[Congressional Record (Bound Edition), Volume 153 (2007), Part 19]
[House]
[Pages 27026-27033]
[From the U.S. Government Publishing Office, www.gpo.gov]




                         HEALTH CARE IN AMERICA

  The SPEAKER pro tempore (Ms. Clarke). Under the Speaker's announced 
policy of January 18, 2007, the gentleman from Texas (Mr. Burgess) is 
recognized for 60 minutes as the designee of the minority leader.
  Mr. BURGESS. Madam Speaker, I appreciate you letting me come to the 
floor tonight to talk, as I often do, about health care, the state of 
health care in our country.
  This is a unique time in our Nation's history. We are kind of coming 
up on the 2008 Presidential campaign, and the reality of unfettered 
election-year politics intersects harshly with the perennial challenge, 
the perennial challenge we face in this House, how do we refine, 
transform, transform this Nation's health care system.
  The history of health care in America over the last century and the 
very beginning of this century, it's a fascinating, fascinating 
subject. Medicine is a very highly structured, highly ordered, 
scientific-oriented, disciplined, scientific process, the scientific 
method. And then coupled with a number of governmental policies, we 
would like to think that they are science driven, we would like to 
think that they are fact based, but oftentimes they are more 
emotionally based, and how those policies interact with the scientific 
basis of the fundamental world of medicine and how, when we enact those 
policies and what seems like with every good noble intention in the 
world, how those policies then affect things decades into the future in 
ways

[[Page 27027]]

that most people who enacted the policies would have had no idea what 
became of them.
  Now, last century, in the 1940s, really a pivotal year in health 
care, medical care in America, both from a scientific aspect and from 
the policy aspect. From the scientific aspect, it was a time of great 
discovery and great excitement.
  Mr. Alexander Fleming, the famed British scientist, isolated 
penicillin in 1928 in his laboratory, didn't quite know what he had or 
what to do with it. Certainly the substance produced by this mold in a 
petri dish inhibited the growth of the microorganism staphylococcus, a 
known cause of infection. For the first time, mankind had an agent to 
battle these unseen microscopic entities that plagued mankind for 
centuries.
  Now, 1928 is not exactly 1940, and I referenced 1940. What happened 
in 1940 was American scientists, American scientists in this country, 
recognizing the value of this discovery, elucidated a method for mass 
production of penicillin. Penicillin, which had been a miracle drug 
before but available in very small quantities only for a very select 
few was now suddenly available for everyone, and available cheaply.
  This affected our soldiers, who landed at Normandy on D-Day in 1944, 
the wounds that they suffered, which otherwise may have become infected 
and caused serious disability or even death were now even amenable to 
therapy with an antibiotic. Therapy with an antibiotic is something we 
now just take as almost second nature, just for granted. We get sick, 
we go to the doctor, they write a prescription for an antibiotic, we 
take it, we get well. In the 1940s, this was almost unheard of. So this 
was truly a breakthrough in the 1940s in the scientific realm in 
medicine.
  Another discovery, that had actually occurred earlier, the discovery 
of cortisone. A very potent anti-inflammatory, cortisone was actually 
taken from the adrenal glands of oxen who were slaughtered. It was a 
very laborious, labor-intensive process to get small amounts of 
cortisone, so it really wasn't something that was amenable to 
treatment.
  Then in the 1940s, a scientist that we, in fact, honored in this 
House during the last Congress, an African American gentleman, Percy 
Julian, who was a biochemist, not even a physician, a biochemist who 
worked heavily with soybeans and soybean products elucidated a method 
to mass produce cortisone, cortisol, which had not been able to be 
produced other than in very small quantities before, and now suddenly, 
again, it's available to very large numbers of people at a very 
reasonable price.
  These two entities, antibiotics, anti-inflammatory, introduced in the 
1940s changed forever the practice of medicine not just in America, but 
worldwide. What else happened in the 1940s? Obviously, World War II.
  The Supreme Court made a decision in the 1940s that affects us to 
this day. During the Second World War, President Franklin Roosevelt, in 
an effort to keep down problems with inflation, it was a wartime 
economy, and he was worried about inflation taking hold and taking off, 
said we are going to have to have wage and price controls.
  There was a lot of demand for labor in this country. We were 
producing materiel, things that were needed on the frontlines in the 
war. Yet the workforce were all off fighting the war, so employers who 
were lucky enough to have employees to work wanted to keep them and 
keep them happy. How do you do that? You pay them more money. But the 
President said we better not do that or we are going to have trouble 
with the inflation.
  Well, employers, being enterprising and ingenuous sorts, said, let's 
then offer benefits. Let's offer health care benefits, let's offer 
retirement benefits. A decision by the Supreme Court in the 1940s said, 
yes, you can do this. It does not violate the spirit of the wage and 
price controls. Not only that, you can pay these with pretax dollars.
  So the era of employer-derived, employer-based health insurance was 
born, turned out to be enormously popular. People liked the idea, and, 
for decades into the future, that was the model that was followed in 
this country.
  Then, fast-forward another 20 years and we are in the mid-1960s. What 
other health care policy happened at that time? Well, it was the 
institution of the Medicare program by President Lyndon Johnson. The 
Congress at that time who said, You know what? We are going to provide 
protection for our seniors.
  Now, at that time, they provided protection for the doctors in the 
hospitals. Prescription drugs came 40 years later in the 108th Congress 
when we enacted the prescription drug benefit, but think how the 
interposition of the Medicare policies changed the fundamentals of how 
health care is paid for in this country.
  The Medicare and Medicaid programs of the mid-1960s meant all of a 
sudden the government is in a position to finance a large portion of 
health care provided in the United States. Now, prior to the Second 
World War, most health care was paid for at the time of service and was 
a cash exchange. With the advent of employer-derived health insurance 
and the position of a large governmental program, most health care now 
is administered through some type of third-party arrangement.
  That's useful in that it protects the individual who is covered by 
insurance from large cash outlays, but there is a trade-off. The 
covered individual is generally unaware of the cost of the care that he 
or she receives, as well as the provider, who remains insensitive to 
the cost of the care that that provider orders.
  This arrangement has created an environment that permits really rapid 
growth in almost all sectors of health care and the cost of health 
care. America's challenge in the early part of the 21st century, 
America's challenge becomes evident. How do we improve the model of the 
current hybrid system that involves public and private payment for 
health care but at the same time anesthetizes most of us as to the true 
cost of that care?

                              {time}  1945

  It's also perhaps wise to consider that any truly useful attempt to 
modernize the system, the primary goal really has to be, first off, you 
protect the patient. You protect the person, not the status quo. And we 
also need to ask ourselves if the goal is to protect the system of 
third party payment or to provide Americans with a reasonable way to 
obtain health care and allow physicians a reasonable way to provide 
health care for their patients. Sometimes, with some of the legislation 
that I see come before my committee, Energy and Commerce, I wonder if 
we don't forget that fundamental rule.
  In health care, the basic fundamental unit of production is the 
interaction that takes place between the medical professional, the 
doctor and the patient in the treatment room. That fundamental 
interaction, Madam Speaker, if you will, is the widget. That's what 
this large health care machine produces. And sometimes that concept 
also gets lost in the process when we talk about how do we reform 
health care.
  The current situation subsidizes, makes payments to those indirectly 
involved with the delivery of that widget and, ultimately, that drives 
up the cost. Now, currently in the United States, about half of every 
health care dollar that's spent originates here in the United States 
Congress.
  The United States gross domestic product, we spend about 15 percent 
of that on health care, and half of that expenditure is generated from 
the Congress. The gross domestic product currently is about $1.6 
trillion. Medicare and Medicaid systems pay for or cost about $600 
billion in aggregate. You've got the Federal prison system, the Indian 
Health Service, the VA system, all of the other interactions that the 
Federal Government has with paying for health care amount to about 
half.
  What's the other half? Is it all private insurance? No, of course 
it's not. There are a certain number of people who are uninsured.
  Private insurance, to be sure, occupies a significant percentage of 
that

[[Page 27028]]

half that's not paid for by the government. Some is paid for by the 
individual. Some of it is self-pay, and I would include health savings 
accounts, medical savings account in that self-pay group because I 
think that's an important concept that sometimes gets lost in the 
discussion.
  And finally, let's be honest. There is a good deal of care that is 
delivered that is simply a charitable offering by doctors, nurses, 
hospitals, a charitable offering that is given to patients who lack the 
ability to pay.
  Again, the test before us, protect the people, not the special 
interests. Madam Speaker, we ought to define that which ought to be 
determined by market principles and that which, of necessity, must be 
left in the realm of the public provider, the government realm, and 
how, in all of this process, we preserve individual self-direction 
instead of establishing supremacy of the state.
  Additionally, we must challenge those things that result in 
distortion of market forces, especially those market forces in health 
care, and acknowledge that some of that distortion is, in fact, 
endemic. We'll never be able to subtract it out of the system. Some of 
it is hidden. We'll never even know that it's there, and since it's 
hidden, or we can't subtract it out of the system, it's not readily 
changed. So recognize that and acknowledge that we're not going to 
change that part, but also recognize that there's part of it that is 
actually easily amenable to change. And the key here is how to maximize 
the value at the production level.
  Again, I go back to that fundamental unit of production, the doctor-
patient interaction in the treatment room. Yes, I know it may be the 
emergency room, the operating room, but that fundamental unit of 
interaction, how do we maximize value at the production level?
  How do we place a patient who exists on a continuum between health 
and disease, how do we move that patient more in the direction of 
health and slow that movement in the direction of disease?
  How do we allow physicians an appropriate return on their investment, 
their investment of time, their skill, their intellectual property? And 
that opens up a host of questions relating to future physician work 
force issues.
  How do we keep the employer, if the employer is indeed still involved 
in providing health insurance for an employee, how do we keep the 
employer to continue to see value in the system? They get a quicker 
return to work for their injured or ill employee. Perhaps there's 
increased productivity, better maintenance of a healthy and more 
satisfied work force. All of these things are of value to the employer, 
and that ought to be recognized.
  In regards to health insurance, how to provide a predictable and 
managed risk environment, remembering that insurance companies 
themselves, of necessity, they tend to seek a state of monopoly, and if 
left unchecked, that's the direction in which they're going to move. If 
that is a good thing, okay. If that needs to be monitored or regulated, 
we need to be willing to provide that regulatory expertise as well.
  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, Madam Speaker, individual legislation, H.R. 2583, H.R. 2584, 
H.R. 2585 deal specifically with medical work force issues. And as some 
of the hubbub around the current health care debate dies down, I hope 
we get a chance to actually articulate and debate those issues.
  Another bill, H.R. 2203, that was introduced in the 109th Congress 
would provide low-income Americans with a direct subsidy to help pay 
for their health care and many others that would chart a path to true 
reform in our health care system.
  But let's keep in mind some principles when we talk about 
legislation. And I would say the first principle that Americans, at 
least in my estimation from 25 years of practicing medicine, what do 
Americans value in their health care system?
  They value that freedom of choice. They want to go see the doctor 
they want to see. They want to see them when they want to see them, not 
when the system says they can come in. When hospitalization is 
required, you know, no one objects to incentives, but freedom of choice 
must remain central.
  Another principle that certainly a number of people talk to me about 
is a principle of ownership. Madam Speaker, I had a medical savings 
account before I came to Congress. The whole concept of having what we 
now call a health savings account or a medical IRA and being allowed to 
accumulate savings, a nest egg, dollars to offset future medical 
expenses, is a fundamental desire of many Americans, and I think we 
should encourage that.
  These dollars that are then dedicated to health care should be 
properly owned by the individual. And guess what? When this individual 
leaves this life, those dollars stay in that individual's estate and 
they don't go back to any governmental body upon the death of the 
individual.
  Another principle would be independence, the preservation of 
autonomy. The patient or the patient's designee should ultimately be 
responsible for their care or the ability to decline medical 
intervention.
  Another principle that I think we need to keep foremost in our minds 
is that of high standards. 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, the 
pathways to facilitate future growth in excellence should always be 
encouraged.
  Again, it gets back to delivering value for the dollar. Innovative 
approaches. We Americans pride ourselves on innovative approaches. 
American medicine has always been characterized as embracing innovation 
and developing new technologies and treatments. Clearly, this must be 
preserved.
  Madam Speaker, we just came through the FDA reauthorization bill 
earlier this year. The whole purpose, years ago, with the development 
of the Prescription Drug User Fee and the Medical Device User Fee Act 
was to provide additional funding so that inventions and discoveries 
and intellectual property that was developed, whether it be a 
pharmaceutical or a medical device, would not sit so long in the 
approval phase and could be brought, not just to market, but to be able 
to help patients more quickly.
  The difference between practicing medicine in the 1980s, when we had 
the old system, and the 1990s, under the new system, was phenomenal, 
and the ability to deliver drugs and devices to the patient public was, 
in fact, vastly increased. I was grateful to play a small role in the 
reauthorization of the FDA process when we did that earlier this year.
  In fact, Madam Speaker, we heard a lot of talk just a few minutes ago 
about the SCHIP bill. I would hold out the FDA legislative process as a 
model which this Congress should follow because that was truly a 
bipartisan process. The SCHIP bill that came through this House that 
everyone is now holding their breath waiting to see whether or not the 
other side has the votes to override a veto, but the reality is that 
bill came through this Congress in what I consider a very pernicious 
way that is likely to poison any future attempts at bipartisan 
cooperation because here was a bill that was simply thrown across the 
transom, rammed through committee, rammed through the House on a party-
line vote. Then we go back to the Senate. Well, we can't really do a 
conference committee. So what do we do? We take up a brand new bill. 
But we don't bring it back through the committee. We don't bring it 
back through the subcommittee. No. We come right to the floor and take 
it or leave it. That's not the way America wants to see this Congress 
operate. America wants to see this Congress operate as it is supposed 
to operate. They want to see my committee, the Committee on Energy and 
Commerce, have a subcommittee markup on the bill. There might be a good 
idea out there on the Republican side. There might not, but there might 
be.

[[Page 27029]]

  And what reason could anyone in this body give for saying, we're just 
not going to do that? They say it was in the interest of time.
  Madam Speaker, every single Member of this body who stood in this 
House in January of 2007, raised their right hand and swore an oath to 
defend the Constitution, knew that at the end of September, what's 
going to happen? SCHIP expires. It was a 10-year authorization. It 
started in 1997. Time's up at the end of September. The fiscal year is 
over. So we all knew this was coming. Why did we leave it till the last 
minute? And then why did we bring such an imperfect product through and 
then ram it through at the last minute, without any of the usual 
consultative advise and consent that goes on at the subcommittee level 
and the committee level. I frankly don't understand.
  If people are watching this process, if people are able to dig 
beneath the political rhetoric, they ought to be outraged at the way 
this was handled. But I'm getting off message.
  When we talk about principles for health care reform, one of the 
things that we really have to focus on is timeliness.
  Madam Speaker, we always hear about American comparisons to other 
health care systems around the world. But consider this: Access to a 
waiting list does not equal access to care. This was the message 
delivered by the Canadian Supreme Court to its medical system in 2005. 
We must diligently seek not to duplicate the most sinister type of 
rationing than that that exists in a system of nationalized health care 
which prevents citizens from getting care because it just simply takes 
so long to get to the doctor or get that needed procedure or get that 
needed hospitalization.
  Another principle that really, I think, we ought to spend some time 
discussing and debating, not everyone agrees with this, but really this 
ought to be a market-based solution and not an administrative solution. 
The pricing should be based on what is actually indicated by market 
conditions, and not that that is assumed by an administrator, either an 
administrator at a private insurance company or an administrator at a 
Department of Health and Human Services or Center for Medicare and 
Medicaid Services.
  Madam Speaker, we hear a lot of talk about mandates. Mandates, in 
general, in my opinion, lead to a restriction of services. State 
mandates cause more harm than good and impede competition and choice 
and drive up the cost and limit the availability of health insurance.
  Employer mandates. We've heard various reform schemes that have been 
talked about that deal with employer mandates. That was the crux of the 
Clinton plan in 1993. Individual mandates, some of the things that have 
been talked about at some of the State levels. But employer mandates 
and individual mandates are likewise restrictive. A discussion of 
mandates should include an accounting of cost and whether those 
mandates limit the availability of insurance for those who may operate 
a small business, those who may be self-employed or self-insured. 
Remember, Medicare part D, the prescription drug program from 2 or 3 
years ago, achieved a 90 percent enrollment rate with education, 
incentives, competition, and not a single mandate. We must not forget 
that lesson because that's been a highly successful program and one 
that, in fact, enjoys very high popularity in the population that it 
serves.
  The concept of premium support. Premium support is kind of like a tax 
credit, kind of like a voucher, but not quite.
  Let's be honest. Our Tax Code is complicated enough as it is. We 
don't need to layer more complexity on the Tax Code. I know that's a 
topic for a different discussion, but when we're talking about health 
care reform, I'm not such a big fan of tax credits. But if there is the 
ability for, whether it be the SCHIP program or the Medicaid program, 
to help someone buy down the cost of that health insurance premium so 
they can, in fact, afford an insurance policy, I think the concept of 
premium support is one that this Congress really ought to investigate. 
In fact, that was an amendment that I had for the SCHIP process, but, 
again, we weren't allowed to amend that bill in subcommittee, full 
committee or here on the House floor.

                              {time}  2000

  You know, on the concept of the premium support, one thing that we 
could think about doing is some individuals receive some additional 
help to the earned income tax credit. Well, what if we made it not just 
a good idea but a requirement that people who receive money on the 
earned income tax credit that some of those dollars are actually 
earmarked for their health insurance? Maybe an idea worth exploring.
  Another principle is that of antitrust enforcement. It has to be 
balanced. If the Federal Government picks winners and losers, we're 
going to further distort and make the playing field unlevel, and as a 
consequence, we are going to thwart our best efforts for health care 
reform. Creating winners and losers via the antitrust law actually 
erodes the viability of the American health care system.
  Well, what about talking about some of the policies that actually may 
affect some change? For health care within the public sector model, the 
transformation after the experience with Medicare part D has been 
instructive. Six protected classes of medication, which were required 
of all companies who wish to compete and participate in the system, 
allowed for greater acceptance by the covered population and greater 
medical flexibility when treating patients. At the same time, the 
competitive influences brought to bear in that part of the program, 
indeed, have managed to control costs. In fact, the projection of the 
cost of the Medicare part D program is $130 billion less over that 
moving target we call the 10-year budgetary window. It's solely the 
result of competition. It is likely we will get some additional 
benefit, some additional cost relief by more timely treatment of 
disease and delivering more value for the health care dollar. But those 
concepts, those savings are going to necessarily appear later in the 
timeline of that process. But just from competition alone, a 
substantial amount of dollars savings were achieved under the part D 
program.
  Madam Speaker, one of the most important 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, and this was achieved how? By mandates? No. 
But by creating plans that people actually wanted. What a concept. You 
don't mandate you have to do it. You build something that people want, 
and they come to it. We ought to follow that model more often when we 
are talking about health care reform in this country.
  Ninety percent of seniors have prescription drug coverage, and 
providing that coverage means that incentives to sign up in a timely 
fashion had to be provided. And, indeed, that worked. It emphasized 
that the personal involvement responsibility was there to maintain some 
type of credible coverage if it already existed or to buy into credible 
coverage during the open enrollment period. And, in fact, people 
accepted that and behaved accordingly.
  Employer-derived health insurance I think will be a significant 
player in the American health care scene. A lot of writers who write 
about health care insurance say the employer-based model is passe. It's 
dead and gone, never to return. I don't know that I agree with that. 
Certainly it is still a very viable presence, a very robust presence in 
the insurance market today. And while again there are some problems, it 
is hard for me to see that the day is coming where that will completely 
fall by the wayside.
  I think that's because it adds value. It adds value to the contract 
between the employer and employee. It rewards loyal employees and 
builds commitments within the organization. Businesses can spread risk 
and help drive down cost.
  Now, one of the features that is inherent in that model is the 
proposed associated health plans that the previous Congress and the 
Congress before

[[Page 27030]]

that have voted on on several occasions. We have never been able to get 
that concept to pass in the Senate, but maybe it's time to look at that 
again. Associated health plans are allowing small businesses of a 
similar business model to pool together to get the purchasing power of 
a larger organization. It gives, say, a group of Realtors or a group of 
doctors' offices the ability to go out and perhaps achieve some of the 
same kind of discounts that Verizon or AT&T or Wal-Mart get because 
they are such big employers. This is a very powerful concept to put in 
the hands of employers.
  In fact, it was a concept that was so good it was actually first 
proposed on the floor of this House by Bill Clinton in 1993 in his 
September speech to this body when he outlined his proposals for health 
care reform. Associated health plans were part of that reform package. 
I don't know what happened to them on the way to the end of the 
legislative process, but somewhere along the way, people stopped 
talking about them. But they are a good idea. Again, the concept has 
passed this House twice, in the 108th Congress and 109th Congress. It's 
a mystery to me why we don't take it up again. I think that is 
something the American people would be interested in our doing, and, 
goodness knows, they would like to see us work on something meaningful 
when it comes to health care.
  Now, regardless of whether the system is public or private, what have 
we seen in the way that information is transferred and handled? Have 
there been any changes in the last 100 years? Yes, I think so. Are 
there going to be changes in the next 25 years? I think you can bet on 
that. Vast changes in information technology are going to occur whether 
doctors want them to, whether hospitals want them to, whether insurance 
companies want them to. Those changes in how information is handled are 
going to occur, and they need to be facilitated. We are coming up to a 
time of rapid learning, and because of improvements in health care 
technology, the ability to manage databases, retrieve data in a timely 
fashion are going to be critical for the delivery of health care and 
protection of patients in the future.
  Madam Speaker, if I could, let me just share with my colleagues in 
the House a picture. When I was first elected to Congress in 2002, I 
have got to say I wasn't a big believer in electronic medical records. 
They are kind of cumbersome. When you are first learning them, they 
really slow you down. Your productivity suffers because you have got to 
learn this system.
  But 2 years ago at Charity Hospital in New Orleans, one of the 
venerable, venerable health care institutions of this country, the 
whole city of New Orleans was hit with Hurricane Katrina and then the 
flooding to follow the hurricane. Well, here is a picture from January 
2006. So 5 months after the hurricane, the water has been pulled out of 
the city. Here is the medical records room at Charity Hospital. These 
records haven't been burned. This black stuff here, that is black mold. 
You could not send anyone in there to retrieve data off of one of these 
charts without imposing a significant health risk. I don't know what's 
contained within there, maybe a bone marrow transplant, childbirth, 
kidney transplant, heart attack. All of that information lost to the 
ages because they were contained on paper records.
  Again, I wasn't a big believer in electronic medical records, but 
walking through the records room at Charity Hospital that day, how many 
hours have I spent in the records room doing my medical records when I 
was on staff at various hospitals. It looked a lot like our records 
room at Parkland Hospital back in the 1970s.
  These records are lost. This patient's data are now forever 
irretrievable. And at some point we are going to have to come up with a 
system that allows that data to be stored in an area where it is not 
vulnerable to this type of degradation and that it is readily 
retrievable. And then guess what. If a patient is being seen in New 
Orleans and treated for a condition but they happen to travel to Fort 
Worth, Texas, and their medical records are needed, they are accessible 
online and immediately available to the treating doctors in the 
destination city.
  Another issue that I think we will have to pay some attention to is 
quality reporting. In my opinion, quality reporting should be 
voluntary, but it is important. Programs need to be generally 
available. They have got to be accessible to the medical personnel who 
desire to participate.
  Currently, I think in all 50 States, we have got quality improvement 
organizations, and they currently do a good job. They provide 
information, timely information, information back to the provider as to 
how the care was delivered. Was it delivered in a timely fashion? Was 
it delivered in a fashion that was utilizable?
  There are other ways of establishing quality. Legislation that passed 
in this House last time to establish a medical home also will result in 
the accumulation of some quality and some utilization data. I think 
that data needs to be available to the treating physician. It doesn't 
have to be widely disseminated publicly, but you make that data 
available to the physician, and physicians being naturally competitive 
sorts are going to ask the question, Well, that's interesting. I wonder 
if I could do better or how have I done in comparison to the people 
around me? And that will be useful information to provide to physicians 
and hospitals.
  Any of the quality reporting methods that are out there have to be 
generally available and accessible to all of the physicians practicing 
in a community. Yes, I would like for it to be voluntary, but if it is 
not generally available, ultimately it is not going to be useful.
  Now, this approach was a component of the Medicare physician update 
proposal by, at that time, Chairman Joe Barton of the Energy and 
Commerce Committee. He offered that late in 2006. I think it is a 
concept that should be revisited.
  Within the individual market, and, again, within the individual 
market I would include self-pay and also that individual who is the 
owner of a health savings account, within that portion of the market, 
transparency of information is critical, and that is another area where 
we are going to see rapid evolution and rapid change. It is going to 
require that there is adequacy of the reports that detail the 
information about cost, price, and quality, and they are not all the 
same. This information has to be linked to data detailing things like 
complications and infection rates.
  Web-based programs. We have got a good one in my home State of Texas. 
Web-based programs will begin to build databases and actually build 
familiarity with the consuming public so that these will become useful 
in the future. And www.txpricepoint.org is a Web-based program that is 
up and functioning in Texas. It's just beginning. Some people will look 
at it and say, well, that information is really pretty rudimentary, but 
currently it allows patients, say, in my home county of Denton County 
where there are four hospitals, to compare the costs of treating a 
fractured femur, episode of childbirth. How do those four hospitals 
compare in the area? Is there one that is significantly cheaper or one 
that is significantly more expensive than its counterparts? Maybe if 
that information is present, then to begin to ask the questions why and 
for the consumer to begin digging a little deeper and finding out more 
information about the hospital, whether or not they want to choose that 
hospital for their care. Again, not for people who have Medicare, 
Medicaid, SCHIP, or private insurance, but for the individual who is 
paying out of pocket or the individual who has a health savings account 
with a high deductible so, again, is probably paying out of pocket for 
a portion of their care. This is a useful exercise, and, again, I 
encourage people, particularly people in my home State of Texas, 
www.txpricepoint.org.
  Now, crafting a readily affordable basic package of insurance 
benefits perhaps modeled after what we already do in the Federally 
Qualified Health Center program is another important opportunity for 
reform that this body could look into. Currently, Federally

[[Page 27031]]

Qualified Health Centers are required to provide a basic level of 
primary care. They also provide dental and mental health services. 
Providing a basic package of benefits along this line that is 
affordable and available with the option of adding on additional 
benefits at additional costs, that could be a powerful option for many 
Americans. This could remove some of the influence of some of the 
special interest groups, which I talked about earlier, and, again, 
allows us to focus on the patient and certainly allows a functioning 
business model to replace some of the draconian institutional standards 
that are now required.
  Providing a truly affordable basic package of benefits, that coverage 
which insurance companies then would want to market to segments of the 
uninsured population, you've got to believe that companies like Aetna, 
United look at 47 million people who are uninsured and say that's a 
potential market share. If we only had an affordable product that we 
could deliver to that population, we actually could perhaps provide a 
good deal of coverage for that population.
  Madam Speaker, let's not forget that care that is truly charitable: 
Organizing and providing a tax credit for donated services by doctors, 
nurses, even hospitals, I think that is something that is fundamental 
to the American psyche and something to be readily embraced by the 
American people.

                              {time}  2015

  We could provide additional protection under the Federal Tort Claims 
Act, perhaps a legal safe harbor from lawsuits where, in good faith, 
charitable care is provided and, in effect, allow providers who are 
retired or semiretired to return and fill some of the vacuum for 
indigent care.
  I had an acquaintance whose father is a physician. Hurricane Katrina 
hit, obviously, the next-door neighbor State of Louisiana, but a lot of 
people left Louisiana and came to Texas. There were a lot of areas that 
were strained in their availability to deliver health care in that time 
2 years ago.
  This acquaintance's dad was a physician. He was a retired physician, 
no longer carried insurance, and said, well, I'm going to go down to 
the shelter where these people are being received and offer my 
services. And my friend was quite concerned about his dad and said, you 
don't have insurance. If you go down there and something bad happens 
and you get sued, you have no coverage for that. Maybe we ought to 
provide a mechanism for providing that coverage for someone who truly, 
out of the goodness of their heart, wants to respond to a national 
emergency, wants to respond to their country in a time of need, allow 
them the opportunity of doing that.
  And along those lines, we ought to have a system of emergency 
credentialing so that when people just show up on a scene of a 
disaster, whoever is in charge, the first responders in charge will 
have a way of quickly and rapidly assessing whether this individual, 
indeed, possesses the credentials that they purport to have. And that 
would go a long way towards alleviating, frankly, some of the confusion 
that occurred on the ground in various health care sites, not just in 
Texas, but back in Louisiana as well.
  Madam Speaker, the late President Ronald Reagan used to say, ``trust, 
but verify.'' Trust the market to make correct decisions, and to the 
extent that distortions can be removed, remove those distortions, but 
remember that some guidance from market principles will always be 
required, whether the system is completely public or completely 
private.
  Finally, as part of this discussion, there must be a rational 
breakdown of the numbers of the uninsured. We want to talk about, how 
do we cover the uninsured? We don't have accurate numbers, not for the 
total number of the uninsured, but who comprises that population? We 
just say 47 million uninsured. And we're happy to talk about that in a 
political sense, but we need the data on the breakdown of those numbers 
so we know how to better craft policies that will provide coverage 
that's needed for those individuals. Is it just that some people aren't 
bothering to buy insurance? Maybe we craft a policy that would 
encourage them to do that.
  I don't like mandates. I prefer incentives. Other people may like 
mandates. But let's have that discussion. But if we don't know how big 
the population is who just choose not to have health insurance but has 
the means to pay for it, we will never be able to enter into that 
discussion because we don't know. We just say 47 million uninsured. We 
hit each other over the head with it. We go home at the end of the day 
and feel like we've done a good job, the American people say not so 
much.
  Finally, just a point of contrast. And we've heard it a lot because 
of our health care discussions this week. My good friends on the other 
side of the aisle want to expand a culture of dependence on the state, 
while on my side of the aisle we want to expand the number of 
individuals who actually own and direct their own care. Which system 
would you choose? Which system gives you the greater liberty, the 
greater freedom that we all treasure and cherish as Americans? The 
answer for me is obvious.
  Finally, Madam Speaker, we talked about this a little bit at the 
beginning of this discussion, but the concept of American 
exceptionalism. The American health care system has no shortage of 
critics, critics throughout this body, critics throughout the city, 
critics throughout the world, but it is the American system that stands 
at the forefront of innovation and new technology, precisely the types 
of system-wide changes that are going to be necessary to efficiently 
and effectively provide care for Americans today and on into the 
future.
  Now, Madam Speaker, I would rather this information not be widely 
disseminated, but from time to time I pick up and read the New York 
Times. An article in the New York Times from October 5, 2006, a year 
ago, by an individual named Tyler Cowlan, he writes, ``When it comes to 
medical innovation, the United States is the world's leader. In the 
past 10 years, 12 Nobel Prizes in medicine have gone to American-born 
scientists working in the United States, three have gone to foreign-
born scientists working in the United States, and seven went to 
researchers outside this country; 15-7, America, the rest of the 
world.''
  He 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.'' Now, comparisons with other countries may be 
useful, it may be information that we want to go out and seek and 
consider when crafting health care policy, but it is important to 
remember that it's the American system that's always reinventing itself 
and always seeking to improve itself. It is precisely because of the 
tension inherent in our hybrid system that creates the impetus for 
change. A system that's fully funded by a payroll tax, well, that's 
what they've got in Sweden. I think it's 7.1 percent that they pay on 
their payroll tax, and it funds their health care system. But quite 
honestly, Madam Speaker, there is no reason for them ever to seek 
improvement; and as a consequence, a system like that faces stagnation.
  And indeed, if such a system, if it becomes necessary to control 
costs, guess where they look? Doctor, they look at you. They look at 
the provider. You know this. It's happening in the Medicare system, 
cuts projected for as far as the eye can see. Make no mistake about it, 
if the Democrats are successful with this SCHIP system that they are 
proposing to vastly expand, it's going to drive kids off of private 
health insurance onto an SCHIP program. The difficulties faced by 
providers within the Medicare system on an ongoing basis are certainly 
witness to this.
  The fact is, Madam Speaker, the United States is not Europe. American 
patients are accustomed to wide choices when it comes to hospitals, 
physicians and pharmaceuticals. Because our experience is unique and 
because it's different from other countries, this difference should be 
acknowledged and embraced when it comes time to talk about reform or 
transformation, whether it's contemplated in a purely public or private

[[Page 27032]]

health insurance model within this country.
  One final point that's illustrated in a recent news story that was 
covered by a national Canadian television broadcaster about a Canadian 
Member of Parliament who sought treatment for cancer within the United 
States. The story itself is not particularly unique, but the online 
comments that followed the story I thought were pretty instructive.
  To be sure, a number of the respondents felt that it was unfair to 
draw any conclusion because this was, after all, an individual who was 
ill and was seeking treatment. No argument with that concept. I hope 
she got the treatment that she sought, and I certainly pray that she 
got better. No one could argue this point. 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.''
  A further comment from another individual: ``The story here isn't 
about those who get treatment in the United States. It's about a 
liberal politician who is part of a political party that espouses the 
Canadian public system and vows to ensure that no private health care 
is going to usurp the current system. She is a Member of Parliament for 
the party that relentlessly attacked conservatives for their ``hidden 
agenda'' to privatize health care. The irony and the hypocrisy in that 
position supports the notion that the rich get health care and the rest 
of us wait in line. All because liberals' fear-mongering that does not 
allow for a real debate on the state of the health care system in 
Canada.''
  One final note from the online postings, ``It's been sort of alluded 
to, but I hope everyone who is reading this story realizes that, in 
fact, we do have a two-tiered system in Canada. We have public care in 
Canada. And for those who have lots of cash, we've got private care in 
the United States, which is quicker and better.''
  Well, Madam Speaker, a little over a year ago, maybe now a year and a 
half ago, Alan Greenspan came and talked to a group of us one morning 
before he left Capitol Hill. And as it often happens with Chairman 
Greenspan, the talk came around to entitlements and entitlement 
spending. And the question got around to Medicare, how are we going to 
pay for Medicare. And the chairman acknowledged this is going to be a 
tough problem. But after he thought about it, he also said, ``When it 
comes time, I think that the Congress is going to end up doing the 
right thing and it will find a way to pay for Medicare.'' He said, 
``What concerns me more is, will there be anyone there to actually 
deliver the services that you want?'' That's a pretty profound 
statement, and one that certainly has stuck with me for the past year 
and a half or more.
  Now, in March of this year, back in my home State of Texas, the 
official magazine of the Texas Medical Association, Texas Medicine, put 
out a story. In fact, their cover story that month was, ``Running Out 
of Doctors.'' I think that's something we need to pay some attention to 
in this body. With all of our discussion about health care reform, all 
of our talk about changing the system this way or that way, more 
public, less public, more private, less private, if we ain't got the 
docs on the front line, it doesn't matter what we do because the care 
won't be there for the patients. We see this in the Medicare system. 
There is probably no other issue that I deal with with more frequency 
than the program cuts that are going to happen to Medicare physicians, 
again, literally, as far as the eye can see; 5 percent cut this year, 5 
percent cut next year, oh, by the way, we've got to make up that 10 
percent cut from last year. The problem is, the formula by which we pay 
physicians is different from the formula by which we reimburse 
hospitals, HMOs, drug companies and nursing homes.
  Bear with me for just a moment because, wouldn't you know it, I have 
a poster that illustrates that. And I apologize, this one has gotten a 
little bit dated. The 2007 number has an asterisk beside it because 
that was projected, and now we're well into 2007.
  This didn't happen because we held it back at zero. So it looks like 
there is no recording here for physician reimbursement under 2006; in 
fact, it was held at zero. Again, by a last-minute maneuver last year, 
we held it at zero for 2007 as well.
  2002, pretty big cut. We did some last-minute changes in 2003, 2004 
and 2005, which prevented the program cuts. We were unable to come up 
with any additional money in 2006 and 2007. Now, for 2008 and 2009, 
move this bar graph over a notch for those 2 years because that, after 
all, is what we're looking at, Medicare Advantage, hospitals, nursing 
homes, they're basically reimbursed on a cost of living adjustment, 
it's called the Medicare Economic Index. Physicians ought to be 
reimbursed on the Medicare Economic Index, but they're not, and we need 
to fix that. It's not easy to fix it. It's going to cost some money. 
The Congressional Budget Office puts a very big number up there. Deep 
down in my heart I don't believe it's a real number, but nevertheless, 
we do need to be sensitive to that fact and we do need to fix it.
  I would encourage Members to look at H.R. 2585. It is a way to sanely 
repeal the sustainable growth rate. It doesn't do it next year, waits a 
couple of years to do it, but because of some adjustments to the 
baseline, physicians won't, in fact, take a cut for 2008 and 2009. We 
need to keep them involved. And then in 2010, the SGR is repealed, with 
savings that are going to occur over the next 2 years. And we know 
savings are going to occur in the Medicare program over the next 2 
years because that's the history that we've seen in the last several 
years.
  The trustees' report that came out just this past June had some good 
news and some bad news. The bad news was, we're still going broke; but 
the good news is we're going to go broke a year later than what we told 
you last year. The reason is because 600,000 hospital beds weren't 
filled in 2005 that they thought would be filled in 2005. And why 
weren't they filled? Because the doctors were doing a better job. They 
were keeping people out of the hospital. Maybe the prescription drug 
benefit was allowing them for more timely treatment of disease, to 
treat disease earlier. So we didn't push them on that health disease 
continuum in the arena of disease, we kept them on the side of health. 
Things that are done in ambulatory surgery centers that are billed to 
part B, the physicians' part of Medicare, are actually savings that 
accrue in part A. Let's take those savings, sequester them, wall them 
off, a lock box, like we used to talk about back in 2000. Remember 
that? Put those savings in a lock box and use them to offset the cost 
of repealing the SGR in 2010.

                              {time}  2030

  That is the type of innovative thinking that is going to be required 
to get us out of this conundrum. And why is it important? Again, Alan 
Greenspan said, ``What worries me more is not how you pay for it, but 
is there going to be anyone there at the bedside to provide the 
service?''
  I don't want to make light of what is a very serious situation. Yeah, 
there will always be someone there at the bedside, but I don't know 
that you want to look up and find it is Dr. Nick who is delivering your 
care, Dr. Nick, the famous physician from Springfield, Somewhere, 
U.S.A. who can do any operation for $199.95. That may be the physician 
of the future. We don't want to leave that legacy for our children. We 
need to correct this situation now. We can do it in this Congress if we 
just have the political will to work together to get this done.
  Now, my time is almost up. This discussion on health care is likely 
to consume the better part of the next 2 years of both dialogue here on 
the floor of the House, dialogue on the Presidential campaign trail, 
and indeed dialogue in the general public. The United States is, 
indeed, at a crossroads. It is incumbent on every one of us here who 
believes, who believes in the American system of providing health care, 
that we be educated and we stay involved

[[Page 27033]]

and we be committed to being at the top of our game every single day, 
whether we agree on every principle or not. We have to be on the top of 
our game every single day.
  This is one of those rare instances where it is necessary, certainly 
on my side, to be prepared to win the debate because we don't have the 
votes to win much of anything in subcommittee, committee or the House 
floor. But it is an important topic. It is one of that the American 
people believe that we should be involved in.
  If we adhere to the principles that I have outlined here this 
evening, I think that ultimately we are going to post a win for the 
health of the American people and for generations yet to come. That is 
the central task in front of us.

                          ____________________