[Congressional Record (Bound Edition), Volume 152 (2006), Part 5]
[House]
[Pages 6228-6235]
[From the U.S. Government Publishing Office, www.gpo.gov]




                              {time}  2245
                   HEALTH CARE AND WHERE WE ARE GOING

  The SPEAKER pro tempore (Ms. Foxx). Under the Speaker's announced 
policy of January 4, 2005, the gentleman from Texas (Mr. Burgess) is 
recognized for 60 minutes.
  Mr. BURGESS. Madam Speaker, I come to the floor tonight to talk about 
health care, but I have to spend just a minute or two addressing some 
of the things that we just heard in the previous hour.
  There has been a lot of discussion about the Jobs and Growth Act that 
was passed in 2003, in fact in May of 2003, a reinvestment of $80 
billion back into the American economy, back into the productive sector 
of the American economy. The American people rewarded the United States 
Treasury with an increase in collections to the Treasury the next year 
with $260 billion that were not anticipated. Investment in the 
productive sector of the American economy works every time it is tried, 
and I am grateful to be part of the Congress in 2003 that provided that 
reinvestment opportunity for the American people.
  There has been a lot of discussion this past couple of weeks about 
gas prices. We passed an energy bill at the end of July last year. Part 
of the deal on that energy bill was that there was going to be no 
liability protection for a compound called MTBE, a federally mandated 
oxygenate in gasoline that is sold in this country in order to comply 
with clean air restrictions.
  Without MTBE, we are left with only ethanol as the only oxygenate 
available for the mixture of gasoline that is required to be sold in 
States that have clean air issues. We removed the MTBE because it was 
placed in legal peril.
  We had an opportunity in October after the hurricanes hit, after we 
knew there was going to be trouble, we had an opportunity to address 
the oxygenate requirements in the blended fuels that are going to be 
blended and sold for this summer's driving season, precisely the time 
we are up against right now.
  This House passed that bill which would have allowed for that 
relaxation of oxygenation requirements. We passed it with no Democratic 
votes. It was only Republican votes that passed the bill, and it has 
never been taken up by the Senate. The consequences are quite 
predictable.
  Now, we were told during the hearings on the energy bill the prior 
year by individuals from, and you talk about a special interest group, 
that is the ethanol lobby; we were told that the ethanol manufacturers 
in this country had unbelievable success and they were able to produce 
ethanol that exceeded their wildest expectations. Well, they were wrong 
and they have not been able to produce the quantity they said, and it 
is time for this country to look at the tariff that we place on foreign 
imported ethanol. If we are going to require foreign imported ethanol 
to be part of our gasoline oxygenate system, we are going to have to 
import ethanol at least temporarily until we can increase production in 
this country.
  But I did not come to the floor to talk about gas prices and ethanol, 
although that is important. I came to the floor tonight to talk about 
health care. I want to talk about where we are and where I see us 
going. I would like to spend a considerable time on the affordability 
of health care because I believe that is the central issue. Whether you 
talk about a single payer, government-run system or a system that 
embraces the private sector, affordability of health care is going to 
be one of the main drivers that we need to keep in our uppermost 
consideration.
  We need to talk about the uninsured and federally qualified health 
centers. We will have a bill in the next couple of weeks in the 
committee that will authorize the federally qualified health center 
statute. Those are an important aspect of our delivery of medical care 
in the 21st century in this country.
  We have to talk about liability reform. We have talked about it a lot 
in the past 3 years. We have yet to produce a satisfactory result, and 
it is going to continue to be a part of a major discussion on health 
care until we get something done in that regard.
  We have to talk about provider relief and paying our doctors and 
health care providers what they rightfully earn, and not continue to 
cut their reimbursement rates year after year in the Medicare system 
and ask them to shoulder a greater and increasing burden of the health 
care costs when, after all, we turn to them to take care of the 
uninsured at no compensation and then we continually cut their Medicare 
compensation. We are driving good doctors out of practice and that is 
wrong. We need to address that.
  There has been an explosive growth in information technology in 
virtually every sector of the American economy. Health care is no 
exception. We need to make certain that we have the right kind of 
informational technology at the disposal of people who provide health 
care.
  Of course, you cannot look at the last year with the problem with the 
large hurricanes, the problems that loom on the horizon as hurricane 
season is upon us again, and the problems that loom on the horizon from 
an infectious disease, the likes of which none of us have ever seen in 
our lifetimes, the specter of the avian flu. We have to talk about 
preparedness.
  When ethicists talk about health care and health care in this 
country, they always seem to talk about affordability, access and 
quality. I remember an ethicist that spoke to one of our classes years 
ago said affordability, access and quality; we have only learned how to 
handle two of the three at any one time.
  Since I do not want to pick the one that is going to be left out, let 
me concentrate on affordability. We will leave quality and access 
discussions to other days. And I might add that I trust the American 
medical system to provide us with the quality that we have come to 
expect.
  We already have a system that is paid for by, to a large degree, by 
governmental agencies and by the Federal Government with a GDP of $10 
trillion to $11 trillion and $1.4 trillion spent on health care. In 
fact, in the HHS appropriations bill that we passed last December, over 
$600 billion was spent on Medicare and Medicaid alone. So clearly, 
almost 50 cents of every health care dollar spent in this country 
arises right here in the halls of the United States Congress. The 
remainder, the other 50 percent, is largely carried by private 
insurance, commercial insurance. There is also some amount of that is 
carried by self-pay. Again, we cannot forget the charitable care that 
is delivered by hospitals and doctors and nurses all over the country 
every hour of every day of the year.
  The problem that I see if we do not address affordability of health 
care, the

[[Page 6229]]

default position on the horizon is going to be a single payer, 
government-run system. Would that necessarily be a bad thing, to vastly 
expand the public expenditure on health care? I look to our neighbors 
to the north that have an entirely government-run, single-payer system, 
and I think it was just in late 2004 or perhaps 2005 that the Canadian 
Supreme Court ruled that their system, with its long waiting lines, was 
no longer adequate. In fact, I think the Canadian Supreme Court, their 
statement was access to a waiting line is not the same as access to 
care.
  In that system there are the problems with long waits for so-called 
elective surgeries. Now, an elective surgery may be something as 
serious as replacement of a diseased hip or fixing a problem that 
someone has with a ruptured disk in their back or neck. It may even 
include coronary artery bypass grafting. It may include some things 
that we may not think of as being entirely elective. I would submit 
that health care in Toronto would significantly suffer if they did not 
have the safety net of Henry Ford Hospital in Detroit, Michigan to take 
care of some of their excess.
  On the other hand, in the United States, if we had a single-payer 
system with long lines for access to care, I do not think we could 
count on a hospital on our southern border to bail us out in a similar 
fashion.
  So in short, I believe we need the private sector, and in fact I 
believe we need to encourage and expand the private sector as far as 
delivery of health care in this country. Congress can take action by 
promoting policies that keep the private sector involved in the health 
care marketplace. Indeed, we have done exactly some of those things in 
the short 3 years that I have been here.
  One of the most significant things I think that has happened in the 
last 10 years, in 1996 with the passage of the Kennedy-Kassebaum Act, 
and the allowance for the first time for what is called medical savings 
account. These were those high-deductible insurance policies where you 
could put money away towards that deductible into a medical IRA, if you 
will; allow that money to grow tax free to be a medical nest egg for 
someone who may need it in future years, or to pay that high deductible 
out of the medical savings account.
  Now, medical savings accounts had a lot of restrictions upon them. 
But even at that, when they were first offered back in 1996 and 1997, I 
very quickly went out and signed up myself for a medical savings 
account. I made one available in my medical practice to anyone who 
wanted it, because I saw this as the tool for the future. It put the 
decision-making for health care decisions back in the hands of the 
health care consumer. I thought that was such a powerful concept.
  Even though at the time medical savings accounts were kind of an 
untried and untested premise, I thought that concept of putting the 
health care decision back into the hands of the health care consumer 
was so important, I was willing to take a chance on that. Mind you, 
1996 and 1997 and 1998 was a time we saw explosive growth of HMOs in 
this country. And more and more medical care was being dictated by the 
chief executive officers of HMOs or medical review boards in a HMO, and 
I saw this as a wonderful chance to reclaim the health care decisions 
for myself and my family. I gratefully took that option. I am glad I 
did because that policy served me very well until I came to Congress.
  Now, coming to Congress in 2003, medical savings accounts were not 
available in the Federal Employees Health Benefit Plan. Again, medical 
savings accounts had a number of restrictions on them and they were 
capped. Only 750,000 could be offered across the country, and they were 
not that heavily subscribed.
  When we passed the Medicare Modernization Act in November of 2003, we 
expanded medical savings accounts in a way that I frankly did not think 
was possible. But kudos to the Ways and Means Committee and Chairman 
Thomas; they got the job done and vastly expanded the access to health 
savings accounts not just for recipients of Medicare, but for anyone 
who wanted to participate in that kind of high-deductible policy, and 
having a savings account that is dedicated entirely to their medical 
expenses.
  There are some other improvements that can be made, and indeed there 
are several pieces of legislation out there currently to allow for a 
hybridization, if you will, between flexible spending accounts, health 
reimbursement accounts and health savings accounts. I think those are 
important steps that yet need to be taken. But with the expansion of 
health savings accounts in 2003, making them more generally available 
to the population, we unleashed a very powerful tool for providing 
insurance to more people in this country.
  Madam Speaker, in the year 1994, I had a family member who was no 
longer able to get insurance off my employer-based insurance. I set out 
to get an insurance policy for that family member and it was all but 
impossible to do at any price. I was a practicing physician at the 
time, willing to write a large check for that insurance coverage, but I 
could not find anyone who would write a single policy for a young, 
single, uninsured person.
  Well, fast forward 10 years to 2004, the year after we passed the 
health savings account legislation and the Medicare Modernization Act. 
And that summer you could go on the Internet, you could go to your 
favorite search engine and type in ``health savings account'' in the 
window, click ``go,'' and it would immediately return all kinds of 
options to that person for the potential purchase of a health care 
policy. I do this periodically to see what is available in my State for 
a 20- to 25-year-old single person for single coverage, and you can get 
a very reasonable, I do not want to say an insurance company's name, 
but a large insurance company that has a color as part of its first and 
second name; you can get a reputable insurance company's policy for 
around $50 a month. Again, a young person age 20 to 25, with a high 
deductible.
  But think of that, a young person getting out of college who wants 
to, instead of going to work for a large corporation, wants to work for 
themselves. They want to do an Internet start-up company or any type of 
self-directed entrepreneurial-type activity. No longer do they have to 
turn their back on that as a career option because insurance is not 
available. They can purchase a policy on their own, a policy that is 
reasonably priced. Yes, it has a high deductible; but they also have 
the ability to put money away towards that deductible, do so tax free, 
and the money grows tax deferred.

                              {time}  2300

  And if it is used for a medical expense, it is not going to be taxed 
under any circumstance. We have another tool at our disposal. And the 
House has passed what are called association health plans. We have 
passed this two times a year, every year that I have been in the House 
of Representatives.
  The Senate very recently passed an association health plan bill out 
of their committee. And this, again, is a powerful tool that allows for 
small businesses, small businesses of a similar business model, to band 
together and accrue the purchasing powering of a large group. The 
association health plan is envisioned to be sold across State lines 
such that a group of realtors in Texas could band with a group of 
realtors in Oklahoma and combine and pool their resources in order to 
get a lower price on their insurance coverage. Again, a very powerful 
tool, one we have passed in the House on several occasions. It did 
finally pass out of the health committee over in the Senate side, and I 
do look forward to them taking that issue up to the floor of the 
Senate, passing that successfully, and let's get to conference and 
let's get the differences worked out, because this is something we need 
to provide to our small businesses, the engine that drives productivity 
in this country. We need to put this tool in the hands of small 
business in this country.
  When you think of consumer-directed health care, like a health 
savings account, there has to be some method that the consumer, that 
the purchaser

[[Page 6230]]

has of evaluating different hospitals, different doctors. There has got 
be a measure of transparency brought into the overall purchase of that 
insurance plan. Right now there is opacity in the system, and I 
understand there is opacity in the system because opacity has value. It 
is perhaps worthwhile for a health care facility, a hospital, surgery 
center, doctor's office, to have a little bit of opacity in their 
pricing structure so that it is a little bit hard to figure out what 
something costs. But we need to move and make an honest effort to 
provide the information that the health care consumer needs to make a 
well-founded, consumer-oriented decision. After all, we are asking for 
consumer-oriented health care. We can't very well deny the consumer the 
opportunity to be able to evaluate two health plans side by side, two 
hospitals side by side, two surgery centers or two doctors' practices 
side by side. They need the ability to do that.
  Finally, a concept that has been around as long as I have been here, 
and, I suspect, longer, is the concept of tax credits for the uninsured 
or the underinsured, a voucher system, perhaps, if you will, just 
helping someone who didn't make enough money to be able to pay for 
insurance, helping them pay for insurance with an EITC-type tax credit 
that is prefundable, not refundable. That is at the beginning of the 
tax year that money would be made available to that person.
  Some of the proposals that are out there would fund $1,000 for an 
individual, $3,000 for a family. A lot of people will say, well, you 
can't buy much in the way on the health insurance market for $3,000 for 
an individual. But if you go to the health savings accounts Web sites, 
you certainly can find products that are available that would allow 
someone to purchase insurance coverage, again, for well under $1,000 
for an individual, perhaps for 6- or $700 a year, and to begin to put 
money away towards that high deductible. And I think that is a 
worthwhile product, a worthwhile activity.
  And I do look forward at some point to this Congress or the next 
Congress taking up the concept of tax credits for the uninsured because 
I believe that will, over the long term, all three of those concepts 
taken together, health savings accounts, association health plans and 
tax credits for the uninsured. Mort Kondracke in an editorial in the 
Roll Call Magazine really 2 years ago estimated that you could cut the 
number of uninsured by perhaps 13 million by those three entities 
alone. I actually think the number on his estimate on health savings 
accounts is a little low, because we have seen, over the last 2 years, 
an increasing number of people select that type of health insurance, 
such that now there are over a million people enrolled in health 
savings accounts. The vast majority of these are individuals over the 
age of 40, and a great number of these are people who would not be 
regarded as high-income. Probably 40 percent of people earn under 
$50,000 a year. So it is not just for the healthy and the wealthy; it 
is a program that does have high utility for Americans across the 
spectrum of all age groups and all earning capabilities.
  As far as the uninsured is concerned, the U.S. Census Bureau, and it 
seems like this number is higher every week when I read it, right now 
between 43- and 45 million people who are estimated to be uninsured. 
Now, this number is a little bit tricky because it does include people 
who are uninsured for any portion of the year. So someone who is 
uninsured for part of the year, but has insurance for the balance of 
the year is going to be counted uninsured for the entire calendar year.
  Does it count people who are perhaps in this country without a valid 
Social Security number, people who are in this country without the 
benefit of a valid visa or immigration papers? And the fact is that it 
does, and it is going to be difficult to provide coverage to someone 
who breaks the law by entering this country illegally.
  But that doesn't remove the fact that there are a lot of people in 
this country who lack health insurance. One of the things that causes 
it, of course, is the high cost of health insurance. And when I talk 
about the affordability of health insurance, I acknowledge that for 
every dollar that health insurance premiums go up, a certain number of 
people are going to be excluded from the rolls of the insured. And we 
have done things that cause the cost of insurance to inexorably go 
higher and higher, and as we do that, we are going to drive more and 
more people away from the ranks of the insured onto the rolls of the 
uninsured.
  Now, one of the things that is not often talked about in context with 
uninsured individuals is the concept of federally qualified health 
centers. Now, the President talked about federally qualified health 
centers on at least the last two occasions when he delivered his State 
of the Union Address, and I believe the last time he was here he said 
he wanted to see a federally qualified health center in every poor 
county in the United States.
  I submit that is a worthy goal, and I would also submit there are 
some counties such as in my district back home in Texas that you 
wouldn't necessarily record as poor, but they have areas of poverty 
within them that are as large as counties, and indeed as large as some 
States back East, and these populations would benefit from access to a 
federally qualified health center.
  Now, we are going to be taking up the bill that will reauthorize 
federally qualified health centers within the next few weeks in the 
Energy and Commerce Committee. I suspect it will come to the floor 
perhaps the latter part of June during Health Care Week. This is a 
worthy exercise and one that the committee needs to take up, and indeed 
the whole House needs to take up. I hope there are some improvements 
that we can make upon the system.
  One of the things I learned last year with the large number of 
evacuees that came to my district from Louisiana, to my district in Ft. 
Worth, Texas, it takes a long time to set up a federally qualified 
health center. And if you have a large number of displaced persons who, 
by virtue of the fact that they are low-income, by virtue of the fact 
that they had to leave their homes under the worst possible of 
conditions, and it is taking some time to get them set up in a new 
life, or perhaps they are just temporarily going to be displaced in my 
district, it takes too long to set up that federally qualified health 
center structure to be able to help individuals like this in the time 
frame where they need the help. So some streamlining of the federally 
qualified health center application process, I believe, would really go 
a long way towards helping these individuals. Backstop it. Make certain 
that within 2 years time all of the other regulations that surround 
federally qualified health centers have to be complied with, but ease 
up the rules just a little bit in an area that is desperately medically 
underserved to allow the setup and startup of one of these centers in a 
timely fashion.
  We have to provide that degree of flexibility. Otherwise, we are only 
driving up the cost of health care in the hospital emergency rooms in 
the area, in the doctors' offices in the area, where they are going to 
see more and more uninsured patients and deliver more and more 
uncompensated care, which they, in turn, will have to pass that cost 
off to other patients and other health care consumers.
  But the beauty of a federally qualified health center is it allows a 
patient to have a medical home even though the patient does not have 
insurance, and that is the least expensive way of delivering health 
care to that group of individuals. Again, it keeps them out of the 
emergency room. It keeps them from accessing health care at the most 
expensive entry point into the health care system. It allows them to 
enter in at the level of the medical office or medical clinic, as 
opposed to the emergency room. And they frequently see the same doctor 
for visit after visit, so that a problem such as high blood pressure, 
diabetes, congestive heart failure, chronic long-term problems again 
are going to be better managed if you see the same provider time and 
time and time and time again. That continuity of care really is worth 
something in that environment.

[[Page 6231]]

  Now, there are a number of federally qualified health centers in this 
country. I don't know the precise number. I believe that the number of 
people who are actually served by federally qualified health centers is 
going to number in the 15 million range, so that 15 million individuals 
who are maybe uninsured but have access to health care through a 
federally qualified health centers, it may not be actually accurate or 
fair to carry them on the ranks of the uninsured. And that is why I say 
that number of 42 to 45 million that is always reported by the Census 
Bureau may be overreported because it doesn't take into account the 
millions of people that get their medical care through a federally 
qualified health center, which is a very reasonable, cost-effective way 
to get good medical care for someone who doesn't have access in some 
other form.
  We have State governments that have, over the years, required that a 
lot of things be covered on insurance policy, the so-called mandates 
that are added to insurance policies. And tonight, not really the 
purpose to get into what mandates are good and what mandates are bad, 
but recognize that adding enforced coverage to insurance policies does 
increase the cost of insurance policies. And again, for every dollar 
that we drive up the cost of an insurance policy, we are excluding 
people from insurance.
  If it were possible to come to some agreement on what mandates were 
absolutely necessary, people just can't live without, and which are 
more optional, and come to a conclusion about is it possible for us to 
designate a type of insurance, what would be covered under that type of 
insurance that could be sold from one State to the other, sold on the 
Internet, get the benefit of that type of competition across the 
country, if it were possible to come to that type of conclusion about 
what we have to have, what we can't live without in an insurance 
policy, and allow insurance companies to market lower-cost products to 
people who fall into the ranks of the uninsured, I believe that our 
American insurance companies would look at that 42 to 45 million 
uninsured as a market opportunity and would want to market an insurance 
policy to that segment of Americans if they only were allowed to do so.
  The good news, Madam Speaker, is we have actually kind of already 
come to that agreement. And I go back again to the federally qualified 
health center template. We have already decided within the federally 
qualified health center structure what procedures have to be offered, 
what conditions have to be covered, what benefits have to be offered in 
the federally qualified health center structure. And if we could take 
that template as a starting point and come to agreement amongst 
ourselves, Republican and Democrat alike, stop the tennis match of my 
mandate is more important than your mandate; stop the arguing over this 
process, and simply come to an agreement, here is an insurance policy 
that is good enough to be sold to America's uninsured, it covers the 
things that should be covered, it doesn't add a lot of additional 
expense for things that might be considered as optional; and then allow 
American insurance companies to compete to sell to that segment of the 
market, I think we would find that that is a very powerful tool and one 
that, quite honestly, we do need to explore. And we need to explore it 
in this Congress. We don't need to wait. The guys an hour ago were 
talking about how different things are going to be a year from now.

                              {time}  2315

  Well, it does not need to wait for a year from now. This is work that 
we can do today, this month, this year. And I submit that it is good 
work and one that we must take up in this Congress.
  Madam Speaker, when I was originally talking about this, the concept 
of liability reform is one that we visited on the floor of this House 
many, many times since I took office in the beginning of 2003, I 
believed before and I still believe now that we do need a national 
strategy for medical liability insurance reform.
  And I am from Texas. Texas has done a great job with medical 
liability reform. Texas has done a great job with putting a cap on 
noneconomic damages and has, I think, built upon and strengthened some 
of the earlier programs such as the California program of the Medical 
Injury Compensation Reform Act of 1975. I think the Texas compromise of 
2003 really built on that earlier experience and is a very valuable 
program. In fact, it is delivering cost savings on liability insurance 
for the doctors of Texas. One of the unintended consequences was that 
it really brought the cost of liability down for self-insured, not-for-
profit hospitals. They have been able to make more investments in 
capital and equipment and nursing personnel than they thought possible 
because of the cost savings they have gotten off of the Texas medical 
liability reform that was passed in 2003.
  Now, in this House we passed H.R. 5, which was a major medical 
liability reform bill, in 2003. And when we passed that bill, Madam 
Speaker, the Congressional Budget Office scored that as a savings of 
$15 billion over 5 years' time. Now, it is not just the lower cost of 
liability insurance that they are talking about and doctors passing 
that cost on to their patients. No. The real savings in that H.R. 5 was 
because of the perceived reduction in what is called defensive 
medicine: I do not think this person has this condition, but I need to 
do this test in case I am wrong and this case comes into court and I 
want to be certain that I have got this evidence to back up my 
decision-making process.
  A study done back in 1996 at Stanford University estimated that out 
of the Medicare program alone, just the Medicare program, the cost of 
defensive medicine in 1996, that was 10 years ago, the cost of 
defensive medicine for Medicare in this country was nearly $30 billion 
a year. I submit that that 10-year-old study, if it were done again 
today, would find that dollar figure to be actually much higher. CBO 
did not score it as high, but still acknowledged that there was 
significant savings to the Federal budget every year if the Congress, 
House and Senate, would pass meaningful, meaningful medical liability 
reform.
  The problems of the expense of defensive medicine and the high cost 
of the medical liability system as it exists today means that we are 
taking money out of the health care sector of our economy and pushing 
it off to somewhere else. And that somewhere else is too often paying a 
contingency fee for a trial lawyer. And as harsh as it is to say it, we 
can no longer afford that kind of luxury. We can no longer afford to 
divest that kind of money in order to continue the medical liability 
system that we have in this country. We need a fairer medical justice 
system than we possess today.
  The bill that we passed, H.R. 5, back in 2003, again basically put a 
cap on noneconomic damages. It capped noneconomic damages at $250,000. 
I believe it was a good bill. I voted for it in 2003. I voted for it in 
2004. I voted for it in 2005. In fact, I will vote for it again if we 
bring it to the floor of the House again this summer. But when you look 
at the Texas bill that was passed in 2003, it actually structured 
itself a little bit differently. Yes, there is a $250,000 cap for 
noneconomic damages, but that cap exists for the physician, for the 
hospital, and for a second hospital or nursing home if one is involved. 
So the total aggregate cap is $750,000. I would have been concerned 
back in 2003 if someone had said this is the way we are going to go 
about the cap, that that was too high, that that would not bring the 
cost of medical liability insurance down, that that would not reduce 
the cost of defensive medicine. But, in fact, the story in Texas is 
that it has brought costs down.
  I will give you an example. In 2002 when I was running for office the 
first time, we went from 17 insurers in the State of Texas, medical 
liability insurers, 17 of them in the State of Texas at the start of 
the year, 2 in the State at the end of the year. And the problem was 
the high cost of medical liability and the draining of those insurance 
companies by lawsuits.

[[Page 6232]]

  The effect of passing that bill in June of 2003 and then the 
subsequent constitutional amendment that was required to allow that 
bill to become law in September of 2003, by the middle of 2004, less 
than a year later, we had gone from 2 medical liability insurers in the 
State of Texas back up to 13 or 14, and they had come back into the 
State without an increase in rates. That is pretty powerful, because if 
you go from 17 insurance companies down to 2, you have not got much in 
the way of competition. You pretty much have to take what they say as 
the going rate. So getting those insurers back into the State of Texas 
was critical as far as keeping doctors involved.
  I remember an event that I went to during the fall of 2002 when I was 
running for Congress, and a young woman who was a radiologist came up 
to me and said, ``I really hope you get something done on medical 
liability. I have lost my insurance, not because of a bad case but 
simply my insurer left the State of Texas and now I cannot get 
liability insurance, and as a consequence I am a stay-at-home mom now. 
I am not practicing radiology.'' Because, obviously, she cannot without 
the protection of a medical liability insurance policy. So the State of 
Texas had paid for her medical education. The State of Texas had 
subsidized her during her radiology residency down at the University of 
Texas at San Antonio. And now just a few years later, she was out of 
medicine altogether and raising her children. I am sure she was very 
happy in that role, but at the same time, what a waste of that woman's 
talents. What a waste of that woman's training that she would not be 
able to practice radiology in Texas simply because her insurer left the 
State and she could not get someone else to cover her. That is the kind 
of very stark reality that we were up against in Texas in 2002. We were 
one of the top crisis States as designated by the American Medical 
Association of that year.
  Fast forward to June of 2003, a major liability provision was passed. 
Again, it capped the pain and suffering damages at $250,000 for the 
doctor, $250,000 for the hospital, $250,000 for a second hospital or 
nursing home if one was involved, and very quickly there was a 
turnaround, the insurers coming back into the State, hospitals saving 
money. Doctors from Texas Medical Liability Insurance Trust, my old 
insurer of record, the savings now, the accumulative savings, from when 
that bill was passed to the present day is in excess of 20 percent 
savings on their medical liability policies. These are policies which, 
by the way, were going up by 10 and 20 percent every year for the 2 or 
3 years that preceded that event.
  So I think the Texas plan is a good one, and I like to sing its 
praises every time that I come to the floor of the House. I think any 
medical liability reform that we pass in this House, we could do worse 
than to base it off of the Texas plan and the Texas compromise, the so-
called trifurcated cap. I would like to see us champion that concept 
over in the Senate and see if we could not get their attention with the 
trifurcated cap and perhaps get a bill that we could get to conference 
that way.
  But one of the critical things about medical liability insurance 
issues, people say, you are from Texas and if you have solved the 
problem in Texas, why do you continue to worry yourself about it in the 
House of Representatives? And I will tell you why. Because that bill is 
under attack every legislative session in Texas. There are special 
interests. And, yes, addressing the Democrats, there are special 
interests that work on your side as well as our side. There are special 
interest groups that want to roll back that legislation. But there are 
other issues as well.
  During my first term, my first year in Congress, we took a visit up 
to the ANWR up in Alaska. And coming back from ANWR we came through 
Nome, Alaska. Nome, Alaska is a pretty remote place out there. So you 
can just imagine that when a big plane with a bunch of Congressmen 
land, it is a big deal in Nome, Alaska. They wanted to have a chamber 
of commerce-type lunch for us, which they did. And when they learned 
that there was a Congressman who was also a doctor on the plane, all 
the medical staff got real excited and all 19 doctors on the medical 
staff of the Nome, Alaska hospital came out to that lunch that we had.
  And one of the doctors who was there said, ``Boy, I sure hope you get 
that medical liability law passed up in Congress, because we cannot 
afford the medical liability policy for an anesthesiologist here at the 
hospital; so we need your help and we need you to get that done so we 
can afford to have an anesthesiologist.''
  I said, ``Well, gosh, what kind of medicine do you practice, sir?''
  He said, ``I am an OB-GYN, just like you.''
  ``An OB-GYN. How in the world do you practice obstetrics and 
gynecology? How do you deliver a baby without the availability of 
anesthesia? Forget a labor epidural and pain relief during labor. What 
do you do if you have to have do a C-section?''
  And he said, ``Congressman we get that woman onto a plane and we get 
her down to Anchorage as fast as we can.''
  Anchorage, an hour and a half away from Nome, Alaska. And I am not 
entirely sure about this, but I believe there is a significant amount 
of bad weather in Nome, Alaska. I do not want to upset the people at 
the chamber there, but I believe there is a significant amount of bad 
weather in Nome, Alaska, particularly in the winter months. How do we 
further the cause of patient safety by requiring that that doctor put 
his patient on a plane and send her to Anchorage to get a C-section 
done with the care of an anesthesiologist? That system makes no sense.
  Another opportunity I had was to visit with someone who was in charge 
of the residency program of a large New York hospital. I trained at 
Parkland Hospital, but I was aware of their training program, and 
certainly it is a good second to Parkland Hospital in Dallas. But this 
individual was in charge of the residency program. And I said, ``How 
has the liability issue affected your ability to recruit medical 
students for your OB-GYN residency there in New York?''
  And she said, ``Well, it is a real problem, and currently we are 
accepting students that 5 years ago we would not have interviewed.'' In 
other words, they have lowered their standards in that OB-GYN 
residency, because medical students coming out of medical school with 
huge debt do not feel that they can take on the expense and the trauma 
of a large liability policy when they start their practice; so they 
just do not go into OB-GYN.
  These are our children's doctors. These are our children's children's 
doctors that we are talking about. How are we furthering the cause of 
better medical care in this country when we are allowing that system to 
continue? It truly is unconscionable, and it is time for this Congress 
to correct that. Both the House and the Senate need to take action on 
this. We do have a President who has pledged to sign this bill if we 
will get it to his desk, and I believe that we must do that.
  On the concept of physician payment, I will say that we spend a good 
amount of time in this body discussing health information technology 
and pay-for-performance scenerios. We talk about them frequently. But 
we do not address a serious problem that has been plaguing America's 
physicians for the past 10 years, and that is the issue of the 
continuing erosion of physician payments under the Medicare system.
  Currently, physicians are paid under what is called the sustainable 
growth rate, or SGR, which provides for a payment cut of 4 percent for 
every year, year over year, to a cumulative total of some 26 percent. 
And that has a negative effect upon the number of doctors who continue 
to provide services for Medicare patients.
  Now, I have done a lot of town halls around in my district, and I 
have heard a lot of discussion about prescription drugs. But I have 
also had a lot of people come up to me at the end of a town hall and 
say, ``How come I turned 65 and I have got to change doctors?'' The 
reason they have to change doctors is that their physician has 
evaluated the Medicare reimbursement schedule and has decided that it 
is not in their best

[[Page 6233]]

interest to continue to provide care for Medicare patients because of 
this continued erosion of provider reimbursement rates that goes on 
year over year. Doctors look at that and they think, well, Congress is 
likely to reverse that at least temporarily this year. But it is very 
difficult to plan. It is very difficult to hire. It is very difficult 
to justify equipment purchases if you have got to factor in a pay cut 
of 4 to 5 percent every year for the forseeable future.
  Now, we passed a bill called the Deficit Reduction Act right at the 
end of the year, but it turned out we really did not pass it until 
January. Within the Deficit Reduction Act was a provision to keep the 
doctors from having that negative 4.4 percent update; in other words, 
just hold payment rates at a level amount and not decrease it.

                              {time}  2330

  The effect of not passing that bill in December and allowing January 
1st to hit without addressing that problem meant that every physician 
in the country who does Medicare got a letter from CMS, the Center for 
Medicare and Medicaid Services, saying your rates just went down 4.4 
percent, or our reimbursement to you just went down 4.4 percent. My fax 
machine lit up, because it was over the holidays and doctors wanted to 
get word to me, saying here is the letter I accept to my patients, 
Congressman. I will no longer be able to provide your care after the 
first of the year because Medicare has again cut my rates.
  So doctors not just in my district, but across the State and some 
even across the country, called me and notified me that they were going 
to drop their coverage of Medicare patients.
  The problem is that these are doctors who are in the peaks of their 
career. These are doctors who have established practices, the doctors 
who come to a diagnosis the quickest, the doctors who spend the least 
amount of time in the operating room, the doctors who are at the 
pinnacle of their medical expertise, and they are being driven out of 
the system. The problem is if you drive out your first tier of 
providers, it is only going to cost you more in the long run.
  So when we talk about things like pay for performance, I cannot help 
but think if we run off our top tier of providers, we are going to have 
to pay a lot more to get less performance in the future, and it is 
incumbent upon us to take up that legislation, to take up that concept 
and pass legislation that will once and for all fix the problems with 
the sustainable growth rate and not make our provider community face 
that 4 to 5 percent pay cut every year, year over year.
  A concept derived by the Medicare Payment Advisory Council, so-called 
MEDPAC, was for consideration of what is called the Medicare economic 
index, which calculates the true cost of providing Medicare health 
services, and the reimbursements would be based upon a formula which 
factored in the actual cost of delivering that care, a very powerful 
concept and an idea whose time I believe is long since overdue.
  Another issue that we spend a lot of time talking about here on the 
House floor and over in committee is the concept of increasing health 
care technology. This is appropriate for Congress to be considering 
this. It is an appropriate expenditure. It is terribly difficult for 
small doctors' offices with one, two, three and four providers in an 
office, to justify the kind of expense that would be required to 
purchase that off-the-shelf health care information technology.
  A lot of times a hospital would be willing to partner and help offset 
some of that, because the hospital benefits as well. Currently we have 
laws such as stark laws and anti-kickback statutes that prevent that 
from happening. We need to seriously look the a those pieces of 
legislation. They may have been of some value back in the 1980s, but 
they are not a great help in the 21st century. They are not really 
protecting anyone from any malfeasance, and they are preventing getting 
this technology into the hands of people who need it the most.
  The other thing that we have to consider is we have to assure 
physicians, providers, hospitals, that they are not going to run afoul 
of some statute in the HIPAA legislation, the patient privacy 
legislation. Finally we need to concentrate on some coding uniformity 
so that people will have confidence in these systems and know that they 
can use them and that they are not only helping their patients, they 
are helping their practices, they are helping their bottom line, they 
are helping their hospital. It could be a win-win situation all the way 
around, but we are going to have to change some Federal regulations to 
allow that to happen.
  One of the things that I talked about when I originally started this 
evening was that we needed to touch on preparedness. When you talk 
about preparedness, looking back over the last year, the twin 
hurricanes of Katrina and Rita that hit Louisiana, Mississippi and then 
Texas and Louisiana later in the year, it is impossible to talk about 
preparedness without thinking about some of the lessons that we 
learned.
  When the hurricane was out there churning in the Gulf, the first 
hurricane, Hurricane Katrina, you just knew it was going to be bad 
news. It was a hurricane unlike anything that any one of us had seen 
before, and there is no way in this day and age that it could select a 
location for landfall along the Gulf Coast where it was not going to 
affect a significant number of people.
  Well, we all know the story. It came ashore. It kind of took a little 
turn before it came ashore. We thought New Orleans had dodged a bullet, 
only to find out that it got hit with even a larger bullet than any of 
us thought possible.
  I was back in Fort Worth and Denton, Texas, during the August work 
period, and it was at that time that almost 25,000 people that were 
displaced from that storm came to North Texas seeking shelter, seeking 
medical care. To say that we weren't expecting it would be an 
understatement. But the people of North Texas opened their homes and 
their hearts. Hospitals, hotels, church camps did yeoman's work taking 
in people who were affected by the storm.
  Where my district office is in Fort Worth, at the Tarrant County 
Resource Center, they immediately made provisions to take in 80 
individuals. We set up pallets and cots well into the night on 
Wednesday night and started receiving our first evacuees on Thursday.
  A small Baptist camp in Denton, Texas, Camp Copus, opened its gates 
up and received some 130 people who had driven in buses all night, in 
two buses all night, from the Superdome in Louisiana when they finally 
got out of there.
  Probably one of the most heartwarming stories in the North Texas area 
was the way that the Dallas County Medical Society really rallied 
around and got their members out to provide care for these individuals 
as they got off the buses. There are about 3,600 members of the Dallas 
County Medical Society. When they heard the buses were on the way up 
from the Superdome, we were right on top of Labor Day weekend, so most 
people were closing their offices early, making plans for a holiday 
weekend.
  The Dallas County Medical Society sent out a blast fax to all its 
member physicians, and 800 doctors showed up to provide medical care, 
triage care, urgent care to these people that got off the buses who had 
been displaced from Hurricane Katrina; people who had chronic medical 
conditions, who had been off their medications for 3 or 4 days, who 
with their chronic medical condition were about to have an acute 
decompensation of hypertension, diabetes, congestive heart failure.
  So as these people came off the bus, as the evacuees, they were 
interviewed. If they thought they were ill enough to have to go to the 
hospital, they were taken to the hospital, to Parkland Hospital there 
in Dallas. If they simply needed a shower and a meal and a refill on 
their medications, that was provided for them.
  Of the 17,000 people who got off the bus in those first hours that 
evening, less than 500, I think the number is actually in the range of 
about 300, were actually hospitalized at Parkland Hospital, a 
phenomenally small number

[[Page 6234]]

when you consider that these were people who had been in the worst of 
conditions for the past 3 or 4 days, again many of them ill with 
chronic medical conditions who had been off their medications for 
several days. Very few required hospitalization because the doctors of 
the Dallas County Medical Society were there to receive them.
  One the great stories of that evening was some of the pharmacies in 
the area provided mobile communications and mobile computer hookups, 
and if those patients had received their medicines at one of the chain 
drugstores in Louisiana, in New Orleans, they were able to actually 
replicate their medications, duplicate their records for the 
medications, what they were taking and the dosage schedules, and make 
sure the right medicines were gotten to the right individuals. A 
phenomenal story that occurred there on Labor Day weekend.
  Another story you will never read about in the newspapers but really 
was one of the phenomenal good news stories, the way you can save a lot 
of money with just a small investment, everyone was given a little tube 
or little canister of hand sanitizer, and every few minutes you would 
see people sanitize their hands with an anti-bacterial, anti-viral 
preparation.
  In these kinds of conditions, where you have got a lot of people who 
have been wet from a storm and then housed in the Superdome and then 
got wet again when the Superdome flooded, on a bus for hours, you can 
just imagine the bacteria and viruses find that an environment they can 
thrive upon.
  Diseases like the Norwalk virus, where gastrointestinal illnesses, 
epidemic diarrheas are very, very common in those types of conditions. 
They had very, very few people who became ill. Those that did have 
symptoms were identified early and sequestered off in another facility. 
But, again, the hand sanitizing that was done by providing low cost 
hand sanitizing solution to every person within the Reunion Arena 
shelter there really kept down trouble and spared a lot of human 
suffering, spared a lot of medical expense for having to treat people 
then of the subsequent gastrointestinal illnesses, the nausea, the 
vomiting, the diarrhea, the dehydration that could accompany that.
  As a follow-up, I have been to the City of New Orleans twice since 
Hurricane Katrina hit. The first time was in October. I was there as a 
guest of one of the hospital administrators who wanted me to see, he 
had come before our testimony to testify in Washington and he wanted me 
to see firsthand myself the destruction that is there.
  Even if October, two months after the date, it is unbelievable. There 
is work to be done that realistically will carry on for years. It is a 
phenomenal task that is ahead of the people of Louisiana, the people of 
New Orleans, the people of Mississippi and the people of the United 
States of America as we help that part of the world recover.
  I do want to share one other good news story. We toured Charity 
Hospital and saw the degree of devastation there, and there is a lot of 
work to be done if Charity Hospital is ever going to recover. Across 
the street at Tulane Hospital, which is a private hospital, they had 
invested insurance money, they had invested new capital and were well 
on their way to having the HCA hospital up and running. In fact, I 
believe their emergency room was open in time for Mardi Gras. I am not 
sure if the hospital has opened up any of its wards yet, but it looked 
like they were well on their way to getting that done.
  An entirely different story just across the street from Tulane. They 
both had the same degree of flooding, they both had the evacuation on 
the same day, late that week after the storm, but involvement of the 
private sector really did make a positive difference in the recovery of 
the Tulane Hospital.
  It is my hope that Charity Hospital will be able to recover as well. 
I hope the individuals there involved in the State Medical System can 
work with Federal agencies and can work with the doctors and the very 
capable administrators on the ground, but they have got a long way to 
go to recover the Charity facility.
  I guess one of the main things that was learned down there, one of 
the main lessons learned, an off-the-shelf preparedness plan that is 
purchased by a hospital or nursing home is not going to do a bit of 
good if it is not taken off-the-shelf and put into action. 
Unfortunately, that did happen in more than one occasion in that area 
after the hurricane.
  I do need to add that just because a hospital was private does not 
necessarily mean that it fared better than a public hospital. There 
were other private hospitals that still lag far behind the HCA facility 
there at Tulane, and it is my hope that more of those will follow the 
Tulane model and make that private investment, invest those insurance 
dollars that they receive and bring their facilities up and on line 
quickly.
  We did have hearings. The other side complained this evening about 
oversight. There were excellent oversight hearings by Tom Davis' 
Special Select Katrina Committee. All Members received or should have 
received their report. It is called Failure of Initiative. It is a very 
large book, but it is not a hard read. In fact, it is a very 
interesting read. For those Members who have received that and not read 
it, I would urge you to do so.
  There is an excellent part in there about medical preparedness, but 
in fact it talks about preparedness all down the line, and it is a 
valuable instruction for all of us, especially when we talk about the 
specter of the avian flu which could be facing us here in this country 
as early as late August or early September.
  When you look at the spread of that illness in bird populations 
across Southeast Asia and then the Middle East and then in Eastern 
Europe and now in Europe, clearly there is a continued spread of that 
disease. When it gets into the flyways of the migratory bird patterns, 
gets up in the polar regions perhaps by this summer, then down through 
the upper North American continent in Canada, arriving in the United 
States, pick the month, but one could easily assume it would be early 
or late fall of next year.
  I must stress that this is still a disease in animals, a disease in 
birds, but there is a lot about it that is not known. Felines in 
Germany have contracted the disease. Whether that is because they have 
come in contact with animal waste or whether they have eaten animals 
that is diseased, no one really knows. It does appear to be a different 
disease in felines than you would expect the avian flu to be in humans 
if it were to mutate to a human form.
  We have a lot of work to do as far as bolstering our vaccine 
manufacturing capability within our shores, within our borders. It 
needs to happen in this country. We need some liability relief to allow 
that to happen quickly, but we also need to protect and indemnify our 
first responders.
  Those 800 people that came to the Reunion Arena parking lot from the 
Dallas County Medical Society for Katrina victims may have an entirely 
different view on the situation if they are being called to come attend 
a large number of casualties from a disease that might well be an 
infectious disease that they could catch. They will need to have the 
availability of anti-virals. We will need to have the availability of 
vaccines. But if those vaccines are relatively new and untested, we 
need to have the ability to indemnify those first responders or their 
families if the first responders are harmed by the vaccines.

                              {time}  2345

  The disease knows no boundaries. It does not respect any Governmental 
jurisdiction. If it does arrive on the upper part of the North American 
Continent it will spread through the lower parts to the United States.
  Can anyone guess how quickly? Suffice it to say that the conditions 
are a little bit different here than in Southeast Asia and the Middle 
East. Containment policies that have been somewhat sporadic would 
likely be much more effective over here on this continent.
  But that is not to say that we could not face a very serious problem. 
It would be economically disruptive if

[[Page 6235]]

nothing else if large numbers of the poultry population had to be taken 
off line. But a very serious potential human tragedy if the virus 
changes in its ability to infect not just bird populations but humans 
as well.
  But in summary, Madam Speaker, we have got a lot of work ahead of us 
as far as health care is concerned over the balance of this year. I 
know that the leadership takes this responsibility very seriously. 
Certainly I want to make certain that the leadership and indeed every 
Member of Congress knows that those of us who have a background in 
health care stand ready and willing to help in this regard.
  The concept of affordability of health care is one that I just cannot 
stress enough, because if we do not attend to the affordability of 
health care we may end up with a default position that none of us 
really cares for.
  And with that, Madam Speaker, I yield back.

                          ____________________