[Congressional Record Volume 156, Number 44 (Monday, March 22, 2010)]
[House]
[Pages H2201-H2207]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
HEALTH CARE
The SPEAKER pro tempore. Under the Speaker's announced policy of
January 6, 2009, the gentleman from Texas (Mr. Burgess) is recognized
for 60 minutes as the designee of the minority leader.
Mr. BURGESS. Mr. Speaker, I, too, am coming to the floor of the House
tonight to try to clarify for the American people some of the things
that have happened here over the weekend. As you know, we passed a very
big bill last night, hasn't been quite 24 hours, it was about 11 p.m.
Eastern time when everyone else in the country was watching basketball
tournaments and otherwise engaged with weekend activities, this House
was in full session, the place was packed, Democrats and Republicans,
and we passed a bill that had been passed by the Senate on Christmas
Eve.
Now, I remember when I first got here, Republicans were in the
majority, and when we would pass major pieces of legislation, if there
was an all-day fight, we would be accused of waiting until the dark of
night to try to sneak this legislation through. Now, I have never been
one who would pass on the chance to attribute to coincidence that that
can be adequately explained by conspiracy, but how is it that we
passed, in the Senate, this very difficult legislation the day before
Christmas when America was engaged in other activities, and then here
on the floor of the House last night at 11 o'clock on a Sunday when
most every other honest American was doing something other than
watching their Congress.
I do have to address some of the things that I just heard mentioned
from the other side. Remember that there were two pieces of legislation
passed here last night. One was the previously passed Senate bill which
the House passed. That one is on its way down to the White House.
That's going to be signed by the President. That's going to be the law.
And then we also passed a sham bill, a bill that might be called a
fig leaf because no one really likes the Senate bill. The Speaker of
the House said that herself. No one wants to vote for the Senate bill,
and I agree with the Speaker. No one wanted to vote for the Senate
bill. So how did they get their side to vote for the Senate bill? Well,
they said don't worry, we are going to fix the problems that you don't
like in the Senate bill, and we will do that under reconciliation so
it's only going to require 51 votes over in the other body, don't
worry, we will get that taken care of.
The only problem is, the Senate bill that we passed here last night
had already passed the House before last summer--you might not
recognize it because it was a housing bill then, but it passed the
House last summer--went to the Senate, got changed into a health care
bill and then got brought back to the House. And the question before
the House, will the House now accept the amendment, the Senate
amendment to H.R. 3590, the answer was affirmative, and the bill is on
its way down to the White House for a big signing ceremony, probably
tomorrow.
Now, what's going to happen to the reconciliation bill? It also
passed, and it passed, and went back to the Senate. And is there
anything that compels the Senate to take up that bill and work on it?
Why, no, there is not.
In fact, the Senate might rationally argue, I am sorry, Mr. Speaker,
the other body might rationally argue that, hey, we already passed our
health care bill, we passed it on Christmas Eve, you guys apparently
liked it because you ratified the amendments we had to it, and last we
saw, it was on its way down to Pennsylvania Avenue to the White House.
So why would we pick up this contentious package of fixes in the bill?
You know, quite honestly, the oxygen may have all gone out of the
room for health care legislation in this Congress. Fourteen months is a
long time to have fought this thing, and the Senators may just not have
the stomach to pick this thing up and fight through it again.
So some of the things that we need to be careful about when people
are talking about the bill--and I will do this too, many of us here in
the House are not that familiar with the Senate bill that we just
passed because it was the Senate bill. We had a health care bill that
was marked up in my committee and passed out of committee over my
objection July 31. I didn't like the bill, but I knew it. I submitted
amendments and some of those were even accepted. So I had a lot of
familiarity with that bill.
Now, that bill went to the Speaker's office, sat there for a couple
of months, got changed all around. All of my amendments got pulled out,
every other Republican's amendments were pulled out of that bill. It
became a 2,000-page bill, even with the loss of those amendments, and
was brought back to this House in early November, and this House passed
the House bill.
{time} 2100
We knew the House bill. Many of us were--although we didn't like the
House bill, we were fairly comfortable with what it contained and what
it didn't contain. The Senate bill is completely different. Most of us
did not ever see the Senate bill before the Senate brought it up on
Thanksgiving and then passed it right before Christmas.
Mr. Speaker, quite honestly, many of us felt like we'd already read a
lot of health care bills this year; do we really need to read that
Senate bill? Maybe not. Because the Senate will pass it and then the
normal procedure is we call a conference committee. We go to conference
committee and we debate both sides, get to the debate the House bill,
the Senate bill, Republicans and Democrats, a true bicameral process.
We're finally going to have that open and transparent process that was
promised to us and we'll read the conference report. We won't have to
worry about the Senate bill because it's all going to be changed
anyway.
Except that didn't happen because, for whatever reason, the Democrats
did not want to do a conference report. They say it's because
Republicans were going to block the appointment of conferees. But, Mr.
Speaker, I would just point out to you that in December and early
January there were 60 Democratic votes in the Senate, 256 Democratic
votes here in the House. There wasn't much we could block, even if we
wanted to. So how we would have blocked the appointment of conferees is
anyone's guess, but I did hear that mentioned several times during the
debate. So let me just set that point straight.
They thought they could just put things together on their own outside
of a conference, and they were doing a darn good job of it. The last
week in December, the first week in January on into the second weekend
in January, people were meeting in this Capitol, meeting in this
building, in the new Capitol Visitors Center, and putting together the
pieces, cutting secret deals with unions, cutting secret deals with
this group and that group, and we were going to have a bill that would
just be blessed by both sides. No conference report. Not necessary
because we'll just bring a new bill to the floor that will be the
amalgamated bill. The Senate will vote for it. They've got 60 votes.
[[Page H2202]]
The House will vote for it. They've got 256. And if they don't lose too
many, then they can pass pretty much whatever they want. Then we'll
have a health care bill.
What happened in that scenario was that the second Tuesday in January
they had an election in the State of Massachusetts. As a consequence of
that election, suddenly the Democrats' 60-vote supermajority in the
Senate was no more. Now, the new Senator was not seated for several
weeks after that election and there was still time to come together
with a hasty conference committee and get that thing done or even push
through that amalgamated bill, but, for whatever reason, they didn't do
that. It really looked for a while like things might just languish
indefinitely.
Now we all know the story. In those last 10 days, the President
really engaged, the White House engaged, and the Speaker's office
engaged. They were just going to get this bill through the House
because that was the quickest way--they always say a line is the
shortest distance between two points. The shortest distance to getting
health care legislation passed in this Congress, in this President's
first half of his first term, was to pass the Senate bill through the
House. It was something no one wanted to do. No one wanted to vote for
that bill. It had awful things. Most of us don't know all of the awful
things in that bill because it was the Senate bill. We passed House
bills. We knew the House bill, but we heard the minority leader say it
last night from this floor, Most of you on the Democratic side do not
know what's in that bill.
Now, I dare say, today you've learned a lot of what's in that bill
because you've got the phone calls from the press the same as I have.
Suddenly, the press got real curious about what was in the Senate bill
and they're asking all kinds of questions. So tonight perhaps we can
deal with some of those. But one of the things I wanted to point out at
the very beginning, be careful what you talk about when you hear us
talk about what's in the bills, because both sides of the aisle, both
Democrats and Republicans, may not be quite sure what's in the bill.
We heard testimony, or we heard the speeches on the other side here
just a moment ago about how Medicaid rates now were going to be
plussed-up for primary care doctors. Medicaid rates will become
Medicare rates. Well, that actually, in fact, is only for primary care
doctors and it is only for 2 years, but it is also only in the
reconciliation bill. Did we pass the reconciliation bill? We did in the
House. They haven't in the Senate. What did we pass that has passed the
Senate? The Senate bill. And that does not have that plus-up in
Medicaid rates. In fact, the expansions of Medicaid that we have now
put forward that were in the Senate bill, the expansion of Medicaid,
will be reimbursed at standard Medicaid rates, which vary from State to
State. But I will tell you, as a medical provider, those put a lot of
providers back on their heels, because those rates do not pay the cost
of delivering the care, and there is only so much of that kind of
business you can do in an average day and still keep your doors open.
So there is a problem with expanding Medicaid to larger and larger
populations. The provider community is going to find it difficult to be
able to absorb that many more Medicaid patients into their practices
because the reimbursement rates are going to remain low. In fairness,
it was fixed in the reconciliation bill, but if the Senate doesn't take
that up, it never happens. It was the skinniest of fig leafs because
it's not there when you need it. What is there is the Senate bill,
which is on its way down to the White House, and that will be the law
of the land, which will expand Medicaid, to be sure, but does it have
the enhanced Federal matching in there for Medicaid? In one State it
does. In one State it does. The reconciliation bill was going to fix
that so all States would have what that one State now has in the Senate
bill, but it is the Senate bill, and only one State has that enhanced
Federal match for Medicaid: the State of Nebraska. The famous
Cornhusker kickback.
So what happened here last night, what transpired on the floor of the
House last night was really dramatic and, in many ways, a fitting end
to the 14 months of chaotic process that had brought us to this point.
We've heard over and over and over again--and I don't want to belabor
the point, and this may well be the last time that I discuss the
process that brought us here. But it is worth mentioning, because over
and over and over again last night during the debate we heard, You
Republicans obstructed at every step of the way. Remember, there's 177
of us; there's 256 of you. We can't obstruct anything, particularly the
House of Representatives, where majority rules on almost everything.
And, oh, by the way, the Rules Committee really rules. And the Rules
Committee has a nine-to-four advantage for the Speaker. There's not
much you can do with 177 Republicans in the House of Representatives if
you want to obstruct. Well, you can all hang together and make a
principled vote that we're all against this. And that's indeed what has
happened.
But the real debate was an internal debate within the Democratic
caucus, because had they had the votes, they could have done this in
February. Had they had the votes, they could have done this in January.
They could have done it in December, the day after Christmas, as
opposed to the day before Christmas when the Senate bill was passed. If
they'd known this was what they were going to end up with, maybe they
should have just done that and saved everybody 3 months of additional
anxiety.
The fact of the matter remains, Republicans did not obstruct this
bill. Democrats obstructed this bill. Democrats and, oh, yeah, one
other thing. They never had the popular support of the American people.
Now think about that for a minute. We passed a bill that's going to
affect in a very profound and personal way the next three generations
of Americans. That's a pretty big bill. One-sixth or one-seventh of the
Nation's economy. That's a pretty big bill.
Now, we've heard over and over again, if you're going to do something
like that, it needs to be bipartisan. So Republicans should have signed
onto the bill. Republicans should have backed the bill. Republicans
should have been there. But, wait a minute. The people did not want
this bill. Poll after poll after poll has shown, fill in the blanks--52
percent, 55 percent, 60 percent--of the people did not want this House-
passed bill, did not want the Senate-passed bill, did not want what the
United States Congress was going to do to health care.
Now, if you don't have popular support, then even if you've got 256
Democrats and, now, 59 Senators and the White House, it's very
difficult to get your Members to--it's a very technical term we use
here in the House of Representatives. It's called, ``walking the plank
for your leadership.'' It's very difficult to get your Members to walk
the plank for leadership when everybody back at home is howling mad
because of what you're doing. And I'm sure many people felt--the old
saying that Everett Dirksen used to have, ``When I feel the heat, I see
the light.''
A lot of people saw the light when they went back home. Now they came
back to Washington and got their arms twisted and things promised and
things promised to be withheld and goodness knows what and they lined
up and walked the plank last night. That's what we saw.
{time} 2110
People are voting in favor of things they said they would never do.
They misled their constituents back home. People turning at 90-degree
intersections to principles that they've held for a long time. It was
painful to watch. I felt some sorrow for people I saw on the Democratic
side having to make these very tough gut-wrenching decisions.
These are good people that are well intentioned, but they got pushed
into a corner from which there was no escape. And that corner was the
Speaker of the House and the President of the United States. And as a
consequence, this bill passed, a pretty slim majority. Not a single
Republican. In fact, the only thing that was bipartisan about this bill
last night was the opposition because you had 30 Democrats standing
with 177, or 178 now, Republicans. That was the bipartisan block on
this bill, but they were in opposition.
This bill presents a real problem for the American people. The
American
[[Page H2203]]
people don't like it. The American people don't want it, but now the
American people have it. Now ideally--and people have asked me all day
long, Well, what are you, as a Republican, going to do about this now?
And the answer is, You fix what you can, and you work toward repeal of
the bill.
Now working toward repeal of the bill, you've got to ask yourself.
There likely will be bills introduced today and bills introduced
tomorrow that will call for the repeal of the bill. I may very well
sign on to one or more of those bills. But with the same vote total
that we had last night, do you think any of those bills are even going
to be brought up for debate? Is the Speaker of the House, is the
majority leader going to bring up one of those repealed bills and say,
Let's go through this argument and see if any of our Members now feel
differently? Well, they could. And there is history there. There is
precedent there.
In the late 1980s, this House passed a seriously flawed catastrophic
coverage bill for Medicare. They charged Medicare recipients the
premium for that catastrophic insurance; and all across the country,
people said, Wait a minute, we didn't want that. We didn't ask for
that. You're charging us for something we didn't ask for or want. And
the seniors in this country rose up, and the very famous pictures of
then-chairman of the Ways and Means Committee, Dan Rostenkowski, being
chased out of his own town hall by senior citizens who objected to what
they had done. And Congress did come back in short order and repeal
that bill. Will that happen now? I don't know. That's a pretty painful
thing for people to have to go through. We'll see.
We've got an Easter recess coming up. If people do town halls and
they get that kind of reaction, maybe we'll be back here talking about
one of those repealed bills. But honestly, Mr. Speaker, I think that's
a pretty heavy lift to repeal this bill that we passed last night, this
bill that's now on its way to the White House to become public law.
It's pretty difficult to do that in this Congress because it's not
likely that there will be the votes. And then, of course, on the Senate
side, it's really not likely that there would be the votes. And if it
happened, the President likely would feel differently about it and
would exercise his authority to veto that repealed bill, and it is
unlikely to get to the threshold of a veto override, two-thirds of the
House and two-thirds of the Senate to override a Presidential veto.
In fact, if America has the reaction to this bill that I think
they're going to have, there may be many more Republicans and many
fewer Democrats here in the House of Representatives next year. I don't
know if that number will be enough to change the majority control of
the House. It sure could be. It certainly looks increasingly likely
from the degree of anger and how upset people are that talk about this
bill out in the middle part of America. But I don't know if there is
the political will to change the majority makeup of the House. Again,
even if there is, sure, we'll bring that repealed bill up. We'll bring
it up pretty quickly and send it down to the White House, and the White
House will veto it. I doubt that there will be a new Congress that's
seated that will also have the ability to override a President's veto.
Again, that's a tall order, two-thirds of the House, two-thirds of the
Senate. So I don't know within the time frame between now and January
of 2013, if the numbers work out, for this Congress to have the ability
to repeal the bill. It's worth trying. It's worth testing. But I don't
know if that's a realistic trajectory.
Well, then, what can we do? I think it is extremely important to at
least begin to work on some of the more egregious portions of this
bill. And I will just tell you, one of the things that really bothers
me about this bill that we did is the instituting of an individual
mandate to purchase health insurance. Now surely it is the responsible
thing for every American, every family to have health insurance against
the unlikely but frightening occurrence of some of the diseases that
can happen to us as human beings. It's the responsible thing to do. But
just because it's the responsible thing to do does not mean that your
Federal Government has the responsibility to require you to buy it.
We've never done that in this country. Simply as a consequence of being
born or living in this country, your Federal Government now says that
you're going to buy this product.
In fact, when the bill was passed, people said, Well, under the
commerce clause, we have the authority to do that. But that kind of
turns the commerce clause on its head. The commerce clause is there to
protect commerce, but coercing someone to buy a good or service or
product and then invoking the commerce clause to protect that
transaction really seems to be going at things the wrong way. Now, if
an individual State wants to say as a condition of living in our State,
there is a mandate that you will buy health insurance--and there are
States that have done that, and if their State legislature passes that
legislation, and their Governor signs it, and the citizens of that
State are okay with that, then good on 'em. That's fine. That is their
prerogative. That's one of the things that a State government is there
for. If they pass an individual mandate, and the people turn out the
State legislature, well, then they learned their lesson. But that's a
different set of circumstances than having the Federal Government make
that decision that we're going to require everyone to purchase
insurance. In my opinion, mandates have no place in a free society; and
in my opinion, mandates are not going to get us the kind of coverage
numbers that people expect it to.
You stop and think for just a minute, for a mandate to work, there
has to be general knowledge that this mandate is there; there has to be
general knowledge of the penalties that one would possibly incur for
not complying with the mandate; and there must be general knowledge
that those penalties will be swiftly and surely administered.
Now, we do have a model for that in this country, and that is called
the Internal Revenue Service. The Internal Revenue Service says that
everyone who earns income has to pay a percentage of that income in
income tax. In fact, it's withheld from most of us from our paychecks
every month. But that income tax must be paid, and we all know that,
and we all know that if we don't pay our taxes, we may not know exactly
what's around the corner, but most of us know it's something we really
don't want to find out about.
Now, with such a draconian mandate for Federal income taxes
administered by the Internal Revenue Service with such a mandate, you
would expect the compliance rate to be pretty high. Well, it is. But it
might be lower than what you might think. The compliance rate is around
the order of 85, 86 percent. That's with a pretty severe mandate.
What about health insurance? Right now it's voluntary. As I said,
it's the responsible thing to do. People should have coverage. People
want to have coverage. In this country, most people are covered by
employer-sponsored insurance. There is another 8 to 15 percent covered
in the individual market. But insurance is a responsible thing to do.
And in the voluntary program of insurance that we have in this country,
what is the problem that we hear about over and over again? We've got
15 percent of our population without health insurance. Well, that does
mean conversely you have 85 percent with insurance. And what is the
compliance rate with the IRS? It's pretty close to the same number.
{time} 2120
So are you going to get more of that 15 percent to sign up for health
insurance if you put this very draconian, liberty-stealing mandate from
the Federal Government out there? I don't think so. I think mandates
have no place in a free society; and as a consequence, I don't think
they belonged in this bill.
Further, what did the stock market do today? It jumped up a bunch,
didn't it. You might say, well, see that proves the point, Americans so
wanted this health care bill to pass the House of Representatives that
they rejoiced by going out and running up the stock market. Or perhaps
because insurance companies and pharmaceutical companies are going to
profit so much by the fact that you now have to buy health insurance,
that their prices went up. Their stock went up because people looked at
futures and forecasting and said, wait a minute, insurance might
[[Page H2204]]
be a good stock to buy because in just a short period of time,
everybody in the country is going to have to buy insurance.
Wouldn't it be a better approach, instead of mandating people to buy
insurance, and again, I don't believe you are going to get a reduction
in insurance rates by demanding that everyone buy health insurance,
because what incentive is there for the insurance company to hold the
price down? There isn't any. If anything, there is an incentive to
raise rates because you have to buy it, otherwise the IRS is coming to
visit grief upon your household. So the insurance companies may be
feeling pretty good about this bill that we just passed last night
because they are going to sell a ton of product. You are going to have
to buy it, or you get into all kinds of trouble. The IRS is going to
come and raise billycane on your head if you don't buy this insurance.
So the insurance companies are feeling okay with this.
And the pharmaceutical companies, yes, they came to the table with a
big bunch of money, and they gave up something to get this health care
bill passed. But at the end of the day, the closure of the doughnut
hole, yes, but it is for brand name products you get that discount, so
they will sell more of that branded product which is the most expensive
product, and people are going to blow through that area where they have
to match some of the expenses and the catastrophic coverage will kick
in pretty darn quick. Pharmaceutical companies may stand to gain a
great deal from the passage of this bill. So it is really no surprise
that the stock market went up today. Drug companies and insurance
companies, they may look to be doing okay in this brave new world order
that we gave to the American people last night.
A very famous quote from the Speaker earlier in the debate on all of
this was: We need to go ahead and pass this bill so people can find out
what is in it, and then they will really like it after the fog of the
discussion is removed.
In fact, I have heard essentially that same statement on the floor
here today. One of my friends on the Democrat side said, You know,
finally, all of the rhetoric can be put aside and people will see what
is in this bill, and they will really like it.
So let's talk about what is really in this bill, and I will leave it
up to the American people how much they like it. We have already talked
about the individual mandate. Absolutely unprecedented. The government
has never required people to buy a good or service as a condition of
lawful residence in the United States. That is a quote from the
Congressional Budget Office.
It will be invoked under the commerce clause. The power to regulate
commerce among the States is not unlimited. And here is a thought: What
if the courts allowed this to stand? What if that power was in fact
unlimited? Your imagination almost cannot handle what some of the
things that your Federal Government might decide to do if we removed
that power, or we removed that condition on exercising that power.
Some of the other things that are going to be found in this bill are
tax increases. I know I heard it over and over again during the debate
that the Republicans shouldn't mislead people about tax increases in
the bill, but they are there for all to see. Go to the Web site Thomas,
the Library of Congress Web site, and download the CBO letter on S.
3590, the Senate-passed bill, and look at some of the tax increases
that are there.
Medicare cuts, are they there? Yesterday the Democrats kept saying,
There are no cuts to Medicare in this bill. Well, there darn sure are.
Again, looking at the tables at the back of the CBO report, some of
them look to be pretty darn significant. Reductions in annual updates
to Medicare fee-for-service payment rates over the period 2010 to 2019,
that is a 10-year budget cycle, that is a cut of $86 billion. Medicare
Advantage rates based on plan bids, that is cut $118 billion. Medicare
and Medicaid disproportionate share hospital payments, that is cut $43
billion over that 10 years. Community living assistance services and
supports, that is cut $70 billion over 10 years.
One of the things that is really disingenuous about these cuts, and
they have it laid out year over year in the Congressional Budget Office
report, and the next 4 or 5 years those cuts are actually pretty
modest, and then they really kick in the last 5 or 6 years. And we all
know there is a big Presidential election coming up again in 2012, and
so perhaps it is no accident that those cuts are diminished in the
early years and then expanded in the out-years.
Payment adjustments for home health care, that is almost $40 billion
in reduction. Again, Medicare disproportionate share hospital payments
down significantly. That is one of the significant things. It is hard
for people to understand what is a disproportionate share hospital
payment. Some hospitals see--and remember I told you that Medicaid
doesn't really reimburse providers the cost of providing their care.
Now no one cares so much about the doctor because who needs doctors in
the health care system anyway, but we do care about hospitals. And
hospitals historically have been protected. If they see what is called
a disproportionate share of uninsured patients or underinsured
patients, Medicaid where the reimbursement rate is low, they get a
plus-up from the Federal Government, and it is called a
disproportionate share payment.
One of the things that they did in the State of Massachusetts, they
said we are giving all of this money to hospitals for disproportionate
share payments, what if we just took that money and helped people buy
insurance? Everybody is insured, and then you don't need to provide the
disproportionate share payments any longer.
But you take a State like mine, a State like Texas, where a great
number of the uninsured happen to be in the country without a valid
Social Security number, for whatever reason. Now we heard the President
of the United States stand here in this House in September and say very
clearly that no one who is in this country illegally will be able to
participate in any of these benefits. If that is correct, and Texas has
a problem with people who are in the country without the benefit of a
Social Security number who also happen to be uninsured, they won't be
eligible for any of these benefits. They won't be eligible for any of
the subsidies in the exchanges. They won't be able to access the
insurance that Congress is passing. That is not necessarily a bad
thing. You don't want to provide an incentive for someone to come into
the country without going through the proper channels. So what are we
going to do in a State like Texas where we have vast numbers of
uninsured who are there without benefit of a Social Security number?
They are still going to access care through the emergency rooms of our
safety net hospitals, but we are also at the same time cutting those
disproportionate share payments to those hospitals. So the hospitals
are actually catching the grief from both sides. Their uninsured and
underinsured populations are going to go up, and their reimbursement
rates are likely to stay low, and disproportionate share payments are
going to go down. That is a business plan that may make sense to the
Federal Government, but I bet it doesn't make sense to most hospital
administrators who run our safety net hospitals around the country.
So anyway, when people tell you that the Republicans are misleading,
we are trying to scare you on the Medicare cuts, they are outlined in
the Congressional Budget Office report, and they are as plain as day
for everybody to see. The subtotal for Medicare cuts: A negative $430
billion over 10 years. Add the other community-living reductions of $70
billion, and that is $500 billion. That is what you have heard
Republicans saying for the last several months. You are going to cut
Medicare by $500 billion. At the same time, you have more people coming
into the Medicare system, and you are really doing nothing to hold down
the cost of delivering medical care.
{time} 2130
You're creating a situation where you're actually going to increase
the stress on the system, not decrease the stress on the system;
additionally, $500 billion in new taxes coupled with that $500 billion
of Medicare cuts. The President stands in front of us and says, And
this bill will be paid for; in fact, this bill will reduce the deficit.
Well, you're leaving out a big part of one of the things that didn't
get fixed
[[Page H2205]]
in the Senate bill. You've heard me talk before about what's called the
sustainable growth rate formula. This is the formula under which
doctors are reimbursed in Medicare.
Back in 1988, the institution of the, what's called, relative value
payment scale, RBRVS, whatever that acronym stands for, every year we
tended to try to ratchet down reimbursements to physicians because we
felt, if we didn't, they'd just spend too much money.
Well, what has happened over time, of course, as doctors'
reimbursement rates have gone down, they've tried to see more and more
patients so that their bottom line didn't suffer. And, as a
consequence, the spending has gone up and the SGR has had exactly the
opposite effect of what was intended.
We are in a real problem with this formula right now. This year,
there were projected to be cuts of almost 21 percent to doctors who
provide services to our Medicare patients. The payment rates for part B
in Medicare were going to go down by one-fifth. For some specialties,
it was going to go down even more than that. But just in general, it
was going to go down about 21 percent.
We put a stay on that just about a week ago with a bill that passed
by voice vote in this Congress, so it wasn't a recorded vote, and this
put a stay on that cut until November. What happens then is anyone's
guess because we didn't fix the problem in the House-passed bill. I
mean, we didn't fix the problem in the Senate-passed bill. That bill's
going down to the President for his signature.
What's going who happen to the doctors in Medicare? Well, Congress
needs to fix that. Why hasn't Congress fixed that, by the way? It's
been going on for years. Started with the Democrats, then it got worse
under Republicans, and it's getting a whole lot worse now that the
Democrats have retaken the majority.
Well, why didn't anybody fix that? The reason they don't fix it is
because it scores, by the Congressional Budget Office, as a cost, a
cost that is, no one really agrees upon the price, but it's somewhere
between $250 billion to $350 billion. It could even be more than that
if you tried to protect some part B premium payers from the rapid
expansion of Medicare costs, Medicare part B costs caused by the rapid
increase in repealing the SGR.
Remember that part B premiums are based on a formula: 25 percent of
the actual cost of administering the part B program. We add another big
cost to the part B program in the repeal of the sustainable growth rate
formula, and Medicare recipients, Medicare participants in the part B
program may see their premiums go up even faster than they've seen them
go up the past several years.
So that's a problem. If we are honest about addressing the problem,
it is likely to be $350 billion to $400 billion. But it could be scored
as low as $250 billion if you use some smoke and mirrors, which we try
to do when we do budget things.
Nevertheless, it's still a big amount of money that will have to be
added to this bill, and we didn't do it. We just simply didn't do it.
The congressional Democrats told the Congressional Budget Office, don't
score the SGR repeal in this bill.
Now, the House will tell you that, Hey, we passed an SGR repeal last
November, didn't get any Republican support. Oh, wait, they got one.
Okay. It was me. But that bill was going nowhere and everybody in this
House knew that was going nowhere. In fact, the Senate had previously
rejected the same bill 10 days before. So that was another fig leaf.
Oh, we're going to take care of the doctors. Let's pass this SGR
repeal. And, Oh, the rascals in the Senate or the rascals on the
Republican side wouldn't let this thing stand.
But the fact of the matter is it hasn't been fixed. The fact of the
matter is the Democrats are in charge. The fact of the matter is they
need to tell us how they propose to deal with that. This kicking the
can down the road--and we did it, too, when we were in power. But this
kicking the can down the road is making the problem a lot worse, and it
is really putting our seniors at risk of not being able to access
physicians. Just look at the statistics out there.
A company called Medicus that is a doctor search firm did a survey in
December. And kind of depending upon how you ask the question, they
said, If the Democrats' health care bill passes, will that affect
your decision to retire or continue practicing medicine? If the public
option was contained within the bill, almost 45 percent of physicians
said they would consider retirement. That doesn't mean 45 percent of
doctors will retire, but it meant nearly half of the doctors in this
country would seriously look at it. Doctors who were near retirement
age, about a quarter of them, about a quarter said, Seriously consider
retiring early. Doctors who were nowhere near retirement age, about a
fifth of those said, Yeah, I could see myself having to get out of
this.
Now, if you remove the public option from the equation, if you remove
the public option, the number goes down, and it's about 30, 31, 32
percent of doctors who would consider retiring early. A significant
number of those who are already near retirement age, about 20 percent
of doctors who were near retirement age would consider retiring early,
even with the public option out of the Democrats' health care plan. And
about 7 percent, 7 or 8 percent would if they were nowhere near
retirement age. But still, that's a lot of doctors who are considering
retiring if we pass one or two of these bills.
Let's leave the public option question alone for just a minute. We
need to come back to that later because that is a significant part of
this, but amongst the things that are in the bill that people may want
to know about are these tax increases, are the Medicare cuts.
Of course, one of the big fights here last night was would the bill
contain what's called the Hyde amendment language that would prevent
Federal funding for abortion. A lot of controversy ensued. The bottom
line is the Senate-passed bill did not contain the Hyde amendment
language. The Stupak language that passed in the House bill in November
did, but that wasn't the bill we were debating. That wasn't the bill we
were passing.
Again, another fig leaf was trotted out in the form of an Executive
order. But how many Executive orders did President Obama repeal on his
first day of office, Executive orders that President Bush had had in
place? It was a ton of them.
Now, the President, to his credit, did say that he would not tear up
the Executive order the first day after the bill is passed, but I don't
recall if he made a promise about the second day or the third day or
the fourth day.
The fact of the matter remains that protection against using Federal
funds for abortion, for paying for abortion is pretty tenuous right
now, and that thread could be snapped at any time. And the fact is the
American people just don't know at this point. And it's a shame,
because we could have had that argument. We could have had a more solid
amendment. But the fact of the matter is we didn't do that.
Other things in the Senate-passed bill:
The special deal for Nebraska, the Cornhusker kickback, it is in the
Senate bill. It did pass. It's on its way down to the President for
signature. Does that violate any constitutional principle like equal
protection under the law? It might. It might. If the good, long-
suffering, taxpaying citizens of Texas now have to subsidize Medicaid
in Nebraska, that might get some suspicion from the Supreme Court of
violating the 14th Amendment, but we'll have to see.
A special deal for Florida where their Medicare Advantage would not
be cut in certain counties in southern Florida. Medicare Advantage
cuts, as I pointed out to you, are going to be steep and significant in
this bill, but the three counties in Florida will not sustain those
cuts. Again, equal protection under the law. That may be a violation of
the equal protection clause of the Constitution.
In fact, my attorney general back home in Texas said the Federal
health care legislation passed tonight violates the United States
Constitution and unconstitutionally infringes upon Texans' individual
liberties.
{time} 2140
To protect all Texans' constitutional rights, preserve the
constitutional framework intended by our Nation's Founders, defend our
State from further infringement by the Federal Government, the State of
Texas and other
[[Page H2206]]
States will legally challenge the Federal health care legislation.
So what looked like a Federal health care bill may in fact have
represented a bill for full employment for lawyers in this country.
There are some other bad provisions. There is a tax on the so-called
Cadillac health insurance plans. Remember that was supposed to be fixed
in the reconciliation bill, but the reconciliation bill is not the law
of the land. The Senate bill is the law of the land and that Cadillac
tax is in there. So for individuals with incomes under $250,000,
they're going to get a significant tax if they have one of the high-end
insurance policies. Clearly, that is a broken promise by the
administration.
Boy, construction firms. I mean, who did they irritate in the Senate?
Construction firms were singled out for higher taxes. In the Senate
language, the employer mandate only exists or a fine if you don't
provide--if your employees have to access care under the exchanges with
subsidies. The fines don't kick in until you have more than 50
employees, but construction firms, there is a much smaller number.
Single digits. If they're employed by a construction firm, they will
have to pay an employer mandate or an employer fine.
Now, here's one of the provisions that is really--I don't think
people know about it. I'm not sure if they do know about it and they
understand it, but this new board that has been created in the Senate
bill. One of the ways that they attempted to deal with Medicare
spending was to assemble this board, this board of commissars and
commissioners who are going to set Medicare spending targets, and they
will do that and they will set those targets. Yes, they have to come
back and be voted on by Congress, but we just have to vote them up-or-
down. We can't amend them. We can't say, well, we're just going to plus
them up a little bit and reduce this one down a bit. We've got to take
the whole board of recommendation as a slate. It's an up-or-down vote
here on the floor of the House.
I will just tell you when Congress has to be the enforcers on these
things, look what we've done with doctor payments over the years. We're
supposed to reduce them, but we really didn't because we didn't want to
face the wrath from doctors for seniors so we took the easy way out and
gave them a 1-year stay on that. And the consequence on that is the tab
continued to run on those doctor payments. So now it's as high as $20
billion that--I am sorry, a 20-percent cut that will have to come out
of doctor payments.
We might do the same thing with this independent board, or we would
lack the courage to vote on the cuts anyway if we didn't like the way
they came down to us. Congress does have a history of doing that.
Some other provisions of the bill double-counts some Social Security
payroll tax revenues, double-counts the premiums collected for what was
called the CLASS Act. That was one of the great bait-and-switch things
that was included in this bill. We're going to provide long-term care
insurance. You pay for that $50 a month and then you can get a benefit
of $50 a day if you need to access long-term care insurance. Well, this
actually scores as a savings because for the first several years it is
in play, more premiums are collected than money is paid out. But guess
what happens in the second half of, or the second 10 years of, these
expenditures? Those payouts are going to exceed the premiums paid. And
that is going to be an unmitigated disaster.
And the real pernicious part of the CLASS Act--look, people my age,
if they can afford it, they should buy long-term care insurance. Don't
wait on the Federal Government to give it to you. Don't believe you're
going to get it from Medicare for you. It's only for a short period of
time. Yes, you can get long-term care under Medicaid, but you've got to
spend yourself to near bankruptcy before you get any of that benefit.
The sensible thing to do if you can afford the premium is to buy a
long-term care policy.
The CLASS Act is going to tell people, Hey, you don't have to worry
about that. Pay your $50 a month for long-term care. You're covered.
That's nonsense. The coverage is thin. It will not be there after a
period of time because that program is going to pay way too much money
after a few years. And the problem with long-term care insurance is the
longer you wait to buy it, the higher the premiums are going to be. For
people who are in their early fifties, it's something worthwhile to
look into.
But we're going to send a message to the next 10 years of Americans
who are turning--Don't worry about it; We've got you covered with the
CLASS Act. There is no coverage at all there. In fact, it is going to
be an unmitigated disaster when people start trying to access that.
Besides that, anyone who's paid for long-term care, anyone who's had a
family member in a long-term care facility, does 50 bucks a day really
take care of what you need in a long-term care facility? It's nowhere
even close.
The bill double-counts some of the Medicare cuts. So we get to count
them once, and we get to count them a second time.
Texas is really going to suffer under a reduction in disproportionate
share funding. Drug makers will face an annual fee of $2.5 billion. But
you know what? That $2.5 billion is not doing to come out of the CEO
salaries. It's going to come out of product sales. So that will be
passed on to the consumer. So although they look like they're being all
great and helping out the President and putting out $2.5 billion, this
goes back to the Americans who buy their product.
In 2011, this bill will limit flexible spending accounts to $2,500
per year. Yeah, you'll still be able to have your FSA, but you will be
limited on the amount you can put into it.
Here's one that really most people are not aware of. There is a
medical device manufacturers' fee which is again going to be passed on
to the end user, the consumer, the patient, which is you. Continuing on
the time line in 2011, there is a health insurance provider fee--$2
billion in 2011, $4 billion in 2012, and then it goes up from there
rather dramatically. Again, a tax on health insurance providers.
Who do you think is going to pay that, the CEO of the big insurance
company? Probably not. The guy that's buying the insurance? Probably.
Again, I talked about this before. In 2013, the excise tax of 40
percent will be imposed on the Cadillac plans. In 2013, new Medicare
taxes on individuals earning more than $200,000 a year and couples
making more than $250,000 a year, the Medicare tax on your withholding
is going to rise to 2.35 percent. There is going to be a new 3.8
percent tax. Starting in 2013, a new 3.8 percent tax on unearned
income. Dividends, interest, capital gains. 2013, an excise tax of 2.9
percent imposed on the sale of immediate medical devices.
Now, not all medical devices--and we all heard the stories about the
Band-Aids when the Senate was talking about this. There will not be a
Band-Aid tax. This will be for so-called class 2 and 3 medical devices.
Class 2 devices would be syringes, sutures, some testing that a doctor
might do in their office. Some of those testing kits will be taxed at
that 2.9 percent rate.
Let me tell you something here. As a doctor, you don't get to pass
that tax on to your patient because most of your patients that come in
that are insured, you actually see them at a contractual rate. So
whatever the code is, there is a contractual rate for that code and it
doesn't include that 2.9 percent tax. And employers with more than 50
employees must pay a fine of up to $3,000 if employees receive tax
credits to purchase insurance.
So billions of dollars are going to be spent to hire thousands of new
IRS employees needed to collect the taxes. Yet three out of 10 doctors
says if Congress goes against their will and the will of the American
people and passes this bill, they may retire from practicing medicine.
So that's what the people are going to get--more IRS agents, less
doctors.
Simple equation. How does that equal health care reform?
Ideally, we would repeal the entire bill and start over with real
reforms. It seems unlikely that's going to be able to happen. Really,
Members on both sides of the aisle that were concerned about this bill
last night need to work together to repeal the more egregious portions
of this bill and ultimately work toward the repeal of the entire bill
when the make-up of the Congress
[[Page H2207]]
and the White House has sufficiently changed to allow that to happen.
Let me talk a little bit again about the Senate-passed bill. We're
not talking about the reconciliation bill. We're not talking about the
House-passed bill. Remember the Senate-passed bill in December? There
was a Senator from Connecticut who said, I cannot vote for a bill if
it's got a public option in it.
{time} 2150
Maybe it's because there are a lot of insurance companies in
Connecticut, I don't know what the reasoning was, but that Senator was
very firm that they would not have his vote, and they needed every vote
they could to get to 60, so the public option was very reluctantly
stripped out of the Senate bill. But is it really going? And the answer
is it might not be.
Now, you have heard that several States around the country are
looking at, I believe it's up to 37, was the last count, are looking at
either filing a constitutional challenge or somehow exempting their
State from participating in this new Federal legislation, and that also
means that they may not set up the State-based exchange that the bill,
the Senate bill, calls for.
Well, what happens in a State that doesn't set up an exchange? Is
there not going to be any exchange, so there won't be any insurance in
the exchange available to citizens of those States? You would think so,
because States should ultimately have sovereignty, except that there is
a little known Federal agency called the Office of Personnel Management
that is going to be charged with setting up a State-based exchange or a
national exchange that every State that doesn't have a State-based
exchange, that their citizens can buy through this national exchange.
And the Office of Personnel Management, in the language of the bill, is
required to set up one insurance company, one for-profit insurance
company, and one not-for-profit.
Does this federally administered, national exchange, not-for-profit,
insurance company begin to look a lot like the public option that was
discussed in the Democrat's bill in the House? The answer is, of course
it does.
The Office of Personnel Management currently administers the Federal
employee health benefits plan here for all Federal employees, not just
in Congress, but all employees. So they are a relatively small agency.
That's a big insurance plan, but still, as Federal agencies go, that's
a relatively small agency.
It is going to have to rapidly ramp up with a great number of new
employees. Perhaps that's one of the ways we are going to deal with
unemployment is to hire more people in the Federal Government. But the
Office of Personnel Management will have to get considerably larger,
and this Office of Personnel Management will now be the de facto public
option as it administers the not-for-profit that's in the national
exchange that is available to people who are in States that don't set
up a State-based exchange.
It is a public option by another name. Unfortunately, the Senator
that sought to prevent that from happening did not see the way this was
going to work out in their own Senate bill. So when I say the doctors
who look at retiring from practice, if there is a public option in the
bill, perhaps the more they get to understand that this public option
is really in the bill, maybe they will rethink their willingness to
continue to work within the system.
Are there other ways to change this bill that we passed last night?
Certainly, everyone ought to be treated equally under this bill, and
they haven't been. Maybe that's one of the technical fixes we could
work on so that there is no geographic disparity, there is no racial
disparity. People, equals, ought to be treated equally, and that is one
of the things that really we should work on.
I think we should work on getting rid of the individual mandates and
the employer mandates. Certainly we could encourage comprehensive
coverage for seniors. Right now, look what we are doing to Medicare
Advantage. Look what we are doing to putting the tax on the
supplemental insurance.
We really should, rather than discouraging seniors from having a
Medicare Advantage plan or a supplemental plan, maybe we ought to
encourage that. After all, the Medicare Advantage plans are doing what
we asked them to do. We asked them for care, coordination, disease
management, expanded health IT, expanded use of physician assistants,
nurse practitioners, paraprofessionals.
Medicare Advantage plans are performing those functions. They are
just now getting to the point where they are really starting to see the
cost savings that we all said would be there if they would do those
things, and now we are going to take them away. Okay, never mind, we
shouldn't have done it anyway, so sorry about that.
Allow health insurance to be sold across State lines. We have talked
about this a lot. If you want competition, don't have the Office of
Personnel Management create a nonprofit that everyone is going to
compete with. That's only one other bit of competition. Let the 1,300
insurance companies that exist in this country, let them compete. Let
them compete up on the Internet, let them compete across State lines.
The portability of insurance, Congress attempted to address that back
in 1996, arguably made kind of a mess of things. But if we would do
things that would establish and create an enhanced portability of
insurance, we would go a long way towards establishing a longitudinal
relationship, a patient with their insurance company.
If you go from job to job, you don't change insurance companies. You
have your insurance company, and you can take it with you. Allow
private insurance and alternatives to Medicaid and SCHIP, special
health savings account for the chronically ill, health insurance plans
to specialize in solving problems for the chronically ill.
All of these things are out there and within our purview. These are
all things we should undertake to fix the egregious problems that are
in the Senate bill.
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