson
     Smith (NE)
     Smith (NJ)
     Smith (TX)
     Souder
     Stearns
     Stupak
     Sullivan
     Taylor
     Terry
     Thompson (PA)
     Thornberry
     Tiahrt
     Tiberi
     Turner
     Upton
     Walden
     Wamp
     Westmoreland
     Whitfield
     Wilson (SC)
     Wittman
     Wolf
     Young (AK)
     Young (FL)

                               NOES--252

     Abercrombie
     Ackerman
     Andrews
     Arcuri
     Baca
     Bachmann
     Baird
     Baldwin
     Barrow
     Bean
     Becerra
     Berkley
     Berman
     Berry
     Bishop (GA)
     Bishop (NY)
     Blumenauer
     Blunt
     Boccieri
     Boren
     Boswell
     Boucher
     Boyd
     Brady (PA)
     Brady (TX)
     Braley (IA)
     Broun (GA)
     Brown, Corrine
     Butterfield
     Capps
     Capuano
     Cardoza
     Carnahan
     Carney
     Carson (IN)
     Castor (FL)
     Chandler
     Chu
     Clarke
     Clay
     Cleaver
     Clyburn
     Cohen
     Cole
     Connolly (VA)
     Conyers
     Cooper
     Costa
     Costello
     Courtney
     Crowley
     Cuellar
     Cummings
     Dahlkemper
     Davis (AL)
     Davis (CA)
     Davis (IL)
     Davis (TN)
     DeFazio
     DeGette
     Delahunt
     DeLauro
     Dicks
     Dingell
     Doggett
     Donnelly (IN)
     Doyle
     Driehaus
     Edwards (MD)
     Edwards (TX)
     Ellison
     Ellsworth
     Engel
     Eshoo
     Etheridge
     Farr
     Fattah
     Filner
     Foster
     Frank (MA)
     Fudge

[[Page H13319]]


     Garamendi
     Giffords
     Gonzalez
     Gordon (TN)
     Grayson
     Green, Al
     Green, Gene
     Griffith
     Grijalva
     Gutierrez
     Hall (NY)
     Halvorson
     Hare
     Harman
     Hastings (FL)
     Heinrich
     Herseth Sandlin
     Higgins
     Hill
     Himes
     Hinchey
     Hinojosa
     Hirono
     Hodes
     Holden
     Holt
     Honda
     Hoyer
     Inslee
     Israel
     Issa
     Jackson (IL)
     Jackson-Lee (TX)
     Johnson (GA)
     Johnson, E. B.
     Kagen
     Kanjorski
     Kaptur
     Kennedy
     Kildee
     Kilpatrick (MI)
     Kilroy
     Kind
     Kirkpatrick (AZ)
     Kissell
     Klein (FL)
     Kline (MN)
     Kratovil
     Kucinich
     Langevin
     Larsen (WA)
     Larson (CT)
     Lee (CA)
     Levin
     Lewis (GA)
     Loebsack
     Lofgren, Zoe
     Lowey
     Lujan
     Lynch
     Maffei
     Maloney
     Markey (CO)
     Markey (MA)
     Marshall
     Massa
     Matheson
     Matsui
     McCarthy (NY)
     McCollum
     McDermott
     McGovern
     McIntyre
     McNerney
     Meek (FL)
     Meeks (NY)
     Michaud
     Miller (NC)
     Minnick
     Mitchell
     Mollohan
     Moore (KS)
     Moore (WI)
     Moran (VA)
     Murphy (CT)
     Murphy (NY)
     Murphy, Patrick
     Murtha
     Nadler (NY)
     Napolitano
     Neal (MA)
     Nye
     Oberstar
     Obey
     Olver
     Ortiz
     Owens
     Pallone
     Pascrell
     Pastor (AZ)
     Payne
     Perlmutter
     Perriello
     Peters
     Pingree (ME)
     Platts
     Polis (CO)
     Pomeroy
     Price (NC)
     Quigley
     Rahall
     Rangel
     Reyes
     Richardson
     Rodriguez
     Ross
     Rothman (NJ)
     Roybal-Allard
     Ruppersberger
     Rush
     Ryan (OH)
     Salazar
     Sanchez, Linda T.
     Sarbanes
     Schakowsky
     Schauer
     Schiff
     Schrader
     Schwartz
     Scott (GA)
     Scott (VA)
     Serrano
     Sestak
     Shea-Porter
     Sherman
     Shuler
     Sires
     Skelton
     Slaughter
     Smith (WA)
     Snyder
     Space
     Speier
     Spratt
     Stark
     Sutton
     Tanner
     Teague
     Thompson (CA)
     Thompson (MS)
     Tierney
     Titus
     Tonko
     Towns
     Tsongas
     Van Hollen
     Velazquez
     Visclosky
     Walz
     Wasserman Schultz
     Waters
     Watson
     Watt
     Waxman
     Weiner
     Welch
     Wexler
     Wilson (OH)
     Woolsey
     Wu
     Yarmuth

                             NOT VOTING--5

     Brown (SC)
     Carter
     McCaul
     Melancon
     Miller, George


                Announcement by the Speaker Pro Tempore

  The SPEAKER pro tempore (during the vote). There are 2 minutes 
remaining in this vote.

                              {time}  1622

  Mr. CLEAVER changed his vote from ``aye'' to ``no.''
  Mr. LAMBORN changed his vote from ``no'' to ``aye.''
  So the motion to recommit was rejected.
  The result of the vote was announced as above recorded.
  The SPEAKER pro tempore. The question is on the passage of the bill.
  The question was taken; and the Speaker pro tempore announced that 
the ayes appeared to have it.


                             Recorded Vote

  Mr. WAXMAN. Mr. Speaker, I demand a recorded vote.
  A recorded vote was ordered.
  The SPEAKER pro tempore. This is a 5-minute vote.
  The vote was taken by electronic device, and there were--ayes 243, 
noes 183, not voting 8, as follows:

                             [Roll No. 909]

                               AYES--243

     Abercrombie
     Ackerman
     Adler (NJ)
     Altmire
     Andrews
     Arcuri
     Baca
     Baldwin
     Barrow
     Bean
     Becerra
     Berkley
     Berman
     Berry
     Bishop (GA)
     Bishop (NY)
     Blumenauer
     Boccieri
     Boswell
     Boucher
     Boyd
     Brady (PA)
     Braley (IA)
     Bright
     Brown, Corrine
     Burgess
     Butterfield
     Capps
     Capuano
     Cardoza
     Carnahan
     Carney
     Carson (IN)
     Castor (FL)
     Chandler
     Childers
     Chu
     Clarke
     Clay
     Cleaver
     Clyburn
     Cohen
     Connolly (VA)
     Conyers
     Costa
     Costello
     Courtney
     Crowley
     Cuellar
     Cummings
     Dahlkemper
     Davis (AL)
     Davis (CA)
     Davis (IL)
     Davis (TN)
     DeFazio
     DeGette
     Delahunt
     DeLauro
     Dicks
     Dingell
     Doggett
     Donnelly (IN)
     Doyle
     Driehaus
     Edwards (MD)
     Ellison
     Ellsworth
     Engel
     Eshoo
     Etheridge
     Farr
     Fattah
     Filner
     Foster
     Frank (MA)
     Fudge
     Garamendi
     Giffords
     Gonzalez
     Gordon (TN)
     Grayson
     Green, Al
     Green, Gene
     Griffith
     Grijalva
     Gutierrez
     Hall (NY)
     Halvorson
     Hare
     Harman
     Hastings (FL)
     Heinrich
     Higgins
     Hill
     Himes
     Hinchey
     Hinojosa
     Hirono
     Hodes
     Holden
     Holt
     Honda
     Hoyer
     Inslee
     Israel
     Jackson (IL)
     Jackson-Lee (TX)
     Johnson (GA)
     Johnson, E. B.
     Kagen
     Kanjorski
     Kaptur
     Kildee
     Kilpatrick (MI)
     Kilroy
     Kind
     Kirkpatrick (AZ)
     Kissell
     Klein (FL)
     Kratovil
     Kucinich
     Langevin
     Larsen (WA)
     Larson (CT)
     Lee (CA)
     Levin
     Lewis (GA)
     Loebsack
     Lofgren, Zoe
     Lowey
     Lujan
     Lynch
     Maffei
     Maloney
     Markey (CO)
     Markey (MA)
     Marshall
     Massa
     Matheson
     Matsui
     McCarthy (NY)
     McCollum
     McDermott
     McGovern
     McIntyre
     McNerney
     Meek (FL)
     Meeks (NY)
     Michaud
     Miller (NC)
     Minnick
     Mitchell
     Mollohan
     Moore (KS)
     Moore (WI)
     Moran (VA)
     Murphy (CT)
     Murphy (NY)
     Murphy, Patrick
     Murtha
     Nadler (NY)
     Napolitano
     Neal (MA)
     Nye
     Oberstar
     Obey
     Olver
     Ortiz
     Owens
     Pallone
     Pascrell
     Pastor (AZ)
     Payne
     Perlmutter
     Perriello
     Peters
     Pingree (ME)
     Polis (CO)
     Pomeroy
     Price (NC)
     Quigley
     Rahall
     Rangel
     Reyes
     Richardson
     Rodriguez
     Ross
     Rothman (NJ)
     Roybal-Allard
     Ruppersberger
     Rush
     Ryan (OH)
     Salazar
     Sanchez, Linda T.
     Sanchez, Loretta
     Sarbanes
     Schakowsky
     Schauer
     Schiff
     Schrader
     Schwartz
     Scott (GA)
     Scott (VA)
     Serrano
     Sestak
     Shea-Porter
     Sherman
     Shuler
     Sires
     Skelton
     Slaughter
     Snyder
     Space
     Speier
     Spratt
     Stark
     Stupak
     Sutton
     Tanner
     Teague
     Thompson (CA)
     Thompson (MS)
     Tierney
     Titus
     Tonko
     Tsongas
     Van Hollen
     Velazquez
     Visclosky
     Walz
     Wasserman Schultz
     Waters
     Watson
     Watt
     Waxman
     Weiner
     Welch
     Wexler
     Wilson (OH)
     Woolsey
     Wu
     Yarmuth

                               NOES--183

     Aderholt
     Akin
     Alexander
     Austria
     Bachmann
     Bachus
     Baird
     Barrett (SC)
     Bartlett
     Barton (TX)
     Biggert
     Bilbray
     Bilirakis
     Bishop (UT)
     Blackburn
     Blunt
     Boehner
     Bonner
     Bono Mack
     Boozman
     Boren
     Boustany
     Broun (GA)
     Brown-Waite, Ginny
     Buchanan
     Burton (IN)
     Buyer
     Calvert
     Camp
     Campbell
     Cantor
     Cao
     Capito
     Cassidy
     Castle
     Chaffetz
     Coble
     Coffman (CO)
     Cole
     Conaway
     Cooper
     Crenshaw
     Culberson
     Davis (KY)
     Deal (GA)
     Dent
     Diaz-Balart, L.
     Diaz-Balart, M.
     Dreier
     Duncan
     Edwards (TX)
     Ehlers
     Emerson
     Fallin
     Flake
     Fleming
     Forbes
     Fortenberry
     Foxx
     Franks (AZ)
     Frelinghuysen
     Gallegly
     Garrett (NJ)
     Gerlach
     Gingrey (GA)
     Gohmert
     Goodlatte
     Granger
     Graves
     Guthrie
     Hall (TX)
     Harper
     Hastings (WA)
     Heller
     Hensarling
     Herger
     Herseth Sandlin
     Hoekstra
     Hunter
     Inglis
     Issa
     Jenkins
     Johnson (IL)
     Johnson, Sam
     Jones
     Jordan (OH)
     King (IA)
     King (NY)
     Kingston
     Kirk
     Kline (MN)
     Kosmas
     Lamborn
     Lance
     Latham
     LaTourette
     Latta
     Lee (NY)
     Lewis (CA)
     Linder
     Lipinski
     LoBiondo
     Lucas
     Luetkemeyer
     Lummis
     Lungren, Daniel E.
     Mack
     Manzullo
     Marchant
     McCarthy (CA)
     McClintock
     McCotter
     McHenry
     McKeon
     McMahon
     McMorris Rodgers
     Mica
     Miller (FL)
     Miller (MI)
     Miller, Gary
     Moran (KS)
     Murphy, Tim
     Myrick
     Neugebauer
     Nunes
     Olson
     Paul
     Paulsen
     Pence
     Peterson
     Petri
     Pitts
     Platts
     Poe (TX)
     Posey
     Price (GA)
     Putnam
     Radanovich
     Rehberg
     Reichert
     Roe (TN)
     Rogers (AL)
     Rogers (KY)
     Rogers (MI)
     Rohrabacher
     Rooney
     Ros-Lehtinen
     Roskam
     Royce
     Ryan (WI)
     Scalise
     Schmidt
     Schock
     Sensenbrenner
     Sessions
     Shadegg
     Shimkus
     Shuster
     Simpson
     Smith (NE)
     Smith (NJ)
     Smith (TX)
     Smith (WA)
     Souder
     Stearns
     Sullivan
     Taylor
     Terry
     Thompson (PA)
     Thornberry
     Tiahrt
     Tiberi
     Turner
     Upton
     Walden
     Wamp
     Westmoreland
     Whitfield
     Wilson (SC)
     Wittman
     Wolf
     Young (AK)
     Young (FL)

                             NOT VOTING--8

     Brady (TX)
     Brown (SC)
     Carter
     Kennedy
     McCaul
     Melancon
     Miller, George
     Towns


                Announcement by the Speaker Pro Tempore

  The SPEAKER pro tempore (during the vote). There are 2 minutes 
remaining in this vote.

                              {time}  1629

  So the bill was passed.
  The result of the vote was announced as above recorded.
  A motion to reconsider was laid on the table.
  Stated for:
  Mr. KENNEDY. Mr. Speaker, I regret that my vote on H.R. 3961, the 
Medicare Physician Payment Reform Act of 2009 was not recorded in the 
House of Representatives today.
  Had my vote been recorded on rollcall No. 909, final passage of H.R. 
3961, the Medicare Physician Payment Reform Act of 2009, I would have 
voted ``aye'' on the question.
  Mr. BRADY of Texas. Mr. Speaker, on rollcall No. 909, I was 
unavoidably detained. Had I been present, I would have voted ``no.''


 =========================== NOTE =========================== 

  
  November 19, 2009 on Page H13319 the following appeared: Mr. 
BRADY. Mr. Speaker, on rollcall No.
  
  The online version should be corrected to read: Mr. BRADY of 
Texas. Mr. Speaker, on rollcall No.


 ========================= END NOTE ========================= 


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