[Congressional Record (Bound Edition), Volume 153 (2007), Part 19]
[House]
[Pages 26246-26252]
[From the U.S. Government Publishing Office, www.gpo.gov]




                  THE STATE OF HEALTH CARE IN AMERICA

  The SPEAKER pro tempore. Under the Speaker's announced policy of 
January 18, 2007, the gentleman from Texas (Mr. Burgess) is recognized 
for 60 minutes.
  Mr. BURGESS. Mr. Speaker, I am coming to the floor tonight to talk, 
as I often do, about health care, the state of health care in America, 
some of the things that we face as a country, as a Congress. And, Mr. 
Speaker, we have reached a point where it is kind of a unique time, and 
it occurs from time to time in our Nation's history in political cycles 
that we have the political reality of unfettered election-year politics 
meeting head on with the perennial challenge of redefining or reforming 
America's health care system.
  Mr. Speaker, the history of health care in America over, say, the 
past 60-plus years going back to the 1940s is that of a very highly 
structured, highly ordered scientific process coupled with a variety of 
governmental policies, policies each aimed at achieving a specific 
objective; but rarely do we get the opportunity to reexamine the 
policies and what follows on from those policies and how they continue 
to affect things years and decades into the future.
  Mr. Speaker, if we go back to that time in the middle 1940s, the time 
of the Second World War, some significant scientific advances occurred. 
In 1928, for example, Sir Alexander Fleming rediscovered penicillin. It 
actually had been discovered in the late 1800s, but Sir Alexander 
Fleming in England discovered that the growth of a bacteria called 
staphylococcus could be inhibited by the growth of a certain type of 
mold on the auger plate. Well, it took some additional research. It 
took some additional input from other scientists who actually came to 
this country and developed the process of fermentation that allowed for 
the large-scale production of that compound that we now know as 
penicillin, a compound that when it was first discovered was priceless. 
You couldn't get it at any cost and by 1946 had come down to about 55 
cents a dose, all because of American ingenuity coming into play in the 
mid-1940s. In fact, soldiers injured during the invasion of Normandy on 
D-Day were oftentimes treated for their wartime-acquired wounds that 
became infected with penicillin.
  Another individual, an individual we have honored on the floor of 
this House during the last Congress, Dr. Percy Julian, an African 
American scientist or, actually, an organic chemist, who didn't 
discover cortisone. Cortisone had been discovered earlier. But the 
extraction of cortisone from the adrenal glands of oxen was a laborious 
time-intensive process, and as a consequence, cortisone was only 
available as a curiosity, as an oddity. But Dr. Julian perfected a 
methodology for building cortisone out of precursor molecules that were 
present in soybeans and, as a consequence, ushered in the age of the 
commercial production of cortisone.
  So there in the 1940s, we had the development of two processes that 
allowed for the commercial application of an antibiotic, an anti-
infective agent, that previously was unavailable on the scale that it 
was made available after the Second World War, and an anti-
inflammatory, cortisone, for treating things like rheumatoid arthritis, 
Addison's disease. Cortisone now on a commercially available basis. 
These changes profoundly affected the practice of American medicine 
starting at about the time of the Second World War.
  But what about on the policy arena? Did anything significant happen 
during the Second World War? Well, you bet it did. What happened during 
the Second World War is President Roosevelt said in order to keep down 
trouble from inflation, he was going to enact some very strict wage and 
price controls on American workers. And he felt it was necessary to do 
that because, after all, the country was at war.
  Well, employers were looking for ways to keep their workers involved 
and keep them on the job, and they came up with the idea, well, maybe 
we could offer benefits. Maybe we could offer health insurance, 
retirement plans. It was somewhat controversial as to whether or not 
these could, in fact, be offered at a time of such strict wage and 
price controls, controversial as to whether or not these added-on 
benefits would be taxed at regular earnings rates. Well, the Supreme 
Court ruled that they could, indeed, be offered; that they did not 
violate the spirit of the wage and price controls, and, in fact, they 
could be awarded as a pretax expense.
  Fast forward another 20 years to the mid-1960s, and now the 
administration and the Congress are locked in the discussion and the 
debates that ultimately led to the passage of the amendment to the 
Social Security Act that we now know as the Medicare program. Suddenly 
we have a situation where the body of scientific evidence, the body of 
scientific knowledge is expanding at an ever-increasing rate. We have 
got some fundamentally different ways of paying for health care, some 
in the private sector and now some in the public sector, all leading to 
what is happening currently at the present time.
  Now, again, going back to the Second World War, most health care was 
paid for at the time of service, and that was a cash exchange between 
the patient and the physician or the patient and the hospital. Now, 
with the advent of employer-derived health insurance and with the 
interposition of now this large government program, most health care is 
now administered through some type of third-party arrangement.
  Now, this is useful. It protects the individual who is covered from 
large cash outlays. But there is a trade-off, and this covered 
individual is generally unaware of the cost of the care that is 
rendered, as well as the provider who is quite happy to remain 
insensitive as to the cost of the care that is ordered. This 
arrangement has created an environment that permits rapid growth in all 
health care sector costs.
  We have a hybrid system. America's challenge then becomes evident. 
How do we improve upon the model of the current hybrid system, which 
involves both public and private payment for

[[Page 26247]]

health care and which anesthetizes most parties involved as to the true 
cost of this care? It's also wise to consider that any truly useful 
attempt to modernize the system, any attempt to modernize the system, 
the primary goal has to be, first off, protect the people instead of 
protecting the status quo.
  Now, we must also ask ourselves if the goal is to protect a system of 
third-party payment or provide Americans with a reasonable way to 
obtain health care and allow physicians a reasonable way to provide 
care for their patients. Remember that the fundamental unit of 
production is the interaction that takes place between the medical 
professional, the physician, and the patient in the treatment room. 
That fundamental interaction is the widget that is produced by this 
large health care machine, and sometimes that concept gets absolutely 
lost in translation.
  Now, the current situation subsidizes and makes payment to those 
indirectly involved in the delivery of that widget, and ultimately that 
drives up the cost. Now, currently in the United States, we spend, 
depending upon what you read, 15, 16, and 17 percent of the gross 
domestic product on health care, amounting to about $1.6 trillion a 
year. Within that total amount of spending, the government accounts for 
approximately half. When you add together the expenditure of the 
Medicare, the Medicaid system, the Federal prison system, VA system, 
Indian health service, all of those things together equal about 50 
cents out of every health care dollar that is spent in this country.
  The other half is made up by commercial insurance, self-pay, and I 
would include health savings accounts in that grouping of self-pay. 
Certainly some percentage is made up by services that are just simply 
donated or never reimbursed. We might call it charity care.
  A lot of money is spent in health care, but only a fraction on direct 
patient care and oftentimes too much on an inefficient system.

                              {time}  2030

  Now, the test before us, the test before this Congress, the test 
before this country is to protect the people instead of providing 
protection to special interests. Define that which ought to be 
determined by market forces, market principles, and that which of 
necessity must being left in the realm of a government or public 
provider; that balance between the public and private sectors, and how 
in all of this process we preserve the individual self-direction 
instead of establishing supremacy of the State.
  Additionally, we must challenge those things that result in the 
extortion of market forces in health care and acknowledge that some of 
that extortion is endemic, some of it's built into the system, some of 
it's hidden and not readily changed, and some of it is, in fact, easily 
amenable to change. And we need to know the difference, and we need to 
know what is worthwhile to try to effect change.
  Now, the key here is how to maximize value at the production level; 
again, where that widget is produced, the doctor-patient interaction in 
the treatment room. How do we place a patient who exists on a continuum 
between health and disease, how do we shift that balance more in the 
favor of a state of continued health, which is obviously less expensive 
than paying for disease? Do we allow physicians a return on the 
investment, which opens up a host of questions relating to future 
physician workforce issues, and I am going to touch on those in more 
detail in just a minute.
  How do we keep the employer, if the employer is involved, how do we 
get them to see value in a system, things like a quicker return of an 
ill employee to work, increased productivity, better maintenance of a 
healthy and more satisfied workforce? In regards to health insurance, 
how to provide a predictable and manage risk environment, remembering 
that insurance companies are, of necessity, they tend to seek a state 
of a natural monopoly; and if left unchecked, they will, indeed, seek 
that condition.
  And finally, how do we balance the needs of hospitals, ambulatory 
surgery centers, long-term care facilities and the needs of the 
community, as well as the needs of doctors, nurses and administrators?
  Now, Mr. Speaker, some legislation has already been introduced to try 
to effect some of these changes. I want to make reference at this point 
to a publication that's produced by my home State organization, the 
Texas Medical Association. Last March, this was the cover of their 
publication, Texas Medicine. It referenced that the United States may, 
in fact, be running out of doctors.
  So I've introduced three pieces of legislation geared toward the 
physician workforce and how do we keep the workforce involved and 
engaged. Alan Greenspan, talking to a group of us right before he 
retired as chairman of the Federal Reserve, came in and talked to a 
group of us one morning and was asked the question: How in the world 
are we ever going to pay for Medicare going into the future? And he 
thought about it for a moment and he said, if I recall correctly he 
said, ``Well, I'm not sure. But I think when the time comes, you will 
do what is necessary to preserve the system.'' And I believe he is 
right. But he went on to say, ``What concerns me more is will there be 
anyone there to provide the services that you require.''
  Well, Mr. Speaker, in an effort to be certain that there are the 
people there to provide the services that we require, I introduced 
legislation such as 2583. This establishes low-interest loans for 
hospitals seeking to establish residencies in high-need specialties, 
primary care, general surgery, OB/GYN, gerontology in medically 
underserved areas. It turns out one of the thrusts of this article is 
that doctors tend to have a lot of inertia, they tend to go into 
practice close to where they had trained. So if we can establish 
residency programs where none currently exist in communities of 
moderate to small size and allow those physicians to undergo their 
training in those community hospitals, they're very likely to settle in 
or very close to those communities, thereby driving the equation in 
favor of supplying physicians in high-need specialties in medically 
underserved areas.
  Another piece of legislation, H.R. 2584, is more geared at the 
medical student or perhaps even the student in college, the student 
who's considering a career in health professions. And this expands the 
old health professions scholarships, provides the availability of 
scholarships, provides the availability of low-interest loans, provides 
the availability of favorable tax treatment if an individual is willing 
to go into practice in a medically underserved area in a high-need 
specialty.
  And then finally, the third piece of legislation, 2585, deals with 
more of what I would describe as the mature physician, that physician 
who has been in practice. But one of the problems of our publicly 
financed side of health care, one of the problems in the Medicare side 
is that reimbursement rates for doctors are decreased year over year as 
an effort to control costs in the overall program, but the result is it 
tends to drive doctors away from practice. So this bill would have at 
its heart the repeal of a payment formula that is referred to as the 
``sustainable growth rate,'' or SGR formula, which I believe is 
critical. I believe we have to repeal that formula if indeed we're 
going to keep physicians involved in the process.
  Mr. Speaker, another component of this bill, 2585, does allow for 
some voluntary compensation if a physician or group wishes to 
participate in a system to upgrade health information technology. And I 
put this slide up here, Mr. Speaker, because this is the records room 
at Charity Hospital in New Orleans taken in October of 2005. You can 
see that, although the records themselves were not disturbed by the 
wind of that particular storm, that records room is in the basement and 
it was completely under water for several days. And you can see there, 
this is 2 months after the storm, probably a month after the water was 
removed from the downtown area of New Orleans and removed from the 
basement, you can see the destruction evident on

[[Page 26248]]

those paper records. And clearly, that's a situation that has to be 
addressed. If we are going to move America forward into the 21st 
century, that's a condition that has to be addressed. And I have 
attempted to do that in H.R. 2585, as it deals with the medical 
workforce; it also deals with some bonus payments to allow physicians 
who wish to voluntarily participate in an upgrade of health information 
technology, allows them the freedom to do that.
  Other legislation that is out there, H.R. 3509. H.R. 3509 is a 
medical liability bill. And this bill was crafted after legislation 
that was passed in my home State of Texas in September of 2003. This 
was legislation that was crafted, it was styled after the Medical 
Injury Compensation Reform Act of 1975 passed by the State of 
California and then modernized for the 21st century. And what this bill 
does is provide a cap on noneconomic damages. It is a cap that is 
shared between physicians, hospitals, a second hospital or a nursing 
home, if one is involved. Each entity is capped at a $250,000 payment 
for noneconomic damages, or an aggregate cap of $750,000.
  Now, the reason I bring this up, the reason I introduced this 
legislation that is similar to the Texas-passed legislation in the 
House of Representatives, is, after all, our Founding Fathers said that 
the States should function as laboratories for the country. So here we 
have the State of Texas functioning as a laboratory for meaningful 
liability reform in the health care sector. And the results are in and 
the results are clear; 4 years after this legislation was passed we 
have held rates down for premiums for medical liability insurance for 
physicians. More importantly, a State that was losing insurers at a 
rapid rate, we had gone from 17 insurers down to two by the end of 
2002, which was my last year of active practice, and now we're back up 
to numbers in the twenties or thirties. And these liability insurance 
carriers have come back to the State without an increase in premiums. 
In fact, the Texas Medical Liability Trust, my old insurer of record, 
has lowered rates by about 22 percent at the time of my last 
calculation.
  This is critical for getting the young individual who is in high 
school or college interested in a career in the health profession. The 
crisis in medical liability that exists in many areas of the country 
serves as a deterrent, a repellant that keeps young people from even 
thinking about a career in health care. And that is, in fact, one that 
we do desperately need to change.
  Let me, just for a moment, go back to the Texas Medical Association 
hypothesis, ``are we running out of doctors,'' and the comments of 
Chairman Greenspan as he spoke to our group early that morning, now 
probably some 18 months ago. Will we run out of doctors? No. The answer 
is we probably won't. I guess we should ask ourselves: If we make the 
climate too inhospitable, if we make the climate too difficult, what 
will the doctors of the 21st century look like? Well, I don't know. But 
from time to time I allow myself some internal speculation as to what 
the medical workforce of the future might resemble, and sometimes I 
come across this young individual, kind of a health care entrepreneur 
from a famous American sitcom that is seen on the Fox Network. I don't 
know. But it's not worth running the risk of running out of physicians 
and not attracting the best and brightest into the practice of 
medicine.
  Now, that brings me to what I would describe as a set of principles 
that for any health care legislation that I endorse, that I embrace, 
that I put out there myself or that I cosponsor, what are the 
principles that I need to see? Well, certainly, first and foremost, you 
have to have freedom of choice. American patients, they want to see who 
they want to see, they want to see them when they want to see them, and 
if hospitalization is required, no one objects to an incentive. But 
freedom of choice must remain central to any system, whether it is 
private or public, in this country.
  Ownership. We hear a lot about the ownership society, things both 
good and bad. But I will tell you something, from having myself had a 
medical savings account starting back in 1997, when they first became 
available, until the time I left private practice in 2002. The whole 
concept of having a health savings account or, if you will, a medical 
individual retirement account, a medical IRA, and being allowed to 
accumulate savings in that account to offset future medical expenses, 
that's a fundamental desire of many people in this country. And many 
Americans in this country feel the same way, and, in fact, I'm of the 
opinion that that should be encouraged. The dollars accumulated in 
those accounts, and this is the great thing about them, even if you no 
longer have the account, which I no longer am insured through an HSA 
because when I came to Congress they weren't generally available. Now 
they are and I haven't switched back, but that money is still there. It 
still grows month by month at the regular savings rates. Right now I 
think it's about 4.5 percent, so a reasonable rate of return on that 
investment. But that money is there for me and my family to use in the 
future should any medical expenses arise that maybe aren't covered by 
other insurance.
  Well, what happens if I get to the end of a long and happy life and 
I've never had to tap into those savings, what happens to them then? 
They stay in my family. They're available to my heirs and assigns for 
the coverage of their care going into the future, and all the while 
continuing to grow in value, tax deferred because that's the way the 
law was written back in 1997 when I first opened that account.
  These dollars are dedicated to health care, they're owned by the 
individual, and they don't, by default, go to some governmental entity 
upon the death of the individual who's covered.
  Now, another principle that I think is just critical to any 
discussion of health care is independence. There has to be preservation 
of autonomy. The patient or the patient's designee should ultimately be 
responsible for their care and the ability to accept or decline medical 
intervention.
  High standards, one of the things that we pride ourselves on in this 
country, one of the underpinnings of the American medical system has 
always been high standards of excellence, and nothing in any future 
change should undermine that. And, in fact, pathways to facilitate 
future growth in excellence really ought to be encouraged.
  Mr. Speaker, we have to preserve innovative approaches. American 
medicine has always been characterized as embracing innovation, 
developing new technologies and treatments. Clearly innovation must be 
preserved in any process going forward.
  Another key is timeliness. Access to a waiting list does not equate 
to access to care; so spoke the Canadian Supreme Court to its medical 
system in 2005. We must diligently seek not to duplicate the most 
sinister type of rationing, which is a waiting list. And that can be, 
unfortunately, involved with any large health care system, whether it 
be a nationalized single payer system or, indeed, a very, very large 
private system.

                              {time}  2045

  We have to keep it market based and not administrative. Pricing 
should always be based on what is actually indicated by market 
conditions and not what is assumed by administrators. Remember, in 
general, mandates lead to a restriction of services. State mandates 
cause more harm than good, impede competition and choice, drive up the 
cost of care and can actually limit the availability of health 
insurance. Another type of mandate, we heard a lot about it in 1993 
when health care reform was discussed last decade, employer mandates 
and individual mandates are likewise restrictive. A discussion of 
mandates should include an accounting of cost and whether the mandates 
limit the availability of insurance for those who may operate a small 
business, for example, for those who may be self-employed or self-
insured.
  Mr. Speaker, it is worth remembering that Medicare part D in its 
first year of existence, the year 2006, achieved a 90 percent 
enrollment rate. They didn't do that with mandates. How did they do it? 
With education, incentives, competition, but certainly

[[Page 26249]]

not mandates. Well, what about premium support? That is something you 
hear about from time to time. In fact, premium support was a big part 
of when President Bill Clinton talked about how to modernize the 
Medicare system. Bill Thomas who recently was chairman of the Ways and 
Means Committee, Bill Frist who was Senate majority leader, Bobby 
Jindal who serves as a Member of this House currently, these 
individuals were on a task force appointed by President Clinton to try 
to improve the Medicare system. One of the concepts they came up with 
was premium support to help someone who doesn't make quite enough money 
to pay a health insurance premium, help them, support them in 
purchasing that premium or buy down the cost of that premium. A 
subsidy, yes, but I prefer to think of it in terms of support.
  Now, people also talk about tax credits. It is a similar rationale 
for helping an individual who can't quite afford the premiums on their 
health insurance. Mr. Speaker, I just submit that our Tax Code is 
currently complicated enough. We don't need to do anything that further 
complicates the Tax Code. That is why I move in the direction of 
premium support as opposed to tax credits or other incentives. One of 
the things we ought to do, though, when we do talk about mandates, and 
certainly that has been one of the stories coming out of Massachusetts, 
the plan that Governor Romney talked about when he came and addressed 
our House Policy Committee a couple of years ago when that program was 
first established, one of the mechanisms they had at their disposal was 
the ability to, because they have a State income tax, the ability to 
help someone understand the validity of buying insurance. I don't know. 
Maybe we ought to look at that when we provide money to individuals 
through the earned income tax credit. Perhaps a portion of that money 
ought to be earmarked for at least a catastrophic policy or a high 
deductible policy, those that can be had generally at lower expense. 
Maybe it is time to think outside the box in that regard and provide 
those individuals an earmark, if you will, of that tax credit so that 
they, in fact, do purchase health insurance if they are going to be 
covered under the earned income tax credit.
  Then finally, and this is a terribly difficult concept and a lot of 
people just tune me out when I talk about it, but we have to balance 
the way we handle our anti-trust laws. We have to balance anti-trust 
enforcement, and we have to prohibit overly aggressive anti-trust 
treatment under the law. Exemption or enhanced enforcement is only 
likely to further distort the market. It means the desired results are 
never obtained because we are always providing this market distorting 
influence by either protecting one side or one group and potentially 
punishing another side. Creating winners and losers via our anti-trust 
law erodes the viability of our American health care system. Again, I 
think we would do well to pay some attention to that and prevent that 
from being part of our lexicon in the future.
  Now, as far as the specific policies for health care within the 
public sector model, the transformation after the experience with 
Medicare part D has, in fact, been instructive. Six protected classes 
of medication were required of all companies who wish to compete within 
the system. That allowed for greater acceptance by the covered 
population and certainly greater medical flexibility as far as the 
physicians were concerned when treating patients. At the same time, the 
competitive influences brought to bear in that part of the program, in 
fact, managed to bring down cost.
  In fact, the projection of $130 billion over the 10-year budget 
window less than was originally outlined was a success story. That is 
solely the result of competition. I feel certain that, in the future, 
we are going to get benefits for more efficient treatment, timely 
treatment of disease. I think there are additional successes out there 
to be had, but certainly competition within the first year or two of 
the existence of part D program certainly showed where competition can 
pay off.
  Now, one of the most important points of lessons learned in the 
Medicare part D program is that coverage can be significant without the 
use of mandates. Ninety percent of seniors now have some type of 
prescription drug coverage. That was achieved by creating plans that 
people actually wanted. It was achieved by providing the means and 
incentives to sign up in a timely fashion. This emphasized that 
personal involvement and responsibility was there, was important to 
maintain, and it was important to maintain credible coverage. There 
was, in fact, a premium to pay if someone signed up after the initial 
enrollment cycle.
  Mr. Speaker, employer-derived insurance will continue to be a 
significant player in the American health care scene. It adds value. It 
adds value to the contract between the employer and the employee. It 
rewards loyal employees and builds commitments within the organization. 
Businesses can spread risk and help drive down cost. A feature of the 
proposed association health plans have been, in fact, proposed in this 
House in every Congress that I have been a Member of since the 
beginning of 2003. In fact, the first time I heard about the concept of 
association health plans, Mr. Speaker, was when it was actually 
delivered from the rostrum here in this House of Representatives. The 
concept was delivered by President William Jefferson Clinton in 
September of 1993. It is a concept that I believe we ought to explore. 
We ought to be able to discuss it rationally without impugning each 
other's character, because after all, it was brought to this Chamber by 
a Democratic President. It has been endorsed and supported by 
Republican Congresses in the past.
  Again, the concept of association health plans is one that I think 
going forward could provide a great deal of utility as far as 
preventing the inexorable increase in health insurance premiums that 
are faced by small businesses and individual employees. These are 
people who don't get the benefits of spreading out the risk through a 
large insurance market.
  Now, Mr. Speaker, regardless of whether the system is public or 
private, vast changes in information technology are going to occur. 
They are going to need to be facilitated. We are coming up to a time of 
rapid learning. Because of improvements in health care technology, the 
ability to manage databases and retrieving data in a timely fashion are 
going to be critical for the delivery of health care and for the 
protection of patients.
  Mr. Speaker, let me share this picture with the House of 
Representatives. This is Master Sergeant Blades. I met the master 
sergeant at building 18 at Walter Reed Hospital last January. Of 
course, everyone remembers The Washington Post story about building 18 
and how there was great concern that some of our soldiers were not 
being properly cared for, individuals who were on medical hold at 
Walter Reed and awaiting a ruling on their request for going back in 
with their unit or their request to have a disability claim evaluated.
  Those individuals on medical hold became the subject of a good deal 
of discussion in the press here in Washington, DC. Well, like many 
Members of Congress, I decided to go see for myself. I went out to 
Walter Reed. I went through building 18. The paper was right: it was 
crummy. But Master Sergeant Blades drew to my attention something that 
he said was, in fact, more significant and more important and, in fact, 
more of a frustration for him and his men who were there on medical 
hold. And that is the fact that there was no interoperability between 
medical records contained within the Department of Defense and that of 
the Veterans Administration.
  You see here the master sergeant is preparing his medical record. It 
may not show up that well, but here is a medical record that he is 
going through with a yellow highlighter. He is making his case for, 
again, either going back and joining his unit or making his case for 
perhaps a future disability claim. What he told me that day is that he 
can go through a medical record that may be the size of several stacked 
phonebooks on top of each

[[Page 26250]]

other, go through and painstakingly pull out the bits of data that he 
thinks will be important to his case. This paper record will then go to 
someone's desk. It might sit there for a week, two or three, before it 
is opened. And then at some point it gets lost, and he has to start all 
over again, or his men have to start all over again.
  So his admonition to his men who are under his command there at the 
medical hold unit at Walter Reed was to prepare several copies of your 
medical record. Don't leave your future, whatever it might hold, don't 
leave your future in the hands of a single medical record and at the 
discretion of someone who might be cleaning off a desk one night, think 
they are doing everyone a great favor by moving some charts or papers 
off to the side or some other location, where, in fact, they become 
lost and not retrievable. Again, I bring this up to just point to some 
of the problems that are out there.
  We are in the 21st century. Rapid learning and rapid turnaround of 
data is something that is just expected. We go into an ATM in a foreign 
country. We swipe our card. We punch the number in. If it takes more 
than 12 seconds for the money to come out at the other end, we wonder 
what the problem is. We need to be moving to that same type of system 
within our medical information system because it is truly to the point 
where it is untenable. We saw that as, again, Master Sergeant Blade so 
eloquently pointed out to me that day at the Walter Reed Hospital. But 
we see it over and over again replicated in tests that have to be 
duplicated. Someone goes into a hospital emergency room late at night. 
They have had a CT scan earlier in the week in the physician's office, 
but it is not available to the emergency room doctor who then orders 
another test and, oh, by the way, there is another $1,000 spent by some 
insurance company, government or perhaps even the hospital itself if 
that patient is uninsured.
  Another thing that I think really is something that we are going to 
have to really concentrate on in the future is introduced legislation, 
H.R. 1046, to modernize some of the quality reporting systems that are 
present in this country. I think quality reporting is going to be part 
and parcel of medical care going forward. I think it should be 
voluntary at this point. I think while we are in the mode of gathering 
data, a physician or group who wishes to voluntarily associate 
themselves with some type of quality reporting scheme, I think that 
should be rewarded at this point. I don't know that we have developed 
enough of the systems to require that. Now, State Quality Improvement 
Organizations, QIOs, were actually developed back in the '80s and early 
'90s across the country. They were developed to primarily deal with 
quality issues within the Medicare program itself.
  But there is no need to reinvent the wheel here. These organizations 
are already out there. They exist. They do a credible job. If they need 
to be modernized for the 21st century, then so be it. But H.R. 1046 is 
an effort to bring those Quality Improvement Organizations into the 
21st century and allow concepts like a medical home and allow concepts 
like the accumulation and utilization of data so it can be for the 
benefit of all of the physicians who attend the patient and of course 
the patient themselves.
  Now, this approach was a component of the Medicare physician payment 
update proposal by then-chairman Joe Barton on my Energy and Commerce 
Committee when he offered it right at the end of 2006. I thought it was 
a good proposal then. I think it is one that certainly bears further 
exploration.
  Mr. Speaker, within the individual market, and that is going to 
include for the purpose of my discussion both individuals who are 
paying their freight themselves out of pocket and those individuals who 
own a health savings account, introduced legislation, H.R. 1666, to 
provide for increased price transparency within the medical pricing 
system.

                              {time}  2100

  Information is going to evolve rapidly. It's going to evolve rapidly 
for individuals who are paying cash for their procedures, as was 
certainly the majority of cases back before the 1940s. But, again, we 
may see a growing, increasing segment of the population who hold 
medical savings accounts and will be the primary dispensers of their 
health care dollars, so those dollars will be spent much the same as a 
self-pay individual would handle their medical affairs. But it's going 
to require that the adequacy of reports and the detail of information 
that is available to patients on things like cost, price and quality, 
and, yes, there is a difference between what a procedure costs and what 
its price is, and quality information is going to be increasingly 
important for health care consumers to make best decisions about the 
health care of their families and how they wisely spend their health 
care dollars. This information needs to also be linked to data 
detailing perhaps complications and other issues, like perhaps 
infection rates, so that families and individuals are able to make the 
best decisions.
  Now there are some Web-based programs that are out there right now. 
Again, in my home State of Texas on the Internet there's something 
called texaspricepoint.org, except it is abbreviated to 
txpricepoint.org. The individual who lives in the State of Texas can go 
to that Web site and, after the obligatory legal disclaimers that you 
have got to scroll through to ensure that you understand the data that 
you're about to call up, you can get some significant data on the 
difference in cost and price between hospitals in a given county, 
different hospitals that perhaps are offering the same procedures, 
something as simple as a fractured leg without complications. You can 
click on the appropriate button, scroll through the appropriate number 
of screens and get a cost comparison between all of the hospitals that 
exist within a given county and what the difference in cost is at each 
of those facilities.
  Now someone who is truly on a third-party payment such as Medicare, 
Medicaid, SCHIP, they are not going to be perhaps so interested in 
that, but they might be from just a quality perspective. If one 
hospital is a lot more expensive than the others, that may be a quality 
issue that is driving that increased expense.
  So I can see that that information would be useful to individuals who 
aren't in fact even the target population who's paying out-of-pocket 
for their own care. But certainly the individual in a family who's 
paying out-of-pocket, they're financing their health care out of cash 
flow, or the owner of a medical savings account, that individual is 
likely to be very interested in what that information on cost, price 
and quality is as it becomes available. I think we are going to see 
increasing utility of programs such as these going forward.
  As we have talked about crafting a readily affordable basic package 
of insurance benefits, it's something that this Congress really ought 
to set itself seriously to do. Now we have had discussions in the 109th 
Congress. Sometimes those discussions got kind of rough. Let's 
remember, we, Congress at one time has agreed upon what exactly is a 
basic package of benefits that ought to be available to an individual 
who subscribes to a program, and that program is the program under the 
Federally Qualified Health Center statute. The statute is probably 
about 35 years old and it details at a significant level of detail what 
benefits ought to be available to the individual who goes in for their 
care at what is known as an FQHC, or Federally Qualified Health Center.
  What if we were to get together and decide that same basic package of 
benefits ought to be available to an individual, but they wouldn't 
necessarily have to go into the Federally Qualified Health Center? 
Maybe it's embedded in a card that they take into a clinic or 
provider's office within their community who agrees to participate in 
the program. Clearly, there is some out-of-the-box thinking that can go 
on here in trying to provide a meaningful, affordable product for 
individuals who are currently lacking health insurance.
  One of the things, again, that drives the cost up is all of the 
mandates that

[[Page 26251]]

 we put on insurance companies. But maybe if we agreed on what should 
be the basic package of benefits, Republican and Democrat alike, sit 
down and agree on what should be that basic package of benefits and 
allow individuals to access that type of care within their own 
communities.
  One of the problems with Federally Qualified Health Centers, and I am 
a believer in the concept, in fact, I am trying mightily to get a 
second such facility in my part of Tarrant County. I'd like to see one 
in Denton County, another county that I represent that doesn't have 
such a facility available. What has happened is we have picked winners 
and losers across my State, across the country. Some areas are replete 
with Federally Qualified Health Centers; other areas are seriously 
lacking in that type of care.
  Maybe we need to take that thinking to the next level. Maybe we ought 
to, instead of building the bricks and mortar of a Federally Qualified 
Health Center, simply provide the patient with, ``Here's the card, 
here's the list of individuals that participate in the program in your 
community, and they will accept the card at any one of these facilities 
that you see.''
  That would also have the advantage of perhaps separating out, once 
again, some of that special interest stuff that tends to keep things as 
they are, to keep things from moving forward, to keep any meaningful 
progress from coming into any of the arenas and delivery of health care 
to low-income individuals, but particularly in this particular arena.
  The other thing is I will tell you, as a practitioner of medicine, 
you look at some of the rules under which these facilities have to be 
set up, and it becomes very, very difficult to construct a business 
model that will actually be able to stay afloat, given some of the 
restrictions and regulations that are placed on these facilities. 
Again, if we would allow perhaps a little bit more of that hybrid-type 
system that you could have coexistence between a private facility and a 
government-paid program, providing each side was willing to behave by 
some mutually agreeable guidelines.
  Well, providing truly affordable basic coverage to individuals in 
this country I think is a concept that insurance companies, I think is 
something they would want. I can't believe that an insurance company 
doesn't look at a figure like 47 million people who are uninsured and 
not say, ``that is a lot of market share I could have,'' if we would 
only allow them the ability to construct a policy that is affordable to 
the individuals who fall into that group.
  Another concept, Mr. Speaker, and this is one that I have held for a 
long time, a lot of clinics, a lot of doctors, a lot of medical 
practices, a lot of hospitals simply donate their time and their 
efforts. Their actions are truly charitable. Well, maybe we could 
organize and provide a tax credit for those services that are truly 
charitable and donated. We could provide perhaps additional protection 
under the Federal Tort Claims Act, maybe a safe harbor from lawsuits, 
wherein good faith, charitable care is provided, and allow other 
providers to participate and fill the vacuum for indigent care.
  Another area where this might be extremely useful is in times of 
national emergency, national crisis. Maybe if we had some type of 
emergency credentialing facility, and I know the CDC is looking into 
that, but if there were a way for a practitioner to precredential if 
there were a national emergency in their area, or they traveled to an 
area where the next Katrina hits so that they could be immediately 
credentialed within that area and begin to help provide that care. 
Again, also allow them some relief from liability under the Federal 
Tort Claims Act.
  This could help fill the vacuum that exists sometimes in care. We 
don't want people to stay away from where actual help is needed in time 
of a national emergency. We don't want doctors and nurses to stay away 
from those areas for fear that, number one, they will be sent away 
because they are not credentialed, or, number two, out of fear that 
they might bring on some condition of liability that they would then 
have to defend for months, years, decades after.
  The admonition of Ronald Reagan, ``trust but verify.'' Trust the 
market to make the correct decisions, but to the extent that some 
distortions are there, acknowledge that they are there. Sometimes there 
are going to have to be some protections that can only be provided by 
the Federal level. Some guidance for market principles will always be 
required, whether the system is public, private, or is a hybrid system.
  Finally, as part of this discussion, there needs to be a rational 
breakdown. We always talk about the number of uninsured. As near as I 
can tell, this is a formulaic number that simply goes up by the 
addition of 2 million people every year.
  I don't know that any of us really knows what is the makeup of this 
number. It is pretty hard to craft public policy to deal with the 
number of 45, 46 or 47 million uninsured when you don't know what makes 
up that population. Are some of these young individuals who are simply 
between college and their first job and haven't yet found it a wise 
investment or necessary to get insurance? Are part of these individuals 
who have serious long-term medical conditions who find medical coverage 
unavailable to them at any level, at any place?
  Obviously, those are two very different populations. You can't craft 
a policy to help one that is not terribly distorted by the time it is 
applied to the other. We need to know what the makeup of that number 
is. So agencies like the Census Bureau need to do a better job for us 
as far as detailing and delineating what exists within the parameters 
of that large number that simply gets added to every year, and a lot of 
times you wonder if it is not just added to for political reasons. But, 
nevertheless, we need accurate data on who is encompassed within that 
population.
  Finally, I will just leave this segment with a point of contrast. 
There are some people in this House who think it is a good idea to 
expand the culture of dependence, dependence on the State. There are 
other individuals in this Chamber who want to expand the number of 
individuals who can actually participate, direct and own their own 
health care.
  Mr. Speaker, I don't have to tell you what side of that question I 
come down on.
  Finally, Mr. Speaker, I want to talk just a little bit about, again, 
I said I was going to talk about health care in America. I have talked 
a lot about health care. Let's talk a little bit about America. Let's 
talk about American exceptionalism.
  Mr. Speaker, the American health care system has no shortage of 
critics, here in this House, across the country, and certainly in 
foreign countries. But, Mr. Speaker, I would emphasize, it is the 
American system that stands at the forefront of innovation and new 
technology, precisely the types of systemwide changes that are going to 
be necessary to efficiently and effectively provide care for Americans 
for today and into the future.
  Now, Mr. Speaker, I don't normally read the New York Times, so please 
don't tell anyone in my district that I did. But last year, in fact 
just about a year ago, October 5, 2006, Tyler Cowen wrote, ``When it 
comes to medical innovation, the United States is the world's leader. 
In the past 10 years, for instance, 12 Nobel Prizes in medicine have 
gone to American-born scientists working in the United States, three 
have gone to foreign-born scientists working within the United States, 
and seven have gone to researchers outside of this country.''
  Remember, Mr. Speaker, when I first started this discussion I talked 
about the contributions of Sir Alexander Fleming, albeit an Englishman, 
but it was a lab in Peoria, Illinois, that developed the ability to 
mass-produce penicillin, and it was that ability that allowed the 
clinical trials to go forward. It was that ability that allowed 
penicillin to become part of our modern lexicon.
  Percy Julian, again, an African American biochemist honored in this 
House during the last Congress. Remember, it was Percy Julian, he 
didn't

[[Page 26252]]

invent cortisol, he wasn't the first to identify the compound, but he 
was the first to delineate a formula by which this compound could be 
mass-produced and available to much, much greater numbers of patients 
than would have ever been possible with the old animal extraction 
method that had preceded it. All developed within and because of the 
United States.
  Tyler Cowen goes on to point out that five of the six most important 
medical innovations of the past 25 years have been developed within and 
because of the American system.
  Mr. Speaker, comparisons with other countries may, from time to time, 
be useful. It is important to remember that the American system is 
always reinventing itself and seeking improvement. But it is precisely 
because of the tension inherent in a hybrid system that creates this 
impetus for change. It drives the change.
  A system that is fully funded by a payroll tax or some other policy 
has no reason to seek improvement, and, as a consequence, faces 
stagnation. Indeed, in such a system, if there becomes a need to 
control costs, that frequently is going to come at the expense of who? 
The provider. Precisely the person you need to stay involved in the 
system.
  Mr. Speaker, I have got one final slide, and I ask your indulgence to 
let me put this up here.
  This just shows the Medicare comparative payment updates for 
physicians, Medicare HMOs, hospitals and nursing homes. The years are 
delineated there in separate colors.
  The year 2007, when the slide was developed, was in fact an estimate 
for physicians. The reality is this number actually came back to zero 
because of some changes we made right at the end of last year.

                              {time}  2115

  Under physicians, you don't see a number for 2006 again because that 
number in fact was zero for 2006. You stop and think about that, this 
reduction was planned but never happened, but physicians were held to a 
zero percent update for the past 2 years.
  Mr. Speaker, what do you suppose the cost of delivering that care in 
a doctor's office, what do you suppose has happened to that over the 
last 2 years? Well, their electricity prices probably went down because 
they went down all over the country. Cost for gasoline to go to the 
office every morning probably went down because the cost of gasoline 
went down everywhere across the country. I don't think so.
  The Medicare system is designated to reimburse at about 65 percent of 
cost under ideal conditions, but the reality is there has been 
significant erosion of that. This is important because hospitals, 
nursing homes, and to some degree the Medicare HMOs, their prices are 
adjusted every year based on essentially what is called the Medicare 
economic index. That is a cost-of-living formula. Only this group, the 
physicians, is under a separate formula that is somehow tied to changes 
in the gross domestic product.
  The sustainable growth rate formula penalizes physicians and has the 
perverse incentive of driving doctors out of the practice of medicine. 
As was detailed to us by Alan Greenspan many months ago, there is only 
so long that can go on before ultimately you reach a place where it is 
going to be very, very difficult for the people who need the care to 
get the care.
  Mr. Speaker, the United States is not Europe. American patients are 
accustomed to wide choices when it comes to hospitals, physicians and 
pharmaceuticals. It is precisely because our experience is unique and 
different from other countries, and this difference should be 
acknowledged and embraced, particularly when reform is contemplated in 
either the public or private health insurance programs in this country.
  Mr. Speaker, one final point illustrated in a recent news story 
covered by a Canadian television broadcaster. It was about a Canadian 
member of Parliament who sought treatment for cancer in the United 
States. The story itself is not particularly unique, but the online 
comments that followed the story, I thought, were instructive. To be 
sure, a number of respondents felt it was unfair to draw any conclusion 
because, after all, this was an individual who was ill and seeking 
treatment and therefore deserving of our compassion, and I wouldn't 
argue that.
  But one writer summed it up: ``She joins a lengthy list of Canadians 
who go to the United States to get treated. Unfortunately, the 
mythology that the state-run medicine is superior to that of the 
private sector takes precedent over the health of individual 
Canadians.''
  The comments of another individual: ``The story here isn't about who 
gets treatment in the United States. It is about a liberal politician 
that is part of a political party that espouses the Canadian public 
system and vowed to ensure that no private health care was ever going 
to usurp the current system. She is a member of Parliament for the 
party that has relentlessly attacked the conservatives for their 
`hidden agenda' to privatize health care. The irony and hypocrisy is 
that position supports the notion that the rich get health care and the 
rest of us wait in line, all because of liberal fear-mongering that 
does not allow for any real debate on the state of health care within 
the country of Canada.''
  One final note from the online postings: ``It has been sort of 
alluded to, but I hope everyone reading this story realizes we do have 
a two-tiered health care system. We have public care in Canada and for 
those with lots of cash, we have private care in the United States 
which is quicker and better.''
  Mr. Speaker, this is a discussion that will likely consume the better 
part of the next two years of public dialogue, certainly through the 
next Presidential election. The United States is at a crossroads. It is 
incumbent upon every one of us who believes that the involvement of 
both the public and the private sector is best for the delivery of 
health care in the United States of America. And it is incumbent upon 
us to stay educated and involved and committed.
  Mr. Speaker, we have all got to be at the top of our game every 
single day. This is one of those rare instances where it is necessary 
to be prepared to win the debate, even though those of us on my side 
may lose when it is taken to a vote here in the House of 
Representatives. But if we adhere to principles, we may ultimately post 
a win for the health of the American people, and not just the American 
people today, but for generations to come.

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