[Congressional Record Volume 157, Number 29 (Tuesday, March 1, 2011)]
[House]
[Pages H1429-H1436]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                           THE DOCTORS CAUCUS

  The SPEAKER pro tempore (Mr. Griffith of Virginia). Under the 
Speaker's announced policy of January 5, 2011, the gentleman from 
Georgia (Mr. Gingrey) is recognized for 60 minutes as the designee of 
the majority leader.
  Mr. GINGREY of Georgia. Mr. Speaker, I thank you, and I thank Speaker 
Boehner and my leadership for giving me an opportunity and my 
colleagues an opportunity during this next hour to talk about something 
that, yes, indeed, is still fresh on everybody's minds.
  That is, of course, the passage on March 23, 2010, almost a year ago 
now, of something that some might affectionately refer to as ObamaCare, 
I guess officially we would say the Patient Protection and Affordable 
Care Act. Some people struggle with the acronym of PAPA Care. Whatever 
you call it, this health care reform act that was passed last year is 
something that a preponderance of the American people have been and 
continue to be opposed to.
  Mr. Speaker, as the designee of the majority, I am taking this 
opportunity during this hour to talk a little bit more specifically 
about why we feel the way we feel, why the American people--why our 
constituents--keep telling us even a year later they are still worried 
about it and are opposed to it after President Obama signed the Patient 
Protection and Affordable Care Act into law. I think the bill number 
was 3590. That's what we're going to be spending our time on here in 
the next hour. We will be discussing that issue.

                              {time}  1630

  I have a number of my colleagues, Mr. Speaker, who are members of the 
GOP House Doctors Caucus. Now, in that Doctors Caucus, we have all 
health care providers--not all M.D.s, a lot of M.D.s, but we also have 
some dentists. We have a clinical Ph.D. psychologist, and now, with our 
new freshman class, we have three registered nurses on our side of the 
aisle, Mr. Speaker. So the Republican GOP Doctors Caucus is growing, 
growing almost double in the 112th Congress as compared to the 111th. 
So many of my colleagues in the Doctors Caucus will be part of this 
discussion.
  I would like to point out to my colleagues on both sides of the aisle 
a couple of slides before yielding time to the other members of the 
Doctors Caucus. This first slide that I'm pointing out to you--GOP 
Doctors Caucus, of course--``ObamaCare hurts States and patients.''
  I know that a lot of the discussion today will be about the strain 
that certain provisions of this bill place on our 50 States, not just 
my home State of Georgia. I do want to talk a little bit about that and 
the strain that my Governor and the members of the Georgia General 
Assembly are experiencing in trying to balance a budget when they have 
all this added requirement under the sections pertaining to Medicaid. 
So that's what I mean when I say in this slide the GOP Doctors Caucus 
feels that ObamaCare hurts States, and certainly potentially hurts 
patients.
  I'd ask my colleagues to also--again, on both sides of the aisle, 
because our purpose here is to inform. We're not to be overly critical, 
but I think it's very important that we state the facts as we see them, 
as we know them.
  In this slide a little bit further to my left, ``ObamaCare,'' it 
says, if you can't see it, ``You can have whatever you like as long as 
the boss approves it.'' And the boss, if you remember from that pretty 
popular TV series ``The

[[Page H1430]]

Dukes of Hazard,'' that would be Boss Hogg. Now, if you're wondering 
who I'm referencing in regard to ``the boss,'' I'm referencing the 
Federal Government, Mr. Speaker, not any individual, but the Federal 
Government.
  It was said many times in the markup of this bill and the lead-up to 
this bill--which, as I say, we call ObamaCare--``You can have whatever 
you like as long as the boss approves it.'' And just in this year 
alone, the boss--and the boss in this instance happens to be Secretary 
Sebelius and the Department of Health and Human Services--has had to 
grant--now listen to this, my colleagues--has had to grant 733 waivers 
to make sure that this pledge of ``if you like what you have you can 
keep it''; otherwise, without those waivers, you couldn't--733 of them.
  So this is what we're going to talk about tonight, and I thank my 
colleagues for being on the floor and joining with me.
  At this point, one of the members of the GOP Doctors Caucus, in his 
second term, a gastroenterologist of a number of years practicing in 
Louisiana, my good friend, Representative and Doctor Bill Cassidy.
  Mr. CASSIDY. Thank you, Dr. Gingrey.
  Now, Dr. Gingrey, I'm struck. Sometimes folks think that when we 
speak about health care, we're only speaking about health care. That 
seems kind of a simplistic statement. But let's think about it.
  Right now, States are having these huge budget crises. We see in 
Wisconsin where there's a protest. We see in some States where there 
may be as much as a $10 billion budget deficit. In my State of 
Louisiana, there is a $1 billion to $2 billion budget deficit. And if 
you think about this a little bit deeply, you understand that this can 
be related to health care.
  Now, specifically, for Medicaid. Medicaid, for those watching who are 
unfamiliar with it, is a combined program in which the State puts up 
some money and the Federal Government puts up some of the money, and 
with this it is used to care for the elderly, for pregnant women, for 
children, typically people of low income. Well, as it turns out, it is 
this program which is bankrupting the States. In a State, if you're 
paying this amount for health care and this amount for roads and this 
amount for education, as the amount for health care increases, you 
either raise taxes or you decrease spending on the other areas. Now, as 
it turns out, this has had tremendous impact.
  Today, the Governor of Massachusetts came and spoke to one of our 
committees regarding the impact of their health care program, which is 
very similar to the bill just passed last Congress, in Massachusetts, 
and I was struck by what a nice view he gave. If you heard Governor 
Patrick speak--I didn't have a chance to ask him questions, but if you 
heard him speak, there's no problems with it whatsoever. But as I 
logged on and, say, read the Boston Globe, I learned different things.
  First, I learned that Massachusetts, which has already implemented a 
program like this, the amount of money spent on health care has gone 
from 21 percent of the State budget in the year 2000 to 37 percent now. 
So from 21 percent to 37 percent is the amount the State of 
Massachusetts is now spending on health care. Well, you can only 
imagine the crowd-out effect that has on spending for other issues.

  Well, the Governor again, as he went on and praised their program, 
said that there has been no problems paying for it. Well, as it turns 
out, and according to the paper, there's about a $1.5 billion to $2 
billion shortfall in the Massachusetts budget. And in Massachusetts, 
the Governor of Massachusetts has said that the Medicaid spending is 
unsustainable. Hmm, that's different. So this is, if you will, the beta 
version of the Affordable Care Act--or as I call it, the unaffordable 
care act. This is the beta version of it, but it gives us an idea of 
what our future is going to be like.
  Now, in order to deal with these costs--again, I'm quoting the 
Globe--it says that ``most recently dental benefits have been slashed 
for hundreds of thousands of Massachusetts Medicaid patients and they 
have lost access to their dentists.''
  Now, by the way, the goals of health care reform are to provide 
affordable, quality health care that is accessible to all; but if you 
can't afford it, you eventually lose access. And I think what we found 
in Massachusetts is that the inability to afford is, of course, 
decreasing access. And it's not just the fact that these folks lost 
access to their dentists. Last year, folks who are recent immigrants to 
the United States who have been enrolled upon Medicaid in Massachusetts 
were disenrolled. So, if you will, this Massachusetts Medicaid program 
that has grown from 21 percent of the Massachusetts budget to 37 
percent and still growing, now the cost is being controlled by denying 
access.
  Now, we also mentioned a third goal of health care reform, which is 
quality care. You know, there's actually now concerns about the quality 
of health care afforded by Medicaid. If you will, there's a study 
recently reported in the Archives of Surgery in which someone looked at 
the outcomes of patients covered by Medicaid, Medicare, private 
insurance, or uninsured. As it turns out, they say, of all four groups, 
the cost and length of stay associated with Medicaid was longer than 
the rest.
  Also, mortality rates--now, that's a way to say how many people die. 
Mortality rates associated with uninsured, Medicare, private insurance, 
and Medicaid was highest for Medicaid. So if you had Medicaid, you had 
a higher death rate from your hospitalization than if you're on private 
insurance, if you're on Medicare, and if you're uninsured.
  Now, it's so counterintuitive that being on Medicaid is worse than 
being uninsured in terms of outcomes. Clearly, this is an issue that 
has to be studied further, but it certainly calls into question the 
very premise of using Medicaid as the basis for health care reform.
  Just to make a point, under the Affordable Care Act--or the 
unaffordable care act--many people are insured; 20 million Americans 
are put on Medicaid as a way for them to be now insured.

                              {time}  1640

  And yet if we see that it's bankrupting States, it's clearly not 
affordable. If we see that because it's not affordable States are now 
denying access to care, as is the case in Massachusetts, and the care 
that is provided is of problematic quality, we can say to ourselves 
that this is not the basis for reform. It's like the antithesis of 
reform.
  So I will yield back to you, Dr. Gingrey, just pointing out that this 
not only involves health care but also involves our ability as a State 
to afford other things, like roads and education. And to use that State 
government-Federal Government program as a basis for reform does not 
serve patients, does not serve the States.
  Mr. GINGREY of Georgia. I thank the gentleman from Louisiana, Mr. 
Speaker.
  At this time, I want to yield a little bit of time to our colleague, 
a freshmen Member, a new member of the Doctors Caucus, a registered 
nurse from the great State of North Carolina, Renee Ellmers. 
Representative Ellmers has worked in a medical practice with her 
husband, who is an M.D., and we look forward to her comments.
  And at this time, I yield as much time as she may use to Renee 
Ellmers.
  Mrs. ELLMERS. Thank you.
  I'd like to just contribute a little bit more on the overall burden 
that ObamaCare places on our States in covering patients on Medicaid.
  As we've seen, this has grown, especially with the recession and the 
undue costs to our States' budgets to provide Medicaid at no cost 
sharing from the patients. I think that this is a key issue. It's 
basically free health care for those individuals at taxpayer expense. 
And it's just a huge strain on our States' budgets, as my colleague has 
pointed out.
  One of the key factors--and very important, certainly very important 
in health care--are the preventative mandates. Certainly preventative 
medicine is a way that we can all heal, that we can all be looking for 
those issues that can down the road prevent excessive costs. But such 
things as no copays or deductibles for colonoscopies, mammograms, such 
things like this is there again, an undue cost to our States at 
taxpayer expense. It's just too much of a burden.

[[Page H1431]]

  You know, I want to help everyone. I think that everyone should be 
able to have health care. As we know, if you pull up to an emergency 
room in any hospital across the country, you will receive health care. 
So the misnomer that there are those individuals who are not receiving 
health care is really an untrue statement.
  Now, of course, you're going to receive a bill for that care. And I 
think that just as if you go to the grocery store and you have your 
cart full of groceries when you check out, you have to pay for it. It's 
the same thing with health care. Health care is a business, and someone 
has to pay for it.
  But when we continuously pass this cost on to our taxpayers and, of 
course, our State budgets, it is just unbelievably difficult; and, of 
course, that is what ObamaCare does. It increases the number of 
patients on Medicaid, and it is just an unsustainable cost.
  Mr. GINGREY of Georgia. If the gentlelady would let me reclaim my 
time for just a second, and then I will yield back to her.
  Colleagues, look at this first slide again, the heading, ``Who Is the 
Boss?'' And of course we've already talked about Boss Hogg. And I said 
at the outset, the Federal Government is the boss. But there are one, 
two, three, four, five bullet points under that. And this is really 
what Representative Ellmers is referring to in regard to the Federal 
Government putting all of these mandates onto the State budgets.
  159 new boards, agencies, and commissions created by ObamaCare to 
support the boss, the government--159 new boards. Sixteen thousand new 
IRS agents help the boss, the government, enforce the new law. That's a 
report from the House Ways and Means Committee.
  The Secretary of Health and Human Services, Kathleen Sebelius, under 
this law, this 2,400-page monstrosity, is given broad new powers to run 
ObamaCare--rulemaking, regulatory authority. No wonder the doctors and 
their patients are scared to death.
  And then, of course, the new Director of CMS, the Committee on 
Medicare and Medicaid Services, Dr. Donald Berwick, a brilliant man, a 
Harvard-trained doctor, M.D., written several books. Unfortunately, in 
those books, Mr. Speaker, he talks about rationing of care. This is a 
paraphrase of a quote: It's not if we ration; it's how we ration.
  And, again, these are the things that we have great fear of.
  The CBO actually, in this last bullet point, Congressional Budget 
Office, nonpartisan, says it will cost between $5 billion and $10 
billion just to hire all of these new employees needing to help the 
boss, the government, run ObamaCare.

  Mrs. ELLMERS. I would like to expand on some of the points that 
you're making there.
  We're basically talking about the same issues, and we can see what an 
increase in costs this is going to be and how incredibly difficult it 
would be to put this in place. And, you know, this isn't yet another 
situation where the good intentions and well-meaning intentions that 
are put forward to help this situation are just truly not the answer.
  You know, basically, how do we increase the access to health care 
coverage? Medicaid is not the route to take. There again, it passes too 
much cost on to our States and it is not--it is an imperfect situation. 
And I'll expand a little bit on the Congressional Budget Office 
numbers.
  Very conservative estimates indicate Federal spending for Medicaid is 
expected to reach $427 billion by 2019. And the Congressional Budget 
Office notes the program will consume more than 4 percent of GDP by 
2050.
  You know, one of the unintended consequences to this--you know, we 
were talking about some of these bad situations, poor outcomes. One of 
the things that we're seeing right now, unfortunately, in health care 
as we move into this transition into ObamaCare is the decrease in 
Medicaid reimbursements to physicians. They're not very good to begin 
with, and I would say that that's probably going to decrease to doctors 
and hospitals as we decrease the reimbursement to hospitals especially.
  This will basically--we were talking about the possibility of 
rationing of care and knowing that this is down the line and the 
quotes, of course, that we see from Centers for Medicare & Medicaid. 
But basically what we're seeing here is that physicians will be forced 
to have to stop taking Medicaid patients.
  As we all know, physician offices are businesses. They're small 
business owners. They have staff that they have to pay. They have 
payroll that they have to meet. And, unfortunately, when faced with a 
situation like this--we're already seeing it with Medicare as well; 
physicians, you know, having to dial back on the number of Medicare and 
Medicaid patients that they're seeing. This ultimately will not help 
the situation and get that health care for the American public that 
we're looking for.
  If this is the answer--well, let's just say it's not the answer. 
We're creating another problem with this solution. And once again, how 
will we deal with that down the road, with these incredibly large 
numbers of costs that we're passing on to our taxpayers?
  Mr. GINGREY of Georgia. Reclaiming my time, Mr. Speaker, again, I 
thank the gentlewoman from North Carolina and hope she'll stay with us 
during the remaining portion of the hour, and I'd like to yield 
additional time to her later in the hour.
  At this time, I would like to yield to another freshman Member, 
another physician Member, Mr. Speaker, and also I'm proud that he is a 
member now of the House GOP Doctors Caucus. And I will yield time now 
to my good friend from Indiana, Dr. Larry Bucshon.
  Mr. BUCSHON. Thank you, Dr. Gingrey.
  Mr. Speaker, I rise today to talk about how ObamaCare will hurt my 
State and ultimately hurt my patients. And I would like to start with 
an example of the Medicaid program.
  As a cardiothoracic surgeon in Evansville, Indiana, I see a lot of 
patients from neighboring States because we're right in the corner next 
to Illinois and Kentucky.

                              {time}  1650

  Many of these patients are Medicaid patients and, without treatment, 
face grave results. However, every year the Illinois Medicaid program 
runs out of money in September, October. They don't have enough money 
to fund the entire year. And what does that mean? That means that 
without denying any patients care that they need and deserve, my 
practice was forced to delay billing to the Medicaid system of 
Illinois. And then once the new fiscal year came into play, about 50 
percent of those claims were subsequently denied by Illinois Medicaid. 
So those patients that came over for our services, they don't have 
quality health insurance, Mr. Speaker.
  Some physicians in my community don't even bother to bill the 
Medicaid program in some States at all. This is an example of the 
broken Medicaid system, a system that has many issues focusing on the 
access to quality health care. And it was said earlier you see the 
outcome difference between Medicaid and private insurance patients 
because we have an access and quality problem with these patients, a 
system that ObamaCare will break even more by adding millions of 
Americans to the States' Medicaid rolls. It's estimated that this may 
cost the State of Indiana as much as $3.6 billion to cover these folks.
  From Indiana we have an innovative and effective solution, and that's 
called the Healthy Indiana Plan. Beginning in January 2008, uninsured 
Hoosiers between the ages of 19 and 64 started enrolling in this plan, 
a consumer-driven health care plan. The Healthy Indiana Plan operates 
on an 1115 demonstration waiver from CMS, the Center for Medicare and 
Medicaid Services. Due to the program's success, the State of Indiana 
would like to use the Healthy Indiana Plan as a coverage vehicle for 
the newly eligible population under ObamaCare. This has been requested 
by my State Department of Health and Human Services, but to this point 
we have not heard a response about whether this will be possible. And I 
am hoping that we get a response in the positive direction because this 
is a great program.
  The plan is for citizens that earn less than 200 percent of the 
Federal poverty level and works on a sliding scale for individual 
contributions, based on the ability to pay, that cannot exceed more

[[Page H1432]]

than 5 percent of his or her gross family income. Each participant is 
enrolled in a health savings account valued at about $1,100, and will 
not make copays except for non-emergency use of the emergency room. And 
believe it or not, this program reimburses providers at a Medicare, not 
Medicaid, level. This gives citizens a financial incentive to adopt 
healthy lifestyles and personal responsibility to make their own health 
care decisions.
  Healthy Indiana Plan is an innovative, market-based, consumer-driven 
plan that is working. In a recent survey, 94 percent of Healthy Indiana 
Plan participants are satisfied with the program, and 99 percent 
indicated they would re-enroll. There is data in the fact sheet that I 
have included in the Congressional Record showing the success of this 
plan both for patients and for the State of Indiana.
  It's a commonsense, market-based solution to a broken Medicaid system 
that ObamaCare does nothing to fix, but only further burdens my State, 
and all States, and will ultimately continue to hurt patients' access 
to quality health care in America. So I would urge everyone to review 
what the State of Indiana has done with its Healthy Indiana Plan.
  With that, Dr. Gingrey, I thank you.

       The Healthy Indiana Plan is a consumer-driven health care 
     plan for uninsured Hoosiers between the ages of 19-64. The 
     program began enrollment in January 2008, and operates under 
     an 1115 demonstration waiver from the Centers for Medicare 
     and Medicaid services (CMS). During the first two years of 
     the program, HIP served 61,797 Hoosiers.


                            who is covered?

       HIP is for uninsured Hoosier adults between the ages of 19-
     64. Parents or caretaker relatives of children in the Hoosier 
     Healthwise (CHIP) program are likely candidates for HIP.
       Eligibility Requirements: 1. Earn less than 200% of the 
     federal poverty level (FPL). A single adult earning less than 
     $20,000 or families of four earning less than $40,000 likely 
     meet the basic financial requirements. 2. No access to 
     employer sponsored health insurance coverage. 3. Uninsured 
     for the previous six months.


                             plan structure

       A POWER (Health Savings Account) Account valued at $1,100 
     per adult. Contributions to the account are made by the State 
     and each participant (based on ability to pay). No 
     participant pays more than 5% of his/her gross family income.
       Sliding scale for individual contributions (based on % of 
     gross family income): 0-100% FPL: 2%; 100%-125% FPL: 3%; 
     125%-150% FPL: 4%; 150%-200% FPL: 4.5%-5% (Caretaker 
     relatives/parental adults in this income bracket contribute 
     4.5%, and the childless adults contribute 5%).
       No co-pays except for non emergency use of the ED.
       Providers are reimbursed at Medicare, not Medicaid, rates.


                             Plan Benefits

       A basic commercial benefits package, once annual medical 
     costs exceed $1,100.
       Coverage for preventive services up to $500 a year at no 
     cost to participants.
       Services include: physician services, prescriptions, 
     diagnostic exams, home health services, outpatient hospital, 
     inpatient hospital, hospice, preventive services, family 
     planning, and case and disease management.
       Mental health coverage is similar to coverage for physical 
     health, and includes substance abuse treatment, inpatient, 
     outpatient, and drugs.
       HIP does not cover vision or dental. HIP also does not 
     cover pregnancy services, as these services are available 
     through the existing Medicaid program.


                       Why a POWER (HSA) Account?

       Personal Wellness and Responsibility (POWER) Accounts give 
     participants a financial incentive to adopt healthy behaviors 
     that keep them out of the doctor's office. When they do seek 
     health care, participants will seek price and quality 
     transparency so they can make value conscious decisions.
       If all age and gender appropriate preventive services are 
     completed, all (State and individual) remaining POWER Account 
     funds will rollover to offset the following year's 
     contribution. If preventive services are not completed, only 
     the individual's prorated contribution (not the State's 
     portion) to the account rolls over.


               Program Results & Personal Responsibility

       HIP members, in general, have demonstrated the personal 
     responsibility emphasized by the program.
       Lower ER Use: Some HIP members do not make POWER account 
     contributions due to CMS income-counting guidelines. HIP 
     members required to make POWER account contributions: 9% 
     decrease in ER use in 3 months; 15% decrease in ER use after 
     6 months. HIP members not required to make POWER account 
     contributions: Initial 5% decline in ER use after 3 months; 
     no additional decline in ER use.
       High Generic Drug Utilization:
       HIP generic drug utilization: 80%; comparable commercial 
     population: 65%.
       High Use of Preventative Care: 76% of HIP members received 
     their required annual physical in the first year of the 
     program. Use of preventive services was significantly higher 
     than the traditional Medicaid population in Indiana: 445.4 
     well care visits per 1,000 (HIP caretaker adults); 281.8 well 
     care visits per 1,000 (HIP childless adults); 195.2 well care 
     visits per 1,000 (Indiana Medicaid adults).
       Strong Personal Responsibility: 97% of members made their 
     required POWER account contributions during program year one. 
     Individuals can be removed from the program for failure to 
     make POWER Account contributions within 45 days. Once removed 
     from the program, an individual may not re-enroll for 12 
     months.
       High Member Satisfaction: 94% of HIP participants surveyed 
     said they are satisfied with the program, and 99% of 
     respondents indicated that they would re-enroll in the 
     program.


                   Impact of the Affordable Care Act

       The Affordable Care Act maintenance of effort requirements 
     turned HIP into an entitlement program for adults. Despite 
     funding limitations (HIP was funded through an increase in 
     the cigarette tax), the State cannot limit the number of 
     parental enrollees. Therefore, the State is not currently 
     enrolling childless adults on the wait list.
       Due to the success of the program, the State would like to 
     use HIP as the coverage vehicle for the newly eligible 
     population. Indiana has asked for direction from CMS (May 
     letter to Cindy Mann) and has not received any official 
     guidance.
       The success of the program depends on its innovative 
     market-based, consumer-driven structure. There is concern 
     about whether or not CMS will allow the program to continue 
     in its current form.
       For more information: www.HIP.in.gov.

  Mr. GINGREY of Georgia. I think, Mr. Speaker, the good doctor is 
pointing out some things that our colleagues on both sides of the aisle 
and the American people need to understand. This plan that was just 
described to us by Representative Bucshon, the Healthy Indiana Plan, 
it's so typical of what the States are capable of doing, Mr. Speaker, 
if they're allowed to do that.
  But we have great concerns, and when I say ``we,'' I am talking about 
the governors of all 50 States, be they Republican or Democrat, and the 
territories, to be told by the boss, again, that, no, you can't be an 
incubation center, you cannot be innovative in regard to developing a 
health care plan for those who can't afford to purchase health 
insurance on their own and they qualify for safety-net programs like 
the Federal-State shared program Medicaid.
  And the States, Indiana, my own State of Georgia, Governor Herbert 
testified before the Energy and Commerce Committee today in regard to 
what he is doing in Utah. In fact, they had already set up exchanges at 
the State level 5 or 6 years ago, long before this Patient Protection 
Affordable Care Act even was on the drawing board.
  But when you have things in the bill, when the boss writes a section 
of the bill that says States, it doesn't matter that you have to 
balance your budget, we don't at the Federal level, but we're going to 
dictate to you that you're going to have to start covering Medicaid 
constituency up to 138 percent of the Federal poverty level. We're 
going to put that into law. That's part of this new law ObamaCare. And 
you have no choice. Now, we're going to give you a little breathing 
room, and we're going to say it's not going to start for a couple of 
years, indeed January of 2014 you have got to expand your Medicaid 
rolls from the typical State covers 100 percent of the Federal poverty 
level. This goes up to 138 percent of the Federal poverty level.
  And the boss says, well, we'll pay all of it with Federal dollars for 
the first couple years, but we're going to phase that out. And then, 
oh, yes, guess what happens, the boss adds eventually at the end of the 
day $60 billion to State Medicaid costs. And also there is a section in 
the bill, Mr. Speaker, that tells the States, and it's called 
maintenance of effort, you can't change one thing that you currently do 
in your Medicaid program to prepare yourself for this tsunami. If 
you're covering today 185 percent of the Federal poverty level, you 
can't all of a sudden say, well, gosh, you know, we're going to have to 
lower that to 150 percent and put some oats away and get ready for that 
real rainy day in 2014.
  We heard from another governor today in that hearing--there were 
three--Governor Deval Patrick of Massachusetts was one, and Governor 
Haley Barbour from Mississippi, Mr.

[[Page H1433]]

Speaker, was the other. And Governor Barbour was saying that a couple 
of years ago he instituted a program in the State of Mississippi that 
would make sure that people that were on the Medicaid program were 
eligible, that they deserved to be there. They weren't eating somebody 
else's lunch, as the expression would go. They weren't illegal 
immigrants. Their income wasn't too high to make them eligible for this 
safety-net program.
  And of course, Mr. Speaker, as we all know, thank goodness, income 
from year to year can get better. We're still waiting for that to 
happen. I think ObamaCare and some of these other policies that we're 
seeing over the last 4 years is preventing that from happening. So 
Governor Barbour would make people come and face to face verify that 
they were still eligible from year to year. As I understand it, this 
rule, this maintenance of effort would prohibit--he has already done it 
in Mississippi--but in any other State, as an example, to make sure 
your rolls were clean and were you covering the people that were 
eligible and that really needed that care.

                              {time}  1700

  This is the kind of thing that we are dealing with, and why we are 
talking about this tonight and why we are talking about it so 
passionately.
  Mr. Speaker, I yield to my colleague from Tennessee, Representative 
Diane Black, another new Member, a delightful new Member, also assuming 
leadership positions and going to do a great job here in the House.
  Mrs. BLACK. Thank you.
  Mr. Speaker, I rise today as a registered nurse who worked in 
emergency rooms and caring for patients. I also rise as a former member 
of the Tennessee General Assembly who saw firsthand the devastating 
effects of TennCare on our State and was a part of the group, of the 
effort, to dismantle it.
  Finally, I rise today as a representative of the Sixth District of 
Tennessee, where my constituents have told me over and over how they do 
not want ObamaCare bankrupting our Nation and getting between them and 
the doctor.
  Mr. Speaker, I know that the health care industry, and I know that 
the new health care law, is not the solution to our problem. Pretty 
soon, the health care law will be the problem. I know this because for 
many of us in Tennessee, the President's new health care law is like a 
bad dream all over again.
  And let me tell you what I mean. Tennessee was the pilot project for 
universal health care and the experiment was called TennCare. Put 
simply, the experiment failed.
  After TennCare passed, we watched the cost grow exponentially, and 
those of us in the legislature knew that if we did not do something, 
TennCare was going to bankrupt our State and, much like ObamaCare, the 
sheer size of TennCare was more than government could handle. The 
government could not perform all of the functions of the medical 
insurance industry. Promises of care and access were made, and promises 
were far beyond what our State could possibly do.
  It didn't take long before TennCare became riddled with waste and 
fraud and abuse. I can remember talking with people who had gone from 
doctor to doctor and specialist to specialist using TennCare to fill 
more than 50 prescriptions. Yes, 50 prescriptions is what they would 
put in front of me and tell me that TennCare was paying for, and it was 
all on the taxpayer's dime.
  TennCare became the monster that even the creators could not control. 
Today, TennCare is gutted, only available to a small group of people, 
and Tennessee has been brought back from the brink of bankruptcy.
  Last month, Republican Governors wrote to ask the administration to 
``waive the bill's costly mandates and grant States the authority to 
choose benefit rules that meet the specific needs of their citizens.'' 
The Governors were asking for commonsense solutions like waiving 
provisions that punished consumer-driven plans like the most popular 
plan and the cost-effective plan of health care savings accounts. Give 
the States the ability to do what States can do best, and that is to 
determine what's best for them.
  But the President shows no sign of granting States some flexibility 
in how they will apply ObamaCare. And only yesterday, President Obama 
said he is supporting letting the States propose their own health care 
plans by 2014. However, that would be only if he will not change the 
mandates for the States in the current law.
  So in one side of his speech he says, yes, he will allow some 
flexibility. On the other side he says, there still must be certain 
mandates.
  Mr. GINGREY of Georgia. If the gentlewoman would yield, it is kind of 
like you can keep what you like until you can't. That's what we are 
seeing, and that's why, as I pointed out earlier, that 733 waivers, 
just this year in 2011, had been grant happened by Secretary Sebelius 
to try to fulfill that promise, but they can't do it. They can't keep 
up with it. There is a need for a new waiver every day.
  Mrs. BLACK. Dr. Gingrey, as you said, States will still be forced to 
comply with benefit levels and mandates that are set by Federal 
bureaucrats, not by the States themselves. That certainly doesn't give 
States rights.
  Secretary of Health and Human Services Kathleen Sebelius has already 
said that if the State were to propose its own plan that they will be 
forced to provide comprehensive, comprehensive coverage, and that 
coverage will be defined by government. So much for being able to keep 
your plan or for the States to make a determination on what plan best 
suits them.
  Now President Obama wants every State to live through its own version 
of TennCare. With ballooning budgets for each State and no way to curb 
their health care costs that will cripple the States during a time of 
already strapped budgets, it's simply unacceptable.
  Mr. GINGREY of Georgia. I would say it's unconscionable and 
unacceptable.
  Mrs. BLACK. We averted this disaster in Tennessee by dissolving 
TennCare and now, as a Member of Congress, I will work to stop this 
financial and fiscal disaster that ObamaCare will bring to our Nation. 
This health care law must be replaced, and I believe this House can do 
it.
  Mr. GINGREY of Georgia. I thank the gentlewoman from Tennessee. I 
failed to mention, of course, that she is also a part of our GOP House 
Doctors Caucus and, as she pointed out, a registered nurse for many 
years in a great Volunteer State, so we appreciate Representative Black 
being with us tonight.
  Before I yield to our next speaker I wanted to, Mr. Speaker, go back 
to this current chart. I wish I had brought a magic marker. I didn't. 
But I circled this, I guess, third bullet point because I think it's 
really telling in regard to what's happened at the State level as a 
consequence of the provisions of ObamaCare.
  And this bullet point says the boss, the Government, the boss 
prohibits 16 million patients from buying private insurance by trapping 
them in Medicaid, and that's really what they have done, Mr. Speaker. 
By expanding the Medicaid eligibility from 100 percent of Federal 
poverty to 138, that means that a lot of the folks out there today who 
are uninsured can't afford health insurance; they are not eligible, 
they are not poor enough, if you will, to be eligible for their safety 
net program known as Medicaid.
  In the Federal Government, the boss comes along with this idea of 
letting people buy their health insurance in an exchange in each State, 
maybe over the Internet. If they are low income, then they get a 
Federal subsidy, not a Federal-State subsidy, but a Federal subsidy.
  Well, clearly as the Democratic majority and President Obama were 
crafting this thing, they figured out, well, you know, if we can shift 
more of these people into the Medicaid program where the States have to 
pick up some of the tab, then we will get them off our back. You know, 
we will lower the cost. We will make this thing work.
  Unfortunately, the poor States, and they are poor, all have to 
balance their budgets, and the Federal Government doesn't. That's why 
we owe $13.4 trillion, and now they are even talking about us wanting 
to raise the debt ceiling so we can borrow some more money. It's a 
smoke and mirrors game, maybe even a Ponzi scheme, in my opinion, Mr. 
Speaker.
  Mr. Speaker, at this time, I want to yield to another member of our 
GOP

[[Page H1434]]

House Doctors Caucus, the gentleman from west Tennessee. I don't know 
whether the area is called Pell Mell or Pall Mall--maybe he will 
describe it to us when he stands to speak--but I am talking about a 
fine physician, a family practitioner, Dr. Scott DesJarlais.
  Mr. DesJARLAIS. Thank you, Dr. Gingrey. I hail from Marion County, 
which is South Pittsburg, would be the hometown.
  Before coming to Congress I had the opportunity to serve the people 
in Tennessee as a primary care physician. In 1994 Tennessee embarked on 
an experiment with the Medicaid program, which became known as 
TennCare. Unfortunately, it never accomplished its goal of improving on 
the flawed Medicaid system.

                              {time}  1710

  To the contrary, it became a breeding ground for waste, fraud, abuse 
and inefficiency. I witnessed the frustration of my patients, my staff 
and myself as we struggled to combat this bureaucratic web that forced 
us to spend time navigating administrative hurdles rather than focusing 
on quality care.
  Another problem that rapidly evolved was over-utilization of the 
system. Often, only one family member was ill, but other family members 
were requesting to be seen simply because it was more convenient than 
making other arrangements for the non-ill member, such as children, to 
be cared for elsewhere. This also became, and continues to be, a 
problem in the emergency rooms. There is no cost difference to the 
patients, so there is no disincentive to utilize the ER for nonemergent 
care. In fact, this is a national problem, with up to 80 percent of ER 
visits being deemed nonemergent. This leads to much longer wait times 
in emergency rooms for those patients who are critically ill. It should 
also be noted that ER visits are obviously much more expensive than 
office visits, further driving up the cost unnecessarily.
  A simple solution to improving the problem of over-utilization would 
be implementing a nominal copay system in which office visits cost 
something like $5 per visit and ER visits might cost $20. This simple 
step would likely have far-reaching effects to reduce costs, over-
utilization, and thus increase availability of care for those who need 
it. We should see TennCare as a warning of the many problems that a 
government-run health care model creates.
  There are certainly issues with our Nation's health care system that 
need to be addressed, and the GOP Doctors Caucus has no shortage of 
good ideas on how to make health care more affordable and expand 
coverage. But what we stand firm in saying is that ObamaCare is not the 
answer to the problem, but, rather, it creates an even bigger problem.
  Mr. GINGREY of Georgia. I thank the gentleman from Tennessee, and I 
thank him for making sure that I know exactly what county and counties 
he represents. I know it's a great State and a great part of the State, 
and we are very proud of the good doctor.
  At this time, I want to yield to another freshman member of their 
class of 87 strong. It's a fantastic class, Mr. Speaker. We are awfully 
proud of each and every one of the new Members, but especially those 
who have that health care background, that experience to come to this 
body, to this Chamber and to this town and bring some professional 
expertise. We don't have all the answers, Mr. Speaker. And I'm proud of 
these physician colleagues of mine because they're not know-it-alls, 
but they know what they know and they know it well.
  At this point, I would like to yield time to the gentlewoman from New 
York, an ophthalmologist, Dr. Nan Hayworth.
  Ms. HAYWORTH. Thank you, Mr. Chairman.
  I observed, sir, that you have brought a sign to the floor that talks 
about stealing America's liberty. One of the fundamental problems that 
I perceive, and I'm not alone in this, but in this entire scheme, if 
you will, that is represented by the Affordable Care Act, as it has 
been called, is that there was a failure to understand the very nature 
of American medical care. When it's at its best, and we recognize--
every colleague of mine, all of my Republican and medical colleagues 
have also appreciated certainly that we want to see all Americans have 
access to good, affordable care and to have affordable, portable health 
insurance. That's not in dispute. So we honor those goals. But the 
means by which the ACA endeavors to achieve those goals go against the 
grain of the American culture. Our culture is one that has always 
allowed us to choose, that has allowed us to pursue, in terms of our 
medical care, the very best that the world has to offer in terms of 
innovation and quality, motivation, incentive to invent and to do 
better. The American medical consumer, our patients, expect no less 
than the best, nor should they receive anything less than the best.
  That's a very different way of thinking about care in a consumer 
society than is the case in so many other systems around the world that 
were cited as exemplars when the ACA was being formulated. We do not 
have, I can tell you from my experience with patients who have had 
care, who have lived in Europe for variable periods of time, some 
Americans who have spent sojourns in Europe because of business 
obligations and working with colleagues from Europe, historically it is 
rather a different model than we have here. American doctors are 
accustomed to jumping and doing and doing all they can and doing it 
fast, and my colleagues can certainly attest to that.
  It's a little bit different sometimes overseas. They have a different 
kind of medical culture. Patients don't expect quite as much. It's not 
the same sort of thing that we have here. And indeed, that is consonant 
with the fact that there isn't any other country's dream necessarily as 
there is an American Dream. My mother is from England. She came to this 
country in 1948 because she was very distressed by national health 
care. There is no British dream. There is not necessarily a German 
dream or Japanese dream. But there is an American Dream.

  Mr. GINGREY of Georgia. If the gentlewoman will yield, Mr. Speaker, 
what the gentlewoman from New York is referencing is something that I 
have heard from people in other countries that have government health 
insurance. And they say, well, I'm real happy with my government health 
insurance. And I know what's going on over here. And I'm thinking, my 
goodness gracious, you're happy? What are you happy about? Well, you 
get to see the doctor within 5 minutes, and you always come out with at 
least three prescriptions.
  Now, if that's the definition of success, Mr. Speaker and my 
colleagues, that's not what American, good old U.S.A. medicine is all 
about. It's time, quality time, spent with that doctor, and maybe no 
prescriptions.
  Ms. HAYWORTH. Thank you, and precisely the point that I'm agreeing on 
with you and that I think we all have driven to philosophically is that 
we need to have solutions that empower our doctors, our patients and 
our providers to do all of them, to have the best and to do the best. 
And consumer-based solutions are possible. Our Doctors Caucus is 
working very hard on providing those ideas. Real liability reform has 
to be part of this. We cannot possibly continue as we have been. That 
was a glaring omission from the ACA.
  In addition, we need to recognize, appreciate and act upon the 
knowledge that our medical care can cost less. We do need to pay 
attention to costs, but we need to empower our patients, our doctors 
and our providers to use their best judgment, not empower something 
like the Independent Payment Advisory Board to make those decisions for 
us. That is a very dangerous thing and something that Americans will 
find very distressing and disturbing. And the inevitable result of the 
ACA is that, and you can trace it out, but we will end up having less 
choice. The government will make decisions for us. They will be 
decisions we don't like. We need our consumers and our providers to be 
able to make those decisions.
  Mr. GINGREY of Georgia. Mr. Speaker, I thank the gentlewoman from New 
York, and I appreciate her time.
  If my clock watching is accurate, I think we may have 8 to 10 minutes 
remaining, and I will try to conclude. I would like to see if my 
colleagues would like to weigh in with additional comments. We do have 
time if any of

[[Page H1435]]

those that are still on the floor would like to bring some more 
enlightenment into this subject.
  I yield to the gentlewoman from North Carolina.
  Ms. ELLMERS. Thank you, Mr. Chairman.
  I think we've come to the point now where we do need to discuss that 
ObamaCare is not the answer. We have all discussed this over and over 
again. I would say that it's probably a good reason that I was elected 
because I ran on repealing it--that and cutting taxes and cutting 
spending. And it all ties in together.
  Those of us who are in health care have been aware of the need for 
reform for quite some time. I think any of us can say that we've seen 
the costs increase. We've seen the cost of health care insurance 
increase. And yet we've all felt that our hands were tied. We didn't 
know how to address it. The bureaucratic system, as my colleagues have 
pointed out, just dealing with billing and trying to get the care for 
patients alone can just take over your office.

                              {time}  1720

  We have seen these things. We know there are problems that exist, but 
we all agree that it needs to be a patient-centered, doctor-nurse-
patient relationship that we have to be putting forward. And it has to 
be in the private sector. There are ways to do this. There is a role 
for government in it, especially when we are talking about Medicare, 
Medicaid, and those who are unfortunate. We want everyone to have 
health care. But there are ways we can address it.
  It is not a health care crisis; it is a crisis of culture. We have to 
change the culture that we are dealing with. We want everyone to have 
affordable health care, and there are simple solutions we can put in 
place to do that.
  Mr. GINGREY of Georgia. I am so glad that I called on the gentlewoman 
from North Carolina and she brought up this point, colleagues, because 
what Renee Ellmers just said is absolutely the truth. We are not on 
this side of the aisle, and those Democrats who agree with us, we are 
not opposed to reforming the health insurance industry, to eliminating 
abusive practices such as canceling policies after the fact or denying 
children with preexisting conditions, and that is exactly what the 
gentlewoman from North Carolina was referencing.
  The pledge to repeal ObamaCare is because in our humble opinion it is 
too bad to fix. That doesn't mean that when we replace it, and we may 
have to do it piece by piece, bit by bit, that we don't incorporate 
some of the things in there that most people would agree are good, like 
allowing youngsters, young adults, Mr. Speaker, to stay on the health 
insurance policy of their parents until they are 26 years old. With 
this economy and the destruction of jobs because of bailouts and 
stimulus, trillions of dollars that don't work, unfortunately, our 
young college graduates have no job to go to; otherwise, they would 
have health insurance from their place of work. So they darn well need 
to stay on their parents' policy until they are 26, and maybe until 
they are 36 if we don't quite get our act together and quit spending 
and get this economy going.
  Let me yield quickly to the gentleman from Tennessee, Dr. Roe, my OB-
GYN colleague from Tennessee.
  Mr. ROE of Tennessee. I thank the gentleman for yielding.
  When I came, as we all did, doctors, physicians tend to look at a 
problem. When a patient comes in, the first thing we ask them, Dr. 
Gingrey: Why are you here today? It is a fairly obvious question. It is 
called the chief complaint.
  When I came to Washington, D.C., I asked the same thing about the 
American health care system. I said: What is the problem with the 
American health care system? I thought there were probably three.
  Number one, it was too expensive. The cost of health care had 
skyrocketed way above inflation so it is way too expensive to come see 
a doctor or go to the hospital.
  The second issue I saw you just brought up was that there was a 
segment of our population that didn't have access to affordable health 
insurance coverage. These are not the very poor who had access in my 
State to TennCare or in other States to Medicaid, but these are folks 
who are out working. Maybe they are a carpenter and their wife stays at 
home. Or maybe they have a job, a small business, where they can't 
afford it. So there was that segment that didn't have it.
  Lastly, there is a liability crisis in America. Our friends on the 
other side, our trial lawyer friends can tend to say that is not the 
case, but let me give you a personal example. When I started my medical 
practice, probably about the same time you did, Dr. Gingrey, it cost 
$360. That was the first baby I delivered in 1977 that I got paid for. 
I was out of the Army and out of my training, $360. My first year's 
salary was $32,000. That is what I made my first year in practice. I 
delivered 260 babies that year; a lot of babies. The next year I was up 
to $60,000 a year. My malpractice was $4,000 a year. When I came to 
Congress 2 years ago, the malpractice in Tennessee for an obstetrician 
was $74,000. And there is no value that we get, that patients get from 
that. We will go into that when we have another hour.
  But the thing about the ObamaCare plan that bothered me was it did 
nothing to bend the cost curve. If you looked at this and if you look 
at plans that have been out there in the past, Medicare, for instance, 
came on board in 1965 as a $3 billion program; $3 billion in 1965.
  The estimators, there was no Congressional Budget Office then or 
folks who make these estimates, but the government estimators at that 
time said in 25 years this will be a $15 billion program. The actual 
number was over $100 billion. And today it is over $500 billion.
  In Tennessee, we noticed we had the same problem 20 years ago. We 
have been through all of this before. Unfortunately, no one here chose 
to listen to us in our Doctors Caucus. We said we had lack of access 
and we had prices rising back in the 1990s, the early 1990s, exactly 
the same debate that we are having today except today it is more severe 
than it was.

  We spent $2.6 billion on TennCare in 1993. In 2004, 2005, just 10 
budget years later, it was up to $8.5 billion. The cost had tripled.
  So when you see these cost estimates--and remember that the same CBO, 
and these are good folks. I'm not pointing the finger at them. It is 
very hard to do what they do. They are given a set of data. They crunch 
the numbers and they hand them to us. They only missed this year's 
budget deficit by $400 billion in 1 year. So I am to stand here and 
believe, looking at these other examples I have just given you, that 
this is going to be budget neutral in 10 years? There is no way it will 
be.
  I know we have a lot to discuss. I'm sorry I was a little late. I had 
some folks from the great University of Tennessee in my office to see. 
I look forward to continuing this discussion.
  Mr. GINGREY of Georgia. Dr. Roe, we appreciate you being with us. I 
know the time is rapidly coming to a close.
  But, Mr. Speaker, I guess the last slide basically says it all, cuts 
right to the chase: ObamaCare steals Americans' liberty. Our 
forefathers intended certain basic rights--life, liberty, pursuit of 
happiness--to be inalienable--that means can't be taken away from you--
and consider them self-evident and universal.
  ObamaCare lets the boss steal liberty from every American by forcing 
them to buy health insurance whether they want it or need it or not. We 
can encourage them to have it and try to make it possible and 
affordable. But to force them to do it, the next thing we know, 
everybody will be eating broccoli by government edict because it is 
healthy, it is healthy food. They are going to have a hard time getting 
me to eat broccoli.
  But I am telling you the judge in Florida, Judge Vincent, and the 
judge in the Commonwealth of Virginia, Judge Hudson, they got it right. 
We need expedited processing of those suits so the Supreme Court will 
tell the American people this is unconstitutional and will not stand.
  With that, Mr. Speaker, I yield back the balance of my time.

[[Page H1436]]



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