[Congressional Record Volume 156, Number 39 (Wednesday, March 17, 2010)]
[House]
[Pages H1586-H1592]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
HEALTH CARE REFORM
The SPEAKER pro tempore (Mr. Tonko). Under the Speaker's announced
policy of January 6, 2009, the gentleman from Texas (Mr. Burgess) is
recognized for 60 minutes.
Mr. BURGESS. The last hour just ended, and you heard the admonition
at the end of the hour that it is extremely important for people to pay
attention. And during this hour, I am going to echo that thought. It is
important for people to pay attention, Mr. Speaker, and, yes, I will
direct my remarks to the Chair. But, Mr. Speaker, if I could talk to
the American people, what I would tell them is now is the time, it is
late at night, but now is the time for you to be keeping this House
under intense scrutiny and watch what happens here over the next 72
hours as we drag this carcass of a health care bill across the finish
line.
Now, how did we get here? It's probably useful to think about things
for just a moment. We had a big election in 2008. People said they
voted for change. Right before that election in 2008, in the other
body, the chairman of the Senate Finance Committee held a big meeting
over in the Library of Congress and had all the big players and the
stakeholders in health care in the room, and came up with what was
called a white paper on health care reform. For all the world, it
looked like a bill. For all the world, it looked like it would be the
bill that was brought forth in the Senate should the Democrats take
control of the White House, the House and the Senate. Indeed, the
election was held, and they did.
I will tell you, Mr. Speaker, I was somewhat surprised that there was
not a health care bill, no health care bill came forth in those early
days after the election. I thought perhaps we would see one in December
of 2008 during the holiday season, but no health care bill. No health
care bill in the weeks that the Congress was getting organized. We had
a big inauguration, no health care bill. We had a designee named to be
Secretary of Health and Human Services. Still no health care bill was
forthcoming. Well, surely it will come along right after that
confirmation for Health and Human Services. But as it turns out, that
individual had some tax problems and that nomination was withdrawn
before it ever got to the confirmation vote in the full Senate. So we
were left without a Secretary of Health and Human Services for several
months, no health care bill.
Suddenly, it was early summer. There was a letter sent from the other
body from the two committees of jurisdiction, the Health, Education,
Labor and Pensions Committee over in the other body, and the Senate
Finance Committee in the other body, they sent a letter to the
President and said, We will be producing a health care bill within the
next couple of weeks. In fact, the Health, Education, Labor and
Pensions Committee did produce a bill. The coverage and cost numbers
were quite startling when they were revealed: A cost of $1 trillion. It
left a lot of people uncovered as the original plan was unveiled, and
then several weeks were spent in what was called the markup of that
bill over in that committee over in the Senate.
Then the three committees of jurisdiction in the House had a health
care bill that was rapidly brought forward. We didn't really get a lot
of time to look at it. There was certainly no subcommittee markup. It
came straight to our Committee on Energy and Commerce for a markup. And
to give credit to the chairman of the Energy and Commerce Committee, we
did get a little more time than the other two committees, the Committee
on Education and Labor and the Committee on Ways and Means. They each
had a day, a 24-hour period, to mark up this bill. Think of that. This
bill, this legislation that's going to affect the lives and livelihood
of Americans for the next three generations was allowed 1 day in markup
in Ways and Means, 1 day in markup in Education and Labor. We at least
had 8 days in Energy and Commerce. Four of those days were spent
recessed because we couldn't agree on some things, but we did have more
time in the Committee on Energy and Commerce than in any other
committee in the House.
Think back, Mr. Speaker, to the Clean Air Act in the early 1990s. I'm
told it was an 8-month markup for the Clean Air Act, 8-month. Think how
the people on those committees must have hated each other at the end of
those 8 months. But what did they get? What did they get for that 8
month investment? They got a bill that had support from both
Republicans and Democrats, eventually passed the House, eventually
passed the Senate, eventually was signed into law by George Herbert
Walker Bush, and the Clean Air Act became the law of the land and
arguably has been successful since that time. So that's the way the
process is supposed to work.
Let me take one step back. The House passed a bill, the Senate passed
a bill, they went to a conference committee, had a continuation of that
long and drawn-out process, but the conference committee produced a
conference report that was endorsed by the Senate, endorsed by the
House, again bipartisan majorities on either side, the bill then went
to the President for his signature, and that's what we now know as the
Clean Air Act.
But think of the difference between that major piece of legislation
that had a great and far and reaching affect on the lives and
livelihood of every American, contrasted with what we've done over the
past year.
And quite honestly, Mr. Speaker, it's not that we didn't have time.
It's not that we didn't have time. After all, we have been working on
this thing nearly 15 months. We actually had time to do a real markup
in each of the three House committees. We had time to do a real markup.
We had time to do a real conference committee.
Look at the timeline of this bill. We got it in Energy and Commerce
in the middle in July. We didn't have a lot of time to deal with it
before, but when we got it, we worked on it, we worked hard. I offered
a multitude of amendments. I had 50 amendments prepared in committee.
Five of those were accepted by the time the bill passed out of
committee, all of those on a voice vote, so presumably a unanimous
vote, and every one of those amendments was stripped out when the bill
went to the Speaker's Office before it came back to the House, to the
House floor in late October, and then we had the vote in the House in
early November.
The Senate had their bill. The Senate Finance Committee completed
their work in the fall. They brought their bill to the Senate in the
month of December. It was voted upon, famously, on Christmas Eve, and
then the normal sequence of events would be for the bill to go to a
conference committee. And there in the conference committee, yes, the
Democrats have substantial majorities in the House and the Senate. The
Democrats would have had a significant advantage in the conference
committee. The idea of the conference committee is to meld the
differences of those two bills to create a product that can be endorsed
by both Houses in the Capitol.
But they didn't do that. They thought, well, that was hard to get
that one through the Senate. Let's not go through regular order. Let's
try something different. And that something different was, maybe we can
just get the House to pass the Senate bill because the Senate bill was,
in fact, a House bill. It has a House bill number. In fact, it was our
appropriations bill, I think, for Treasury Department appropriations
last year. It did pass the House as an appropriations bill, went over
to the Senate for work on their appropriations bills. That never
happened, but the bill was then used as a shell. The legislative
language for appropriations was stripped out, the health care language
was put in, so the Senate passed a House bill on Christmas Eve, and
then that bill can come back through those doors, come into the House,
and the Speaker of the House will say, the business of the House is
now, will the House concur with the Senate amendment to H.R. whatever
it is, the House agrees by a simple majority, at that time 218 votes,
and the bill goes to the President's desk.
[[Page H1587]]
But House Members didn't want to do that. They didn't like the Senate
bill. For some it didn't go far enough. For some it went way too far.
But the Senate bill was not seen to be an acceptable product. So while
all of that discussion was going on, there was a little-noticed, to
that point, election that took place in the State of Massachusetts, and
the election was to fill the vacancy that was created when Senator
Kennedy died. And that election was won by Scott Brown, who is a
Republican who said he would be the 41st Republican vote against this
health care bill.
Whoa. Now, a lot of doors are closed over in the other body. They can
no longer go to a conference committee and expect that they will have
their 60-vote majority to pass anything they want. In fact, to take any
bill back to the Senate now, and under Senate rules where you need to
have 60 votes to cut off debate, that is going to be a pretty tall
order because they only have 59 votes, 41 votes on the Republican side.
So what to do? We do still have the bill that was passed by the
Senate. That Senate bill passed with a 60-vote margin, so it is still
quite viable. If there is just some way to convince the House to vote
for that bill. Now the Republican side, we didn't vote for it in the
first place, we are not likely to vote for it in the second place. But
on the Democratic side, if they can put together enough coalitions and
enough votes, now the number is only 216, with some unfortunate deaths
we have had on this side and some people who have left the House of
Representatives, so 216 is the simple majority in the House. That is
all that is required. So, well, look, maybe if we could do some
technical corrections, we can't really do them to the bill because the
bill has already passed the Senate, and if we took those corrections
back to the Senate, we would have to have 60 votes to cut off debate.
But there is a Senate process called reconciliation to deal with
budgetary and fiscal matters. And under reconciliation, only a simple
majority is required in the Senate. Maybe we could do those technical
considerations in the Senate under reconciliation and pass that through
the Senate with 51 votes.
{time} 2100
And if we, the Senate, do that, will the House then agree to pass our
bill with the understanding that these technical corrections would
quickly be instituted? That is the big question right now. And are
there going to be any problems with any of those technical corrections
to be done under reconciliation?
Well, there might be. There might be. Because, remember,
reconciliation is to pass those very tough budget and fiscal bills that
are really hard to get the number of votes because sometimes you are
actually cutting spending, sometimes you are actually irritating a
constituency back home because we are reducing Federal spending in some
of those reconciliation bills.
If it deals with budgetary issues and spending issues, then it could
pass under reconciliation with 51 votes. The Vice President gets to
vote in the case of a tie over in the Senate. So 50 Senators plus the
Vice President would actually pass any of those reconciliation
provisions, unless, unless someone makes a point of order over in the
Senate that they don't deal exclusively with budgetary issues, that
they are in fact changes in policy that are outside the budgetary
process. Then the Senate has rules that say if a point of order is
made, that it would require 60 votes to put that provision into the
reconciliation bill, the so-called Byrd rule initiated by Robert Byrd,
the dean of the Senate many, many years ago, to keep just this type of
problem from happening. Didn't want the Republicans if they got in
charge to be able to do things like this.
So the Byrd rule has been in effect for a number of years; and the
Byrd rule would say, well, say you have a contentious issue in the
House bill. Say there is some issue with the language regulating the
Federal funding of abortion. Say there is some question of what do we
do as far as dealing with people whose legal status in this country may
be in some question. Well, those issues are beyond budget and may in
fact be subject to a point of order and may require 60 votes to then be
included in the reconciliation bill.
So it is not a given that everything that is wanted by House
Democrats in changes in the Senate bill for the House to agree to pass
the Senate bill, they may not be there when those technical corrections
are finally voted on in the Senate. And that will take some time,
because every amendment in the Senate may not necessarily be debated,
but every one will be voted on; and all of that is going to take some
significant time.
So where we are in the House tonight is that my understanding is the
Rules Committee is to meet soon, if they are not already meeting, and
the Rules Committee will come up with the language for that
reconciliation bill. None of us have seen that yet. It hasn't really
been scored by the Congressional Budget Office, so no one really knows
what this bill will cost yet. So all of that is still hanging out
there.
Then there is one more wrinkle thrown in. The Speaker of the House
said it very well the other day: no one wants to vote for the Senate
bill.
Well, that is a problem if you are going to need to get 216 votes in
the House for the Senate bill to allow the reconciliation bill to then
go forward to fix the technical problems in the Senate bill. I know
this gets a little confusing, but no one wants to vote for the Senate
bill.
Is there a way around voting for the Senate bill? Probably not. But,
wait. What if we voted on a rule that allowed us to go forward with
reconciliation, and within that rule we kind of made it like the Senate
bill had already passed without actually having to vote on it?
Mr. Speaker, I would just ask the question: Do you really think the
American people are not paying attention? The last Democrat who spoke
here in the well of the House said it is time for the American people
to pay attention to this process. I would submit that is exactly right.
Now, many people will recognize this icon, the Capitol Rock figure
from when my children were young. This was the individual who was just
a bill, and one day he hoped to be a law but today he was just a bill.
But you can see today he is mad. He is angry. And why is he angry? He
is still a bill. He wants to be a law. But he doesn't want to be
deemed, and he doesn't want to be ``slaughtered,'' referring to the
Slaughter rule that the House may vote on. By this time on Sunday the
House may vote on the Slaughter rule which would deem acceptance of the
Senate product.
Well, you can see why Mr. Bill is upset. He wants to go through
regular order. He wants to go through committee, he wants to be voted
on by the House, he wants to be voted on by the Senate. He really would
have liked to have gone to a conference committee and have those two
products melded together and then come back for an up-or-down vote in
the House or the Senate. But as it appears tonight, he may not get his
wish.
And is there a consequence to doing this? Now, you are going to hear
people say that, oh, things have been deemed for a long time. This is
nothing new. I will tell you, this is different. This is new. This is
not something that, certainly in my short tenure, I have seen.
In fact, I recall a reconciliation bill in 2005 when the Republicans
were in charge, it was called the Deficit Reduction Act, a very
contentious bill, because we were trying to bend the cost curve on
Medicaid spending. Does that sound familiar? You have heard the term
``bending the cost curve.'' We were trying to bend the cost curve on
Medicaid spending from an increase of 7.7 percent year over year to 7.3
percent growth year over year. Not a heavy lift in anyone's book, but
it was a big lift here in the United States House of Representatives.
Now, we were coming to the end of the calendar year 2005. In fact, it
was coming up on to the Christmas holidays. People were anxious to get
home and be with their families. We voted on that bill, as I recall,
early on a Monday morning. We had been here through the weekend, up all
night, debates, debates, debates. A lot of changes, a lot of moving
things around on the chessboard. And then, in the final analysis, the
bill passed very early in the morning on a Monday morning. I think it
was December 19, so it was getting very close to that cutoff for
Christmas.
Later in the week, that bill was voted on in the Senate. And this was
a
[[Page H1588]]
conference report. We had voted on the regular bills, it had gone to a
conference, so these were the conference reports that we were voting up
or down on.
The House passed its version. The Senate passed its version on
Tuesday or Wednesday, quickly left town, and were gone. The House had
already vacated the premises. And it was found that there was a little
discrepancy. There were some differences in wording between the two
bills.
Well, as they should have done, the Democrats that were then in the
majority went nuts and they said, You cannot send that bill down to the
White House for a signature because the House and the Senate did not
pass the same bill, the same identical language. And it was a big deal.
The reason I remember this so well is, remember the doctor fix that
we talked about a lot? In fact, we did a little doctor fix today. We
extended the time before the doctors get their big pay cut; we moved
that from April 1 to May 1. Well, there was a doc fix in the
Deficit Reduction Act. At that point, I think the doctors were facing a
6 percent reduction in Medicare reimbursement, and that clock ran out
at midnight on December 31.
We fixed it in the Deficit Reduction Act, but there was a problem.
The House bill and the Senate bill were not word for word identical. I
don't even remember the number of words that were different. It was not
many. It seemed like an awfully picky process. But in order to comport
with all of the laws in our Constitution, the House and the Senate had
to pass identical bills for the bill to be regarded as passed and be
available to go down to the President for his signature. So the clock
ran out on Medicare and the doc fix.
Now, everything else that was in the bill was not perishable, and it
would keep until the House came back in January of 2006 and could fix
the damage. In the meantime, there was much wailing and gnashing of
teeth here in the House on the then-minority Democratic side: this is
unconstitutional. We will go to court. We will take this down. So the
bill did not go to the President for his signature. It stayed and
languished. And then, when the House came back, they passed identical
language to the Senate. The bill was passed and went off to the
President for his signature. The doc fix was taken care of a month
late.
Dr. Mark McClellan, who was then the administrator for the Center for
Medicare and Medicaid Services, told the country's doctors that he
would make good and retroactively supply that difference in the bills
that they had submitted; they would not have to resubmit. He tried to
paper over the problem and make it as painless as possible.
But it was a big deal. It was a painful deal for the country's
doctors. That is why I remember it so well, because so many were
calling me in my district office and my staff here in Washington and
voicing their displeasure that Congress really couldn't have gotten
this right and passed the identical bill through the House and the
Senate. But the fact is they didn't. And the fact is that that was a
problem as far as passing a bill and getting it signed by the Senate.
Well, what are we doing today or this weekend? What are we doing? We
are not even going to pass the bill. We just deem it as having passed.
Because, you know, a lot of the things that are in the Senate bill are
things that we have talked about a lot here in the past 14 or 15
months, and some of them we may have even voted on a time or two. So we
can just deem it as having passed.
Well, no wonder, no wonder Mr. Bill is so mad. That is not what he
signed up to do. He didn't want to be deemed or Slaughtered.
Slaughtered refers to the chairwoman of the Rules Committee who has
created the so-called Slaughter rule, which means that the rule that
allows us to take up the reconciliation bill is a self-executing rule
and will deem passage of the Senate product that passed on Christmas
Eve.
Do you think the American people can't see through that, Mr. Speaker?
Do you think there are many phone calls going into Members' offices
over the past couple of days about this? I think so, because I have
heard from a lot of people. They are not happy about a lot of things
right now, but they are really upset about this, and I think rightly
so.
We are supposed to do things by the book. That book is called the
Constitution. And when we stray from that on something like this--and
this is no small matter--this is going to affect one-seventh of the
Nation's economy. This is going to affect the lives and livelihood of
every American not just this month, not next month, not the month after
that, but for the next three generations.
Think of Medicare, passed in 1965. How has that affected people's
lives, for good or for ill? But this is sweeping legislation that has a
long half-life and is going to affect the way of life in this country
from this day forward, really long past my time on this Earth, and I
suspect a long time past the life expectancy of almost everyone who is
serving in this body.
So it is so important that we get this right. It is our obligation.
It is the oath that we swore on this floor the early part of January of
2009 after those very famous elections, those historic elections that
created the new Presidency, created a supermajority for Democrats in
the House, created almost a filibuster-proof majority in the other
body. A historic election.
We were signed in, we put our hands on our hearts, we put our hands
on the Bible, we swore an oath to protect and defend and uphold the
Constitution.
What happened to that, men and women who are here with me tonight?
What happened to that oath? Did you not believe it then, or has
something happened that you don't believe it now?
This is critical. I know it looks lighthearted. I know I have copied
a figure from a children's musical. But this is critical. This is going
to change the way of life for every American, not just now, but for far
into the future.
Now, we don't even know yet the cost of this bill. There are multiple
iterations of the reconciliation package that have been floated around
the Congressional Budget Office. You call them up and try to get them
to do anything at all and they will not because they are working on
health care. Unfortunately, it has been that way now for well over a
year. It is almost impossible to get any piece of legislation scored by
the Congressional Budget Office, but we don't even know what this thing
is going to cost.
We talk about bending the cost curve. The Commonwealth Foundation,
the good folks at the Commonwealth Foundation, I attend a number of
their seminars. I think they do a good job of trying to educate Members
of Congress. They will talk in lofty terms about bending the cost
curve. Well, we are just bending the cost curve, all right. We are just
bending it in the wrong direction.
Now, this bill is supposed to cost on the order of $800 billion and
change. I think it was $824 billion. But anyone will tell you that is
not the real cost. In fact, when this reconciliation stuff gets scored,
it is very likely that we are going to see a number in excess of $1
trillion.
You know, just a lot of this stuff people look at it and say, What is
the plain truth here? You say that you are going to raise taxes by $500
million, you are going to cut expenses in Medicare by $500 billion, and
you are going to cover 30 million more people. How is that not going to
affect me? You say if I like what I have, I can keep it, but how in the
world is it possible to do all of those things and it won't affect me?
And the President said this several times during the summer. He said:
Many people look at this bill and say, What is in it for me? What do I
see differently, either positively or negatively, after this bill has
passed?
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For one thing, we know what they will see is a lot of new Federal
regulations. We're going to see new fees on insurance companies, new
fees on medical devices, new fees on prescription drugs, new fees on
insurance plans. All of those, of course, have to, by definition, drive
up health care costs.
One of the things that we're not doing--and you've heard me reference
the ``doc fix'' in the Deficit Reduction Act. We had a baby ``doc
fix,'' if you will, for just the next month. But there is a looming 21
percent reduction in reimbursement for physicians who practice in the
Medicare system, doctors
[[Page H1589]]
who take care of some of our sickest patients, our seniors who might
have multiple medical comorbidities. We've asked them to do this, and
yet we come at them every year with a formula that says we're going to
pay you a little less this year than we paid you last year.
Now maybe that's okay if you're fortunate enough to practice medicine
in a location where energy prices are falling by 5 percent every year,
labor costs are falling by 5 percent each year, cost of capital is no
concern because the banks are just giving away plenty of money at a
zero percent interest rate. Maybe if you live in that area, this is not
a problem.
But most of the doctors who live in the real world, the same world as
you and I, know that their costs of labor are going up. Their cost of
capital is going up. In a doctor's office, you don't make a great many
large capital purchases, but you sometimes hire a new doctor; and in
order to do that, you sometimes have to go down to your friendly banker
and secure either a loan or a line of credit. So the cost of capital
goes up for those physicians' offices year after year.
Energy costs go up the same as they do for every other American. Even
the cost of the doctor buying the health insurance for their employees
will go up. Believe it or not, the insurance companies don't come into
the doctor's office and say, Doc, you know what? You've done such a
good job at taking care of all the people enrolled in our insurance
company that we're going to enroll your employees for free or at a very
reduced rate. It doesn't happen.
In fact, what happens in doctors' offices across the country every
year is the insurance underwriter comes in and says, Hey, you've had
some claims activity. Your rates are likely to go up in your small
business here. And the doctor says, Well, maybe that's okay because
maybe my reimbursement rates are going to go up enough to match it. But
then most private insurance companies actually peg their reimbursement
rates in the private sector to Medicare. So if Medicare is reduced by 5
percent, 8 percent, 21 percent, as we're scheduled to do this year,
guess what? Insurance reimbursement rates go down. So the poor doctor
is left scratching his or her head, saying, How come it costs me more
to insure my employees and my reimbursement rates are going down? How's
that going to work out for me?
The cost of doing business in a medical office is no different than
any other small business in America, and doctors' offices simply cannot
continue to survive if we continue to impose this draconian pay formula
upon them, and yet nothing in this bill fixes that problem. We had a
temporary fix today. We talked in grand terms about this great and
wonderful fix that the House passed last fall, but we all knew over
here in the House, even those of us who voted for it, we knew that the
Senate was never going to take it up and pass it. In fact, they had
already rejected it. As a consequence, this provision has been left out
of this big, gargantuan health care bill, this 2,700-page bill, and
there is no fix for the problems that the doctors face in the Medicare
reimbursement system. There is no fix in the bill.
It's a simple arithmetic problem. The simple arithmetic problem is
that it costs somewhere between $280 billion and $350 billion to fix
that problem. Well, clearly, if you're trying to keep the cost of your
bill under a trillion dollars, and I'm not sure that they have done
that, but if you're trying to do that, a $350 billion addition to the
price tag is not likely to make your life any easier.
There is a cost for simply repealing the sustainable growth rate
formula, as it's called. Medicare part B has an additional problem in
that, by law, seniors are charged 25 percent of the actual cost of
their premium. The Federal Government picks up the other 75 percent
very generously. But if the cost of the Medicare part B program
increases, then Medicare part B premiums, by law, have to increase, and
they have to increase by a formula which, again, is 25 percent of the
actual cost.
Now we hear a lot of talk about insurance companies raising the
rates. They do. Can they justify it or not? There are supposed to be
State insurance commissioners to oversee that process. I know we had a
big hearing in my committee on Energy and Commerce a few weeks ago on
the Anthem, WellPoint rate increases that occurred out in California,
but I honestly don't know where the California insurance commissioner
was when all of that was going on. And the people at Anthem did say
they submitted their paperwork to the insurance commissioner. I don't
know what happened there. I honestly don't know what the disconnect
was, but there are rules in place where these types of increases are
supposed to be justified.
But the fact is that part B recipients will likely get a big increase
in their premiums this year because the cost of paying for the part B
program goes up every year, and, just interestingly enough, that
increase is likely to be somewhere in the order of 12 to 16 percent.
The President is very critical of private insurance companies that will
do that but, wow, he is the CEO of the biggest insurance company in the
world. It's called Medicare. And he's raising his rates by 12 percent
this year. In fact, over the last decade, over the last 10 years, those
premiums have increased almost 150 percent. Again, it's by law. It's no
one doing something that they shouldn't be doing. It is just the cost
of delivering that medical care has, in fact, increased over time, more
people making claims on the system. And as a consequence, those costs
have gone up, and, by law, the seniors who are participants in the part
B program are obligated to pay 25 percent of the cost of the program in
their premium.
So when people tell you that the cost of insurance is going to
increase, that's true whether you're talking about a Federal program,
such as Medicare, or programs in the private sector.
One of the things that concerned a lot of us as the debate was going
through the House this summer was the appearance of what was called a
public option. At the time, a lot of concern by, actually, Members on
both sides of the aisle--probably voiced more consistently by people on
the Republican side--about what this public option was going to do to
pay for insurance coverage in this country. Many people on the
Democratic side said, Oh, it'll be competition for the insurance
companies so it'll bring their prices down.
Well, here's part of the problem. One of the reasons that the
insurance companies are raising their prices is because there is a
cross-subsidization, that there is a shifting of cost from the
government sector onto the private sector. Medicare reimburses at a
rate that's far lower than most of the private insurers for both
doctors and hospitals. In order for those doctors and hospitals to keep
their doors open, that means they need to charge a little bit more to
those patients who come in who have actual insurance coverage. So that
cost shifting or cross-subsidization exists because the government
isn't actually carrying its share of the load today. So if we expand
that part, how are we going to help keep the costs low on the private
side? Because, again, it's a cross-subsidization that we're already
doing in the existing public plans--Medicare, Medicaid, SCHIP, and the
variety of other programs that exist. Those public programs are not
filling the holes that are being dug, the overhead holes that are being
dug at hospitals and doctors' offices, and those holes have to be
filled with dollars from private insurance.
So right now it's about a 50-50 mix. Well, that's not fair. Fifty
cents out of every health care dollar that's spent in this country
today is already spent on one of those public options--Medicare,
Medicaid, SCHIP, add the VA, Federal prison system. It's about fifty
cents out of every dollar that is spent on health care, and it is going
up. The other 50 percent is not all private insurance. Some of it is
paid out of cash flow for some families; some of it is paid out of
savings for some families, and some doctors and hospitals just simply
have to write off some debt because it will never be paid. They
certainly do contribute more than their share of charity care.
So the government, which has about 50 percent of the health care
dollar right now, is not carrying its load, which drives up the cost
for people with private insurance. So we're going to expand that part
and expect that the cost for private insurance is somehow going to go
down. You're talking about magical thinking. That's just never going to
work out. There's no way it can work out.
[[Page H1590]]
And sometimes you step back and you look at this and you think, Wow,
the people who want a single-payer, government-run system have really
set the wheels in motion to accomplish just that. Let's create another
public option, bleed off more dollars from those greedy folks on the
private side. Their prices go up. The President, whoever the President
is at that point, says, Well, I tried. We tried to keep the private
sector involved, but look what they've done to you. There's nothing we
can do about it. We will just have to take over everything. At that
point, you have a completely nationalized health care system in the
United States of America.
A lot of people look at that and say, No, that's not what we want.
You said, if you like what you have, you can keep it. That's what we
want.
Sixty-five percent of Americans have insurance either through their
employer or in the individual market, and they like what they've got.
They're concerned about cost, to be sure. They want costs to be held
down, but they like what they have and they want to keep it. So it does
concern them when they look out over the horizon and say, What might
have happened with this public option?
Now, the Senate bill, at least in theory, does not have the public
option written into the bill. It does. It's kind of hidden. You kind of
have to look for it a little bit. The Senate bill sets up insurance
exchanges across the country in order to ensure that everyone has
access to at least two products in an insurance exchange. The Senate
has said that the Office of Personnel Management, OPM, will ensure that
there is at least one for-profit and one not-for-profit insurance
company in each of those exchanges. Well, what happens if no one shows
up on the day they hold the auction to sell the insurance? Office of
Personnel Management will find a for-profit company and a not-for-
profit company, and if they can't find one, somehow they will make one.
Now, the Office of Personnel Management right now is a relatively
small Federal agency. It administers Federal benefits. It administers
things like the Federal Employees Health Benefits Plan. It does a good
job with that, arguably, but this is a vast expansion of their mission,
a vast expansion of scope to then put them in charge of these various
exchanges that are in place all around the country. The Office of
Personnel Management could become the de facto public option, and in
fact, as it was looking like this bill was getting very close to being
enacted in the early part of January before that famous election in
Massachusetts, the Office of Personnel Management was indeed gearing up
to take on that responsibility.
So whether you get the House bill or the Senate bill, there's still a
possibility that you're going to see a public option. It may not be the
so-called robust public option that you heard talked about here on the
floor of the House ad infinitum last summer, but it will be a public
option nevertheless, and it remains to be seen what happens to that
over time. It may always stay a small part of what is available to the
insurance market or it may grow significant.
What has been mystifying to me about that process, and you heard the
President say earlier or last year in the fall, he cited there's a part
of Alabama that you go to and you have only got one choice of an
insurance company; and if you've only got one choice of an insurance
company, there's not a lot of competition, so let us put a federally
administered program on the ground to compete with that one insurance
company.
{time} 2130
But there's well over 1,000--in fact, over 1,300 insurance
companies--in business right in the United States of America. What if
we changed the regulations such that more companies could, in fact,
sell in that market in Alabama? It looks to me like a market that
companies might be interested in because, after all, there's not much
competition there. That's the way to get robust competition in the
market, and that is the way to get the types of cost controls that we
would all like to see that could be delivered more efficiently by a
competitive marketplace than it can be by government regulation and
price-fixing.
We know what happens when you fix prices. Those of us my age who are
old enough to remember gasoline purchases in the 1970s, when you put
price controls on gasoline, you end up with gasoline shortages. You
remove the price controls, and miraculously there's enough gasoline for
everyone to buy. And as more gasoline becomes available, then the price
comes down. It was a wonderful study in just how markets were supposed
to work. You put the price controls on, it becomes very scarce and very
expensive. And I can remember as a young resident at Parkland Hospital
waiting for hours in line at a gas station because I did not want my
gas tank to be empty and risk running out of gasoline on the way to the
hospital in the middle of the night. It's something I couldn't afford
to let happen to me. So I missed a lot of family time sitting in those
gasoline lines. Fortunately, that didn't last long because the folly of
that decision was recognized, the price controls were removed, and the
price went up temporarily, and then it came back down as the supply of
gasoline increased.
We don't know where we're going on the cost of this bill that's
before us. The one charge that the American people gave us was, We want
you to do something about the cost of health care. The one thing that
we're not doing in this legislation is moving in a sane way towards
doing anything that would get control of those costs. In fact, some of
the things we're doing may, indeed, lead to a reduction of
availability, and that means a reduction of access for patients to
medical care.
An interesting little article that I found online on the way over
here tonight was about what will happen to health insurance premiums
under the bill that has been proposed. And what got this reporter's
attention was a Presidential speech where he said that the cost of
insurance if the bill was enacted would drop by 3,000 percent. Later
on, the White House clarified and said the President meant to say the
premiums would drop by $3,000, and that is money that could be returned
to the worker.
The next quote in the story is, `` `There's no question premiums are
still going to keep going up,' said Larry Levitt of the Kaiser Family
Foundation, a research clearinghouse on the health care system. `There
are pieces of reform that will hopefully keep them from going up as
fast. But it would be miraculous if premiums actually went down
relative to where they are today.' '' So next line in the story is,
``It could be a long wait.'' Indeed, it could.
I do urge people to pay attention. I do urge people to dig a little
deeper in the story--don't necessarily accept what I am saying here
tonight. But do look carefully into this story and understand what your
Congress is doing because if it doesn't affect you the day after the
bill passes, it will affect you at some time.
Now convincing reluctant Members to vote on this bill by doing the
Slaughter rule and deeming the bill passed may be a way to trick some
wavering Members into voting for the bill. But I promise you, it's not
tricking anyone out there in America. You hear stories of people going
to the supermarket at the checkout line, and the person who's checking
their groceries will say, You are not really going to deem that bill as
passed, are you? They get it. People understand it. They've been
watching this. We've been working on this for 14 or 15 months. Goodness
knows we're tired of it. The country is tired of it. People do
understand and are watching.
Now tomorrow in The New England Journal of Medicine, it's been widely
reported that they're going to have an article detailing the attitude
of America's physicians towards this legislation that the House of
Representatives is likely going to try to pass sometime this weekend.
The numbers were somewhat startling, and I don't have the exact numbers
in front of me. But if the bill were to pass, around 30 percent of
practicing physicians would consider concluding their practice and
finding something else to do with their time. And if a public option is
included, that number gets significantly higher--45, 46 percent.
People who have been working in the trenches, who have been
delivering the health care, understand how pernicious
[[Page H1591]]
it has been with the constant reduction in rates for Medicare, to be
sure, Medicaid in some States. In most States, physician reimbursement
is just an easy target. When those State budgets start getting
stressed, that's one of the first places that the State legislatures
will go to try to pull some of those dollars back in. They'll reduce
reimbursement rates to physicians. And as a consequence, if it was
difficult to keep your doors open and pay your overhead costs with the
reductions that we were seeing in Medicare, it becomes an absolute
certainty that those doors are not going to stay open if Medicaid rates
are vastly curtailed.
One of the things we're going to do with this bill is significantly
expand Medicaid. The cost to the States right now is somewhat in flux.
Nebraska got a pretty good deal on the Senate floor right before
Christmas that would kind of protect them against some of the dollars
that the State would have to match into the Medicaid program. Now
there's talk of extending that to every State and not just making
Nebraska a special case but extending that to every State. I promise
you, I promise you that is not going to make the cost of this
legislation go down. It is going to make the cost of that legislation
go up significantly.
If we don't do that, right now there is a Federal share and a State
share of Medicaid expenses that are paid. It varies from State to
State. In some, it's a 50-50 proposition. In some, it's much more
generous from the standpoint of what the Federal Government
contributes. On average, about 57 percent of the Medicaid cost is
contributed by the Federal Government. The State pays 43 percent. In
this bill, the language might be more generous than that, but there
would still--unless the so-called Cornhusker kickback is applied to
every State, then States are going to be hit with additional Medicaid
expenditures.
I have received communications from senators and legislators back
home in my State where that number could approach $20 billion for the
2-year budgetary cycle that we have in Texas. And although many people
in Washington would consider that so small as to not even be worthy of
consideration, in a State budget, it is significant, and that is why
the legislators and senators have written to their Members of Congress
to advise them of this that's occurring. That means money that's not
going to be available to fund transportation projects in the State.
That means money that's not going to be available to pay for
educational activities in the State. These will be real dollars that
are taken out of circulation in the State to pay for the expansion of
Medicaid that the Federal Government is going to require.
The whole question of making everyone buy health insurance, the
question of an individual mandate that is contained within the Senate
policy, is something that this country has not done before. That is a
new phenomenon. Now I know you hear people say, Well, look, look
Massachusetts has a mandate, and it's working okay up there. Well,
maybe. Maybe not. I think the costs went up a little bit because the
insurance companies are now under no--there's no reason for them to try
to hold costs down to attract customers because, hey, you've got to buy
it. It's the law. But still, if a State wants to pass an individual
mandate or an employer mandate, for that matter, within their State to
cover health care costs, that's their business. They can do that under
the 10th Amendment, that those powers not taken by the Federal
Government are reserved to the States. That's one of those powers that
are reserved to the States. So if a State wishes to do that, and the
people who elect the Governor and State legislators and State senators
in those States are saying, Well, that's okay with us, then good on
'em. That's what they should do.
But what's working in Massachusetts likely wouldn't work in Texas.
It's a different demographic, different problems. So we can't apply a
one-size-fits-all solution across the country, and the Founding Fathers
recognized that. You will hear people say, Well, look, it's a mandate
that you've got to have car insurance if you drive your car. But you
are driving your car voluntarily on a public road, and that is a State
mandate for the purchase of that insurance. Not every State has them. I
think there are two States that don't have an insurance mandate. Texas
didn't until a few years ago. I don't know if it's actually increased
the number of people who carry insurance because you are forever
hearing about some poor soul that was hit by someone else who carried
no insurance. But that's a State issue. And the States make that
requirement.
Again, those State governments have to be responsive to their
citizens in the State. If the citizens get too upset by the liberties
that are being taken from them by a State government, they are free to
react against that. And that's what a democratic process is all about.
That's what elections are all about. But never in the history of this
country has there been required the purchase of a product just as a
condition for living in the United States.
Now we do have to pay income tax, it's true. You don't have to earn
any money. And if you don't, then you don't have to pay taxes. But in
order to ensure that this program is administered effectively, we go to
the meanest, biggest Federal agency of all, that very same Internal
Revenue Service, and say that they're going to collect--they're going
to enforce this individual mandate that you buy health insurance.
Just a thought on that in some of the moments that are remaining to
us this evening. Does putting an individual mandate on people increase
the number of people who carry, say, health insurance? Putting an
individual mandate on for the requirement that everyone have health
insurance, does that increase the number of people who have health
insurance? Right now in the country with a robust employer-sponsored
insurance program, people who are employed in the individual market,
small businesses who provide insurance in the individual market for
their employees, the compliance rate or the insured rate is about 85
percent. We hear the figure of the number of people uninsured in this
country, and it works out to be about 15 percent.
In the Federal tax system, does everyone file and pay taxes who
should? The answer is no, they don't. By the IRS' own estimates, by
their own estimates, 15 percent of the population decides not to file
or not to pay their income taxes. Now that's a pretty stiff mandate
that the IRS puts on us. Most people don't know exactly what the
penalty is, but they're pretty darn sure that they don't want to find
out firsthand because they do know it to be severe. So with this very
severe penalty hanging over people's heads, you still have 15 out of
100 who will say, No, thanks, I'll still take my chances. How many more
people are going to buy health insurance who don't already have it if
we put that on as a requirement?
And then one of the other considerations is, if the fine is not as
much as the insurance policy itself, then someone who believes
themselves truly to be at zero risk for any medical condition says, You
know what, I'll just pay the fine if it's less money, and I'll worry
about insurance if I get sick. Of course under the plan that's over in
the Senate now, they can do that because there will be what's called
guaranteed issue. If they get sick, they can literally purchase the
insurance policy from the back of the ambulance on the way to the
hospital.
You know, we heard a lot during the course of this debate on health
care over these past 15 months. One of the things that I will never
forget is the energy and enthusiasm that I encountered this summer in
doing town halls during the month of August. As you will recall, we
passed the bill out of the Energy and Commerce Committee sort of at
midnight Friday night, July 31. We all went home to our districts. We
started seeing the stories on the evening news of vast throngs of
people showing up at Representatives' town halls, both Republicans and
Democrats. Whether they had come out in favor or in opposition to the
bill. We hadn't voted on the bill on the House floor at that point.
Because I was sitting in the committee that voted on the bill, I could
tell my constituents back home that I voted no in committee, and I
would vote ``no'' when it came to the floor, unless there were
substantial changes. And people supported that decision overwhelmingly
in the town halls that I did this summer.
But it doesn't mean that they said, We don't want you to do anything.
[[Page H1592]]
They had some rather specific things that they would like to see
Congress do to help them with the problems that they were having with
either insurance companies or with their doctors or with their
hospitals. There were some things they thought that Congress could do.
Now bear in mind the approval rating for Congress is somewhere south of
20 percent. We do not enjoy a significant amount of political capital.
In order to do something this big, you really have to have the American
people behind you, but we don't. And therein is the trouble that the
Democrats are having passing this bill. Right, they've got no
Republicans, but then they really didn't try. They weren't interested
in having any Republicans a year ago when this process was beginning.
{time} 2145
So it's no surprise that at this point, a year later, they don't have
any Republican support for their proposals. Their problem is within
their own conference.
Now, they've got 40 seats on us. It really shouldn't be a problem.
I'm sorry, they have 40 more seats than they need to pass this bill,
because in the House it's a simple majority. It really should not be a
problem. All you've got to do is keep 40 people from leaving you. That
shouldn't be that hard. These are people who feel the same as you.
They're members of your same party. They believe the same things you
do. That shouldn't be a hard lift.
Why is it so hard?
It's hard because there's not the popular support for this bill that
everyone assumed would be there shortly after the 2008 election. We had
an election. President Obama won the election. Health care was a big
deal during the election, so it was just naturally assumed that the
American people would be with the Democrats no matter what they did,
with, to or from health care. As a consequence, they didn't need any
Republicans. They really couldn't be bothered. We were noisy and
inarticulate in meetings, and they just wanted to write the bill they
wanted to write, and they'd get it passed without any Republican votes.
Now they're up against an impasse with their own side. Very difficult
to pass something this large that affects this many people without at
least some input from both sides. That's never been done before, to my
knowledge, in this country; and that's what we're trying to do tonight.
You might be able to do that if you had the popular support of the
American people behind you. You could say, well I've got the people
with me. I don't need Republicans. And that would be true, but they
don't have the people behind them.
So the fact that the Republicans are not supporting the Democratic
bill is actually of no consequence. Their difficulty is the people
don't believe what they're doing. And, quite frankly, I don't see how
there is a way to change that equation between now and Sunday, the day
we're supposedly going to vote on this monstrosity.
I did hear from people in town halls about things they do want done.
I maintain a Web site that's devoted to health care policy. It's called
healthcaucus.org, @healthcaucus.org. ``Healthcaucus'' is all one word.
Healthcaucus.org. Under the issues tab, you see Dr. Burgess'
prescription for health care reform. And I've listed there the nine
things that people told me most consistently during the summer and fall
that they wanted to see us do.
Number one thing, people sure do want some help with preexisting
conditions. There are things we can do to provide some help, and it
doesn't mean an individual mandate. It doesn't mean guaranteed issue.
It means helping those people who need help. It does cost some money.
The Congressional Budget Office scored an amendment that Ranking Member
Joe Barton had on our committee. It scored at $20 billion. Nathan Deal,
the ranking Republican on the Health Subcommittee and I have introduced
legislation that captures the spirit of that amendment. We erred on the
side of being more generous. That's a $25 billion authorization for
that program. The Congressional Budget Office said $20 billion over 10
years. We plussed it up by $5 billion. Let's start it and see what
happens.
After all, that Senate bill comes over here and becomes law, no one
gets any help tomorrow. It's 4 years before they get help. Preexisting
conditions are a problem today. We heard this over and over again in
the summer time. This is something people actually wanted us to work
on. We could work on this in a bipartisan fashion. We never even had a
hearing on how to approach the problems of preexisting conditions
without a mandate. We never even had one word of testimony about that
in our committee leading up to this.
Does there need to be some fairness in the Tax Code? You bet. Why
does someone in the individual market who's paying for their health
insurance out of pocket have to pay with after-tax dollars when someone
who works for a large multi-state corporation gets their insurance paid
for with pre-tax dollars by their employer? That fundamental unfairness
is something that has to be fixed. I'm not sure that I know the best
way to fix that, but I know we haven't even tried. We haven't even had
those discussions.
We do need some medical liability reform. It's working in Texas; it
could work in other places around the country. It does help keep costs
down, in spite of what congressional Democrats and the White House tell
you.
Portability, the ability to carry insurance with you through life, is
extremely important, especially to younger workers. Think of the
relationship with your insurance company if you had a longitudinal
relationship with that insurance company.
There are some things that we could be doing that are not that heavy
a lift and don't cost that much money. Most importantly, we can show
the American people we can deliver real value and work together while
we're doing it. Then we could improve those approval rates, that low
esteem that the country holds us in.
Dr. Burgess' Prescriptions For Health Care Reform
1. Insurance Reform
We should eliminate the bias against patients with pre-
existing conditions, outlaw rescissions except in cases of
fraud, and ensure states have well-designed high-risk pools.
H.R. 4019--Limiting Pre-Existing Condition Exclusions in
All Health Insurance Markets (Deal)
H.R. 4020--Guaranteed Access to Health Insurance Act
(Burgess)
2. Tax Fairness
Providing individuals the same tax benefits no matter where
they want to get their health insurance, and tax credits to
help individuals purchase insurance in the individual market.
H.R. 3218--Improving Health Care for All Americans Act
(Shadegg)
3. Medical Liability Reform
The success of Texas' 2003 reforms: Texas has licensed over
15,000 new physicians and Texas hospitals have delivered more
than $594 million in charity care.
H.R. 1468--Medical Justice Act (Burgess)
4. Portability
Allowing patients to shop for health insurance plans across
state lines = more choices at lower costs. Example: Average
health insurance premium for a family of four: New Jersey:
$10,000, Pennsylvania: $6,000, Texas: $5,000.
H.R. 3217--Health Care Choice Act (Shadegg)
5. Medicare Payment Reform
The current formula Medicare uses to pay doctors--the SGR--
is unstable, and a permanent fix is needed to ensure seniors
continue to have access to their doctors.
H.R. 3693--Ensuring the Future Physician Workforce Act
(Burgess)
6. Doctors to Care for America's Patients
We must ensure that we have enough doctors to care for all
of America's patients--now and in the future. H.R. 914--
Physician Workforce Enhancement Act (Burgess)
7. Price Transparency
Health care services are the only product that we don't
know the actual cost of before utilization, so let's have the
prices up-front, just like in a restaurant or clothing store.
H.R. 2249--Health Care Price Transparency Promotion Act
(Burgess)
8. Preventative Care and Wellness Programs
Health care reform must include participation from
America's patients, so living healthy lifestyles and making
healthy decisions is very important.
9. Create Products People Want
Mandates have no place in a free society. Instead, we
should challenge insurance companies to create innovative
health plans that Americans want. Example: Health Savings
Account--offers flexibility and control.
____________________