[Congressional Record Volume 159, Number 180 (Wednesday, December 18, 2013)]
[Senate]
[Pages S8965-S8968]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
AFFORDABLE CARE ACT
Mr. WHITEHOUSE. Mr. President, I wish to engage for perhaps the next
20 or so minutes with Senator Cantwell, who is arriving shortly. I will
begin with some remarks and ask unanimous consent for us to engage in a
colloquy.
The PRESIDING OFFICER. Without objection, it is so ordered.
Mr. WHITEHOUSE. I am here today to talk about the health care problem
in the country, because I think the fixation of this body on the health
care Web site has taken our eye off the fact we have a very significant
and fundamental health care problem.
This graph represents how much we spend on health care as a country.
It begins back here in 1960. I was 5 years old in 1960. So this is a
lifetime: 50-some years, $27.4 billion. That is what we spent on health
care. Now here we are. This is up to 2011, and $2.7 trillion is what we
spend on health care. It is 100 times as much in 50 years. Granted,
there are more Americans but not 100 times as many.
This has been an explosive cost growth curve. When we were trying to
pass the health care bill, that is what we were looking at for costs.
It is a big competitive problem for our country.
This is a really interesting graph. I wish every time anybody talked
about health care they would take 1 minute and look at this graph. I
will explain briefly what it is.
This column is the up access and measures life expectancy in years,
country by country, 65 to 85, where countries fall in terms of their
average life expectancy for their population, for their citizens. This
along the bottom is the cost, the health spending per capita per person
in that country. So if you measure it all out, what you see is a great
raft of countries all through here: Japan, Great Britain, Netherlands,
Switzerland, Norway, Italy, Greece. There is a whole large group of
countries right here, and all of them have a life expectancy 80 or
older and they all spend between $6,000 and $2,000 per person on their
country's health care. Essentially the entire modernized, civilized
world is in that zone, from here to here.
Guess where the United States of America is. Boom. Here. We are below
them all in life expectancy. We are trailing the pack of modern
industrialized nations in our life expectancy. We are competing with
Chile and the Czech Republic. But Japan, Greece, Great Britain, France,
Germany, Luxembourg, all manage with their health care systems to
achieve longer lifespans for their people. And we are doing it at a
cost of about $8,500 per person per year.
To give a comparison, here are Switzerland and Norway. They are the
other two most expensive countries in the world per capita on health
care spending, and they are at about $5,700 per year. If we could bring
our per capita health care spending in this country down to the most
expensive countries in the world, if we could compete head to head with
the most expensive countries in the world, we would save more than $1
trillion a year.
This is an interesting graph because it shows basically all the
modern industrialized nations here, and it shows us here as a way
outlier. It is a big deal for us to be an outlier here, because it
means we blow about $1 trillion a year in wasteful and unnecessary
health care which could be building infrastructure, solving problems,
reducing the deficit, and could be doing other work. Instead, we spend
it on a health care system which doesn't produce good health care
results--at least not measured by life expectancy, which is a pretty
good proxy.
There is a huge $1 trillion a year cost to our society in being that
bad of an outlier. The cost is also measured in lost lives and lost
years of life, because we are averaging 77 years and these countries
are averaging 82 years of life.
We have a real problem on our hands, and obsessing about a Web site
is a complete distraction from getting after this problem--5 years off
every human's life in this country and $1 trillion a year. That is
worth paying attention to.
The health care changes we brought are actually making a difference.
Here are some interesting graphs. Each one is a projection done by the
nonpartisan Congressional Budget Office of what health care costs are
going to look like in the future, and what you see is a progression.
They did this graph in August of 2010. This was where they projected
health care spending would go when they projected in August of 2010 for
this period, from 2014 onward to the next decade. A year later they
went back and they projected again, and they projected actually costs
would be lower. Then they came back in August of 2012 and they did
another projection, and their projection showed that these anticipated
costs went down again, every year, lower and lower.
Here is the big one. In May of this year, the Congressional Budget
Office went back and redid its projections for Medicare and Medicaid
spending from 2014 to 2023. Look how far below what they had projected
1 year ago, 2 years ago, and 3 years ago the current projection. That
is a saving of about $1.2 trillion in that decade.
That is a long way from $1 trillion a year we could be saving if we
just got back to where we were on this graph, if we got back from here
to where Switzerland and Norway, the most expensive countries in the
world, are. That is $1 trillion over 1 year. This is $1.2 trillion over
10 years, but it is still a big change and it is still moving in the
right direction. So we shouldn't be too quick to condemn ObamaCare when
[[Page S8966]]
that kind of savings is already being projected.
The last slide I will show before I go to Senator Cantwell, who has
been good enough to join us, is this one. Why might it be that those
costs went down so far in May of 2013? Why might it be that graph of
projected costs keeps going down? It is because of changes in what is
going on in the health care system.
This is one good example. This shows the hospital readmission rate
from January of 2007 until August of 2013. This is how often somebody
was discharged from the hospital, went home, and then within 30 days
had to come back and be readmitted.
That could potentially be for a completely new reason, but usually it
is because the discharge planning wasn't done well enough and there was
a bad handoff between the hospital and the primary care physician or
the nursing home. What we found is you could make that transition much
better for patients. When you do, guess what. They don't get sent back
to the hospital. When they don't get sent back to the hospital, you
save money.
That is just one way the kind of huge $1.2 trillion over 10-year
savings CBO has already projected could be taking place, but this is
clearly a part of it. It is improving the quality of care so people
aren't going back into the hospital, aren't going to the emergency
room, and you avoid that cost at all by having handled the patient
better, by having given them better treatment and better care.
It is pretty astounding. In 2007, right through here until the end of
2011, it was a pretty steady readmission rate. Then when we changed the
signal to the hospitals and cut their payment for readmissions, boom,
down it fell. That represents a very significant savings in the system.
And in the personal lives of those people and their families not having
to go back to the hospital, that is a pretty big plus too.
It was Senator Cantwell's idea that we should come down today and
talk a little bit about the delivery system reform side of the health
care discussion. I got started a little bit before she could get here,
but my wonderful colleague now has arrived, so let me yield the floor
to her. I will put this graph back because I want to leave this here
for whenever the camera swings my way. I want people to see this graph.
It is inexcusable that all of these competitive industrialized nations
of ours should be able to deliver universal high-quality health care
for what would be a $1 trillion a year savings if we could simply match
them, and they produce a longer life expectancy for their people and we
are stuck competing for life expectancy with Chile and the Czech
Republic. Come on. We can do a lot better than that, and that should be
the ball we have our eye on rather than obsessing about the ObamaCare
Web site.
I yield the floor.
The PRESIDING OFFICER. The Senator from Washington.
Ms. CANTWELL. Mr. President, I come to the floor to join my colleague
from Rhode Island. I applaud him for his diligence, making sure this
debate happened today, and for his leadership on this issue. It might
sound kind of wonky to say there is a group of Senators that have a
caucus called the Delivery System Reform Caucus, but we wear that
banner with pride because we know that there are savings in our health
care delivery system. We want to make sure that they are delivered for
the American people.
While some want to talk about cutting people off of service or
raising certain ages, we are focused on the fact that there are
hundreds of billions of dollars of savings in the delivery system and
that it is our job to improve upon them. I like to say to my office
team: There is a reason why Ma Bell doesn't exist anymore. The
challenge is I have so many young people, and some of them don't
remember Ma Bell. But the issue is the delivery system for
telecommunications changed, and look at what it unleashed--a lot of
great technology.
Yes, change, but with ways to drive down costs and deliver better
access. That is what we are talking about here with the health care
system. My colleague from Rhode Island has had a group for more than a
year that has been talking about these delivery system reforms. We are
going to come out on a more frequent basis and try to have a dialog
with our colleagues about why it is so important.
We have taken a small but very important step led by our senior
Senator from Washington Senator Murray on the budget. But there is so
much more we can do if we can include these delivery system reforms. So
I thank Senator Whitehouse, the Senator from Rhode Island, for his
leadership.
I want to talk about one area today, the area of long-term care
services. I authored a provision in the Affordable Care Act called the
Balancing Incentive Payments Program. While that sounds in and of
itself like a wonky title, Balancing Incentive Payments Program, this
program is really there to promote home and community-based care over
nursing home care. If you ask any senior they will say of course they
would like to receive health care services in their home or in their
community. No, they do not want to go to a nursing home. But the
discussion has been limited on how much cheaper it is and how much
better the care could be for delivery in the home as opposed to nursing
home care.
According to a survey by AARP, over 90 percent of seniors age 50 or
over desire to remain in their home as long as possible. We know that
home and community-based care is 70 percent cheaper than nursing home
care--70 percent cheaper. So for us in Washington State we thought
about this long ago, and we decided that we were going to implement a
system to reform our State and put more community-based care in our
State and pull Medicaid patients away from nursing home care. We did
that. We successfully made that transition. This chart shows you what I
was just referring to, that home-based care can be as little as $1,200
a person versus the same person getting care in an institutional
facility at $6,000.
We made the transition in Washington State to be predominantly a home
and community-based care State. We did that with our own State dollars,
our own program, and it was a transition that took place over many
years. We are kind of the antithesis of what the Federal system is. It
is still more weighted on a State by State basis towards nursing home
care. That means people are going into nursing home care, and we are
footing the bill for more expensive care at $6,000 per person when we
could have services in the community that would allow them to stay in
their home and get more efficient care. So in 2009, the long-term care
budget overall for Medicaid accounted for 32 percent of the Medicaid
expenditures or $360 billion a year. You can see that this is a very
expensive area for us at the Federal level. If we could do anything to
help change those numbers, we would be delivering an improvement to the
system.
When we first made this transition from 1995 to 2008, the State of
Washington saved $243 million from this investment. But more important,
even, than the money--in an article in 2010, the Spokesman Review in
Spokane ran a story called ``Dying to live at home,'' the family of
Nancy and Paul Dunham, a couple of more than 60 years, said they wanted
to age at home. Because of the Medicaid funding for in-home services,
they were able to stay. Mr. Dunham was able to stay in his home until
the age of 83.
I am sure many of my colleagues know people who are getting on in
years who prefer to stay at home. But the Balancing Incentives Program,
which was in the Affordable Care Act, was the first Federal effort that
we had that tried to assist States to move away from nursing home care
and move towards community-based care. We put some incentives in the
program. Here are the States so far that have taken up the Federal
Government in the Affordable Care Act on this incentive program: New
Hampshire, Maryland, Iowa, Mississippi, Missouri, Georgia, Texas,
Indiana, Connecticut, Arkansas, New York, New Jersey, Louisiana, Ohio,
Maine, and Illinois.
It is a diverse group of States, I might add. Some States, probably,
where Governors said they did not want to support the Affordable Care
Act yet are taking advantage of this provision. Some States probably
are forerunners of delivery system reform and have done lots of
delivery system reform and want to do more. It is a mix
[[Page S8967]]
of States. I think we have a lot of great examples in those States and
what we can do to transition away from institutional care to home and
community-based care.
The program authorizes grants to States to increase access to their
non-institutional long-term care services, and it supports including
structural changes that help streamline the system--conflict-free case
management, core standardization of assessment instruments, single
entry-point systems so it is not confusing, so that the system is very
streamlined. States have until September of 2015 to increase their
long-term care services in the community and support expenditures of
these noninstitutional-based care facilities.
We are very excited that it has had a robust uptake by these States.
I am encouraged that there has been so much interest shown in changing
the political orientation, if you will, of States, to how do you deal
with long-term care. We know everybody is living longer. We know as
baby boomers retire, it is going to be a bubble to our health care
delivery system. But this is an excellent idea, a way for us to deliver
better care.
What does it do? As I said in the first chart, $1,200 versus $6,000
in nursing home care. It reduces costs. Reducing those costs has to be
a key focus for us.
These Medicaid recipients are people who maybe even start on Medicare
but because of the extreme cost of health care at the end of life, end
up spending it out, end up on Medicaid, end up being a Federal
responsibility. If we can reduce those costs by driving more community-
based care, it is a win-win situation.
The second thing it does is it helps improve quality. If people can
stay at home and get access to the delivery system by these new
requirements, making sure it is case managed and has the single point
of entry and standardization of the home care system, it helps us to be
efficient about the quality of care that is being delivered. Again,
when you have a community-based setting, either in the home or where
care is delivered through the home, there are lots of ways for us to
have checks and balances on the system.
I have talked to many people who are in the nursing home industry.
They will say we like the idea that we are only going to take the
sickest patients. We like the idea we are only going to serve people
who really need to be there as opposed to some people who may not be
ready for those facilities but end up there anyway just because there
are not the community efforts to support it.
Besides reducing costs and improving quality, we save money. That is
why we are here today, to talk about these important ideas that save
money. This is a simple one, but it is already in place. It has already
started. There are many States taking us up on this offer, but it is
critical that we understand and score these costs because they can show
how we can save billions of dollars in our health care delivery system.
I know my colleagues, some of them on the other side of the aisle--
well, all of them on the other side of the aisle--didn't support the
Affordable Care Act. Take a second look at what your States are doing.
Your States are supporting the legislation, at least through one
provision. I think when you check, you will see that one provision is
going to save your State money. It is going to give your citizens
better choice in their quality of care. It is going to help us reduce
our Federal costs and expenditures as well, and that is what delivery
system reform is all about.
Mr. WHITEHOUSE. Will the Senator yield for a question?
Ms. CANTWELL. Yes, I will.
Mr. WHITEHOUSE. Isn't it the heart of what the Senator said just a
moment ago that there is an area that actually touches on a lot of
health care--it is a big area--where you can do two things at once? You
can save significant money for taxpayers and insurance ratepayers, and
at the same time you can improve the quality of care that people
receive.
So often in legislative matters it is a zero sum game. One wins so
the other has to lose exactly by the same amount. This is not like
that. This is a win-win situation. So there really should be energetic
efforts to pursue these win-win opportunities.
Ms. CANTWELL. I thank the Senator from Rhode Island for that
question. I think his charts pointed to the fact that he was
articulating, the fact that everybody is arguing about the Web site. As
somebody who has been involved in a software company that wrote code,
what happened is very unfortunate, but writing code and fixing it is a
straightforward task that can be achieved. It is a little less
difficult than cleaning up oil in the gulf or something of larger
environmental impact.
To me, we will get that fixed. In the meantime, there are a lot of
things that have to happen, that need to change in our delivery system
that are about saving costs, delivering better quality care, that we
know are proven, successful answers to this question. We need to get
more than just these States to take us up on this offer. We need to get
CBO to actually give us a score on how much money this has the
potential of saving, and then we have to figure out a way to
incentivize all other States to implement this as soon as possible.
When you think about our senior population, this is what they want.
They want to stay at home as long as possible. It is so much cheaper
per Medicaid beneficiary to do this.
This is what we have to achieve. We hope by coming out here and
educating people about the various aspects of the Affordable Care Act,
the things in the delivery system reform that are on the agenda to
improve access and help save costs, that this will start taking hold
and we will get more people talking about these solutions. This is
absolutely the direction we need to go.
Mr. WHITEHOUSE. If I could ask the Senator another question in
response to what she just said, not only is it a win-win, being lower
cost and better quality care, but I believe the Senator said that there
is actually a third win here. There is the win of lower cost, there is
the win of better quality care, but for seniors there is a huge win of
maintaining your independence and being able to stay at home. It is
hard to put a price on that, but if you are facing the choice of having
to leave your home and having to go to a more restrictive health care
setting, being able to stay at home is a very big plus.
Really, it is not win-win, it is win-win-win.
Ms. CANTWELL. Mr. President, I thank the Senator from Rhode Island.
He is correct. There are the individuals who win. The State in this
case saves Medicaid dollars, and the Federal Government saves dollars
as well. But to the individual, if you ask them, this is their choice.
They want to stay at home. Nobody says they want to go into nursing
care.
We appreciate the nursing home care delivery aspect of health care.
They deal with some of the most complex patients. But they do not need
to deal with people who do not need to be there. We have to have a
delivery system that helps support community-based care for long-term
care. I hope that we will get more support for these ideas and that we
will help figure out a way to get a score for them as well. I think
that part of the misery in this whole issue of health care savings is
figuring out ways to do things that are not so complex in what they are
doing. Moving from nursing home care to community-based care, $1,200
versus $6,000, that is not the hard part of the equation. What is hard
is to get CBO to guesstimate how much population would be affected.
We do know this. If you take the number of seniors to be affected as
the baby boomer population reaches that retirement age, if you think
they are going to be supported primarily by nursing home care--I think
I am correct that our State has now made the shift so the majority of
our people who are on Medicaid are taken care of by long-term care
services in the community if they are seeking those services, versus
the Federal numbers which are just the opposite. The majority of people
seeking those Medicaid long-term care dollars, the average of those
States is more towards nursing home care. We need to flip that. The
Senator is right, it would be a win-win-win situation for all of us.
I thank the Senator from Rhode Island for his leadership on this
issue.
Mr. WHITEHOUSE. Mr. President, in responding to what Senator Cantwell
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just said about the Congressional Budget Office, it indeed has been
frustrating and bedeviling to run up against their inability to project
these savings in a way that would allow us to--what we call in
Washington--score them and get budget credit for them. But even though
they have that difficulty, there are some very serious organizations
that project that very significant savings of the kind I have
mentioned--the $1 trillion savings--are possible.
Some years ago the President's own Council of Economic Advisers
estimated that we could do savings of $700 billion without affecting
the quality of care in any way for the worse.
The National Institute of Medicine has made several regular
projections. The most recent one is $750 billion a year. The Institute
of Medicine is pretty serious folks, and they are entitled to respect
when they say we can have those kinds of savings.
RAND Corporation--a lot of people know a lot about it--is a very
expert organization. They have done two things. They looked at what we
can save in health care, and then they looked at what we can save in
health care plus an additional bit for dealing with waste and fraud.
They gave ranges for the two. The midpoint of the range for savings is
about $730 billion. If we add their suggestions on waste and fraud, the
midpoint of their range goes to about $910 billion a year.
The Lewin Group, which is another respected think tank that looks at
health care issues, wrote a piece some time ago with George Bush's
former Treasury Secretary, and they said it was $1 trillion.
So is it $700 billion a year? Is it $750 billion a year? Is it
somewhere between $730 and $910 billion a year depending on how you
score the waste and fraud? Is it $1 trillion a year? Either way, I will
take it. Those are big numbers, and wherever it falls in that range, we
should be energetically fighting for it.
I will close with the request I always make in these speeches--and
this is a request to the President and to his administration--and that
is to inspire us and set a bold national target. Sure, CBO, OMB, and
our actuarial and accounting organizations cannot predict what these
savings are going to be, but, by gosh, the President can direct his
administration to target a savings goal and to go after it. I think if
the President were to set a hard date and dollar target for delivery
system savings--a couple of years out so we have a chance to do that--
that would make a big difference.
The example that I use is of President Kennedy. Back in 1961, when it
looked as if we were losing the space race to the Soviet Union,
President Kennedy declared that within 10 years--he put a date on it--
he would put a man on the Moon and bring him back safely. He had a hard
target, something specific so you would know if it was or wasn't
achieved. The message was clear, the mission that was outlined was
clear, and the result was a vast mobilization of private and public
resources to achieve that purpose.
It is not enough to talk about bending the health care cost curve.
That catchphrase should be jettisoned and discarded. We should have a
hard date and dollar figure, and that should be a target the entire
administration aims toward.
Had President Kennedy given that speech back in 1961 and declared as
his purpose to bend the curve of space exploration, I very much doubt
we would have put that man on the Moon within 10 years. It was his
exercise of Presidential leadership and challenge--ahead of what the
scientists knew could be done but with confidence and faith in our
ability to achieve big things--that put the executive branch of
government into focus so we could achieve exactly what he had directed.
We can do the same with health care. We should do the same with health
care. There is no downside to it because this is a win-win area, as I
discussed with Senator Cantwell.
On that note, I yield the floor and suggest the absence of a quorum.
The PRESIDING OFFICER. The clerk will call the roll.
The assistant bill clerk proceeded to call the roll.
Mr. BLUMENTHAL. Mr. President, I ask unanimous consent that the order
for the quorum call be rescinded.
The PRESIDING OFFICER (Mr. Heinrich). Without objection, it is so
ordered.
Mr. BLUMENTHAL. Mr. President, I asked my colleague from Rhode Island
to stay on the floor for a couple of minutes because I wanted to thank
him for the erudite and eloquent explanation he has just given for why
our focus should be so aggressively and unrelentingly on the tremendous
opportunities for saving health care costs and raising health care
quality at the same time. I am very proud to have joined him and other
colleagues in a task force that is seeking commonsense solutions to
lower the costs of health care and at the same time increase its
efficiency and quality. The two go together.
The phenomenon he just discussed of reducing readmissions to
hospitals once patients are discharged also means that the quality of
those discharges, the rehabilitation plans and hand-offs to primary
physicians, and the suffering and pain for those patients is reduced,
and that is just a microcosm of one example of how this goal can be
accomplished.
We are late in this year, and we have no real time remaining before
the end of this year to do the kinds of reforms legislatively that will
help advance this ball. But the attention we need to devote to this
issue is clearly beyond this year and beyond the next year.
We are making progress, and the graphs show it, but there is so much
progress to be made in extending lifespans and quality of life as well
as reducing the cost of health care.
We need to make sure we seize this historic moment to show the rest
of the world that we can do better and we will do better in providing
health care delivery. The cause of health care delivery reform is one
that cries out for a focused effort involving both branches of our
government, executive and legislative, and both parties, as well as
both Houses of this legislature.
The kind of focus given by Senators Cantwell and Whitehouse so
penetratingly and powerfully today is the kind of focus we should
maintain. I hope in the days or months ahead we will devote more
attention by coming to the floor, doing events in our States, and
making sure the administration is aware of our concern in meetings. I
look forward to continuing that effort in the time ahead.
Again, I thank my colleague Senator Whitehouse, as well as others,
such as Senator Schumer and my colleague from Connecticut Senator
Murphy, as well as Senator Cantwell, for their devoted efforts. I am
very proud to be working with them.
I see my colleagues are on the Senate floor. It is late in the day,
and I yield the floor.
The PRESIDING OFFICER. The Senator from Mississippi.
Mr. WICKER. Mr. President, I would point out that the distinguished
Senator from Delaware was on his way to speak and has graciously
offered to defer for moment or two while I make my brief remarks.
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