[Congressional Record (Bound Edition), Volume 153 (2007), Part 9]
[House]
[Pages 12359-12366]
[From the U.S. Government Publishing Office, www.gpo.gov]




                              HEALTH CARE

  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 come to the floor tonight to talk a 
little bit about the Nation's health care system, some of the 
challenges that face us and some of the successes that have happened in 
spite of the fact that they aren't generally noticed by the people who 
report on things.
  Mr. Speaker, my career prior to coming to Congress was that of a 
physician. A lot of people will ask me how did we end up with the 
situation that we have, how did we end up with the system of health 
care that we have in this country? After all, Western Europe, we are 
not that much different from our Western European friends, and yet they 
have largely single-payer, double-fund systems, and why is the American 
system so different?
  Mr. Speaker, there are a lot of reasons for that, but at the risk of 
oversimplification, if we look back to the days when the country was 
involved in the Second World War, of course President Roosevelt at that 
time had put in place wage and price controls in order to keep down 
trouble from inflation. Employers who were anxious to keep their 
employees working, and there was competition for the workforce that 
remained behind and was not called off to fight, in order to keep that 
workforce employed and to keep that workforce interested in working, 
and not being able to expand wages like an employer might like to do, 
they offered benefits.
  They actually sought an opinion, and the United States Supreme Court 
ruled that health insurance benefits could be provided and would be 
outside of the wage and price controls. And in fact, a tax advantage 
was given for employer-derived health insurance, and it made the 
program popular, not only during the war years but in the years 
immediately after the Second World War.
  While this country was undergoing a significant economic expansion, 
this type of insurance policy remained in effect.
  Now, contrast that with Europe, and even though some countries in 
Europe had emerged victorious, others were vanquished. Their backyard 
was the site where that war was fought. They faced significant 
humanitarian issues if they did not quickly stand up health care 
systems and other social systems in order to take care of their 
citizenry. So, it was an entirely different landscape presented to the 
people who represented constituents in this Congress during the war 
years and immediately thereafter.
  I reference an article from Health Affairs from December 2006, just a 
few months ago, an article by Dr. Einthoven who's been a prolific 
writer. I don't always agree with him but a prolific writer on health 
issues, and he talked about employer-based health insurance past, 
present and future.
  Talking about the past, the most familiar aspect of employment-based 
insurance past is its rapid growth in the first three decades after 
World War II, the relative stability that followed for about a decade.
  And then he talks about the declining coverage that has occurred 
since the late 1980s, the exemption of employer payments for health 
insurance from employees' taxable income, combined with substantial 
efficiency advantages of group over individual insurance, fueled a 
rapid expansion.
  And he goes on to cite that by the mid-1950s, 45 percent of the 
population

[[Page 12360]]

had hospital insurance. Coverage increased to 77 percent by 1963, and 
coverage peaked sometime during the early 1980s and, as he points out, 
declined in the late 1980s.
  Lest anyone think that I'm in complete agreement with the article, he 
does end up his piece that the most likely trajectory in the near term 
is continued erosion of employer-based health insurance. In the long 
term, we think that the likely and most desirable income is replacement 
of job-based insurance with some form of universal health insurance 
that encompasses choice competition.
  Again, we may disagree with his conclusion, and I will go through 
during the course of this hour some of the reasons why I do disagree 
with that conclusion, there are a number of things that would need to 
be taken into account.
  But other things that we need to consider with this balance of the 
hybrid system that we have, the public and private, we do need to talk 
a little bit about the uninsured in this country, what's happening with 
the reauthorization of the State Children's Health Insurance Program, 
what's going to happen with the reauthorization of federally qualified 
health centers, a bill we took up last year but didn't complete before 
the end of the 109th Congress and will have to face again this year.
  I'd like to talk a little bit about health savings accounts and some 
about association health plans. Of course, it is hard for me to talk 
about health care without addressing medical liability reform, and I do 
want to spend a few minutes on that in the hour that we have ahead of 
us.
  One of the most pressing needs and one of the issues that is brought 
to my attention with increasing regularity is the whole issue of 
maintaining our physician workforce. We have a problem in the Medicare 
system as to how we reimburse physicians. So certainly physicians who 
are in practice are feeling that burden right now. We also have 
physicians in graduate education and young people who are perhaps 
thinking about whether or not they want to go into medicine as a 
career, and all of those aspects of the physician workforce I think 
require some of our attention.
  Some of the things that the States are doing right now, things that 
are happening in Massachusetts, California, some recent developments in 
Illinois, indicate some of the efforts that are going on at the State 
level, and largely that's because of flexibility we provided to State 
governors when we passed the Deficit Reduction Act in December of 2005.
  Other health care issues, if time permits, I'll try to get into. We 
talked a little bit about the trauma bill that was recently signed into 
law by President Bush 2 weeks ago, some aspects of transparency within 
the health care system, and how we are going to approach coverage for 
long-term care, particularly as the so-called baby boomers continue to 
move along in the demographic chain in this country.
  Again, we talked about how we got this system that looks the way it 
does, the hybrid system that is a combination of both public and 
private systems. I referenced the activity that was going on right 
after the end of the Second World War.
  Fast forward 20 years and a new system into effect in 1965 that was 
called the Medicare system primarily focused on coverage for 
hospitalization and some doctor services for elderly Americans.
  In 1965, my dad was a doctor when Medicare came into being in 1965, 
and I used to tease him that in 1965 you only had two medicines, 
penicillin and cortisone, and you used those interchangeably. So it 
didn't really matter that you didn't have a prescription drug coverage 
when Medicare was first passed. I know he didn't think that was very 
funny either, but that is a discussion we have had on several 
occasions.
  Now, 40 years later, 40 years after the enactment of Medicare, how 
different the world looks just from the standpoint of the 
pharmaceutical agents that are available in the physician's 
armamentarium to not only treat disease when it strikes but to prevent 
the disease from ever manifesting itself in the first place, for 
keeping that patient in the state of relatively good health and not 
coming in, sweeping in at the end stage when the disease has already 
struck and caused the heart attacks or caused some of the problems that 
happens with untreated or poorly controlled diabetes over a lifetime.
  To be able to reach in and control those medical conditions on a 
chronic, ongoing basis ahead of time results in a reduction in the 
overall health expenditure for that particular disease for that 
particular individual, and you don't have to take my word for it.
  The Medicare Trustees Report that came out about a week-and-a-half 
ago pointed out that in the year 2005 there were about 600,000 hospital 
beds that were not filled that were expected to be filled, and they 
were not filled because America's physicians are doing a better job of 
diagnosing conditions early and treating them early and keeping people 
out of the hospital when the full-blown effects of the disease might be 
manifest that in many cases can, in fact, be avoided all together.

                              {time}  2145

  So when we did the Medicare prescription drug plan back in 2003, it 
was a fairly lengthy and involved debate. I remember the President of 
the United States standing in this very Chamber during his State of the 
Union during 2003. Remarkable for me, because it was the first State of 
the Union that I got to see here as a new Member of Congress at the 
time. He said the issues facing Medicare are too important to be left 
to another President. The issues facing Medicare are too important to 
be left to another Congress.
  So, this Congress, at that time the 108th Congress, was going to 
tackle the problem of providing prescription drug benefits to America's 
seniors. Heretofore, prior to that time, they had not been available. 
Arguably, there were some ups and downs with that, but the fact is 
today more American seniors have more access to coverage than at any 
time in Medicare's history. The coverage that is available to them is 
certainly vast and extensive.
  Generally there are at least two medications in every one of the six 
major disease categories. I know Administrator McClellan worked on that 
very diligently in the years between the time the Medicare bill was 
passed and the actual rollout of the Medicare prescription drug plan. 
But that was simply setting the stage for the debate that continues 
today.
  Who is better suited, is it the public sector or the private sector? 
Who is better suited to handle the health care of this Nation? Now, 
currently, the Federal Government pays for roughly half of health care 
in this country. I know I am oversimplifying, but the numbers actually 
back me up on this, the gross domestic product last year was 
approximately $11 trillion, and we spent $1.4 trillion on health care.
  The Health and Human Services budget for Medicare and Medicaid alone 
was in excess of $600 billion. Add the Federal expenditure for the VA 
system, for the Indian Health Service, the Federal prison system, and 
you can see we are quickly going to be at that mark. It is about half 
of the health care expenditures in this country.
  The other half is broken down with a significant amount, the lion's 
share, being covered by people who have traditional insurance, 
commercial insurance, HMO coverage and all the things that we generally 
associate with insurance in the private market, and then smaller 
amounts would be attributable to individuals who simply pay for their 
care out of their pocket, and are uninsured, but are available to pay 
for their care.
  There is no question that there is some care rendered in this 
country, no doubt about it, given by the good graces of either the 
hospital or the doctor involved, so-called charitable care or 
uncompensated care, which does account for a significant amount of the 
care given in this country.
  Well, what is the best way, this tension between public and private. 
Should we expand the public sector? We are going to have that debate in 
a big way, probably in the months to come regarding the expansion of 
the

[[Page 12361]]

public sector, the public side of health care.
  Certainly we can look to Canada as an example of a country that has 
done, essentially done away with the private practice of medicine and 
put a publicly funded payment plan in place. But even the Canadian 
Supreme Court a few years ago said that, you know what, access to a 
waiting list is not the same thing as access to health care. They 
acknowledge some of the problems that exist in the system, some of the 
problems that exist within the Canadian system.
  The British National Health Service, again, I go back to my comments 
earlier about the time during World War II and its immediate aftermath, 
the British National Health Insurance came on the scene earlier in the 
last century, and has evolved essentially into a two-tier system. You 
have patients who are taken care of in the National Health Service, to 
be certain, and everyone has coverage to the National Health Service. 
But, again, there may be issues with waiting times, there may be an 
issue to waiting to see the practitioner or the specialist that you 
wish to see. As a consequence, some of the most expensive health care 
available today is in the private system that exists, that coexists, 
with the British National Health Service.
  Another aspect to that that is troubling to some people because of 
the wait. How long is it reasonable to ask someone to wait for an 
artificial hip replacement, for example? Certainly some of the studies 
done at the National Institutes of Health have shown that with today's 
minimally invasive surgery, and the in-joint replacement surgery, the 
savings to the economy are significant because of the minimization of 
the lost days of work, the lost productivity by a worker who is having 
a problem.
  But, if you have to wait, as in some systems you do, if you have to 
wait 1 month, 2 months, 3 months, is that such a big deal; 6 months, 
going on a year? Well, I would submit that if a patient is in their 70s 
or 80s, that length of time is a significant electricity of time and, 
in fact, may increase the morbidity and, in fact, the mortality of 
people who are suffering from those types of diseases. So those systems 
are not inherently fair if someone is in their seventh or eighth decade 
of life, or they may not survive the wait for the care that is 
involved. So, expanding the private sector, is that the answer? I don't 
know if it's the entire answer, but it's certainly a big part of what 
must be the ultimate answer that we come to.
  I would reference what has happened with medical savings accounts. 
They just turned 10 years old last year. The Kennedy-Kassebaum Act was 
passed in 1996. I was a practicing physician at the time with no 
thought of ever running for Congress, but I knew I wanted a medical 
health savings account as soon as I could get one.
  In fact, 750,000 policies was the cap placed under the Kennedy-
Kassebaum legislation. I was significantly concerned that I would not 
be able to get signed up for one before the cap was reached and no more 
were available. Turns out, I needn't have worried, because the cap was 
never fully prescribed because of some of the restrictions that were 
placed on the old medical savings accounts that were the original type 
of policy that was available.
  In my home State of Texas, because of the restrictions placed on 
insurance carriers, only two carriers were really interested in 
providing what might be regarded as an account, a high deductible 
account, that could be coupled with a medical IRA or a medical savings 
account, which would continue to earn interest, be available to pay 
that high deductible if someone got sick, but in the event that it was 
not required to be used, would grow over time.
  These were pretax dollars that were put away into the savings 
account, again, much like an IRA, but the only difference being that 
these dollars would be earmarked, and I realize that's a bad word, but 
these dollars would be sequestered only for paying for medical care.
  Well, that changed in 2003 with the advent of the health savings 
accounts, as we passed the Medicare Modernization Act. Health savings 
accounts today are accounting for a significant number of policies, and 
I don't have the most recent statistics at hand, but 3- to 4 million 
policies that have now been obtained, and about 40 percent of the 
people who have a health savings account today previously lacked health 
insurance coverage.
  Now, one of the great things that I tell, particularly younger 
audiences, when I address them about health insurance, 1994, trying to 
buy a health insurance policy for someone who was not employed, someone 
who didn't get their insurance through their employer, just wanted to 
go out on their own and get a policy that would provide them coverage, 
if they needed it, and pay for it themselves.
  Number one, they are paying for it with aftertax dollars, so that's a 
more expensive way to go about getting insurance, but the other thing 
was, in 1994, you couldn't get it at any price. It just was not 
available. I know this, because I attempted to buy a policy for a 
family member who was not working at the time, but I thought needed 
insurance coverage.
  Well, fast forward by 10 years. A young American getting out of 
college today, 24, 25 years old, now not able to be carried on his 
parents' insurance any longer, wants to go into business for himself or 
herself, wants to be a entrepreneur, wants to take part in the American 
dream but also wants to do the responsible thing and have health 
insurance. That individual can go to the Internet, go to the search 
engine of choice and type in ``health savings account.''
  Very quickly, they will find a vast array of insurance products that 
are available to them at a high deductible, PPO product, may cost in 
the range, in my home State of Texas, for a male, age 25, nonsmoker, 
those premiums are going to be in the range of about $65 a month. It is 
eminently affordable for someone just getting out of college who wants 
to do the right thing and have that insurance coverage. Moreover, if 
they want to further do the right thing and save some money towards 
that high deductible, should they ever be called on to make that 
expenditure, those monies can go into that account as pretax expense, 
and they will grow tax deferred over the life of the account.
  Now, why is that significant? It's significant in that, correct, it's 
a high deductible policy. So if that person needs a flu shot, their 
insurance is not going to cover it. That is going to be contained 
within the deductible. Yes, they will, in all likelihood, either pay 
for it out of the money they have held in the health savings account, 
or they may just choose to pay for it out of pocket.
  But, if they have a motorcycle accident some night and wind up with 
an evening in the emergency room, and 3 or 4 days in the intensive care 
unit, and face a hospital bill of $15- to $25,000, guess what, that 
bill is going to be covered. That is a significant difference from what 
was available in this country in 1994.
  I would also reference the expansion of, well, you think, gosh, that 
high deductible policy, if you need anything more than a flu shot, who 
is going to want that because the cost of health insurance is so high, 
or the cost of health care is so high?
  In today's Wall Street journal on the back page, the op ed page, 
there's an article about customer health care. One of the things it 
talks about is the growth of so-called minute clinics or urgent care 
centers. Quoting from the article now, written by Grace-Marie Turner, 
these new retail health clinics are opening in big box stores and local 
pharmacies around the country to treat common maladies at prices lower 
than a typical doctor's visit, and much lower than the emergency room, 
no appointment necessary, open daytime, open evenings, open weekends, 
most do take insurance.
  Prices vary from services like from flu shots from $15 to $30 to care 
for allergies, poison ivy, pinkeye, $50 to $60 and tests for 
cholesterol, diabetes, less than $50. Competition is already starting 
to drive these prices down.

[[Page 12362]]

  So there we have some good news. We have the health savings accounts, 
which are now available and sold on the Internet, and that competition 
has driven those premiums down, and we have the growth of people who 
are providing care for someone who is willing to pay for it out-of-
pocket, whether they be someone who just wants to have the convenience 
of a walk-in clinic, or someone who perhaps has one of the consumer 
oriented products, one of the high deductible products, and wants to, 
is shopping around for that bargain in health care. Now there are other 
options available that weren't there before.
  Other things to talk about within the private sector, association 
health plans, that's legislation that we have passed before in this 
House, both in the 108th and 109th Congress. Clearly, we need to take a 
look at that again in this Congress.
  Association health plans allow groups of employers who have a similar 
business model to band together and buy insurance in the larger group 
market to take advantage of some of those economies of scale that may 
be gleaned by a larger employer, make those available to small 
businesses as well. Again, we have passed that legislation twice in the 
House of Representatives, in the 108th and 109th Congress, and 
something that we do need to consider taking up again this year.
  When I talk about consumer oriented health care, when I talk about 
the health savings accounts or the growth in health savings accounts, 
one of the things that is so important for consumers, if they are going 
to be educated consumers, if they are going to make informed decisions 
about when and how they purchase their health care, we are going to 
have to make more information available to people to rationally make 
those decisions.
  Information about cost, price and quality is going to have to be more 
generally available, and I recognize that there is a value in opacity, 
or it wouldn't have developed in the first place, but more information 
available to the health care consumer. In fact, in my home State of 
Texas, this recently has happened with hospital charges.
  In all except for the smallest of hospital markets, an individual can 
go to a Web site, txpricepoint.org, and find out information about the 
hospitals in their area for given classes of hospital care, childbirth, 
for example, fixing a broken leg, for example, with or without 
complications, all listed there. Very quickly you can get information 
about how hospitals in the area compare and how the hospitals compare 
with other hospitals statewide that are of similar size and have a 
similar patient mix.
  This is just the first step in providing that information. I 
recognize there is only so much that can be gained from looking at the 
overall hospital charge for a particular diagnosis, but as more 
information becomes available, and as more information is placed up and 
available on these Web sites, consumers are going to be able to make 
more informed choices about how they spend their health care funds.
  One of the biggest problems ahead us and one of the biggest problems 
we have to tackle is the uninsured.

                              {time}  2200

  Currently the United States Census Bureau says that there are over 46 
million people who lack health insurance in this country. And I know we 
can have the arguments about who is represented in that 46 million and 
that there are some people who lack insurance only during part of the 
year. But they're still counted toward the total number. But the 
reality is it is a significant number of Americans who lack health 
insurance.
  As a physician, first, I will be the first to point out that having 
no insurance does not equate to having no access to health care because 
every physician can tell you about cases they've had where 
reimbursement either never arrived or they just simply did the case 
knowing that the person was uninsured and no reimbursement would be 
forthcoming.
  But I think we also recognize that delivering care in that manner, it 
is not always delivered in the most timely of fashions, and you don't 
always get your best health outcome.
  Now, one of the solutions that we will have to deal with in Congress 
is the reauthorization of the Children's Health Insurance Program. 
Again, that program is 10 years old and had a 10-year reauthorization 
requirement upon it.
  It's not different from Medicaid. It's not an entitlement. It is a 
block grant to States to provide coverage for uninsured children within 
that State. It does provide flexibility for the States to determine 
standards and providing health care funding for those children who are 
not eligible for Medicare, but whose parents truly cannot afford health 
insurance.
  The bill, when we work on that in committee, there are several things 
that I think are important that we do need to look at. One the problems 
of course we have run into with S-CHIP is that some States have found 
themselves in a shortfall situation. And one of the things that is 
troubling about the reason some States are in a shortfall situation is 
that they are covering adults and not just children.
  Now, providing health care insurance or providing health insurance 
for children is less expensive than providing health insurance for 
adults because children obviously, are younger, they tend to be 
healthier, they tend to get better quicker. And although there are some 
illnesses that are particular to children, in general, the children's 
population in this country tends to be very healthy. And if you provide 
a modicum of health insurance and a modicum of prevention on top of 
that population, they are going to be even healthier still.
  So States that cover adults as well as children, if a State is not 
covering all of the children that it could cover under its S-CHIP 
program, perhaps it's not a good idea to be covering adults, non-
pregnant adults. Pregnancy should rightfully be covered under an S-CHIP 
program.
  And, in fact, Mr. Speaker, there are four States that cover more 
adults than children. And I do hope we will look at this when we take 
up our S-CHIP reauthorization in our Energy and Commerce Committee, in 
the Subcommittee on Health, I certainly hope we will look at that.
  One of the ongoing arguments with the Children's Health Insurance 
Program is, do we tend to drive out the private sector by the State 
taking on the burden of insurance children whose parents make too much 
money for Medicaid but not enough money to provide them health 
insurance.
  If an individual has insurance through their employer, but they 
cannot afford the dependent coverage that the employer offers, and 
therefore don't take advantage of that dependent coverage that the 
employer offers, we should allow the flexibility for S-CHIP funds to be 
used to purchase that, or at least buy down the cost of that dependent 
coverage. We'll leverage our S-CHIP dollars so that they go so much 
further if we will do that.
  Indeed, we heard testimony in a hearing the other day from an 
individual who said that as much as 10 percent of a State's S-CHIP 
funding may be used for so-called premium support. And if that is the 
case, I think we need to, but most States find that that is a program 
that is not well subscribed to. So we need to get that information out 
there. And if we need to make more dollars available for that type of 
premium support, then, indeed we should do that.
  Now, that's not going to take care of all the problems within S-CHIP, 
but we certainly don't want to crowd the private sector out with a 
Federal program or a State program because there is value, I believe, 
in keeping the private sector involved and invested in providing health 
care for children.
  A number of other things we could do during the authorization of that 
bill, it's a great opportunity to perhaps expand some of the health 
information technology that everyone talks about but no one ever seems 
to be able to get done, and the opportunity for providing some 
demonstration projects in, say, two or three States, a large State, a 
small State and one somewhere in between might provide us some of the

[[Page 12363]]

background, some of the tools, some of the data that we need to be able 
to make rational decisions when it comes to health information 
technology, and to also get some of the advantages that's going to come 
from a well-functioning information system that provides almost 
instantaneous feedback on what things are working, what things aren't, 
where can we best spend our health care dollars so we maximize the 
return on the taxpayers' investment.
  These are just a few things that I hope we'll take up when we have 
the opportunity to look at that bill in committee. It will be of 
necessity. That has to be reauthorized before the end of the fiscal 
year, and I feel certain that Congress will do that.
  Federally qualified health centers I've already referenced. We did do 
the reauthorization last year, but that did not get completed before 
the end of the 109th Congress. I trust that we will take that up again 
this year. That is an important program that does provide a medical 
home and does provide an insurance equivalent to 15 million Americans. 
15 million uninsured individuals actually have a medical home and 
continuity of care and identified provider through a federally 
qualified health center.
  And one of the things that we talk about, relief of mandates on 
private insurance, one of the things that always gets my attention is 
that we seem to have so much difficulty when we sit down and talk. And 
we saw this last year in our Health Subcommittee. When a bill was put 
forward to allow insurance companies to sell insurance that didn't have 
all the mandates that some States will put on an insurance policy, and 
we had a dreadful fight about that one, it went late into the night. 
And a lot of hard feelings were expressed during the debate on that 
bill.
  But the fact is, not in this Congress, not in the last Congress, but 
several years ago, Members of Congress came together and agreed on the 
types of benefits that should be covered in a basic package, and those 
benefits are the benefits that are mandated to be covered under a 
federally qualified health center. Any community that wants to petition 
for a federally qualified health center will have to show that they are 
going to provide at least this level of care for an identified number 
of illnesses or ailments.
  And it seems to me, if we could extrapolate that experience from the 
federally qualified health center legislation that, again, is almost 35 
years old, if we could extrapolate that cooperation that had to have 
been required to get that legislation up and moving over 3 decades ago, 
perhaps we could come together on the basic package of benefits that 
should be available in an insurance policy that's going to be sold in 
the private market.
  I have trouble understanding that a private insurance company would 
not look at 46 million people as potentially market share if they had a 
product that people could afford to buy. And I do think that's one 
thing that this Congress does need to take up.
  Health savings accounts I've already talked about. There are some 
additional improvements that we can make to health savings accounts, 
although they have been improved significantly in 2003 with the 
Medicare Modernization Act.
  The HSA, the so-called flexible spending account or the health 
reimbursement arrangement that an employer may provide, a flexible 
spending account of course is money that an employee may sequester, 
pre-tax, and use that money on health care expenditures, but if they 
don't use it by the end of the year it goes away. It disappears, the 
so-called use it or lose it phenomenon.
  Similar situation with the health reimbursement arrangement. If an 
employer is willing to provide additional dollars to take care of an 
employee's health care, why not allow those dollars, if they're not 
used at the end of the year, to become a part of that employee's health 
savings account, to become part of that medical IRA, to be able to grow 
over time?
  We already heard the previous speaker reference Einstein's comment 
about the miracle of compound interest. And this is exactly the type of 
power that we could tap into if we were to be able to increase the 
amount of money that either the employee or the employer could put into 
that savings account that will be dedicated exclusively for that 
person's health expenditures.
  Some of the other improvements that we could make in health savings 
accounts would be allow individuals to purchase their health savings 
account with pre-tax dollars. That would leverage so much more, the 
purchase of so much more insurance, even for someone in a relatively 
modest 15 or 20 percent tax bracket. They'd still be buying their 
insurance with 80-cent dollars, and that means that their insurance, 
that part of their budget that they allow for insurance, would go a 
great deal farther.
  Perhaps we could allow early retirees to pay some of their continued 
premiums out of money they've saved in a health savings account. There 
is lots of flexibility that we could build into the program, and I 
believe that we've only just started to tap into the power that is 
available, the power that we can put in the health care consumers hands 
to be able to provide for themselves and their families with this type 
of insurance.
  Again, I had a medical savings account when they first became 
available back in 1996. The reason I did it wasn't because I got to 
have an additional IRA, though that was a great benefit. But the main 
reason I did it was because it left me in charge of health care 
decisions. I didn't have to dial 1-800-California and talk to an HMO 
director somewhere. I was in charge of the expenditure of those medical 
dollars, and I made the decisions for myself and my family. And 
realistically, that is a lot of power that we should put back in the 
hands of the health care consumer.
  Well, a lot of the things that we've talked about so far, about the 
public and private, the creative tension, if you will, that exists 
between the public and private aspects of providing for health care in 
this country. But one of the things that I've referenced before, and I 
think we do need to spend a few minutes on, is we've got to be careful 
we don't put the cart before the horse, because if we are not careful, 
this country could face a significant shortage or a significant crisis 
in manpower, in physicians, in nurses, in other health care providers, 
other people that we rely upon to give us the health care that we need 
when we need it.
  We need to ensure that doctors in practice today, those at the peak 
of their clinical abilities, aren't driven out of the system by 
decisions that we make here in this Congress. And we need to make 
certain that the best and brightest that are in training programs now, 
and those that may be looking at going into medicine or nursing as a 
career, that we don't, because of our decisions in this Congress, that 
we don't drive them out of, we don't drive them away from their career 
goals.
  Now, about a year and a half ago, Alan Greenspan, just before he 
retired as the Chairman of the Federal Reserve Board, was talking to a 
group of us one morning and talked about, someone asked him a question 
about the, being able to afford Medicare in the future. And he said, 
yes, he was concerned about that. But he felt certain that when the 
correct time came, Congress would deal with how to pay for Medicare.
  He said, what concerned him more was, is there going to be anyone 
there to deliver the services when you want them. And those were words 
that really stuck with me, because I'm afraid if we don't take some 
steps to acknowledge and encourage the health care work force in this 
country, we may find we get to that point where a substantial number of 
baby boomers have retired and we face manpower shortages, and then it's 
going to be very difficult to deal with the situation. So I do 
encourage us in this Congress, just like the President said when he 
talked about Medicare. It's too important to wait for another Congress. 
We need to take up those issues in this Congress and deal with them.
  Now, perhaps one of the most striking things that we have to deal 
with

[[Page 12364]]

every year since I've come to Congress is in the Medicare system we get 
toward the end of the year, and physicians in part B of Medicare face a 
5 percent pay reduction. And every year, they become very concerned 
about that. And every year, except 2002, we've come in at the last 
minute and done something to help.
  Now, it may be nothing more than just holding off the cuts for that 
year, but we come in at the 11th hour and do something to help.
  Last year, in an effort to prevent that from being an 11th hour 
decision, I introduced a bill, 5866, to do away with the formula under 
which physicians are paid. And not to go into too much detail, Mr. 
Speaker, but when you look at Medicare part A, part C and part D, 
hospitals, HMOs drug companies, each year get, if you will, a cost of 
living adjustment, a market basket update that increases the 
reimbursement for each of those three entities.

                              {time}  2215

  Physicians, for whatever reason, are treated differently, and there 
is a finite number of dollars allocated for the part B expenditure; and 
the more people who put claims in against that finite number of 
dollars, the thinner the slices of pie are that are ultimately 
distributed to the providers.
  So Congress's attempt many years ago to control Medicare expenditures 
by controlling volume and intensity of services has created this 
system, which every year causes a significant amount of strife not only 
for Members of Congress, not only for practicing physicians, but just 
tension in general in the medical profession that, since Congress 
doesn't value the work that we do, maybe we ought not to work for 
Congress any longer. And I hear that frequently when addressing groups 
of physicians. And, of course, this time of year, Mr. Speaker, as you 
know there are a large number of physician groups through town.
  So last year I introduced 5866 that said let's do away with the SGR; 
let's replace it with the Medicare economic index. That is not some 
formula that I was smart enough to think up. That is basically a market 
basket index, a cost-of-living update that would occur for expenditures 
under part B of Medicare. And this formula was worked out by the MED 
PAC folks many, many years ago. And a lot of physicians asked why we 
don't use the Medicare economic index. The main problem with going from 
the SGR to the Medicare economic index is it scores as an extremely 
high expense when the Congressional Budget Office looks at the bill and 
says this is how much it costs to do it. In fact, last year when I 
introduced 5866, the cost of going from an SGR formula to the Medicare 
economic index minus 1 percent was about $180 billion, and it was just 
a bridge too far, a hill too high, and we didn't get that done.
  This year, for me, it is not just about looking at the Medicare 
payment problems but also looking at physicians at the beginning of 
their time in the workforce as well.
  But getting the Medicare payment policy right has to be one of the 
main pillars, one of the main things that we do to effect reform that 
stabilizes the physician workforce. So paying doctors fairly will 
increase the career of many physicians who will either opt out of the 
Medicare system altogether or perhaps seek early retirement, or you 
never know. They might run for Congress. But principles of the bill 
that I am introducing this Congress will eliminate the SGR, but it is 
going to eliminate it in 2 years' time rather than this year. And I 
know that is a point of contention for a lot of people, but the reality 
is we are not allowed to look at dynamic scoring.
  The Congressional Budget Office simply looks at a static model and 
tries to make predictions on the future with that static model, and by 
law we are not allowed to use dynamic scoring. And yet in the Medicare 
Trustees Report that I earlier referenced, 600,000 hospital beds were 
not filled in this country because of the things that doctors are doing 
in their offices, in their ambulatory surgery centers, in their 
outpatient imaging centers. These were dollars that were savings to 
part A; but, actually, the reimbursement for those was drawn from part 
B. So if we could somehow gather and collect and sequester those 
savings that are happening every day from part A and offsetting the 
cost of the ultimate repeal of the SGR formula, perhaps we could get to 
a number that would be much more workable.
  Additionally, there is the audit enforcement that has increased 
lately. The Inspector General of Health and Human Services came and 
talked to our Oversight and Investigations Committee earlier this year, 
and they talked about the dollars that they were recovering in various 
areas of Medicare. These dollars that are recovered were stolen from 
part B; so these are not dollars that go to the Department of Justice 
or the Department of Health and Human Services in some other form. They 
go to part B to offset the expenditure for repealing the SGR. And I 
think if we will collect and allocate and sequester those funds and use 
those against the scoring for repealing the SGR, within 2 years' time 
we should have a significant dollar amount to be able to use to offset 
the expense of the SGR repeal.
  Now, in the meantime, yes, it is necessary to protect physicians who 
are practicing against the cuts that are already programmed to happen 
in the SGR formula for 2008 and 2009, and I would propose voluntary 
reporting, voluntary health information technology upgrades, and if a 
doctor or medical group is willing to do that, they could achieve as 
much as a 6 percent bonus payment for those 2 years to offset the 
reduction in payment that would come about as a result of the SGR 
formula. But the reality is that if we don't put a premium on 
prevention, if we don't put a premium on timely treatment of disease, 
and if we continue to drive mature physicians out of the workforce, we 
are probably not going to get our best fiscal results with the Medicare 
program, not to mention our best medical results.
  Well, what about the other aspects of the physician workforce? What 
about graduate medical education? And currently we know we are going to 
need more physicians in primary care, OB/GYN, pediatrics, those 
specialties that are devoted to treatment of aging individuals. And it 
only makes sense to increase the number of residencies, particularly in 
or near communities where the need is the highest. So high-need areas 
with high-need physician specialties is something that we could bring 
together and allow hospitals that haven't previously offered a 
residency program the ability to do that.
  We know, for example, in Texas that a physician who trains is likely 
to practice within 100 miles of where that training occurred. We are 
losing Texas-educated medical students who are going to other parts of 
the country for their training and they are not coming back to Texas, 
and the same thing is happening in other States as well. In an effort 
to deal with that, if we were to allow medium-size hospitals to start 
up residency programs, provide some Federal grants and loans for these 
residency programs to start up, it would encourage physicians to be in 
practice in high-need specialties in medically underserved areas for 
those high-need specialties.
  Now, further expanding that to the younger individual who is perhaps 
thinking about a career in medicine, if we expanded the old health 
profession scholarship loan concept and provided loan forgiveness, 
provided tax forgiveness for individuals in medical school, in 
training, who are willing to go and serve after their training is 
complete in a medically underserved area in a high-needs specialty, and 
again, family practice, pediatrics, OB/GYN, and gerontology would be 
the specialties that immediately come to mind; so all three aspects, 
keeping the physician workforce of today involved and providing care to 
arguably that group of the population that is our most challenging, our 
senior citizens, providing help to physicians who are in training 
today, and providing some additional help for young people who are 
looking at medicine as a career but might be concerned about their 
ability to deal with the large number of dollars that they

[[Page 12365]]

would owe at the end of that training, to provide some loan forgiveness 
and some tax incentives for these individuals to, indeed, practice in 
medically underserved areas in high-need specialties.
  Well, I almost can't talk about reform in the Nation's health care 
system without at least talking briefly about medical liability reform. 
We have passed medical liability reform in both the 108th and 109th 
Congresses. We passed it, in fact, a couple of times in each Congress. 
And this medical liability reform, H.R. 5, that we passed in this 
Congress in my first months here, in March of 2003, was legislation 
that put a cap on noneconomic damages in medical liability lawsuits. 
Modeled after the 1975 Medical Injury Compensation Reform Act from 
California, this legislation was scored by the Congressional Budget 
Office as a savings of $15 billion over 5 years back in 2003 when this 
was first proposed by Congressman Greenwood of Pennsylvania. A savings, 
Mr. Speaker, and we held many hours to spend looking for savings that 
the Congressional Budget Office would allow us to credit against 
additional spending. Well, here was savings that we essentially just 
walked away from.
  Now, in my home State of Texas, we passed a medical liability reform 
in 2003 for the State of Texas that has been enormously effective in 
keeping physicians in the State. Previously, physicians were leaving 
the State. Keeping insurance companies providing the coverage in state. 
We had gone from 17 insurers down to two the year I first ran for 
Congress in 2002. And now we are back up to 13 and 14. And, most 
importantly, those insurance companies that stayed and those that have 
come back to the State have done so without increasing their rates. And 
over all, Texas Medical Liability Trust, my last insurer of record 
before I left my practice at the end of 2002, has dropped their 
premiums for their medical liability insurance by 22 percent since this 
law was passed in September of 2003. And mind you Texas Medical 
Liability Trust in the State of Texas was increasing my premiums by 20 
to 50 percent each year for the 3 years preceding 2003. So a real 
victory as far as providing some relief in medical liability premiums.
  The real beneficiary of this law when it passed has been the smaller 
or the midsize community not-for-profit hospital, and these hospitals, 
largely self-insured, have now found millions of dollars that have come 
back to their bottom line that they are able to use to reinvest in 
capital expansion, to pay nurses' salaries, exactly the type of thing 
that you want your smaller community not-for-profit hospital to be 
doing.
  So this is important legislation that passed in Texas. I have drafted 
legislation that essentially copies the Texas law. The Texas law was a 
little different from what we passed in this House that never got 
through the other body. The cap on noneconomic damages in the House-
passed bill, H.R. 5 in 2003, was a $250,000 cap on noneconomic damages. 
The Texas plan actually trifurcates the cap. There is a $250,000 cap on 
noneconomic damages in regards to the physician, a $250,000 cap for 
noneconomic damages for the hospital, and an additional $250,000 cap 
for a second hospital or a nursing home if one is involved. So basing 
off the Texas plan, I think, could give us at least room for discussion 
about how we might provide some stability, some fairness in our medical 
justice system in this country.

                              {time}  2230

  Other things that we have talked about in our committee, we have had 
hearings on concepts like arbitration and mediation, the concept of an 
early offer, where a medical entity, be it a doctor or hospital, could 
make an early offer to an injured party or a family that would put the 
reimbursement or the cash in the hands of the person who is injured 
much more quickly. The current system that we have doesn't do a good 
job of delivering dollars to people who are injured. And the time it 
takes, average 8 years time, between the injury and the time of any 
payment or any settlement is further injury to the person who has 
already suffered something.
  Now, we do need to look at how we structure reporting to the National 
Practitioner Data Bank if we were to have the concept of an early 
offer. But again, it's something we talked about and had testimony 
about in our Subcommittee on Health and I think is something that is 
worthwhile for us to consider.
  One of the other things that I just want to bring up because it is so 
important, we passed the Deficit Reduction Act in December of 2005. A 
lot of stuff has been written about the Deficit Reduction Act, but one 
of the little noticed things about the Deficit Reduction Act was it did 
allow of State Governors a good deal more flexibility to do things 
within their State if they thought they had a plan that would provide 
more people with insurance coverage. And of course the prototype is the 
Massachusetts plan that has been talked about so much. And I recognize 
that there are plenty of things that you can talk about in 
Massachusetts that would not extrapolate to my home State of Texas, but 
still it is a significant feat where a Republican Governor working with 
a Democratic legislature and State senate could get this legislation 
through. Now, the proof is going to be in July, when the program 
actually takes effect and we will see how well it works. But you have 
also seen California and Governor Schwarzenegger talk about providing a 
similar sort of plan in his State. Jeb Bush, before he left office in 
the State of Florida, had additionally a plan for covering more people 
and providing people more coverage with the dollars that were being 
spent under the State's Medicare program; again, all because of the 
flexibility that was brought by the Deficit Reduction Act.
  We recently saw in Illinois where a bold attempt at universal 
coverage did not pass the State legislature. And there I think the 
issue was largely because of the gross receipts tax and not so much the 
health care aspects. But nevertheless, many States are tentatively 
trying to see if there may be some system that works better in their 
State. Again, the one-size-fits-all philosophy may not be in the best 
interest of every citizen in every State.
  The States taking the lead in crafting new approaches I think are 
reasonable attempts, and I think these are attempts that should be 
encouraged by this Congress and not discouraged by this Congress.
  Mr. Speaker, I realize that the information that I've been talking 
about tonight, some of it is technical and complex, some of it is 
confusing, there are some topics that some people do not even want to 
think about, but we are in a debate this year, next year, the year 
after that will forever change how health care is delivered in this 
country. The decisions we make in this body over the next 12 months, 36 
months time are going to affect the health care of our children, of our 
children's children. And it is important to talk about it, it is 
important to debate it and it is important to get it right. We must 
understand the things that are working in our system and the things 
that are not. Fix the things that are not, and encourage the things 
that are working.
  The only way, I believe, is to keep the public private partnership 
that has developed in this country since the end of the Second World 
War, to keep that working for providing health care for the American 
people; plenty of places where it can be improved, and we are obligated 
to work on those improvements. But to simply scuttle the system because 
someone thinks they have a different idea, well, we saw what happened 
back in 1993, the enormous upheaval that happened in this country where 
people really got concerned about whether or not their doctor would be 
there and able to see them if they got sick. We want to reassure the 
American people that, indeed, their doctor will be there, their 
hospital will be there. And keep the thriving private sector, keep the 
growing public sector and allow that creative tension that exists 
between the two to expand coverage for more Americans, and most 
importantly, so that we keep it affordable for our children, our 
children's children and into the future.

[[Page 12366]]

  Mr. Speaker, it has been a long day. Many of us traveled today. And I 
appreciate your indulgence. I am going to yield back whatever time is 
remaining.

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