[Congressional Record Volume 157, Number 137 (Thursday, September 15, 2011)]
[Senate]
[Pages S5693-S5697]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                          COSTS OF HEALTH CARE

  Mr. WHITEHOUSE. Mr. President, we all traveled over to the House 
Chamber a few days ago to hear President Obama present his jobs plan, a 
jobs plan for which I intend to support and fight. But during the 
course of that speech, we also heard the President indicate that he was 
going to come and make some recommendations to the Senate and to the 
House regarding our debt and deficit strategy.
  I come to the floor today to urge the White House, in dealing with 
our debt and our deficit issues, to pursue a strategy for cost 
reduction in our health care system that does not rely on harmful cuts 
to our seniors' Medicare benefits. I cannot tell you how important this 
is in Rhode Island where we have a significant senior population. Many 
of our seniors are low income. The average Social Security benefit is 
around $13,000 to $14,000.
  Some of the ideas that have been floated in this body--more than just 
floated; they have actually passed the Congress, the House of 
Representatives--would be devastating to Rhode Island seniors: an end 
to Medicare in 10 years; $6,000 in increased costs to each senior, on 
average, per year, hidden in what the Republicans like to call their 
cut, cap and balance plan, with an even worse attack on Medicare and on 
Medicare beneficiaries than was in the House budget that passed, which 
was a bad enough attack on its own. That simply is more than seniors in 
Rhode Island can manage. It is not fair; it is not right. And, most 
importantly it is not necessary.
  I do concede that rising health care spending has placed a lot of 
stress on our national budget. In the joint session of Congress in 
September 2009, President Obama himself said: Put simply, our health 
care problem is our deficit problem. Nothing else even comes close.
  If you go to the other side of the political spectrum and to the 
other Chamber of Congress, Congressman Ryan said: Our debt and deficit 
problem is, at its core, a health care problem. I agree with that. We 
need to address it. The question is how.
  The fundamental fact that so many of our colleagues overlook in their 
urgency to attack Medicare--a program that Republicans have been 
against from its very founding and that the renewed tea party assault 
on Medicare has revived--has misled the debate, because the cost 
problem in Medicare is not a problem that is unique to Medicare. 
Wherever you look in the American health care system, costs are 
exploding. They are going up in Medicare probably at a lower rate than 
other quadrants of the health care sector, but they are going up. They 
are going up in Medicaid. States are having trouble dealing with that 
burden. They are going up in TRICARE and in veterans' care. Indeed, 
Secretary Gates said: Health care costs are eating the Defense 
Department alive. Eating the Defense Department alive, health care 
costs are. And if you are in private insurance, whether it is Kaiser or 
United or Blue Cross, pick your insurer, the costs are going up 
dramatically. Our own hospitals in Rhode Island, which provide health 
care, are watching their health care costs accelerate at significant 
rates far above a multiple of our rate of inflation.
  This problem of rising health care costs is creating real strain. It 
is not just creating strain on the Federal budget--granted, it is 
creating strain in the Federal budget--but it is also creating 
incredible stress on seniors, on small business owners who can't afford 
health insurance for themselves, or have to whittle away at the health 
insurance their employees have in order to keep it affordable, or have 
to give it up entirely as they face the stresses of this economic 
downturn.
  As the Presiding Officer, the senior Senator from Colorado, knows 
because

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his, like Rhode Island, is a small business State. When you are a small 
business, your employees are pretty darned close to family. When you 
have to whittle away at their health care benefits, when you have to 
whittle away at what they get, when you have to raise their costs, that 
is a hard decision for that small business owner/manager to make.
  It is tough on American families. It is tough on big businesses. It 
is tough on American big export companies. Our automobile industry, the 
tractor manufacturers, the road building equipment manufacturers, the 
folks who build big American products that we export overseas, we build 
enormous amounts of health care costs into those products. It has been 
estimated that nearly $2,000 in health care costs goes into an American 
car. Well, the foreign car that competes in the international market 
with that American car comes out of a national health care system. So 
that health care cost isn't in the cost structure of the company that 
makes the car. And because they collected most of their taxes through a 
value-added tax, it doesn't even come in through the tax system, 
because the export products get out of those companies and into the 
international market without a tax burden. So there are our products, 
trying to compete overseas, with this weight of our health care system 
cost on them and it helps make America uncompetitive. So it is not just 
Medicare. It is everywhere in the American health care system. It is 
systemwide.
  A couple of years back, when we were first discussing this issue and 
the White House held a couple of health care conferences, I was 
fortunate to be invited to those conferences. The President used a 
metaphor in discussing where we were in health care in those 
discussions. He used the discussion of us being headed for a cliff. If 
we didn't do something about our health care costs as a country, we 
were headed for a cliff.
  Well, nothing has changed. We are still headed for that cliff, and 
the solution we have to find is to take the bus that we are all on and 
turn it before we get to the cliff.
  It is not an adequate solution to simply throw seniors off the bus in 
order to lighten the Medicare cost load without doing what we need to 
do to change the direction of the American health care system to 
alleviate this cross-system, this economywide burden.
  Fortunately, we gave President Obama tools to do this in the 
Affordable Care Act. We fought about all sorts of elements in the 
Affordable Care Act. We fought about the public option. We fought about 
universal coverage. There were imaginary claims raised that there were 
death panels in the health care bill. It was considered to be 
socialized medicine, the same phrase that was trotted out years ago to 
oppose Medicare. They brought that old stalwart phrase out again--
totally false.
  The only socialized medicine we have in this country is the kind we 
give our veterans, which is the very best quality care they are 
entitled to--what Bob Dole has said is the place we should look toward 
for health care reform. But that is a separate argument. But my point 
is there was a whole lot of phony controversy about that health care 
bill.
  What was completely not discussed was that a huge chunk of that bill 
was dedicated to delivery system reform of the health care system, to 
turning the bus before we hit the cliff. There is a lot in there for 
the President to work with. There are literally dozens of programs and 
pilots to turn us in this new direction. I urge very strongly, as we 
address the government health care cost problem that we face, we look 
at it as a systemic problem, and we address it as a health care cost 
delivery system problem rather than pick out seniors, throw them off 
the bus, and keep it careening toward the cliff without changing its 
underlying direction. That would be, in medical parlance, a 
misdiagnosis of the illness and a mistreatment of it as a result, and 
fundamentally malpractice. But that is the direction we are being led, 
and I am here to urge us that we go in a different direction.
  There is a lot to be gained. America's health care system is 
provably, wildly inefficient. We burn more than 18 percent of America's 
gross domestic product on our health care system every year--18 
percent. To put that into context, the next most inefficient 
industrialized competitor that we deal with internationally runs at 
around 12 percent of gross domestic product. So here we are, the United 
States of America--the most innovative, the most technologically 
developed country in the world, a country that prides itself on 
efficiency, on common sense, on making smart decisions--and what are we 
doing? We are 50 percent more inefficient than the most inefficient 
other industrialized country in the world.
  One would think that we would not be the most inefficient. One would 
certainly think we would not be the most inefficient by a margin of 50 
percent over the second most inefficient country in the world. It just 
does not make any sense, but that is how bad it is. That is a pretty 
strong measure of how laden with excess costs our national health care 
system is.
  For all of that, we do not get better outcomes. I wouldn't mind 
spending 50 percent more than Switzerland or France or any other 
country if we got 50 percent better outcomes, if we lived 50 percent 
longer, if we were 50 percent healthier, if we had 50 percent better 
care, if we had 50 percent better maternal mortality in childbirth--but 
we do not. When we look at the measures of how we do for our people in 
the American health care system, we compare with countries such as 
Greece and Croatia. We are down in the thirties in the ranking if you 
look at most of the quality measures.
  Incredibly overbloated expenditure and at best moderate performance 
are the two prevailing characteristics of our health care system. That 
means there is a lot of ground to be gained.
  It has been quantified by President Obama's own Council of Economic 
Advisers who estimated $700 billion every year could be saved if we 
cleaned up the health care system and made it moderately efficient. We 
could save that $700 billion without harming the quality of care for 
Americans.
  That seems like a big number, but actually the New England Healthcare 
Institute says that number is $850 billion a year. George Bush's 
Treasury Secretary, Secretary O'Neill, who knows a lot about this from 
his time as CEO of Alcoa and as the person leading the Pittsburgh 
Regional Health Initiative, combined with the Lewin Group, which is a 
very well regarded Washington institution that looks at health care 
issues and evaluates them, they both agree that the number is $1 
trillion a year that we could save without harming the experience or 
quality of care for the American consumer.
  We tried to throw pretty much everything we could at this problem in 
the Affordable Care Act. A consultant to the administration, MIT 
Professor Jonathan Gruber, said about the Affordable Care Act and its 
delivery system reform component:

       Everything is in here. I can't think of anything I would do 
     that they are not doing in that bill.

  We gave the administration literally everything they could want, 
everything they asked for. I had a group that met with me as we were 
designing the Affordable Care Act, people from unions, people from NGOs 
that work on health care issues, people from the business sector, 
people who are experts in this area--to say, What are we missing? What 
more could we put in to help get at this problem of excessive costs for 
moderate results?
  By the time the bill came to the floor, this was the answer from my 
group: Nothing. We can't think of anything else. We tried. It is all in 
there. So I agreed with Professor Gruber's assessment.
  What is the nature of what we did? It boils down to what I contend 
are five basic strategies. One is quality improvement. The quality of 
American medicine is not anywhere near as good as it should be. Anybody 
who was listening to me talk, who has had a loved one in their family 
seriously ill, ill for any length of time, or who has been seriously 
ill themselves, they know that from their own experience. They know of 
the lost records. They know of the confusion between multiple doctors 
who are treating them and not talking to them, maybe both prescribing 
medications that are contra-indicated with each other, but they don't 
know the other one is doing it. They know the experience of having to 
be your own navigator through this complex system. They know what a 
nightmare that

[[Page S5695]]

is. They know it. It is not a debatable proposition.
  It also works out in some pretty identifiable data. Nearly one in 
every 20 hospitalized patients in the United States gets a hospital-
acquired infection. A hospital-acquired infection should be a ``never'' 
event. If we apply the Pronovost principles and do things started in 
Michigan and are carried out around the country now, we can knock that 
down by about 90 percent, but still it is endemic.
  Everybody knows somebody who has gone to a hospital for a procedure 
and came out with a hospital-acquired infection, often a life-
threatening one. Just treating those infections costs about $2.5 
billion a year. They are completely avoidable.
  That is just one element of the health care system. If we got after 
the quality gaps in our health care system, the savings would be far 
greater. So there is a lot to be gained in quality. That is one of the 
five.
  The second is prevention. We do not analyze and evaluate and 
implement prevention strategies very well as a country. We don't even 
evaluate effectively what prevention methods save enough money in the 
long run that we should just pay for them for everybody because it 
saves money to have people do this. We don't differentiate between what 
is probably a good idea for an individual to pay for and what is such a 
good idea and saves so much money that it should be part of the 
baseline of medical treatment that every American gets. It doesn't 
matter how sick they are, doesn't matter how old they are, doesn't 
matter how wealthy they are, doesn't matter where they live, they 
should be getting this prevention treatment because it saves all of us 
money.
  We should be analyzing those things, proving them and putting that 
prevention strategy to work because the cheapest way to treat an 
illness is to prevent it in the first instance. The third is payment 
reform. We pay doctors more--the more they prescribe, the more tests 
they order, the more medications they order, the more procedures they 
direct, the more they get paid. It should come as no surprise that when 
you send that incentive out there into that particular marketplace, you 
get dramatic overuse, which has been quantified in study after study.

  This bill, the Affordable Care Act, has pilots to start directing the 
payment for medical procedures and for medical care based on the 
outcomes so that its value is how well you get that dictates payment, 
not how much the doctor does to you. That will be a paradigm shift in 
health care. You have to get it right. It is not easy to do. It is 
going to take some doing, but it is vitally important. That is the 
third part.
  The fourth is administrative simplification, in particular, 
administrative simplification in the area of the warfare that currently 
exists between health insurance companies and hospitals and doctors. 
Ask any hospital, ask any doctor what it is like dealing with the 
insurance companies, trying to get paid for the services they deliver. 
They will tell you it is torture.
  The last time I was at the Cranston Community Health Center in Rhode 
Island, they told me half of their personnel are dedicated to trying to 
get paid. The other half do the health care work. Half of their 
personnel are dedicated to trying get paid. And they have a $200,000 a 
year contract with experts to try to help train the 50 percent of their 
personnel who are dedicated to trying to get paid in what the latest 
tricks are from the insurance industry so they can keep ahead of the 
game. Because it is an arm's race. Well, my guess is that about 10 
percent of the health care dollar that goes through the insurance 
companies goes to delay and denial of payment. There is 10 cents right 
off the top, leaving only 90 cents for the rest of the health care 
equation.
  The doctors and the hospitals have to fight back. They have to hire 
their own consultants and their own experts and their own billing 
companies. They are not as efficient. There are more of them. They are 
more spread out. It is not what they are expert at. It is harder for 
them to fight back. I think they pay more than 10 cents out of every 
dollar. You put the 2 together, that is 20 cents out of the health care 
dollar on the private insurance side that does not go to health care at 
all. It goes to fund the arms race between insurers and doctors over 
getting paid.
  This year Health Affairs: Journal of Health Care Policy published a 
study that compared the administrative costs of physician practices in 
Ontario, Canada, and physician practices in the United States. It found 
if doctors in the United States could lower their administrative costs 
to match those of the Ontario physicians, the total savings would be 
approximately $27.6 billion a year. The Ontario doctors have 
administrative costs, but they have a single-payer system and it is 
pretty easy to deal with. The $27.6 billion is primarily fighting with 
the different insurance companies that all have different systems about 
claims and billing. There are big savings to be had by eliminating that 
unnecessary and expensive warfare that produces zero health care 
benefit to anybody.
  The last piece, which is the structure for most of the rest of it, is 
a solid, strong health information technology infrastructure for this 
country. I can go to a bank anywhere in this country and I can take out 
my ATM card and access my checking account. I can find out what is in 
my savings account. I can do transactions. I can make deposits. 
However, if I step out of that ATM booth and get whacked by a taxicab 
and rushed to the emergency room, they have no idea what my health 
history is or what my health records are. We do not have a modern 
electronic health record in this country. We do not have modern 
electronic infrastructure in this country.
  When I started arguing about this a few years ago, I can remember The 
Economist magazine publishing an article that said the health care 
industry in America was the worst industry for the deployment of 
information technology of all of the American industries except one. 
The only industry that was behind the health care industry and the 
deployment of information technology was the mining industry. We have 
improved, thanks to President Obama and this administration putting a 
big investment in this area, but we have a long way to go because we 
were way behind the curve.
  Those five things--quality improvement, serious investment and 
prevention where it saves money, payment reform so that the system has 
incentive to provide value rather than volume, knocking down the 
administrative overhead that drapes over this system and weighs it 
down, and a robust health information technology infrastructure, those 
are the five keys and almost every single one of the programs I 
referred to that is in the Affordable Care Act fits one of those 
principles.
  Why are we not doing this? Why is this not a bigger part of the 
debate if it is $700 billion to $1 trillion a year, if the result is 
better care for Americans, fewer medical errors, more prevented 
illness, less nonsense and unnecessary care from their doctors in 
chasing the payment model of volume, less fighting with the insurance 
company over trying to get paid and a health information record that is 
yours, that is private, that is secure, that goes with you wherever you 
are?
  There was a fellow in Rhode Island whose daughter was taken ill. She 
had a pretty serious condition. She was taken to the emergency room in 
Rhode Island, and they realized that this was bad. They needed 
specialty care, specialty machinery and treatment, and they had to rush 
to the specialty hospital in Massachusetts that could do the work on 
her she needed to save her life. So off they went. When they got there, 
they discovered that they had not brought her paper health records with 
her. They had to redo all the testing. They had to start from scratch. 
Seconds counted as they fought for this woman's life. Thankfully it all 
turned out fine, but it put her life at risk and it cost a fortune to 
redo all the tests. It made her recovery harder because a lot of time 
was wasted. Are you kidding me, a paper health record? But that is 
where we are.
  All of this is win-win. Where is the pressure to do it? Well, there 
is a problem, and the problem is that it is not the kind of change that 
CBO--the people who guide our budget decisions around here--can score. 
I asked Alan Simpson from the Simpson-Bowles budget group during one of 
our Budget Committee hearings if he believed that reducing health care 
costs through delivery system reform is an important

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part of addressing our debt and deficit problem. And he answered: What 
you are saying is exactly right. It is not, unfortunately, scoreable. 
That is why it is not in our report.
  I get it. It is not scoreable. It is not in the report. We should not 
overlook these factors as we make these decisions on behalf of the 
American people because even if you cannot score how you get to that 
$700 billion in savings or if the New England Health Care Institute is 
right, that $850 billion, or if Bush Secretary O'Neill is right, that 
$1 trillion a year in savings using methods that improve both our 
experience and quality of care needs to be a priority even if it is not 
scoreable.
  Tomorrow I will send a letter to the President, which the Presiding 
Officer has been good enough to sign, along with a broad array of my 
colleagues who have agreed to cosign, which reiterates the case I make 
here tonight. The letter urges the President's attention to the 
potential of delivery system reform rather than Medicare benefit cuts 
for seniors. It should be our first priority to fix that overloaded 50 
percent more inefficient than the most inefficient country in the world 
system, the one with $700 billion or $850 billion or $1 trillion in 
annual savings that are possible. Fix that before you go to a senior 
who had no part in this, who cannot help but try to do their best, and 
say to them, we are taking away your benefit. That is not the way to 
proceed. That is the wrong way to proceed. It is morally wrong and it 
is wrong as a matter of policy.
  Where I contend we are--and I will say this in closing--there is a 
movement and an industry emerging in the area of health care delivery 
system reform. It is strong in the private sector, whether we look at 
places such as Palmetto down the Carolina Coast; Geisinger in the 
Pennsylvania area; up in the Wisconsin area, Gundersen Lutheran; out 
toward Utah, the west, Inner Mountain; Mayo in Minnesota and Florida; 
or Kaiser, based in California. These are all major American health 
care delivery companies that have seen the potential delivery system 
reform. They are working hard to make it happen. They are committed to 
it, and they are getting results. We need to have their back. We need 
to support them as they do this.
  But it is never going to be scorable because this is not a 
mathematical equation where we say: You are not getting this benefit. 
We are going to take away 20 percent of what you get. We are going to 
run it through the same nonsensical system that causes most of our cost 
problems and at the end we are going to say it is going to be 20 
percent cheaper. It is easy to do the math that way, but it is a pretty 
cruel way, and it is lazy because we need to be in the middle fixing 
that piece.
  But it is not arithmetically easy because where we are is like the 
early stages, I contend, of the airline industry--I should say of the 
flight industry. What did we know when the Wright Brothers first put 
their flying machine into the air at Kitty Hawk? We knew a curved 
surface sped through the air, generated lift. We knew a whirling air 
screw generated propulsion, and we knew that if you twisted the ends of 
the wings, you could control the direction. Those principles haven't 
changed.
  I just got back from Afghanistan and Pakistan. We flew for 14 hours 
from the Arabian Peninsula back to Dulles Airport. That plane had 
movies on it. It had food on it. Everybody was comfortable. It had air-
conditioning. We landed a plane that was the size of probably the 
average small town in America at the time the Wright Brothers were 
flying and everybody on it felt perfectly safe and comfortable. It came 
down a tube of electronic decision support for those pilots so they 
knew exactly what was going on every moment. If you went back to the 
Wright Brothers, you could not score in the actuarial sense the 
progress that would lead us in less than a century from a rickety 
wooden canvas, manned kite, puffing down the beach at Kitty Hawk, to 
these sleek, computer-guided, miraculous aircraft that fly us in 
comfort around the world today. You could not do it. But that didn't 
mean we shouldn't bet on it. That didn't mean we shouldn't pursue it. 
That didn't mean it wouldn't make a huge difference in the quality of 
mankind's life to be able to have that technological lead.
  So that is where we are. These five principles are a little bit 
beyond the Kitty Hawk stage perhaps but not by much. If we invest and 
if we get behind this, the day will come, and it will come soon, when 
the quality of health care each one of us receives--we will look back 
and we will think, what we are getting now, that was canvas and wood 
sticks. That was primitive. We will have personalized electronic health 
care. Companies will emerge to create applications so whatever illness 
you have, the very best treatment will be downloaded so you know what 
you should be doing, when, and it will be adjusted for your blood type 
and family history and gender, if it is a factor that makes a 
difference, and for your body mass. Whatever it is that is relevant to 
you getting the best treatment as an individual, that is the kind of 
stuff that will be available. We will aggregate the data about what is 
effective, and people who have far more brilliance than I will plow 
through all the data about America's health care experience and they 
will start learning things about what works and what doesn't, what two 
things we didn't notice are connected. We will start to find those 
anomalies or those associations, and that will open a whole new era of 
discovery and treatment. Between those new applications that will guide 
in a personalized way health care for Americans, based on their own 
data and based on the best available information so your doctor is a 
little bit like that pilot landing the plane out of Dulles, making 
their own decisions, flying the plane directly but surrounded by that 
decision support that makes plane landings so safe--if your wheels 
aren't down, the alarms go off. If you get out of the glide slope, the 
alarms go off. If there are wind gusts on the field, the alarms go off. 
All that information and more is captured so the pilots can focus on 
flying the plane. That is the kind of support our doctors can have. 
That is the kind of support we can have. Those are American industries 
that will grow and emerge.
  So we need to get behind this. I feel very strongly about this, as my 
colleagues can tell and as the four pages have had to wait and listen 
to me at this late hour can tell. But I say now it would be a shameful 
act on the part of the Congress of the United States if, with an 
opportunity like that in front of us, if with a compelling cost target, 
as we have from delivery system reform in front of us, and with the 
proven thesis that by getting there we actually improve the quality of 
care for people--we are not taking anything away; we are making their 
quality and experience of care better, which is a win-win-win. If we 
turn away from that win-win-win and instead take the easy, lazy way of 
throwing seniors off the bus and putting Medicare benefit cuts on them 
and let that bus just keep rocketing toward that cliff, that will be a 
moment that will merit the scorn of the American people and the shame 
of our own conscience because we will have done the wrong thing and we 
will have done it because it was the easy way out.
  I urge the White House not to take that road and to instead redouble 
their efforts on delivery system reform, back Secretary Sebelius in 
what she is doing and Don Berwick in what he is doing and, most 
significantly, put a hard date and dollar metric out there so the world 
can evaluate how well the administration did. If this is as important 
as I think it is, if this is as important as the administration thinks 
it is by the work they have already dedicated to it, then they should 
be willing to set for themselves a date and dollar savings target to 
tell the country: By this date, we will save this many hundreds of 
billions of dollars a year through delivery system reform. If we don't, 
then it is murk, it is mush. There is no accountability to it. It is 
generally going in the right direction.
  A young President many years ago had a similar opportunity. We were 
losing the space race to the Soviet Union. He could have said in his 
speech: I think it is time that we bent the curve of America's space 
program. I think it is time we bent the curve of America's space 
exploration. But he didn't. He said something much more specific. He 
said: Within a decade, the United States of America is going to put a 
man on the Moon and bring him home safely. If President John Fitzgerald

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Kennedy had given that first speech, we would never have put a man on 
the Moon. The reason we put a man on the Moon is because when a 
President of the United States sets a hard target for the Government of 
the United States, that vast bureaucracy moves to achieve that purpose. 
If the President of the United States denies that vast bureaucracy, the 
clarity of that purpose does not give a specific measurable goal, and 
it makes that goal far less likely to achieve.
  So not only do I ask the White House to turn away from Medicare 
benefit cuts and redouble their efforts on delivery system reform, I 
ask them to decide how much they are going to save, and by when, and 
let us know so we can evaluate their success in meeting that goal. I 
promise them every support in reaching that goal.
  I thank the Presiding Officer for his patience and yield the floor.

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