[Congressional Record Volume 155, Number 172 (Thursday, November 19, 2009)]
[Senate]
[Pages S11584-S11586]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                           HEALTH CARE REFORM

  Mr. THUNE. Mr. President, we now have a draft of the Senate 
majority's health care reform bill, after spending several weeks behind 
closed doors producing that bill. Some of the details are starting to 
emerge.
  I think it is critical that all Members in the Senate have an 
opportunity to look very closely at what is in the bill. It should come 
as no surprise that it is a 2,000-plus page bill. Much was made of the 
bill in the House of Representatives being a 2,200-page bill when it 
was all said and done. This one is 2,074 pages. It hasn't been amended 
yet, so that will probably expand it as this bill comes to the floor.
  I think we at least now have something we can look at and review. 
There was a lot made last night by the majority when they rolled this 
bill out--how fiscally responsible this bill is and how much of an 
improvement it is over recent drafts of this legislation. I wish to 
point out a couple things that I think, perhaps, put into perspective 
what this bill would do, what it entails, and how, with all the 
rhetoric about how it differs and improves upon previous drafts of the 
bill, it comes down to basically the same elements that have been in 
all the bills we have seen.
  First is with respect to the costs. It is very clear the cost of this 
bill--which was stated last night as $849 billion--is dramatically 
understated relative to its true cost when fully implemented. There are 
several reasons. One, they push back the effective implementation date 
to 2014 for many of the provisions to take effect. So you will not see 
the actual spending in the bill start to kick in until January 1 of 
2014.
  However, many of the revenue components in the bill begin to kick in 
next year, on January 1, 2010. So the tax increases, which are multiple 
and hundreds of billions of dollars, would begin to take effect 
immediately, starting January 1, 2010, while much of the spending in 
the bill would be deferred until much later in the budget window--not 
taking effect until January 1, 2014.
  That distorts the true picture of what this legislation would cost 
and distorts it substantially.
  The other point I will make is that there are a couple other 
provisions in the bill that, by its absence in one case and its 
inclusion in the other, understate the cost of the bill. One is the 
absence of the sustainable growth rate formula, or the so-called 
physician fee fix, the reimbursement form, that is a $247 billion 
hole--$247 billion in additional spending that is not included in the 
bill. That, obviously, understates the overall cost.
  There is also a $72 billion assumption in there for a program called 
the CLASS Act. I wish to read for you something that one of my 
colleagues on the Democratic side said about the CLASS Act. This was 
the Senator from North Dakota, chairman of the Budget

[[Page S11585]]

Committee in the Senate. He called the CLASS Act ``a ponzi scheme of 
the first order, the kind of thing that Bernie Madoff would be proud 
of.'' That is how he refers to this CLASS Act included in the bill and 
the savings that are associated with it. In fact, the $72 billion it 
shows as revenue in the first 10 years turns into a deficit in the 
second 10 years. So when you back out the $72 billion that, it is 
assumed, would add to the revenues in the bill and you add to the cost 
of the bill the $247 billion that would be required to fund the 
physician fee formula over a 10-year period, the so-called surplus that 
this bill generates actually turns into a deficit. It goes from a 
surplus of $130 billion to a deficit of $189 billion.
  Again, a lot of gimmicks are being used to understate the true cost 
of the bill to the American people. All that being said, if you look at 
the overall cost, when fully implemented over 10 years, you come up 
with this: Remember, when the HELP Committee passed its version of this 
bill out of committee, the 10-year, fully-implemented cost was $2.2 
trillion.
  When the Finance Committee passed its version of the health care 
reform bill out of the committee, the 10-year, fully-implemented cost 
of that bill was $1.8 trillion. So that is $1.8 trillion for the 
Finance Committee bill and $2.2 trillion for the Health, Education, 
Labor, and Pensions Committee bill. Guess what the pricetag is on the 
bill that was merged together and has now been unveiled for all the 
world to see. It is $2.5 trillion in overall cost--10-year, fully-
implemented cost. That is a $2.5 trillion expansion of the Federal 
Government in Washington, DC, associated with the fully implemented 
cost of the bill.
  The point I am trying to make is this: The cost of the bill is being 
dramatically understated by the authors of the bill to make it look 
like it comes in under $1 trillion, when, in fact, when you back out 
the two components I mentioned, it is over $1 trillion in the first 10 
years, and that is because they delay implementation of many provisions 
until January 1, 2014--a budgetary gimmick designed to understate the 
true cost of the bill.
  When you look at the fully implemented, 10-year cost of the 
legislation, without the gimmick of the delayed implementation date and 
the other gimmicks in here, it is $2.5 trillion in additional costs to 
the taxpayers of this country. Of course, that $2.5 trillion has to be 
paid for somehow. The way it is paid for isn't any different than in 
any of the other bills we have seen so far. It is paid for with higher 
taxes on small businesses and higher taxes on individuals. It is paid 
for with cuts to Medicare Programs that would impact senior citizens in 
this country, as well as medical providers, from hospitals to home 
health agencies, to hospice--you name it--and medical device 
manufacturers get hit hard in this legislation. Everybody gets hit when 
it comes to the reimbursement side to pay for this.
  Of course, the American taxpayer gets hit hard when it comes to the 
tax increases included in there--$\1/2\ trillion in tax increases and 
$\1/2\ trillion in Medicare cuts to finance this $2.5 trillion 
expansion of the Federal Government to create a new entitlement 
program.
  The other thing this bill does, which wasn't included in a previous 
version, it has an increase in the payroll tax on Medicare. The 
argument is, it only applies to people in the higher income categories. 
They tried to carve out people under $200,000 a year. Remember, the 
Medicare tax--and the payroll tax that every employee in this country 
pays, which is 1.45 percent on their income, matched by their employer, 
for a total of 2.9 percent--is increased. It gets increased to pay for 
not reforming or making Medicare more sustainable, a program we all 
know is destined to be bankrupt by 2017.
  The increase in the Medicare tax will fund a whole new entitlement 
program unrelated to Medicare. The argument will be it is a health care 
program. But the fact is, the Medicare payroll tax was put into place 
to fund Medicare, a program people would pay into so that when they 
retire, they would have the security of health care coverage.
  The payroll tax included in this bill, first off, will hit a lot of 
people. If you are a couple who both make a couple hundred--or $100,000 
a year, you are already into the category where you are going to be hit 
by the tax. One of my main objections--and I am not for this tax 
increase--one of my main objections is the majority has chosen to use 
that tax increase not to make Medicare more sustainable but to create a 
whole new entitlement program with this bill.
  The other thing I wish to point out, because it has come up in the 
last day or two, is there has been all this discussion about 
mammograms, this U.S. Preventive Services Task Force that came out with 
a recommendation that women under 40 should not go through mammogram 
screening; and, of course, a few years ago they made the opposite 
recommendation--back in 2002--when the U.S. Preventive Services Task 
Force made the recommendation that women 40 and older should undergo 
annual mammogram checks for breast cancer. That recommendation was 
completely reversed earlier this week. The 16-member task force ruled 
that patients under 50 or over 75, without special risk factors, no 
longer need annual screening. What is being said about that? They are 
backing away from that in a hurry. The HHS Secretary, Kathleen 
Sebelius, said: No, no, no, nothing will change. This is just a 
recommendation. It is not binding.

  That may be true today. Here is the problem with government-run 
health care, the problem with the direction we are heading with this 
legislation: A greater level of government involvement and intervention 
and more requirements imposed on those who offer insurance products, 
particularly those who contract with the government. I think it is safe 
to assume that. There are many new creations in this legislation, and 
there is a new Medicare advisory board. They will have recommendations 
that are not just recommendations and advisory but, in fact, binding.
  This is exactly the point many colleagues have been making about 
government-run health care. When you start down that path--and we have 
seen the model in Europe and Canada--where the government imposes cost 
control measures, that leads to rationing. Pretty soon, people are 
denied care, and care is delayed when people want to get a particular 
procedure. It has been concluded that this is not cost-effective, and 
some of these decisions that have traditionally been made between 
patients and doctors are made by the government.
  I will read for you something that was in an editorial in the Wall 
Street Journal today. It gets at the very heart of what I am talking 
about. It says:

       More important for the future, every Democratic version of 
     ObamaCare makes this task force an arbiter of the benefits 
     that private insurers are required to cover as they are 
     converted into government contractors. What are now merely 
     recommendations will become de facto rules, and under 
     national health care these kinds of cost analyses will 
     inevitably become more common as government decides where 
     finite tax dollars are allowed to go.
       In a rational system, the responsibility for health care 
     ought to reside with patients and their doctors. James Thral, 
     a Harvard medical professor and chairman of the American 
     College of Radiology, tells us that the breast cancer 
     decision shows the dangers of medicine being reduced to 
     ``accounting exercises subject to interpretations and 
     underlying assumptions,'' and based on costs and large group 
     averages, not individuals.

  He goes on to say:

       I fear that we are entering an era of deliberate decisions 
     where we choose to trade people's lives for money.

  What is important about that observation is that he is pointing out 
what a lot of people will be very concerned about. If you are a woman 
in my home State of South Dakota, and let's say you are 42 years old, 
the recommendation made by this task force, which everybody is now 
dismissing and saying don't worry about it, it is not binding--under 
legislation such as this, where you create a board that actually does 
have statutory powers and is enabled to make many of these decisions 
based on what is cost-effective, you could have someone in a State such 
as mine, or any woman in any State in this country who is in their 
forties--because they said 50 should be the baseline now, the age at 
which you get mammograms or breast cancer screening done--that you 
could actually have women in this country who would be denied the 
opportunity to do that.
  Of course, we all know and everybody can relate to people in this 
country

[[Page S11586]]

who, by virtue of that screening process and that test, have been 
detected early and able to beat breast cancer, which is something that 
afflicts a great number of women across this country.
  That is one example. I use that as an example of how this new type of 
government-run program might work. But there are countless other 
examples of the very same thing.
  As we head into this debate, again I remind my colleagues this type 
of undertaking--reforming health care--ought to be about driving down 
costs, it ought to be about providing more access to Americans, it 
ought to be about maintaining that important relationship between a 
physician and their patient and not getting to where we have the 
government making those decisions, where we are actually bending the 
cost curve up rather than driving it down.
  By the way, the CBO said in response to the majority's bill that was 
unveiled yesterday that it actually increases costs by $160 billion. To 
me, the fundamental goal of health care reform for most Americans, the 
key concern they have about health care today, is its costs. Everything 
we have seen so far, including this most recent version which we are 
going to have at some point on the floor of the Senate, probably 
sometime after the Thanksgiving holiday, increases costs, drives the 
cost curve up.
  How can you be for something that cuts Medicare to providers and 
seniors across this country, that raises taxes on small businesses, the 
economic engine that creates jobs in this country, raises taxes on 
middle-income Americans and which also, ironically, raises the cost of 
health care, increases the cost of health care? I am not saying this is 
the CBO. That has been consistent through all the bills that have been 
produced. It is consistent with this one as well that the proposals and 
all the new provisions that will be included--again, $2.5 trillion, 10-
year fully implemented costs paid for by Medicare cuts, $\1/2\ trillion 
in Medicare cuts, $\1/2\ trillion in tax increases, and obviously much 
more than that when you get into the fully implemented time period, all 
that--all that--to raise health care costs for people in this country. 
How can we label that reform?
  I hope the American people, as they listen to this debate, will 
engage, will take a hard look at this 2,074-page bill. It is going to 
be a lot of legislative, arcane language. We are all going to do our 
best to make sense out of it. But it is a massive bill, just in terms 
of its volume. It also includes a massive expansion of the Federal 
Government in Washington, DC, at tremendous cost to the taxpayers, to 
Medicare beneficiaries and, in the end, doesn't do anything to drive 
down the cost of health care. It simply increases it and puts at risk, 
I would argue, many of the types of things I talked about with regard 
to breast cancer screening. When government is making decisions rather 
than patients and doctors, that is a world in which I don't think I 
want to enter, and certainly I think most Americans don't either.
  Mr. President, I ask unanimous consent to have printed in the Record 
a Wall Street Journal editorial.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                        A Breast Cancer Preview

       A government panel's decision to toss out long-time 
     guidelines for breast cancer screening is causing an uproar, 
     and well it should. This episode is an all-too-instructive 
     preview of the coming political decisions about cost-control 
     and medical treatment that are at the heart of ObamaCare.
       As recently as 2002, the U.S. Preventative Services Task 
     Force affirmed its recommendation that women 40 and older 
     undergo annual mammograms to check for breast cancer. Since 
     regular mammography became standard practice in the early 
     1990s, mortality from breast cancer--the second leading cause 
     of cancer death among American women--has dropped by about 
     30%, after remaining constant for the prior half-century. But 
     this week the 16-member task force ruled that patients under 
     50 or over 75 without special risk factors no longer need 
     screening.
       So what changed? Nothing substantial in the clinical 
     evidence. But the panel--which includes no oncologists and 
     radiologists, who best know the medical literature--did 
     decide to re-analyze the data with health-care spending as a 
     core concern.
       The task force concedes that the benefits of early 
     detection are the same for all women. But according to its 
     review, because there are fewer cases of breast cancer in 
     younger women, it takes 1,904 screenings of women in their 
     40s to save one life and only 1,339 screenings to do the same 
     among women in their 50s. It therefore concludes that the 
     tests for the first group aren't valuable, while also noting 
     that screening younger women results in more false positives 
     that lead to unnecessary (but only in retrospect) follow-up 
     tests or biopsies.
       Of course, this calculation doesn't consider that at least 
     40% of the patient years of life saved by screening are among 
     women under 50. That's a lot of women, even by the terms of 
     the panel's own statistical abstractions. To put it another 
     way, 665 additional mammograms are more expensive in the 
     aggregate. But at the individual level they are immeasurably 
     valuable, especially if you happen to be the woman whose life 
     is saved.
       The recommendation to cut off all screening in women over 
     75 is equally as myopic. The committee notes that the 
     benefits of screening ``occur only several years after the 
     actual screening test, whereas the percentage of women who 
     survive long enough to benefit decreases with age.'' It adds 
     that ``women of this age are at much greater risk for dying 
     of other conditions that would not be affected by breast 
     cancer screening.'' In other words, grandma is probably going 
     to die anyway, so why waste the money to reduce the chances 
     that she dies of a leading cause of death among elderly 
     women?
       The effects of this new breast cancer cost-consciousness 
     are likely to be large. Medicare generally adopts the panel's 
     recommendations when it makes coverage decisions for seniors, 
     and the panel's judgments also play a large role in the 
     private insurance markets. Yes, people could pay for 
     mammography out of pocket. This is fine with us, but it is 
     also emphatically not the world of first-dollar insurance 
     coverage we live in, in which reimbursement decisions deeply 
     influence the practice of medicine.
       More important for the future, every Democratic version of 
     ObamaCare makes this task force an arbiter of the benefits 
     that private insurers will be required to cover as they are 
     converted into government contractors. What are now merely 
     recommendations will become de facto rules, and under 
     national health care these kinds of cost analyses will 
     inevitably become more common as government decides where 
     finite tax dollars are allowed to go.
       In a rational system, the responsibility for health care 
     ought to reside with patients and their doctors. James 
     Thrall, a Harvard medical professor and chairman of the 
     American College of Radiology, tells us that the breast 
     cancer decision shows the dangers of medicine being reduced 
     to ``accounting exercises subject to interpretations and 
     underlying assumptions,'' and based on costs and large group 
     averages, not individuals.
       ``I fear that we are entering an era of deliberate 
     decisions where we choose to trade people's lives for 
     money.'' Dr. Thrall continued. He's not overstating the case, 
     as the 12% of women who will develop breast cancer during 
     their lifetimes may now better appreciate.
       More spending on ``prevention'' has long been the cry of 
     health reformers, and President Obama has been especially 
     forceful. In his health speech to Congress in September, the 
     President made a point of emphasizing ``routine checkups and 
     preventative care, like mammograms and colonoscopies--because 
     there's no reason we shouldn't be catching diseases like 
     breast cancer and colon cancer before they get worse.''
       It turns out that there is, in fact, a reason: Screening 
     for breast cancer will cost the government too much money, 
     even if it saves lives.

  Mr. THUNE. Mr. President, I yield the floor.
  The PRESIDING OFFICER. The Senator from Michigan.
  Ms. STABENOW. Mr. President, I ask unanimous consent to speak for up 
to 20 minutes in morning business.
  The PRESIDING OFFICER. Without objection, it is so ordered.

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