[Congressional Record (Bound Edition), Volume 152 (2006), Part 4]
[House]
[Pages 4496-4502]
[From the U.S. Government Publishing Office, www.gpo.gov]




                              HEALTH CARE

  The SPEAKER pro tempore (Mr. Fitzpatrick of Pennsylvania). Under the 
Speaker's announced policy of January 4, 2005, the gentleman from Texas 
(Mr. Burgess) is recognized for 60 minutes.
  Mr. BURGESS. Mr. Speaker, I wanted to take this time tonight to talk 
to the House about the subject of health care, something that I have 
been involved with for the last 30 years of my adult life, taking in 
that time that I spent in residency and private practice.
  I think the single most important issue that we need to keep foremost 
in our minds as we talk about issues surrounding health care in this 
body over the next year and, indeed, over the foreseeable future is the 
overall affordability of health care. If we do not keep health care 
within the affordable grasp of the average American, we not only keep 
people away from care that they need, but we also put the overall 
prosperity of our country in peril, and in fact, the overall system 
that has been created, the health care system that has been created in 
the United States over the last 227 years will itself be in peril.
  Right now, the Federal Government pays about half of the health care 
bills in this country. It is a big chunk. About 16 or 17 percent of the 
gross domestic product of this country is spent on health care, and of 
that, the Federal Government picks up about half the cost through 
Medicare, Medicaid, VA, Federal Prison System, Indian Health Service. 
All the various federally qualified health centers, all of the various 
groups gathered together all make up an expenditure that is just shy of 
50 percent.
  Well within that money that is spent by the United States Congress, 
we need to be sure that that money is spent wisely. We need to be sure 
we get value for our dollars. So I want to spend some time this evening 
and talk about where we are in health care, where we are in fact going, 
always keeping in mind that affordability has to be first and foremost 
in our mind.
  We have got to discuss, we have got to come up with some solutions 
for the uninsured. Federally qualified health centers, the President 
has mentioned them in every State of the Union address that I have 
heard since I arrived in this body 3 years ago. Federally qualified 
health centers have been mentioned by the President, how he wants to 
see a federally qualified health center literally in every poor county 
in this country.
  There is no question that liability reform is going to be part of the 
picture of the overall reform of the health care system that deals with 
affordability. We have to find some relief for our providers. We 
historically underpaid or cross-subsidized our providers, doctors and 
hospitals alike, by underfunding government systems that pay for health 
care, and the result is we now have people dropping out of the system 
at a time when we, in fact, need more people coming into the system.
  The information technology that is available to health care systems 
in some ways is old, is past its prime. In some areas, it was never, in 
fact, developed at all. So we are going to have to pay some attention. 
There is going to be some expense borne with recreating and creating 
information technology that our health care system, in fact, requires.
  Then, finally, as we have seen so many times over the past 3 years, 
preparedness is going to be part of not just the overall security of 
the country but the overall security of our health care system.
  When I talk about affordability of health care, I think back to a 
time when, just a few years ago, I was, of course, in private practice 
in medicine, but I went back to school and went back to graduate school 
at the University of Texas at Dallas and studied for a Masters Degree 
in medical management at their school of management there. Their 
graduate school of management is a very good school, and one of our 
professors one day, Dr. John Burns, came and talked to our class and 
said, Within medicine you will always want to focus on affordability, 
access and quality.
  Now the dilemma facing us is we have only been able to deliver on two 
out of those three. Mr. Speaker, I do not want to identify the one that 
I am prepared to leave out so I am just going to talk about 
affordability.
  I do think that the American medical system will always provide us 
quality, and I believe if we can improve affordability, we are, in 
fact, going to improve access.
  With the amount of money that the Federal Government spends on health 
care, you have to ask yourself, would it be better if the government 
just picked up the whole charge, if the government just picked up the 
whole tab? In fact, that was discussed in this very House some 10 or 12 
years ago. I did not think it was a good idea then. I do not think

[[Page 4497]]

it is a good idea now, but that is going to be part of the discussion.
  Certainly, you look to our neighbor to the north, and the Canadian 
health care system is oftentimes held out to us as something to which 
the Americans ought to aspire. In the interest of full disclosure, my 
dad was a doctor in Canada and fled to this country because he did not 
like the Canadian health care system, and as a consequence, I was born 
while he was doing his residency in this country.
  But he never went back because the system there was too onerous, the 
waiting lists were too long, and even the Canadian Supreme Court, about 
a year and a half ago, ruled that access to a waiting list is not the 
same as access to care. I would submit to you that the resident in 
Toronto, Canada, who suffers a heart attack may be just as likely to 
get their angioplasty or coronary artery bypass graft done at Henry 
Ford Hospital in Detroit as Toronto, Canada, because the length of time 
spent on the waiting list is just far too long.
  Can we, in fact, keep the private sector involved in health care? It 
is a question that we are going to have to ask, and we are going to 
have to be able to answer it. I believe that it can. I believe that it 
can, and I believe Congress can and should have a part in promoting 
policies that do help keep the private sector in the health care 
marketplace.
  Look at, if you would, the history of medical savings accounts. 
Medical savings accounts were basically born 10 years ago in the 
Kennedy-Kassebaum bill that came through the House and the Senate. That 
is the same bill that gave us HIPAA unfortunately, but it also did give 
us what is called a medical savings account, this old Archer MSA. I 
very happily bought one when they became available in 1977, made one 
available for everyone in my practice of medicine. Some people took it, 
most did not because not much was known about medical savings accounts 
at the time, but think of what a medical savings account does.
  Instead of the power of medical decision-making being in the hands of 
some distant medical director or somebody somewhere or even in the 
hands of the government bureaucrat, the medical decision-making power 
was in my hands, and that was the most important part about having a 
medical savings account.
  To be sure, I was issued a high deductible policy, and I was able to 
put money away to cover that deductible year over year in what was 
called then a medical IRA, a tax-free contribution to a medical savings 
account year after year. The interest in that was not taxed, and even 
though I gave up my medical savings account when I came to Congress in 
2003, that money remains in that medical savings account, continuing to 
draw interest, and will be available to my wife and I when I do retire, 
however many more years I have at this job.
  But the medical savings account is an important tool because it does 
give the power back to the consumer, and it makes a consumer an 
involved participant in health care decisions.
  A lot of concern on some people's part is, well, people delay getting 
medical care if they are going to have to spend their own money. They 
will spend someone else's money, but they do not want to spend their 
own.

                              {time}  1745

  Well, in fact, the National Center for Policy Analysis, a think tank 
that is located in Dallas, Texas, not too far from my home, had a study 
done around the time the medical savings accounts first came out in the 
1990s looking at other countries that had allowed medical savings 
accounts to compete head to head with private indemnity insurance. And, 
in fact, what was found in a comparison of medication usage in one of 
those countries was that drugs such as Ritalin that might be regarded 
as a life-style drug, the usage of Ritalin was in fact decreased. But 
the usage of a drug such as Fossomax, that is a drug that is given to 
individuals who are thought to be at high risk for osteoporosis, to 
prevent calcium loss from the bone and prevent osteoporotic fractures 
in the future, a drug like Fossomax to prevent osteoporosis, that usage 
increased. So life-style drugs perhaps had some diminution, but drugs 
that are really there to prevent problems in the future, the usage of 
those drugs was not curtailed at all. In fact, it was somewhat 
increased.
  I look back to the experience that I had as an individual back in the 
mid-1990s, in 1994, trying to get health insurance for a family member 
who didn't have it and the difficulties, the intractable difficulties 
involved with finding an insurance policy, a single insurance policy 
for a single individual. It just was not available, not at any price. I 
was prepared to pay top dollar. I knew I would have to pay top dollar 
for such a policy. But no such policy was available.
  Well, contrast that with now, where perhaps a young person just 
getting out of college, no longer on their parents' health insurance 
plan, wants to start their own business rather than working for a 
company. One of the big obstacles to that is, well, no health 
insurance. But today, that person can go on the Internet, go to their 
favorite search engine and type in health savings account, hit search, 
and they will be returned a vast number of choices of high-deductible 
health insurance plans that are available to them.
  In fact, the most recent time I did this, there are some insurance 
companies to be sure that I didn't recognize the name, and I would 
always be certain to check out the company before entering into a 
policy with them, but a well-known insurance company name, a high-
deductible PPO-type policy, $50 a month for a male in Texas, age range 
20 to 30. Well, this is a pretty powerful tool that people have at 
their disposal. And prior to our passage of the Medicare Modernization 
Act in November of 2003, this tool was in fact not available. But it is 
now and many more people have insurance because of the availability of 
these high-deductible plans that can then be rolled into a health 
savings account.
  I think from the first year, January 2005, the first year the figures 
were available, a million people had sought that type of insurance. By 
January of 2006, that was up to 3 million people. Over half of those 
individuals were over the age of 40. So it wasn't just the young that 
were looking at those types of policies; it was people in the prime of 
life as well, and perhaps most importantly, 40 percent of that number 
had previously not had health insurance. That is nearly a million 
people that were taken off the rolls of the uninsured and put into a 
health savings account.
  Now, I recognize that as we make a move to enhance so-called 
consumer-directed plans, and that is what a health savings account is, 
a consumer-directed type of health care, as we make the move to 
consumer-directed health care, we are going to have to give people the 
ability to evaluate not just their insurance policy but their health 
care providers and their hospitals. They are going to have to have the 
ability to evaluate health care on the basis of price, cost, and 
quality. It is unreasonable to ask someone to make those types of 
decisions while that information remains obscure.
  That is a concept, the concept of transparency, that I believe that 
this body should investigate. We have had one hearing in our Energy and 
Commerce Committee. I trust we will have more, and I trust we will see 
some type of transparency-related legislation before the end of the 
year, either as a stand-alone bill or coupled with some other process. 
But that is going to be one of the keys to really furthering the cause 
for consumer-directed health care.
  Now, transparency doesn't exist just because it is inconvenient to 
remove it. Transparency, or opacity, in the health care pricing system 
exists because there is some value to it. There is some protective 
value to it. So it is not without some pain that transparency is going 
to be provided.
  Again, I go back to the issues of cross-subsidization of hospital 
costs and doctor costs, Medicare and Medicaid. We don't pay the full 
freight as far as provider fees, so hospitals and

[[Page 4498]]

doctors do need to cross-subsidize with the more traditional indemnity 
plans. Removing transparency or removing opacity from the system is 
going to expose that, and in some cases it won't be especially 
attractive or pretty what we find. But to get to the ultimate goal of 
having transparency within the system, where health care consumers can 
make proper decisions for themselves and their families, I do believe 
that we are going to have to provide that. And I may speak a bit more 
about transparency a little later as time permits.
  One of the other concepts that has been introduced as legislation for 
the past several years, though we have never really taken it up and 
done so in a serious way, is the concept of a pre-fundable tax credit, 
sort of an EITC, if you would, for people of low-income levels for the 
purchase of an insurance policy: a prefundable tax credit that occurs 
at the beginning of the year rather than a refund at the end of the 
year; money exclusively earmarked for the purchase of health insurance. 
Several proposals have been put forth in the past. I know my neighbor 
down in Texas, Ms. Granger, has had a bill about tax credits for the 
uninsured for several years, allowing $1,000 for individuals as a tax 
credit, or $3,000 for a family.
  Again, you might look at that and say, in today's market that is not 
going to buy much insurance. But if you couple that with a high-
deductible policy that costs $50 a month for an individual, you can, in 
fact, price policies that would be easily within someone's reach by 
providing such a tax credit. And if the individual were able to bring a 
little bit of the money to the table themselves, they would find the 
availability of a health savings account with an account that would 
grow over time and eventually would have significant capital within 
their reach that they could use for medical expenditures should they 
happen later in life.
  Well, Mr. Speaker, all of this is great discussion. We do have to 
consider the job, the very big job ahead of us in this Congress, and 
probably many Congresses to come, on how to deal with the problem of 
the uninsured. The Census Bureau will give us figures from time to time 
on that. Whether that number is 42 million more or less, we can argue 
the actual number. This is not something that has happened overnight. I 
remember when President Clinton was running for office in 1992 on a 
platform of health care reform, he talked about the number of uninsured 
in the country being at 37 million during his run for office.
  No question the number has increased. No question that the recent 
recession this country went through was in fact responsible for some of 
that. The good news is that jobs are on the rebound, and more people 
are receiving insurance as a consequence of their employment, so the 
number hasn't gone up in the past year or two as fast as it might 
otherwise have been projected. And also, as I alluded to earlier, some 
people are buying health savings accounts that previously were 
uninsured. But the number continues to grow.
  The true number people will put anywhere between 9 to 10 million to 
in excess of 45 million, so I will have to acknowledge that there is a 
good deal of opacity here as well as the number of uninsured. But that 
doesn't prevent us from working on a solution to the problem.
  Now, the President has talked about a number of solutions during his 
State of the Union addresses. He has of course talked about consumer-
directed health care with health savings accounts, which we have 
already covered. He has talked about association health plans. And I 
was very relieved to see Senator Enzi and his committee finally making 
some movement on an association health plan bill over in the Senate 
earlier this month. We have passed an association health plan bill here 
in this House every year that I have been here, so that is at least 
over the past 3 years.
  Association health plans and achieving that goal is not going to 
suddenly deflate the number of uninsured in this country, but it is 
certainly going to help arrest the growth curve as the number of 
uninsureds increase, because employer costs increase for providing that 
insurance.
  What an association health plan does is allow small businesses, the 
backbone of business in this country, association health plans allow 
small businesses of a similar business nature, it allows them the 
ability to band together and attain the purchasing power of much larger 
companies, even going across State lines if necessary to get the power 
of that large group to negotiate with an insurance company. So that 
means that a group of Realtors, for example; a group of employees of 
your local chamber of commerce, for example; a group of doctors' 
offices, or a group of dentists' offices might ban together to be able 
to grab that purchasing power and get a better deal on insurance, a 
deal such as a much larger corporation might be able to command.
  Federally qualified health centers are a reasonable way of providing 
health care to people who otherwise would not have that health care 
available and would not have health insurance available. Federally 
qualified health centers are present in a number of areas in the 
country. Unfortunately, my congressional district does not contain a 
federally qualified health center. States that border the Mississippi 
River and those east have a number of such facilities available. 
Western States on the coast have a number of such facilities available. 
But we do have some fairly big gaps in the presence of federally 
qualified health centers throughout the middle part of the United 
States.
  One of the things that I think is so powerful about a federally 
qualified health center is that it gives a person a medical home. It 
gives them a place where they can go to receive their care. There is 
some measure of continuity of care, of seeing the same person on an 
ongoing basis, and overall reduces the cost of care for the uninsured 
in that community because that person is no longer dependent upon an 
emergency room for their hospital care. They in fact have a health 
center nearer their home. And because it is nearer their home, it is 
not just a question of access; sometimes it is a question of 
utilization. Utilization isn't always what it should be, but by placing 
these centers close to a person's home, it does increase not only the 
access but utilization as well.
  One of the things that I think this body needs to consider is why are 
there so many people uninsured. Well, of course, one of the reasons is 
the cost of health insurance has gone up so much over the past 10 
years' time. And one of the reasons that health insurance has gone up 
over the past 10 years' time, surely there is advancing complexity of 
what we are able to do, so health care just simply costs more. To some 
degree it is that cross-subsidization with Medicare and Medicaid and 
picking up the tab for the uninsureds in the community hospitals.
  But another reason that the cost of care increases, or the cost of 
insurance increases, which is different from the cost of care, is that 
in some places States mandate that certain procedures or certain 
diseases require special coverage or additional coverage. So placing a 
number of mandates on a State insurance policy can certainly drive the 
price of that insurance policy ever higher and make it more unavailable 
to more people in the population who cannot afford that degree of 
health coverage.
  We have talked in our committee about some of the solutions for that. 
In fact, association health plans will provide some relief for that 
problem. But the issue, Mr. Speaker, is no one wants to take away from 
people what they really need. And if a procedure or if a type of 
coverage is truly basic to human need, no, of course it shouldn't be 
withdrawn from an insurance policy. We have the ability in front of us 
to identify those procedures, those things that should be required in 
an insurance policy. We have already agreed on that list, and that list 
are the procedures, the diseases that are covered through a federally 
qualified health center.

                              {time}  1800

  If we were to work off of that list, if we were to decide what are 
the can't-haves, what are the can't-live-withouts

[[Page 4499]]

on that list and develop a template for an insurance policy that could 
be sold from one State to the other to allow someone at a lower income 
level to be able to afford an insurance policy, it is absolutely 
ludicrous to think that a family of four with a yearly insurance tab of 
$9,000 where the principal wage earner earns a over little twice that, 
that they are going to be able to be in the market for health 
insurance. It is just not going to happen.
  But if we can make a product affordable and within their reach, my 
belief is that most families want to have insurance coverage if a child 
gets sick or if a principal wage earner is involved in an accident and 
needs a prolonged hospitalization.
  I have been involved in numerous situations in the hospital where an 
injured person does not have insurance. It is an uncomfortable feeling 
for the family. Forget how the hospital feels about it or any of the 
doctors feels about it, but someone who is in a hospital knowing they 
are running up a big bill and knowing they have no means at their 
disposal to cover that bill, it is terribly uncomfortable and adds to 
the discomfort of any accident or disease process that brought them to 
the hospital.
  Mr. Speaker, I believe most people want to have that type of coverage 
for their family. And in fact, we are denying it. We are denying it by 
allowing insurance policies to be sold that no one could afford.
  My belief is that some of the larger insurance companies would look 
at that number of 42 million uninsured as potential market share if 
they simply had a product that was priced in a range where people could 
afford it. I think this body ought to look at the procedures outlined 
in the federally qualified health center legislation and make available 
to people a basic policy of benefits. Again, we have already identified 
what those would be, make a basic policy of benefits available to 
people, a policy without all of the bells and whistles that ends up 
costing patients and constituents so much in the way of out-of-pocket 
money.
  The country is looking to us to provide this type of leadership. They 
are tired of the tennis match between our side and their side and who 
has the better ideas. We have already agreed on what that basic package 
of benefits should be. Why not have a federally qualified health center 
without walls that is a basic insurance policy that a husband and wife 
can buy for their family and have that peace of mind and knowing if 
that child gets sick, has an asthma attack, develops diabetes, they are 
going to be covered.
  There could not be any discussion of health care reform in this body 
that did not cover liability reform.
  We need a national solution. We have several States that have done a 
good job at correcting the problem at home. My State of Texas certainly 
is one of those, but that protection that is now provided by the State 
of Texas has only been there since 2003. It is under attack during 
every legislative session.
  We need to step up and do this job. In fact, we are always looking 
for places in our budget where there might be some savings, where we 
might get a savings of a billion dollars here or a billion dollars 
there. And as famous Senator Dirkson said, pretty soon you are talking 
about real money.
  We passed a bill called H.R. 5 in 2003. H.R. 5 was the Medical 
Liability Reform Act. At that time, 3 years ago, the Congressional 
Budget Office scored that bill not with a cost but with a savings of 
$15 billion over 5 years. That is $3 billion a year. In fact, the 
amount is probably higher today. If we were to take that same bill back 
to the CBO and ask them to score it again, I suspect it would be a 
higher figure. I do not think the number of dollars spent on medical 
liability and defensive medicine have come down in the last 3 years.
  We are wasting money. We are wasting the country's money by not 
pushing for national medical liability reform. In my mind, those are 
precious health care dollars, and it is unconscionable that we continue 
to waste that money.
  Mr. Speaker, when I was a very new Member of Congress just a few 
short years ago, in my first August recess, we had a field hearing in 
northern Alaska up where the ANWR oil fields are proposed to be. On the 
way home, we stopped in Nome, Alaska. And Nome is still a fairly small 
town so you can imagine, a military plane with several Congresspersons 
on board landing at their airport caused quite a stir. In fact, their 
whole Chamber of Commerce turned out and had a nice lunch for us. When 
it turned out that one of the people from the Chamber of Commerce was 
also a physician, every member of their medical staff, all 19 of their 
medical staff showed up for that lunch and were eager to ask me 
questions.
  The man sitting next to me at lunch said, I hope you are going to be 
able to do something about medical liability this year. Do you think 
you will?
  I said, I do not know. It is a tough problem.
  He said, We really need some help in Nome, Alaska. We cannot afford 
an anesthesiologist at our hospital because we cannot afford the 
liability policy.
  Well, that certainly limits your ability to deliver services. I said, 
What type of medicine do you practice?
  He said, I am an OB-GYN doctor, just like you.
  I said, wait a minute, an OB-GYN doctor without an anesthesiologist 
at your hospital. Forget about pain relief during labor, what do you do 
if someone needs a C-section? He said, We get them on an airplane and 
send them to Anchorage. Well, that is an hour and a half away by air. I 
think there are probably a lot of days with probably pretty bad weather 
in Nome, Alaska, where air travel is not possible. So I do not know how 
we are furthering the cause of patient safety by not providing medical 
liability reform. I do not see how we can tell ourselves that this is 
unimportant when we have a hospital in Nome, Alaska, that has to put a 
pregnant woman in labor on a plane and send her to Anchorage, Alaska, 
to have her C-section under anesthesia and not feel every portion of 
the operation.
  Mr. Speaker, another time I had an opportunity to have dinner with a 
woman who is head of one of the residency programs at one of the larger 
hospitals in New York. I trained at Parkland, and I know it is the best 
residency program in the country, but they have some good residency 
programs in New York as well.
  I asked her how the liability issue is affecting her residency 
program. She related that they are taking people into their residency 
program that 5 years ago they wouldn't even have interviewed. The 
applicant pool has fallen off so much because of fears of young medical 
students getting out of school with a lot of debt because it took a lot 
of work to get through medical school and they had to get student 
loans. Now they are getting out of medical school and looking at what 
they want to do with their lives and practice, and they say I cannot 
afford to go into OB-GYN. There is no way I can do 4 years of training 
in OB-GYN and then go out and buy the kind of liability policy that I 
will have to have to set up in private practice, and also deal with all 
of these educational loans.
  So the best and brightest are no longer going to this hospital in New 
York for the residency program in OB-GYN. These are our children's 
doctors. These are the doctors that are going to be delivering our 
children and great grandchildren. How can we say we are furthering 
patient safety and patient rights by continuing to allow this to 
happen? And coupled with that, the money that is spent in the practice 
of defensive medicine because of the liability situation in this 
country, it is unconscionable that we do not change this. I hope we 
can. I honestly think the way we are actually going to have to go about 
doing that may be during the budgetary process, perhaps during 
reconciliation. But this issue is too important to wait for the 110th 
or the 111th or the 112th Congress.
  In Texas, we passed a Statewide medical liability reform bill in 
2002. It required a change in the State constitution to allow the bill 
to actually take effect. The bill was passed at the end of

[[Page 4500]]

May or the first of June during the beginning of the 2003 legislative 
session, and then a constitutional amendment was called for an election 
that happened on September 12 or September 13 of that year. That 
constitutional amendment passed, not by much, but it did pass. What a 
difference it has made in Texas.
  When I was first campaigning for office, we were in a situation where 
we had gone from 17 liability carriers down to two. That meant that 
there were a lot of doctors in the State of Texas who could no longer 
get medical liability insurance or they were paying top dollar for that 
insurance. In fact, I ran into a young woman one night during the 
campaign at an event for Senator Cornyn. This young woman said, I hope 
you can get something done about liability. I can't get insurance. It 
is not that I have had any lawsuits, but my company went out of state 
and I can't get anyone to cover me.
  So here was a woman in her mid-forties, trained at State 
institutions. Taxpayers had subsidized her education, and she is now a 
stay-at-home mom and not practicing her specialty of radiology because 
of the medical liability issue.
  The good news is that after Texas passed that law and passed that 
constitutional amendment, we went up from two liability carriers back 
up to 14 today. The liability reform that we passed in Texas was kind 
of unique. It was a cap on noneconomic damages, the same as the one 
that we talked about here in the House. We bifurcated that cap so that 
part was borne by the doctors and part was borne by the hospitals. It 
was in some ways different from the bill that we passed in the House 
but not substantially different. It is perhaps a template that we might 
follow here in the House of Representatives to see if we can't get 
something done on this issue because I will tell you, Mr. Speaker, the 
country is ready for us to take action on this.
  People said, well, and certainly we heard this on the debate in H.R. 
5 in 2003, the insurance companies are not going to reduce their rates. 
If you get this cap on noneconomic damages, it will not bring rates 
down. Well Texas Medical Liability Trust, my last insurer of record 
when I was in practice in 2002, my insurer has lowered rates by a total 
of 20 percent and provided dividends to their plan holders so that 
there has been between 20 and 25 percent savings to providers in Texas. 
Clearly, the people who said that the insurance companies would not 
provide relief to doctors were mistaken in that assumption.
  One of the other things that we talk about a lot in this body is the 
concept of pay for performance, reform of health information technology 
and how these two things taken together will return so much money to 
the medical system that our expenditures on medical care can in fact be 
met. I do not know that is something that I completely buy into at this 
point, but I do know this. We have been paying physicians under a 
formula called the sustainable growth rate since 1997 or 1998. This 
formula, the so-called sustainable growth rate, and bear in mind 
hospitals are reimbursed under a different formula which is the medical 
market basket formula. The sustainable growth rate has gone down every 
year for the last 5 years.
  During the month of December when we were working so hard on the 
Deficit Reduction Act, one of the reasons we were working hard on that 
was because the Deficit Reduction Act did contain language that would 
prevent that negative 4.4 percent update that physicians were to take 
January 1 if we did not pass the act. Passage of the act did not bring 
doctors any more money, it just held them at zero. And of course we all 
know, here in Washington, D.C., if you do not increase something year 
over year, you are in fact cutting it. Well, basically, we cut doctor's 
pay in January. Even holding them at a zero level negative update, we 
were cutting their pay. But even worse, we passed the Deficit Reduction 
Act but then because of a technical glitch it didn't get passed, it 
didn't get signed and doctors did get hit with a negative 4.4 percent 
update.
  January 4 in my district office in Texas, my fax machine was about to 
run out of ink because of the number of doctors sending me letters 
stating that they wanted me to see the letter that they were sending 
out to their patients: ``I will no longer be able to see Medicare 
patients in my practice. The cost of seeing the patients is far greater 
than the amount of reimbursement. We just got our pay cut by Congress, 
and I cannot afford to continue to see you.''

                              {time}  1815

  And this is really a tragedy. In fact, when I did my first series of 
town halls, my first year I was in office, I did 65 town halls around 
in my district. And I heard people talk to me about the difficulty with 
purchase of prescription drugs. This came up time and again.
  But what I heard without question in every town hall that I did, 
someone would come up to me afterwards and say, how come when you turn 
65 you have got to change your doctor? And the reason, of course, is 
because the doctor they were seeing before now is no longer taking 
Medicare. Now this was 3 years ago. It is getting worse year over year. 
What is happening is we are driving doctors out of the business of 
seeing Medicare patients. Doctors who in all likelihood are at the peak 
of their careers, doctors who have the best diagnostic ability, doctors 
who have the best technical skill, whose operations take the least 
amount of time, whose infection rates are best, we are driving these 
doctors out of the practice of taking care of our most vulnerable 
citizens, our senior citizens, individuals who will typically have 
multisymptom disease and chronic ailments for which they need the best 
care.
  But we are taking the best doctors out of the system. I submit that 
by doing so, if we then try to loop back and say, well, we are going to 
pay for performance, we may be paying for performance not with the 
first tier of doctors in this country, but with the second or third 
group. And it is going to cost more to pay for that performance.
  I submit the time to take care of this is now. We don't necessarily 
need to tie reform of the sustainable growth rate formula, which is not 
working, to some pay-for-performance formula, which quite honestly is 
not ready for prime time yet. But we do need to give providers some 
measure of relief and some degree of stability in the pricing of the 
procedures that they perform for us. It is difficult to make decisions 
about, well, how, am I going to expand my office, am I going to hire 
another partner, am I going to hire another nurse, am I going to offer 
this new procedure, when we here in Congress every year are threatening 
them with a 4.5 percent pay cut year over year until we reach a total 
of 26 percent, which, to me is unconscionable. We are driving the best 
doctors out of business; and then we expect to say, but we only want to 
pay for quality out of the doctors that are left.
  You know, the same could be true for the investment in information 
technology. If we drive our best doctors out of practice, then paying 
for information technology, but we don't have the best providers there 
anymore, so we are going to end up paying more for the technology, or 
paying more for the training for that technology. We, in fact, are 
harming ourselves by postponing this decision for another year or 
another two years.
  I submit this is the year to get this done. Reform that formula, 
place it on the Medicare economic index, which has been recommended by 
MedCap, which is the group that we tasked with dealing with this 
program and providing us a solution to the problem. Just like the 
hospitals who get a positive update year over year, we need to provide 
the same for physicians. Then we can get on the business about 
investigating the pay-for-performance issues and the information 
technology issues.
  I will just have to tell you, Mr. Speaker, my own experience with 
information technology, with an electronic prescribing unit that a 
company placed in my office for beta testing. They wanted our group of 
five physicians to try this out and see how it worked for them, to see 
if they could make it work better. But the problem was that it added 1 
to 2 minutes to

[[Page 4501]]

every patient encounter. Well, when you are having to see 45 patients 
during the course of an average day in order to pay the light bills, 
pay the help, pay the rent and take a little bit home at the end of the 
day, if you have got to see 45 patients in order to do all of that and 
you add 1 or 2 minutes to each patient's encounter, you are adding 1 or 
2 hours to that practitioner's day.
  And who pays for that additional 1 or 2 hours? Well, in the situation 
that we found ourselves in, that question just simply went unanswered. 
And what happened was the technology, for the most part, went unused. I 
will admit that I did use it because I like technology and I like 
fooling around with things like that. But my other partners were 
absolutely uninterested in anything that would slow them down or make 
them less productive.
  When we get to the point that we are willing to spend vast amounts of 
dollars for bringing this information technology to, say, a hospital or 
a doctor's office, we are going to have to be prepared to compensate 
individuals, doctors and nurses, nurse practitioners. We are going to 
have to be prepared to compensate them for the time involved in 
learning that process.
  Mr. Speaker, I was in a hearing in our Committee on Energy and 
Commerce just the other day where we talked about this. I will have to 
tell you, two of my worst days as a practicing physician: one was the 
day that this body passed the Stark laws, and one was the day this body 
passed the HIPAA laws. It certainly did not make my practice life any 
easier, and, in fact, made life a lot harder and, as a consequence, 
made the overall cost of delivering that care go up.
  I couldn't help but think that, as we were talking about crafting 
legislation to require doctors and hospitals to use advanced 
information technology, that that may well go down as the third worst 
day in the practice of medicine. We have to be very careful about how 
we structure this. In fact, the Stark laws right now prevent a hospital 
from providing that equipment or that infrastructure to a private 
doctor's office because that would be an unjust inducement to put 
patients in that particular hospital.
  We need to look at these 1980s health care laws and look at them in 
light of the 21st century. We are far past the point of punishing every 
doctor and every hospital for imagined transgressions by this body. We 
have to look at reforming those restrictions and those regulations so 
we can, in fact, allow doctors' offices and hospitals to come into the 
21st century.
  Mr. Speaker, any discussion of medical care would not be complete 
without talking a little bit about what is going on in the gulf coast 
in this country. Now, Hurricane Katrina, in Louisiana and Mississippi, 
Hurricane Rita in my State of Texas and our neighbor, Louisiana, did 
tremendous damage to all sectors of the infrastructure in those States. 
But especially hard hit was the health care infrastructure. And of 
course in the State of Louisiana, in the city of New Orleans, where, 
unfortunately, poverty was so prevalent, these storms did vast damage 
to the health care infrastructure that was at some days before the 
storms only tenuous at best.
  And it continues to be a problem, despite all of the dollars. Just 
last week, we did that supplemental bill, and all of the dollars that 
we have appropriated from this Congress, but you go down on the ground 
in New Orleans, Louisiana, and it doesn't look like we have done a darn 
thing for the folks down there, particularly in the realm of health 
care. Same with Beaumont, Port Arthur area in my State of Texas.
  I can remember watching those hurricanes, both of them, on the 
Weather Channel the nights that they were drawing their bead on the 
various towns in the gulf, and you just knew they were so big and so 
powerful that nothing good is going to come of this.
  My two trips to New Orleans this past year certainly have showed me 
what devastation those storms were capable of inflicting upon those 
areas. The city of New Orleans itself, of course, a virtual ghost town. 
You go into the lower Ninth Ward and you just cannot imagine the 
destruction if you haven't seen it.
  And furthermore, the task ahead, it has not even been decided yet 
whether rebuilding is something we should do in those areas. Certainly 
they continue to be flood-prone because of the number of feet they are 
below mean sea level. When you are standing in the street and you look 
up and you see a boat traveling by in the canal, that just gives you a 
graphic of how far down those communities are. And in a hurricane-prone 
area, to repopulate, it is a question that we are going to have to ask.
  But when you go into the health care facilities there in New Orleans, 
LSU Hospital, Charity Hospital, one of the venerable teaching 
institutions in this country, my professors at Parkland Hospital in the 
1970s, many of them trained at Charity Hospital in the 1950s and 1960s. 
It is truly an icon as far as medical care in this country.
  But when you walk through that facility, you realize that it quite 
likely will never be, ever again, what it was before. And it is a sad 
state. There is equipment that is relatively new equipment, but it has 
been ruined by water, ruined by mold, not likely to be salvageable 
under any circumstances.
  One bit of good news that I do need to share with Congress is that 
across the street at Tulane Medical School, the hospital there, under 
private ownership, has come a long way since the storm hit and since 
the forced evacuation of that hospital. We toured the facilities there 
at Tulane, at the HCA hospital. New paint on the walls, new sheet rock 
where sheet rock had to be replaced. The emergency room, the day we 
were there was about a week before Mardi Gras. It was not open that 
day, but they were going to open for Mardi Gras; and I believe that is, 
in fact, what they were able to do. It was a stark contrast to what was 
going on across the street.
  Now, the difference was that from a corporate level, that hospital, 
that private hospital had made the decision that no matter where the 
disaster happened anywhere in the country, they were going to be ready 
and they were going to respond. As a consequence, insurance money and 
new investment, new capital invested in that hospital brought it back 
much more quickly than any of the other facilities that I toured down 
there.
  But even with that hospital coming back, the service available to the 
residents who have come back to New Orleans, the medical care 
available, has been decimated. Doctors in private practice, when I 
visited the first time in October, would tell me, I have got no mail 
for 2 months. My accounts receivable, I have no idea. No money is 
coming in across the counter because everyone I am seeing, and the 
schedule is full, no one has any money, no one has any insurance. No 
one even knows if the company that they are working for is still in 
business. Things were so disrupted by that storm that day.
  Doctors are leaving the area. The hospitals that remained open may 
not be able to stay open because of the vast debts that they are 
incurring. Again, they are busy, patients are coming in, but nobody has 
any visible means of paying them. It has been a slow, slow process 
getting our Federal agencies to provide the reimbursement for seeing 
those patients that should be there. And it just continues to be a sad 
tale.
  There is no question that State involvement, as well, their response 
has been weak to nonexistent in several of those areas.
  Now, we saw a number of people that fled from the storm path in 
Katrina came to my area of north Texas. Some great stories there about 
how people opened their hearts and their homes to people who had been 
displaced by the hurricane. One of the great stories is, of course, 
from the Dallas County Medical Society. When they heard that 17,000 
people who had previously been in the Super Dome were going to come to 
a similar facility in downtown Dallas, even though it was on a Labor 
Day weekend, the doctors in Dallas, through the Dallas County Medical 
Society, sent out a blast fax to all of their members, and out of a 
3,600-member medical society, 800 showed up on

[[Page 4502]]

the steps of Reunion Arena to help those people and make certain that 
they had medical care.
  But we need to learn our lessons from this crisis. There are areas 
where our medical system performed valiantly. But there are areas 
within our medical system and particularly in our Federal agencies 
where the response was weaker than it should have been. And the reason 
to be concerned about that is we also hear discussion of an illness 
called the avian flu that, while fortunately not in this hemisphere 
yet, may be here before we get back from our August recess because of 
the distribution of the distributive path along the migratory flyways 
of birds.
  A lot of doctors showed up when they were asked to come down to 
Reunion Arena to receive the people from the hurricane. But what is 
going to happen if, instead of a natural disaster like a hurricane, the 
disaster is a communicable disease like the bird flu?

                              {time}  1830

  Can we expect first responders to show up for that when they, in 
fact, themselves may be placed in peril by doing so?
  Well, fortunately, the President and the Department of Health and 
Human Services and the NIH have worked very hard to come up with an 
Institute of Preparedness plan. We have provided some of the funding 
for that right at the end of December in the Department of Defense 
appropriation bill. There is still more money that we are likely having 
to put forth for that. And it is one of those things that it may turn 
out to be another Y2K. It may never materialize. But if it does 
materialize, it could be so severe and so harsh on our country that not 
being in a state of preparedness really makes no sense.
  Mr. Speaker, the House has been very kind with its time tonight. It 
has given us an opportunity to talk about what I see are a number of 
issues ahead for us in health care.
  I want to stress again that affordability of health care is a thing 
that we need to keep first and foremost in our minds. Every bill that 
we introduce, every vote that we take, every committee hearing that we 
hold, we need to keep affordability of health care uppermost in our 
minds. We need to work on the problem with the uninsured. We need to 
make insurance products available so that people can afford them. We 
need to expand and perhaps embellish federally qualified health 
centers. There is no question that we are going to need some type of 
liability reform in this country, and there is no question that we need 
some type of provider relief and to keep the best doctors involved and 
to continue to be involved in the practice of medicine, particularly 
where it is concerning our seniors.
  Information technology will be something that we talk about now and 
for several years to come, but we need to be extremely careful how we 
implement that.
  And then, finally, every hour that we spend thinking about 
preparedness, every dollar that we spend on preparedness is going to be 
money well spent. We can ill afford to have a poor response to the next 
crisis when it happens to this country. Unfortunately, the events of 
the last 5 years, I think, have shown us that bad things do happen to 
good people.
  Mr. Speaker, the House has been very generous with its time.

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