[Congressional Record (Bound Edition), Volume 153 (2007), Part 7]
[House]
[Pages 10401-10405]
[From the U.S. Government Publishing Office, www.gpo.gov]




                         THE FUTURE OF MEDICINE

  The SPEAKER pro tempore. Under the Speaker's announced policy of 
January 18, 2007, the gentleman from Texas (Mr. Burgess) is recognized 
for 50 minutes as the designee of the minority leader.
  Mr. BURGESS. Madam Speaker, I come to the House tonight to talk about 
something that isn't number one or number two or perhaps even number 
three on the list of things that people are concerned about, it is 
number four, it is health care, health care in our country that is 
provided by the private sector, that is provided by the public or the 
government sector. It is a debate that we will be hearing a lot more 
about as we get deeper into a year that's going to be consumed by 
presidential politics.
  Right now in our country we have an amalgam, if you will, of health 
care, part paid by the government, part paid by the private sector. I 
am oversimplifying for the purposes of debate, but the public or 
government sector, in pure dollar amounts, accounts for about 50 
percent of the health care expenditures in this country. The private is 
sector insures about 160 million Americans, and that is roughly 50 
percent of the lives covered by private insurance in this country. And 
we will have the debate, as the presidential year unfolds, more 
government, more private sector. But tonight, what I really want to do 
is focus on the physician workforce, the physician workforce that we 
have now and the physician workforce that we might expect to have in 
the future.
  Alan Greenspan, about a year and a half ago, right as his last days 
at the Fed were winding down came and talked to a group of us one 
morning, and inevitably the question came up about Medicare. In fact, 
we saw the trustee's report yesterday; everyone is concerned about the 
funding for Medicare, the future obligation that is there in Medicare. 
And Mr. Greenspan was pretty circumspect, he said, ``At some point I 
expect the Congress to deal with the problem of funding.'' And then he 
went on to say, ``What concerns me more is will there be anyone there 
to provide the services when you want them?'' That really struck a cord 
with me. And in fact last month, the month of March, back in my home 
State of Texas my Texas Medical Association puts out a periodical every 
month called ``Texas Medicine,'' and the cover story was in fact 
dedicated just to that concept, ``Running Out of Doctors.'' And the 
thrust of the article is how do we keep the medical students that we 
graduate from Texas schools, how do we keep them practicing in Texas, 
particularly in the high-need areas in Texas? And concentrating on the 
physician workforce is what I want to do during this discussion, in the 
time that I have available for the discussion this evening.
  My perspective, of course, 30 years ago I graduated from medical 
school in Houston, Texas, so I do have the perspective of looking back 
over the last 30 years. But I also want us to look over the horizon to 
the next 30 years. What about the young man or woman who is graduating 
from medical school this year, what kind of world do they want to find 
themselves practicing in? What type of practice environment do they 
want to see that we have laid out for them 30 years from now? It is 
going to be important that we take the correct steps today in order to 
provide the correct practice environment 30 years from now.
  Since we're talking about the physician workforce, the part that the 
government pays for is paramount, that is critical. And really the 
thing that I want to focus on of that government sector is the pricing 
and the payment schedule in the Medicare program itself.

                              {time}  2315

  Medicare, a good program, just celebrated its 41st or 42nd birthday. 
We had the second anniversary of the prescription drug benefit part D, 
which in my first year here we passed in 2003 and was added on in the 
year 2006.
  Medicare is an integrated program. Part A is the hospital, part B is 
the doctor's care, part C is the Medicare, what is now called the 
Medicare Advantage Plans or the HMOs, and part D is the prescription 
drugs. But while it is an integrated program, the funding for Medicare 
actually exists in funding silos.
  If we look at the comparative payment updates from the year 2002 to 
projected 2007, you see that there is something wrong with this 
picture. And what is wrong with the picture is that physician 
reimbursement in part B is significantly lagging behind the payment 
updates for the Medicare Advantage Plan's hospitals and nursing homes 
are shown on this graph. And there is a reason for that. It is really 
not a very difficult reason: Medicare Advantage Plan's hospitals and 
nursing homes receive every year essentially a cost-of-living update. 
It is a market-basket update that they receive based on the cost of 
inputs from the previous year. CMS has actuaries that go back and 
figure this out: What did it cost the hospitals to provide the care 
that they delivered to our seniors?
  Part B is calculated differently. Part B is what is described as a 
volumetric formula. It weights volume and intensity. But basically you 
have a fixed amount of money, a finite pie, that if more and more 
people are submitting claims, the slices get progressively smaller. And 
in 2002, you can see there was a big drop. The reason 2003, 2004, 2005 
are not a downward projection is because in fact at the last minute, 
Congress swept in and said we are going to

[[Page 10402]]

do something to prevent this from happening. And, in fact, doctors got 
a modest update in 2003, 2004, 2005. 2006 doesn't really show up 
because that was a zero percent update.
  Now, Madam Speaker, I have not been in Washington all that long, but 
I have learned some of the parlance and the lexicon that we use here. 
And in any other Federal program or any other federally funded program, 
if you are held to a level funding or a zero percent update for that 
year, anyone else would regard that as a cut. But we told the doctors 
that was great, you are going to get a zero update for that year and 
you will be happy for it.
  Projected for 2007, if we don't do something, is going to be a 
substantial decrease. Once again, we may very well ride in at the last 
minute and do something to blunt the effect of that; but year in and 
year out, this problem continues; and the real insidious part of this 
is the dollars to fix the problem get higher and higher every year.
  Last year I introduced a bill to just simply do away with the SGR and 
replace the SGR with a market-basket update. It is called the Medicare 
Economic Index. And it is not my idea; a group called MedPac, a 
Medicare Payment Advisory Commission, worked this out in actuarial 
fashion some years ago. And the Medicare Economic Index would in fact 
provide a 2 to 2\1/2\ percent update for most years based on the cost 
of input for the physicians providing the services to the patient.
  The cost last year scored by the Congressional Budget Office of 
replacing the SGR formula with the Medicare Economic Index was $218 
billion. Clearly, that is a lot of money, and it disrupts any budget 
that either party might put up there. So, as a consequence, I didn't 
get a lot of activity on that bill last year. It is still important to 
do. And every year that we delay doing something, and even those years 
that we come in and it looks like we fixed it a little bit, we actually 
just compound the problem and make it worse in subsequent years.
  So in just very general terms for this evening's talk, we have got a 
lot of people who are going to be joining the Medicare generation. As 
the baby boomers age and retire, the demand for services is going to go 
nowhere but up. And if the physician workforce trends continue as they 
are today, we may be not talking about funding a Medicare program, we 
may be talking about there is no one there to take care of the seniors.
  In my home State of Texas, the number of physicians between 1995 and 
2005 increased by 46 percent or nearly 5,000. Okay, that is good, it 
went up. However, the State is still below the national average, the 
national average being 230 physicians per 100,000 population. In Texas 
the ratio, even with the increase, is 186 to 100,000 residents.
  The American Academy of Family Physicians predicts serious shortages 
of primary care doctors in five States, including Texas, and says that 
all States will have some level of family physician shortage by the 
year 2020. The Council on Graduate Medical Education, a congressionally 
authorized entity, estimates that after 2010, growth in the physician 
workforce will slow substantially; and after 2015, the rate of 
population growth will exceed the rate of growth for the number of 
doctors. In other words, we won't be keeping up anymore. At the same 
time, the demand is only going to increase year over year, resulting in 
critical shortages, particularly in primary care, but the reality is 
all specialties may well be affected.
  So my thesis, my proposition, is that Congress needs to approach this 
sort of as a three-pronged attack or a three-pronged solution to 
mitigate this shortage for the future, to improve payments to current 
doctors, keep them in practice longer, improve Federal assistance to 
medical students, encourage students to go into high-need specialties, 
and increase the number of residency training programs, particularly in 
rural and suburban areas, and keep the physician pipeline open.
  To do that, I am going to be next week introducing three bills to 
deal with those three areas. The first, to insure the physician 
workforce, really deals with the Medicare funding and the SGR. You talk 
to doctors my age, those who graduated from medical schools 30 years 
ago, and their concerns are really consistent. They are concerned about 
the liability environment, which is not part of tonight's discussion 
but one that we certainly need to have and I hope we do have in this 
Congress this year. Their concern is the year-over-year reduction in 
payment that the Center for Medicare and Medicaid Services comes up 
with for physician reimbursement. And it is not just a question of 
doctors wanting to make more money; it turns to be a real patient 
access problem, because there is not a week that goes by that I don't 
get a letter or fax from someone who says, you know what, I have just 
had enough and I am going to retire early, I am no longer going to see 
Medicare patients in my practice, or I am going to restrict the 
procedures that I offer Medicare patients.
  Unfortunately, I know that is happening because I saw it in the 
hospital environment before I left the practice of medicine to come to 
Congress. But I also hear it in virtually every town hall that I do 
back in my district. Someone will raise their hand and say, How come on 
Medicare, you turn 65 and you have got to change doctors? And the 
answer is, because their doctor found it no longer economically viable 
to continue to see Medicare patients because they weren't able to pay 
the cost of delivering the care, let alone making any money on top of 
it. They weren't able to cover the cost of providing the care.
  So in the bill to address that, the bill that I introduced last year, 
again, just simply repealed the SGR outright. The difficulty that I had 
with that was, again, just the cost was too high. But if we do that 
over time, perhaps we can bring that cost down to a level where it is 
manageable.
  Getting the payment policy right in Medicare is going to be the first 
order of business for preserving the physician workforce. Paying 
physicians fairly will extend the careers of many physicians who are 
now in practice who would otherwise opt out of the Medicare program, 
seek early retirement, or restrict those procedures that they offer to 
their Medicare patients.
  It also has the effect of insuring an adequate network of doctors 
available to older Americans as this country makes the transition to 
the physician workforce of the future.
  In the bill, the SGR formula, this volume-based formula would be 
repealed in 2010, 2 years from now, but also provide incentive payments 
based on quality reporting and technology improvements to protect the 
practicing physician against that 5 percent cut that is likely to 
happen in 2008 and 2009. That would be voluntary. No one would be 
required to participate in the quality program or the technology 
improvement, but it would be available to those doctors or practices 
who wanted to offset the proposed cuts that will occur in physician 
reimbursement in the 2 years until the formal repeal of the SGR 
happens.
  Now, why do it that way? Why not just bite the bullet and let's go 
ahead and get the SGR out of the way and get it repealed? Remember, it 
costs a tremendous amount of money to do that. Another problem that we 
have in Congress is we are required to submit all legislation to the 
Congressional Budget Office to find out how much it costs. If we are 
going to be spending the taxpayers' money, how much are we going to 
spend? Over what time will we spend it?
  So that is not unreasonable, but because of the constraints of the 
Congressional Budget Office, we are not allowed to do dynamic scoring. 
We all knew, for example, when we began the prescription drug benefit 2 
years ago, that if you deliver medications in a timely fashion, the 
timely treatment of disease, you are going to get better patient 
outcomes. And, in fact, that is what the trustee's report for Medicare 
that was released yesterday, although it still shows that we have got a 
big problem in paying for Medicare, the actual outlays for Medicare 
were down. And the reason they were down, I suspect, is a compendium of 
things; but part of it is treating disease in a timely

[[Page 10403]]

fashion, not always catching it at the end stage but treating it at the 
beginning, you are going to end up with more functional individuals, to 
be sure, so they are going to continue to be productive in society. But 
the overall cost of Medicare is going to go down.
  Unfortunately, we can't do that look-ahead with the Congressional 
Budget Office and say, you know, I think if we do this, we are going to 
save some money. So give me credit for that against that SGR score that 
you always rate my bill with. They won't and they can't do that.
  So by postponing the repeal of the SGR by 2 years' time, taking the 
savings that occurs during that time and applying it to the SGR 
formula, actually may give us a number that is doable as far as 
releasing the SGR and replacing it with the Medicare Economic Index.
  One of the main thrusts of this bill is to require the Center for 
Medicare and Medicare Services to look at their top 10 conditions that 
drive the highest percentage of payments in Medicare part B, and 
require CMS to adopt reporting measures relating to these conditions 
that have already been developed. It is not reinventing the wheel. The 
AMA Physician Consortium has already developed those reporting measures 
that drive that spending so high.
  You know, the old famous bank robber Willie Sutton when he was asked 
why do you rob the bank, he said that is because that is where the 
money is. Let's go to those top 10 things where the greatest amount of 
money is spent, because that is where the greatest amount of savings 
can occur. If we can deliver care in a more timely fashion and if we 
can improve outcomes, we are actually going to spend less. And by 
focusing on those top 10 programs, at least initially, that will be the 
greatest return on investment for CMS and ultimately will be the 
greatest return on investment for retiring the SGR.
  The same considerations may apply to the Medicaid program as well, so 
it will be a very useful exercise to go through that and identify those 
top 10 conditions. And where cost savings may be most easily gathered, 
not only will it have an improving effect on Medicare, but I suspect on 
Medicaid as well. We are going to establish quality measures focusing 
on these core conditions, and that is where the add-on payment for 
those 2 years, that is where half of it will come from. A 2\1/2\ 
percent update for those physicians who do voluntarily report quality 
measures on those top 10 conditions, that is where the protection from 
the continuation of the SGR for 2 years, that is where that protection 
will derive from.
  We are going to report back to doctors on what their volume and 
intensity is. This information will not be made generally public, but 
it will be made available to the individual physician so they can see 
how they are doing, how they are doing relative to other doctors in 
their practice, other doctors in their community, other doctors around 
the country.
  But the important point here is these are voluntary measures that 
will protect the physicians from the cuts that are inevitably going to 
occur as a result of the SGR program until the SGR can actually be 
repealed.

                              {time}  2330

  But, physicians can opt to take advantage of the bonuses, and it is 
going to return some value back to their businesses and return value to 
the taxpayer. Again, there may be an unintended benefit for the 
parallel Federal program to cover poor Americans under the Medicaid 
program if some of these programs deliver the benefit back that it is 
anticipated that they will.
  The quality measures are going to be built around these high-cost 
conditions, and strive to improve the quality of care not only for 
those conditions and patients, but to drive down the cost of delivering 
Medicare.
  There is also going to be a provision in the bill to help physicians' 
offices to bring their information technology, their infrastructure, 
hardware and software, bring it up to a standard where it will begin to 
derive benefit to not only the patient and the practice but to the 
Medicare system in general.
  The percentage add-on payment is proposed to be 2\1/2\ percent, so 
those two bonus payments in aggregate would be 5 percent. And again, 
that is designed to be a protection against what are the anticipated 
reductions in payments that would occur in 2008 and 2009.
  The provision will also create a safe harbor that will allow clinics, 
physicians' offices, and hospitals to share health information 
technology platforms, and the standards will be established and 
available to physicians' practices so they will understand how they 
need to comply with this. The standards must be established no later 
than January 1, 2008.
  Madam Speaker, I wasn't always a big proponent of things like 
electronic records. I wasn't sure if it would deliver the payoff that 
people said it would. But here is a picture of the medical records 
department in Charity Hospital in New Orleans. This picture was made in 
January 2006, about 4 or 5 months after Hurricane Katrina and the 
downtown flooding that occurred. It is the medical records room. These 
records are ruined. You can see, this is not smoke or soot damage, this 
is black mold that is growing on the records. You look there and it 
almost goes on to infinity, tens of thousands, hundred of thousands of 
records that were active, ongoing charts of people's medical conditions 
absolutely now unavailable. No one is going to get into that medical 
records department and risk inhaling the spores from the mold that is 
covering those charts.
  This is the kind of problem that you can get into with a paper 
medical record. Of course the youngsters of today, the college students 
of today, the young physicians of today, they understand this very 
well. They are all connected and wired in. They would no more imagine 
turning in or doing a paper for one of their classes where they just 
had a single copy, a single paper copy, the old adage ``the dog ate my 
homework,'' most students will have a paper on a disk, on a flash drive 
and readily accessible and retrievable in many forms. We should do no 
less with our medical records.
  But it costs money to do this. It is going to require a push for the 
private sector. I prefer to think as a bonus payment as being an 
inducement, an enticement for physician's offices to participate in 
this type of program. But it is also just good medicine. It is good 
patient care.
  We all heard about the troubles at Walter Reed Hospital a few months 
ago. I went out to Walter Reed probably the week after the story broke 
in the Washington Post and talked to this young man who took me around 
Building 18. Yes, there was some concern. It was a crummy building. But 
his biggest concern was spending hours and hours with his medical 
record, his service record, going through the various parts of that and 
highlighting things. He had a yellow marker, a highlighter, 
highlighting parts of his medical record because this is how he was 
going to establish the benefits that he was going to receive in the VA 
system for his disability.
  He said I can spend 20 man-hours putting this medical record together 
and it ends up on someone's desk and it doesn't get picked up, and then 
no one can find it and I have to start all over again. That was his 
main message to me that day.
  Now the VA system has been indeed very forward-thinking in its 
embrace of electronic medical records and its investment in information 
technology. The problem is the medical records from the Department of 
Defense and the Department of Veterans Affairs do not possess the 
interoperability necessary to make this type of activity unnecessary.
  So clearly delivering value to the patient, particularly a patient in 
that situation, is of paramount importance. And it is my contention 
that if we do make the bonus payment generally available to physicians, 
this will be something that they will embrace. There is a learning 
curve, to be sure. It is going to slow people down a little bit 
initially. But ultimately, the rapidity of the system will be 
impressive. And even in a smaller physician's office the

[[Page 10404]]

ability, just think, never having to wait while they find your medical 
record because somebody didn't put it back in the right place. I know 
it happened in my medical practice, and I suspect it happens in offices 
across the country on a regular basis. If nothing else, you will save 
that time and embarrassment of not being able to locate a patient's 
record.
  One of the problems last year when we dealt with trying to provide 
the health information technology bill that we passed here in the House 
and were never able to come to agreement with the Senate, part of the 
difficulty was being able to have the hospital and the clinic and the 
physician, there may need to be some relaxation in what are called the 
star clause to allow safe harbors so that these conditions can be met.
  But the reality is that once people become used to this technology 
will embrace it. The other unintended consequence, the other unintended 
benefit of this is the rapidity with which the system can learn. When I 
say the system, the entire health care system because wouldn't it be 
nice to know which treatments deliver on the promise of getting people 
better faster at a lower cost. Wouldn't it be great to have that 
information and know what treatments were effective and what treatments 
were only marginal? That information can be literally at a physician's 
fingertips with the right type of computer architecture and technology 
environment. I believe the time has come that we do need to embrace 
that.
  So the bill will include a Federal incentive to implement health 
information technology along with provisions providing safe harbors for 
the sharing of software, technical assistance and hardware, as well as 
the creation of consortiums.
  Now, it is not just about physicians my age, because we have got to 
also concentrate on helping the younger doctors with residency 
programs. The funny thing about doctors is we to have a lot of inertia. 
A lot of us tend to practice very close to where we did our training. 
So the idea to get more training programs in areas that are 
underserved, rural areas, inner city areas, to get more training areas 
where the doctors themselves are actually needed.
  So the second bill or the second prong of this three-pronged approach 
would be to develop a program that would permit hospitals that do not 
traditionally operate a residency training program, allow them the 
opportunity to start a residency training program to build the 
physician workforce of the future.
  This bill would create a loan fund available to hospitals to create 
residency training programs where none has operated in the past. The 
programs would require full accreditation and generally be focused in 
rural, suburban, inner urban or frontier community hospitals.
  On average, it costs $100,000 a year to train a resident and that 
cost for a smaller hospital can be prohibitive. The other issue is in 
1997 the Congress passed what was called the balanced budget amendment 
and within that there is a residency cap that also limits resources to 
nontraditional residency hospitals such as smaller community hospitals. 
For the purposes of this bill, the loan amount to any institution would 
not exceed $1 million, and the loan itself would constitute start-up 
funding for a new residency program. And the start-up money is 
essential. Since Medicare graduate medical education funding can be 
obtained only once a residency program is firmly established, the cost 
to start a training program for a smaller, more rural or suburban 
hospital can be cost prohibitive because these hospitals operate on 
much narrower margins.
  The overall bill would authorize a total of $25 million to be 
available over 10 years. The fund, of course, would be replenished 
because these are constructed as loans and the Health Resources Service 
Administration may make the loans available to new loan applicants or 
extend loans to increase the number of residency slots available at 
existing programs or a loan to continue newly established residency 
programs to hospitals that have been approved.
  To be eligible, a hospital must demonstrate that they currently do 
not operate a residency training program, have not operated a residency 
training program in the past, and that they have secured preliminary 
accreditation by the American Council on Graduate Medical Education.
  Additionally, the petitioning hospital must commit to operating an 
allopathic or osteopathic residency program in one of five medical 
specialties, or a combination of these specialties: Family medicine, 
internal medicine, emergency medicine, obstetrics and gynecology, or 
general surgery. Again, the hospital may request up to $1 million to 
assist in the establishment of this new residency program. Funding 
could be used to offset the cost of the residents' salaries and 
benefits, faculty salaries and other costs directly attributable to the 
residency program.
  The bill would require the Health Resources Services Administration 
to study the efficacy of this program in increasing the number of 
residents in family medicine, internal medicine, and primary care, and 
whether the program led to an increase in the number of available 
practitioners in these specialty areas, particularly in underserved 
areas. The loans would be made available beginning January 1, 2008, and 
the program would be sunsetted in 10 years time, January 1, 2018, 
unless Congress elected to reauthorize the program.
  The third prong of the physician workforce for the future would be 
ensuring the availability for adequate future physicians, and provide 
medical students with assistance and incentives to practice in shortage 
specialties and shortage areas.
  The third bill would establish a mix of scholarships, loan repayment 
funds, and tax incentives to entice more students to medical school and 
create incentives for those students and newly minted doctors to become 
primary care, family physicians, general surgeons, OB/GYNs and practice 
in shortage areas such as rural or frontier areas.
  This bill would provide additional educational scholarships in 
exchange for a commitment to serve in a public or private nonprofit 
health facility determined to have a critical shortage of primary care 
physicians.

                              {time}  2345

  Such scholarships will be treated as equivalent to those made under 
the National Health Service Corps Scholarship Program and penalties 
apply for those that take advantage of the scholarships but do not go 
into one of those practice areas.
  This will be a 5-year authorization, authorizing these loans and 
grants to be $5 million a year. The scholarship amounts will not exceed 
$30,000 per year. The scholarship amounts may be adjusted based on 
financial need, geographic difference and educational costs.
  Again, this is going to be administered through the Department of 
Health and Human Services, specifically through the Health Resources 
Service Administration.
  This program will have an established repayment program for students 
who agree to go into family practice, internal medicine, emergency 
medicine, general surgery, or OB/GYN, and practice in underserved 
areas. Again, HRSA will administer and promulgate the requirements. 
Recipients must practice in the prescribed specialty and prescribed 
area, which is designated as an underserved area, and the practices may 
include solo or group practices, clinics, public or private nonprofit 
hospitals. Again, a 5-year authorization at $5 million per year.
  This will establish the Primary Care Physician Retention and Medical 
Home Enhancement grants to help ensure that primary care physicians 
continue to provide coordinated medical care to patients in underserved 
areas or high-risk populations. Now, I know we can all think of areas 
like that in our home districts and home States.
  Also, in an area such as the gulf coast area where so many physicians 
left after the devastating twin hurricanes of Katrina and Rita a year 
and a

[[Page 10405]]

half ago, it has been very hard on doctors in those areas. Many doctors 
have left. It is going to be difficult to attract doctors back to that 
area, and this will be yet one more tool, one more way, to get doctors 
to consider practicing in an area where the need is great.
  This encourages States to establish Physician Workforce Commissions, 
especially in rural areas and in certain practice specialties such as 
family medicine, again basically primary care, by exempting from income 
tax any amount paid by the Physician Workforce Commission in the form 
of salary to a physician who has signed a contract with the political 
subdivision to practice in that area for any amount of time, no fewer 
than 4 years.
  Every year there would be a report back to Congress about the 
effectiveness of this program, that is, once again, are we spending our 
dollars wisely, are we getting what we thought we would get when we 
initiated that program.
  So, Madam Speaker, those are three bills that, again, I will be 
introducing during the week next week after we get back. I think these, 
while they may not be the answer to all the problems, certainly focus 
on where the problem areas exist, that is, physicians who are my age, 
50 years plus or minus a little bit, who are in the Medicare program 
but looking to drop out or opt out because they can no longer continue 
their practices because we in Congress are cutting reimbursements to 
the point where we are no longer paying our fair share. We are no 
longer paying the freight on taking care of Medicare patients, but in 
addition to that, looking over the horizon to the future, being sure 
that we have the physician workforce of the future, to provide care for 
the baby boomers who are getting older, but just being able to provide 
that care in general.
  In fact, we are not even talking about just the Medicare population 
here. We are talking about doctors who are going to work in primary 
care in a medically underserved area in a specialty which is in short 
supply in that area. That dual approach of increasing the number of 
residency slots, again, doctors tend to go into practice and stay in 
practice where they trained, and the other, a loan forgiveness program 
and a tax incentive program to young physicians getting out of school, 
may have several hundred thousand dollars in debt from their 
undergraduate and then their medical school training, this is a way for 
them to begin their careers without having that incredible debt load to 
carry with them, a loan forgiveness, a tax incentive program, provided 
they are willing to give back some time in a medically underserved area 
in a specialty that is in high medical need.
  I believe that by taking these three steps, Madam Speaker, we really 
will go a long way towards alleviating the physician shortage. There is 
no question that we are going to need to devote a lot more time and 
energy to how we approach the problem dealing with health care in this 
country and dealing with the uninsured. I expect to have many more 
hours on subsequent evenings in the coming weeks to talk about just 
this problem and just what are some of the approaches that may be 
taken.
  We had a fairly long hearing in committee this morning, in my 
committee, the Health Subcommittee of Energy and Commerce, hearing from 
a variety of people about how to provide additional care for the 
uninsured. Again, it is going to be a lively debate, what happens in 
the private sector or do we just simply give it over to a government 
program, perhaps bring the age for eligibility for Medicare down lower 
and lower, expanding the SCHIP program higher and higher, and then the 
two programs will meet in the middle and provide coverage for everyone 
in the country. I do not think that is necessarily a good way to go.
  I think there are some reasons that the private practice of medicine 
does bring value to the entire American medical system. There is no 
question we have no shortage of critics in this country and around the 
world about the system of health care in this country, but my opinion, 
it is the American system that stands at the forefront of innovation in 
new technology, precisely the types of system-wide changes that are 
going to be necessary to efficiently and effectively provide care for 
Americans in the future.
  There was an article in the New York Times published October 5, 2006, 
by Tyler Cowan. He writes, ``When it comes to medical innovation, the 
United States is the world 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 in the United States, and just seven have gone to 
researchers outside of the country.''
  But he does go 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.
  The fact is 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 in this country, 
because Americans indeed are exceptional and we are different from the 
types of programs that are in other countries, this difference should 
be acknowledged and embraced, whether we are talking about public or 
private health insurance programs.
  Madam Speaker, it has been a long day and we have gone fairly late 
into the evening. I appreciate the time.

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