[Congressional Record (Bound Edition), Volume 154 (2008), Part 4]
[House]
[Pages 4908-4915]
[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 as the designee of the minority leader.
  Mr. BURGESS. Mr. Speaker, it has been a long week. We have had a 
pretty tough legislative day today. It is springtime in Washington. 
Springtime brings lots of different groups to town; we saw farmers this 
week, we saw the firefighters, first responders this week, FEMA 
personnel this week. We also saw some of my friends at the American 
Medical Association this week, many of my friends from the Texas 
Medical Association. They came to Capitol Hill to discuss things that 
are important to them in health care. And, as I frequently do at the 
end of the day, I thought I would come down here and talk a little bit 
about health care. I like to call these little visits house calls.
  Now, prior to coming to Congress I was a practicing physician. I am 
still licensed; I am not insured. But in honor of my fellow physicians 
who are here in town this week, I brought a picture of a famous doctor. 
No, he is not a medical doctor; he is a physicist. This is Dr. Albert 
Einstein. But I thought we would have Dr. Einstein accompany me on this 
house call this afternoon. It is going to be a little talk about the 
role of healers, the role of physicians, the roles that perhaps they 
should play in health care reform in America.
  Now, Dr. Einstein did a lot of famous things. He did some things that 
were infamous as well. He is well known for a number of quotes, and one 
of my favorite quotes from Dr. Albert Einstein is, ``Insanity is doing 
the same thing over and over again, and expecting a different result 
this time.'' Of course, Dr. Einstein was right. And I wanted him to be 
with us today because that quote is a terrific theme for a little talk 
about how doctors and policymakers can together work on the things that 
should dictate health care reform in this country. So if you would, 
let's have a candid conversation

[[Page 4909]]

about health care, health care at the Federal level, health care at the 
provider level.
  Now, this is an election year in this country, a Presidential 
election year. It happens every 4 years. There is a lot of big 
discussions, there is a lot of big debates, and health care will be one 
of those big debates. There is a broad national recognition that reform 
is needed in health care. There is not a lot of consensus on how to 
achieve that.
  Now, every one of the Presidential candidates, those who are still 
active in the race, those who were active in the race and have since 
dropped out, everyone has or had their own ideas. It won't surprise 
anyone here to know that Members of Congress also have their own ideas.

                              {time}  1445

  Policymakers are focused on change. That is good. That is 
appropriate. And as we learned this week from visits from doctors of 
the American Medical Association, physicians are focused on change as 
well. And they must be because, after all, in this country health care 
begins and ends with doctors.
  Without our doctors, there is no health care. That means our doctor 
friends, the ones who are in town this week, have to be ones who take 
an active role in the process of transforming health care in this 
country. We need them to take a leading role in creating the road map 
on reasonable reform, to go from where we are now to where we ought to 
be.
  We depend upon our physician leaders because they are leaders and are 
proactive. They are not reactive. Think about it for a minute. When you 
are only in a reactive mode, what you end up with are basically band-
aid solutions. You think about the term death by a thousand cuts, we 
can call this death by a thousand scalpels because we were talking to 
doctors all week.
  You know, refusing to do something about liability laws in this 
country, putting the interest of trial lawyers ahead of patients, that 
is a cut. Let me give you an example.
  My home State of Texas, September 2003, we enacted sweeping liability 
reform as it affected the health care industry. We got fair medical 
justice legislation out of our State legislature. It required a 
constitutional amendment to go into effect, but it did pass under a 
vote of the people. As a consequence, now some 4 or 5 years later, 
Texas is seeing the benefits from passing commonsense legislation that 
limited the amount of payouts for noneconomic damages in medical 
liability cases.
  Because this Texas law has made such a difference in Texas, and let 
me give you an example, in 2002, the year I first ran for Congress in 
Texas, the number of medical liability insurers in Texas had dwindled 
from 17 down to two. You don't get much in the way of competitive 
bidding when you only have two insurance companies that are willing to 
write your business. But all the rest had left. The climate in Texas 
was so hostile that no one wanted to write insurance in Texas.
  As a consequence, you had good doctors who were simply unable to get 
insurance and stopped practicing. I met a young woman during one of the 
stops I made during my campaign in 2002 who was a radiologist, an 
interventional radiologist, highly trained, highly specialized, trained 
by the State of Texas, State-supported schools, so the taxpayers of 
Texas had paid for a portion of her education. And now 4, 5 years out 
in practice, she lost her liability insurance and was not able to get 
another carrier to pick her up. It was too risky. She couldn't practice 
without it, and she became a full-time mom, no longer practicing 
interventional radiology at a time I would argue when our health care 
needs are doing nothing but increasing.
  That was wrong, and the State legislature in Texas recognized that 
was wrong and got busy and changed it. They didn't come up with a new 
idea, they copied an old idea.
  In 1974, the State of California passed a sweeping set of medical 
liability changes called the Medical Injury Compensation Reform Act of 
1974. And with those caps on noneconomic damages, they were able to 
tamp down the premium increases that doctors had seen over time. And, 
indeed, when we passed that legislation in Texas, we have seen the same 
result. It does work and it should be tried in more areas.
  In fact, I have introduced legislation similar to the Texas 
legislation in the House of Representatives, H.R. 3509. This bill 
actually scores as a saving by the Congressional Budget Office. We are 
in our budget time in the springtime here in Washington. We are 
scrapping around for every dollar we can find to pay for Federal 
programs. Here is a gift I will give to Congress. It is a $5 billion 
gift this bill would save over 5 years as estimated under the 
Congressional Budget Office, and it does the same things on a national 
scale as the Texas legislature was able to deliver for their patients 
back home in Texas.
  One of the unintended beneficiaries of this whole process was the 
small, community-based hospital. The small, not-for-profit community 
hospital had to hold many hundreds of thousands, millions of dollars in 
escrow against a potential bad outcome, a bad event in a liability 
case. They have been able to back down those holdings and invest that 
money in just the things you want your community hospital to invest in, 
like nurses and capital investment. The result has been an expansion of 
medical care in Texas.
  Since that bill was passed, we had gone down to two medical liability 
insurers. We are now back up in excess of 20, and they have come back 
into the State without an increase in fees.
  My old insurer of record, Texas Medical Liability Trust, has reduced 
its liability premiums 22 percent in the aggregate since the passage of 
this law in 2003. Clearly it works.
  Remember, our Founding Fathers said that the States should act as 
great laboratories for the Nation, and things that work in States 
should be considered for use countrywide. And, indeed, this is one of 
the concepts that embodies that.
  The principles here on the chart are pretty straightforward. It does 
cap noneconomic damages in a medical liability suit, $250,000 per 
physician, $250,000 for the hospital, $250,000 for a second hospital or 
a nursing home if one is involved. It does allow for some periodic 
payment, and it allows for good Samaritan care. Very sensible, 
straightforward legislation. It is not a complicated bill, and it 
behaves as advertised. And that is one of the things in this Congress, 
we just heard a gentleman talking about solutions. Here is a solution. 
I offer it as a gift to the United States House of Representatives. It 
saves $5 billion over the next 5 years. Use that money somewhere else 
because in a $3 trillion budget, there are plenty of places you can 
spend money.
  Another place where we apply just a band-aid where we really need to 
do something major is in how we reimburse physicians for taking care of 
Medicare patients. They are taking care of our Medicare patients. 
Medicare is one of the largest deliverers of health care in the 
country, indeed the world. We have asked doctors to take care of our 
Medicare patients. They are some of our most complex patients. They 
have multiple conditions, multiple diseases, frequently on multiple 
medications, and we have asked the medical community since 1965 to 
provide care for these patients.
  What do we do in return? We passed legislation a number a years ago 
that reduces year over year the amount we reimburse for that care. That 
doesn't make any sense. Can you imagine a doctor, a small businessman, 
going to his banker with a business plan. He says I am going to expand 
my business and I have this business plan, and part of the business 
plan is I am going to make 10 percent less every year, year over year 
as far as the eye can see.
  Well, even back in the subprime days, no banker is going to make a 
loan on that type of business plan. How do we expect physicians across 
the country who are small business owners, how do we expect them to 
survive? And they certainly cannot thrive in that kind of an 
environment.
  We do this because we have created a condition called the sustainable 
growth rate formula. I have put it up on this

[[Page 4910]]

poster, and I am not going to go through this line by line. It is 
available on the Website of the Center for Medicare and Medicaid 
Services. But just to demonstrate the complexity of this formula and to 
point out that going through all of these calculations, the final line 
in this formula is that you go back to 1996 and capture all of the 
money that you should have saved and add it on at the end. It is a 
formula that is destined to fail over time. Until we in Congress 
recognize that this formula is destined to fail over time, repeal it, 
reverse it, revise it, get rid of it, stop the cuts, pay the doctors 
what they are owed, and get on with things.
  Currently in this country, we have Medicare divided into four parts. 
Each part is supposed to be an integrated member of the whole. We have 
Parts A, B, C and D. Part A deals with hospitalizations; Part B 
compensates physicians; Part C is Medicare HMOs; and Part D is drugs.
  Every part of Medicare with the exception of the physician payment 
receives a cost-of-living adjustment year over year. Part B is 
different. It is governed under the sustainable growth rate formula. So 
a hospital will receive ever-increasing amounts of compensation because 
the cost of inputs increases, because a drug company or HMO will 
receive an upgrade every year, year over year because the cost of doing 
business increases, physician reimbursement will decline over time. 
Clearly, that is unsustainable.
  I have a real problem here in Congress. I show this formula to any 
Member of the House of Representatives, although they recognize that 
patient access is a problem, physicians are in peril, although they 
recognize those features, this is very difficult to understand. This 
quickly goes into the ``too-hard box'' in someone's mind, and we are 
just not going to deal with it. But Congress must deal with this.
  An example of how we don't deal with it, last December we were right 
up against a deadline. Cuts were going to go into effect on January 1, 
so at the last minute we came to this House and we passed a bill that 
would delay these cuts by 6 months. What an insult to the practicing 
physicians in America. What an insult that this was all the time we 
would expend on this very important issue that affects virtually every 
aspect of their practice life.
  I say that because it is not just the Medicare reimbursement that is 
affected, but literally every private insurance company in this country 
pegs to Medicare. And so if Medicare does a 5 percent or 10 percent 
cut, guess what happens to Blue Cross/Blue Shield, United, on down the 
line. They will follow suit. Can't blame them for doing so, it is the 
market price. But as a consequence, this House of Representatives, this 
Congress, exerts wage and price controls over health care in this 
country that most of us here don't really have an understanding of.
  So last December we passed a 6-month delay on phasing in the Medicare 
cuts. We have to deal with that before the end of June. It is the first 
of April. Half of that time has been consumed. Half of that time has 
been squandered, and have we seen any meaningful effort in my 
committee, the Committee on Energy and Commerce, which has jurisdiction 
over Part B in Medicare? No, we haven't. We did steroid hearings, for 
crying out loud, on baseball players. This is the work we should be 
doing.
  We heard the other gentleman talk about solutions. Here is a solution 
we could wrap up and give to patients in America, and they would be the 
better for it.
  Now, one of the other things that happened in December which we 
didn't get done, and sometimes in a way it is a good thing that we 
don't get things done. We talk a lot about trying to bring the 
architecture and information technology in health care, to bring it on 
up into the 21st century. It is a difficult concept for a lot of people 
to understand. It is difficult for some people to understand why we 
don't just flip a switch and turn on a computer and make it happen.
  One of the bills that we saw come to Congress last December which 
didn't get passed was a bill that was going to mandate that physicians 
in the Medicare program use electronic prescribing.
  Conceptually, it is a good idea. I am a physician. I am left-handed 
and have bad handwriting. Every year older I get, my handwriting 
doesn't get any clearer. So e-prescribing will remove some of those 
problems. And yes, it could reduce error rates. And yes, it will 
immediately flag things like medicines that are in conflict with each 
other and allergies that a patient has.
  So it is a good concept, but what do we do with it here in Congress? 
We make it punitive. We come to the medical community and say here is 
our grand plan for e-prescribing. First of all, we give you $2,000 to 
invest in the infrastructure. Two thousand dollars; $2,000, do you have 
any idea how much these programs cost and how much it costs to buy the 
infrastructure and do the training? It is far in excess of $2,000. In 
addition to that, if you do this e-prescribing program, we are going to 
give you a 1 percent bonus over time for doing this program. But if you 
haven't done it in 4 years' time, we are going to come back with a $10 
penalty for every patient that you see.
  Well, a 1 percent bonus, that is better than nothing, but think about 
it for a moment. In my practice if I saw a Medicare patient, return 
visit, moderately complex, on a good day, if that was a $50 visit, they 
reimbursed $50, that would be a miracle in itself. But let's do it that 
way because it makes the math easy and I'm not good at math. So a $50 
patient visit. And if I am really moving and if I am really on my game, 
I can see four of those patients in an hour. So that is a $200 hour 
that I have put in in the clinic that morning. And we are going to get 
a 1 percent bonus for that. So for each of those four patients I saw in 
that hour, I am going to get an extra 50 cents. That is a $2 an hour 
increase. Well, that is not a lot when you think about all of the extra 
work that goes into maintaining and training for these e-prescribing 
programs.

                              {time}  1500

  But what if I don't do it, what's going to happen then? In 4 years' 
time, we're going to come back with a 10 percent reduction. What does 
that 10 percent reduction mean to that same hour of intensity, that 
same hour of work applied 4 years later? Well, a 10 percent reduction, 
instead of now a $2 increase, I get a $20 penalty for seeing those four 
patients but not using e-prescribing.
  If you couple that on top of the program, 10 percent cuts that are 
supposed to go in year after year, is it any wonder that when you pick 
up a phone and try to make a new patient appointment in a doctor's 
office, they say, I'm sorry, we're full, I'm sorry, we're not taking 
any new Medicare patients. And this is becoming a crisis for our 
seniors all because Congress will not do the work for our physician 
community and for our patients. And it's work we've asked our 
physicians to do. Since 1965, we have asked them to participate in this 
program.
  But let's stay on the concept of information technology for just a 
moment. And I will tell you, Mr. Speaker, I haven't always been a big 
fan of some of the advanced and higher information technology, 
electronic medical records. Yeah, those were good for someone else, 
maybe not for me. E-prescribing, I did it with a couple different 
vendors in my private practice. It never was all that it was cracked up 
to be. But in August of 2005, late August of 2005, I changed my mind on 
this subject. And I changed my mind on this subject because of a very 
harsh event that happened in America, and that was the passage of 
Hurricane Katrina over the City of New Orleans.
  And we all know the story there, the multiple breaches in the levees 
and the city flooded. And one of the consequences of that city flooding 
was the flooding of one of the venerable old health care institutions 
in this country, Charity Hospital in New Orleans. The basement was 
flooded for weeks. Guess what we have in our basements of our hospitals 
around the country? That's where we put our records. That's where we 
store these paper records.

[[Page 4911]]

  So, here is a visit. In January of 2006, we did a field hearing on 
one of my subcommittees on Energy and Commerce. We went down into the 
basement of Charity Hospital in New Orleans. The room had been 
dewatered. Prior to that visit, I didn't even know ``dewatered'' was a 
verb. The room had been dewatered, and here is the medical records 
department.
  Now, this black stuff that you see smudged on the charts, and these 
are rows and rows of medical charts, you can see the identifying 
patient numbers on the end, this black material smudged on the charts 
is not soot from a fire, it's black mold. That means that anyone who 
comes in here and pulls a record off the shelf is going to get a lung 
full of mold spores. And clearly, because of that hazardous condition, 
these records will never be accessed again. And of course you can 
imagine, this room was under water for weeks and weeks and weeks. The 
effect of salt water, brackish water on the ink that went to record 
these medical events, these records were likely unreadable even if 
someone had been willing to hazard the mold spores to pull one off the 
shelf. So, all of this data is lost forever.
  And we don't know what's in there. Perhaps a kidney transplant, 
perhaps a premature birth, perhaps just a well-baby check. Absolutely 
impossible to tell. This was so critical because when many of the 
people who left New Orleans after that storm, after the difficulties 
that were encountered in the aftermath, a lot of those individuals came 
to Dallas, Texas and they arrived on the parking lot at Reunion Arena, 
where they were to be triaged to receive health care if they needed, 
housing, start to get their lives back on track. There were many people 
who arrived there who actually had significant medical conditions. And 
it was very, very difficult to obviously go back and access these 
records that were, in effect, under water in the City of New Orleans.
  Now, there were some big chain pharmacies who arrived on the scene 
with a mobile truck. And using the information that they could download 
off their central computer system, from a patient's name and birth date 
they were able to recreate medicine lists. And I will just tell you, if 
you can get an accurate medicine list on a patient, a lot of times you 
can know a great deal about their medical history given the types of 
medications they were on. Or, if nothing else, here was verification 
that this was the anti-hypertensive that this patient needed, this was 
the type of diabetes medication that this patient was on. It 
accelerated care for these patients in an unbelievable fashion.
  And these two series of events made me a believer in electronic 
medical records. If you have an electronic medical record that stays 
with the patient, that follows the patient throughout life, that can be 
accessed by the patient, be accessed by that patient's physician if the 
patient gives permission. If you have that capability, that would have 
gone a long way towards the rapid reinstitution of medical care. For 
some patients who are, frankly, quite ill, not just because their 
underlying medical condition made them ill, but they were ill from 
spending several days in water up to their waists, or in the Superdome 
where they lacked air conditioning or lacked access to some of the most 
basic facilities for hygiene, these were patients in distress because 
of their medical condition and because of the conditions in which they 
had existed after the storm.
  So, how much better was it to be able to resume their care because 
there was the availability of at least a small amount of data that 
could be retrieved electronically. If a patient had their own medical 
record over which they had control, much, much more facile to be able 
to treat those patients in that type of situation.
  Now, we do hear a lot, here in Congress there are various bills and 
ideas out there, as far as how to get the health care community up to 
speed on electronic medical records or health information technology, 
as you frequently hear it referred to here in Congress. There was a big 
study done a few years ago by the RAND people. And in this study they 
talk about the billions of dollars, $77 billion, that can be saved over 
15 years if we go to an electronic medical record model. Now, that's a 
significant amount of money. And the study is a very meaningful one, 
very well thought out, very well constructed. Most people don't go much 
more deeply into it than that, but if you actually take the trouble to 
read the RAND study, if you look into it, most of those savings 
actually occur on up towards that 15th year of that study.
  Most of the investment in information architecture is going to be 
done on an individual basis and wasn't included in the cost or the 
benefit of the RAND study, so it skews the figure a little bit on the 
plus side because of that; no allowance for training, no allowance for 
maintenance. But, nevertheless, still they do show a significant 
savings available by going to electronic medical records.
  Their sum-up paragraph, the very last paragraph of the study, they 
say for this world to go away and the electronic world to occur, it is 
going to take incentives. And they talk about incentives that they must 
begin early, that is, you want to be sure and make that incentive 
available so that you don't penalize someone for getting in early, or 
more importantly, you don't reward a late adopter. So, the incentives 
have to be available early. And the time limit that the incentives are 
available, the time frames that the incentives are available have to be 
limited.
  But the final point, and the one that is always missed on the floor 
of this Congress, is the incentives must be substantial. I would submit 
to you that a 1 percent increase in a Medicare patient's compensation 
for an office visit for using e-prescribing does not fall into the 
category of a substantial benefit. And then, as we so often do here in 
Congress, we go on to add insult to injury by saying, if you don't do 
it, we're going to punish you. Here's a little carrot, but a big stick 
if you don't do what we've asked you to do.
  So, I do think that the day will come when we will see a great deal 
more adoption of electronic medical records. Some of the things I think 
we could do are: encourage the private sector, that is really light-
years ahead of the Federal Government on this, perhaps with a little 
relaxation of some regulatory regimens called the Stark provisions, 
perhaps with at least some definition of what privacy is and what 
privacy means so people have some certainty about the systems that 
they're developing. Maybe a little bit on the liability side. And true 
enough, ask something from the private sector in return. If it's an 
insurance company that's developing this model, make certain that the 
information itself is owned by the patient and may travel with the 
patient if they transition from one company to another, or if they 
transition from one employer and they go to individually owned 
insurance, make certain that that information is not lost in that 
transaction and the patient can control the information.
  But I do believe if we put some of our partisan differences aside, we 
could devise a scenario that would be conducive to the development of 
this type of technology. And again, as the gentleman who was talking 
before me kept talking about solutions, these are the types of 
solutions that the American people want to see us working on. Again, 
they're not really interested if we hold another hearing about steroids 
in baseball. They are interested if we can provide them this type of 
value in their doctor/patient interactions.
  Now, one of the other concerns that I have when you hear people talk 
about health care, and certainly when you hear people talk about it at 
the national scale, is, well, why don't we expand the Medicare program. 
Please be advised, in my opinion, the Medicare program, for all the 
good things that it does do, has enough areas of uncertainty around it 
that, number one, I don't think it is the type of program in which we 
want to be placing everyone.
  But going back to the SGR formula, I spent probably 40 to 60 percent 
of my week dealing with problems that are brought about by difficulties 
administered through Medicare, Medicaid,

[[Page 4912]]

SCHIP, all of the Federal systems that we have to provide health care 
in this country. We are not doing a great job.
  So, at this point, I don't see the value in rewarding the Federal 
Government by giving it a greater and greater share of health care in 
this country. And I would simply ask the question, does the private 
sector have a role to play in the delivery of health care in the United 
States of America? My answer to the question is yes. And, in fact, a 
long hearing that we had today dealing with Medicaid funding, if you do 
not have the private sector, you have no way to pay for Medicare and 
Medicaid because, let's be honest, Medicare and Medicaid do not pay the 
full cost of the care that's rendered. Hospitals, physicians and 
clinics across the country have to cross-subsidize their Medicare and 
Medicaid populations with money from their private practices, with 
money that they receive from the private sector.
  So, I would submit that the private sector does have a role to play 
in the delivery of health care in this country because, at the very 
least, right now we depend upon the excess payment from the private 
sector to fund the cross-subsidization for Medicare and Medicaid.
  One last thing about the physician's compensation let me talk about, 
because I've been very critical of the way the current majority, the 
current leadership handled the Medicare reimbursement at the end of 
2007, but I must say at the end of 2006, when my side was in charge, we 
didn't do a great deal better.
  We decided to provide a 1-1.5 percent increase in physician 
compensation if doctors were willing to undergo some quality reporting. 
Now, quality reporting generally would be thought of as a good thing, 
but again, the incentive was so low as to not cover the cost of 
collecting the data. And now, after the first year and a half of this 
initiative called the Physician Quality Reporting Initiative, started 
out life as PVRP, and then became PQRI, the results are pretty 
disappointing. Not that quality wasn't there, the results are 
disappointing because it wasn't worth the time of the doctors and 
clinics around the country to participate in the program. Almost 90,000 
physicians across the country could have participated in a reporting 
program for asthma patients, but, in fact, less than 100 did.
  Again, if incentives are going to work, if incentives are going to be 
worthwhile, they have to be meaningful. If you provide a meaningless 
incentive, then the person who is to receive the incentive says, this 
is information you really don't value, so I'll tell you what, I'm not 
going to bother with it, it's not worth it to me.
  Incentives will work; they will work if they're meaningful, they will 
work if they start early, they will work if they're time limited, but 
they must, above all else, they must be substantial.
  Now, again, I referenced earlier that a physician's office is nothing 
more than a small business. They need the resources to pay the 
overhead. We heard a very moving story today in committee of a 
pediatrician who practiced in Alabama. Her patient population was 70 
percent Medicaid, and she had reached the point in her practice where 
she wasn't covering overhead any longer; she had to borrow from her 
savings in order to keep her practice open. And from what she described 
to us, it sounded as if she had done all the things she could do to 
hold costs down in her practice, extended hours, hired physician 
extenders, she had a physician's assistant working with her. But the 
reality is, because the payment for Medicaid patients is so low for 
physicians, the result is, if they don't have a sufficient private 
population, again, to bring those earnings up, they're not going to 
make it. So, a practice that is 70 percent Medicaid in rural Alabama 
apparently can't make it paying the overhead and trying to keep the 
doors open for, again, the very critically ill patients, the 
disadvantaged patients, the patients that we in Congress have asked 
this doctor to take care of.
  It is disappointing, to say the least, it's a travesty, it's a 
tragedy, that a doctor in that situation will only be able to keep that 
up so long. There are only so many nights you can go home and explain 
to your family that, once again, you had to raid the retirement savings 
or raid the children's college fund simply to pay for operational 
expenses to keep the office open, because if you were doing that, bear 
in mind, that physician is not drawing a paycheck for those months 
either.
  So, it's difficult for doctors to build their businesses. It's 
difficult for doctors to pay their bills when the very policies 
developed on the floor of this House are so detrimental to the practice 
of medicine.

                              {time}  1515

  And if we can continue to accept these types of Band-Aid solutions in 
liability, in Medicare, in Medicaid, if we continue to accept those 
Band-Aid solutions, just like Dr. Einstein said, we're going to get the 
same results, or worse.
  Doctors are leaving Medicare as a result of some of the activities 
taken on by this country. It is time, it is time for this Congress to 
step up and do something new, try something new. I mean, 435 leaders, 
elected by their respective constituents across the country; 435 
leaders, we need to lead.
  We need to do the hard work, take a short-term, a mid-term and a 
long-term approach to these problems. And they're not insoluble. 
They're hard, to be sure. They're complex. They may require hours of 
work. They may require some hard bargaining and, at the end, they may 
require some compromise. But solutions are within our grasp.
  But when we do stuff like a 6-month Medicare payment fix, we do more 
than harm the physicians who we've asked to take care of our Medicare 
patients. We do more than harm our seniors who now pick up the phone 
and can't find a doctor who will accept their Medicare. We actually 
harm the very credibility of this institution, and we undermine the 
credibility of this institution when we take such short-sighted 
approaches to very significant national problems. And the American 
people, correctly, stand back and say, what's going on?
  And so is it any wonder that approval ratings of Congress are at 
historic all time lows?
  Well, to be certain, there are health care policy reform questions 
and goals that, over time, and with some thoughtful deliberation, can 
result in successes. But we're going to have some big questions we have 
to answer.
  And that's one of the fortunate things about being in the middle of 
an election year because these things now get elevated to a national 
forum; there's a national referendum, if you will, about the future of 
health care.
  We'll have really, I expect, some fairly different choices out there 
to make. We'll have to ask ourselves, how are we going to go through 
these changes and continue to value that interaction that takes place 
between the doctor and the patient in the treatment room? After all, 
that's the fundamental unit of production that occurs in this big, vast 
machine that we call American medicine.
  So how do we keep that relationship sacred? And what do we do that 
delivers value to that relationship?
  We're going to hear a lot of talk about mandates. We already have. We 
hear people talk about individual mandates, where every individual is 
required to buy health insurance. We hear things about employer 
mandates, where every employer is required to have health insurance.
  Do mandates work? Are they a good thing? Will they work in a free 
society? How do you force everyone to do what you think is a good idea 
and ought to be done?
  Well, it turns out it can be terribly difficult to do that, and the 
history of mandates is sketchy, to say the least.
  A very good article in Health Affairs, a magazine or periodical 
called Health Affairs last November, the title was Consider It Done, 
talking about mandates. We're there; we've reached the promised land 
and we're going to have mandates to require health insurance.
  But even in that article, as they go through the history of mandates 
in this country, certainly raises some valuable questions about whether 
or not mandates will ultimately work.

[[Page 4913]]

  And going back into the 1960s, there was the helmet law brought to 
motorcycle riders by this United States Congress. And the outcry was so 
severe when Members of Congress went home from their constituents who 
were part of the motorcycle riding community that they very quickly 
came back and said, well, that's a State's issue. We're going to repeal 
that at the national level and, Mr. State Legislator, you're going to 
have to deal with that; Governor, you'll have to deal with that as a 
problem, and States have over the intervening 40 years. Some States, my 
home State of Texas does not require a helmet. Some States do. But 
Congress very quickly found out that mandates can have some negative 
consequences.
  Well, can you get 100 percent compliance with a mandate? Some people 
argued that if the penalty for not complying is severe enough and well-
known enough, that you will, indeed, get near that 100 percent 
compliance. But think about it for a minute.
  We're just a few weeks away from April 15. We've all got to pay our 
income taxes. There's a mandate. Everyone is aware of the income tax 
law in this country. Everyone is aware of the Internal Revenue Service. 
Everyone is aware, they may not be aware of the specific penalties, but 
if they know that they don't do what they're supposed to do there is a 
very swift and sure penalty out there awaiting them from the Internal 
Revenue Service. And all of us know the story of Al Capone, who was 
arrested not for being a bootlegger and doing bad things to people, but 
arrested because he did not pay his income taxes.
  So you would think, with the mandate for paying Federal income taxes, 
that there would be near 100 percent compliance. But the reality is you 
get about 85 percent compliance. You get about 15 percent of people who 
decide not to follow the rules with the Internal Revenue Service.
  In fact, you'll hear us talk about it on the House floor, especially 
this time of year when taxes are due and we're talking about budgets 
and we're looking for more money. People on the floor of the House will 
talk about the tax gap, that is $300 billion, and if we had that $300 
billion we could do good and great things for the country. We have the 
tax gap because we have 15 percent of the people in this country who 
are willing to look at the penalties for not filing their income tax 
and say, you know what? I'm not going to file my income tax.
  How many people do we have this it country without health insurance? 
A lot. It's about 15 percent of the population. We have 300 million 
people in this country, give or take, probably more than that now. That 
figure's a couple of years old. And how many people do we have without 
health insurance? People argue about the number, but around 45 million, 
and that's about 15 percent of what our population is in this country.
  We already have that compliance, even without mandates. So are 
mandates going to take us to a higher level of compliance?
  And what do we give up in terms of freedom if we go down the road of 
mandates?
  But to me, more importantly, what's the flip side to mandates? If 
you're not going to have mandates, okay, well how are you going to get 
people to recognize that they should have health insurance?
  Well, one thing you can do is work on the affordability side because 
it's no question, if the bills get too high the employer's going to say 
I'm not going to provide insurance for my employees any longer because 
it becomes cost prohibitive. And if an individual looks at the 
individual market and says the cost is so high I'm not going to comply 
with it. So certainly the affordability side is a big part of the 
equation.
  But more importantly, it's creating problems that people want. It's 
creating programs that people recognize as delivering value back to 
their lives.
  And we do have a little experience with this over the past 5 years. 
We did, in a number of Medicare reforms in 2003, provide Medicare Part 
D, a Medicare prescription drug benefit. And there were those in this 
House who argued that this should be something that is mandated by the 
Federal Government and completely controlled by the Federal Government.
  There were others who argued that maybe it would be better to let 
companies compete with seniors for that business. And that was the 
argument that eventually prevailed. And as a consequence, we had, at 
the roll out of Medicare part D, we had complaints because there's too 
many choices; there's too many companies out there that are offering 
this, and I can't make up my mind. The cost ranges from $10 a month to 
$50 a month, and how in the world am I ever going to know what I'm 
supposed to do?
  But after some of the louder rhetoric died down and people began to 
look at these programs, indeed, these were programs that delivered 
value to a segment of the population who had never had an affordable 
prescription drug benefit available to them before and, as a 
consequence, the penetration with this benefit is extremely high in the 
Medicare population. And the overall satisfaction rate is also 
extremely high.
  So that's perhaps a model for us to consider when we talk about 
things about how do we provide insurance. We tell everybody you've got 
to have it, but there are going to be some people who just won't do it. 
We make programs that are affordable and that appeal to people, that 
people want. People want to be able to provide protection for their 
families. They want to be able to provide additional help if health 
care is needed in their families. So that would be another way to 
approach.
  One of the great privileges of serving in the United States House of 
Representatives, you occasionally get to go places or meet people that 
you otherwise may not have gotten to meet. And for me that hour came 
last fall when I had the opportunity to spend an hour with one of my 
heroes, Dr. Michael DeBakey down in Houston. Many people know Dr. 
DeBakey as a famous heart surgeon. He was also the individual who 
developed the Mobile Army Surgical Hospital that has been responsible 
for the saving of so many lives in our Nation's conflicts over the last 
50 years. Dr. DeBakey himself is going to turn 100 years old this year, 
so it was a phenomenal ability to talk with an individual who has 
witnessed and lived through and directed the last century of medicine.
  And many of the comments Dr. DeBakey made to me were similar to the 
same things that I wrestle with; how do you provide mandates? How do 
you require mandates in a free society? Wouldn't it be better to give 
people things, make available to people things that they would want and 
would willingly sign up for, rather than forcing them into individual 
programs that really might not appeal to them?
  One of the other things that Dr. DeBakey said to me that gives me, 
really gives me a lot of hope, really gives me a lot of optimism in 
looking forward to the future, because he said, Congress can do this. 
Congress is up to this task. And he said he knew that because when he 
was a young man, having just graduated from LSU, I'm sorry, graduated 
from Tulane down in New Orleans, Louisiana, as a young man, after 
graduating from medical school he had to go to Europe in order to get 
the credentials in order to be a research physician. Those credentials 
were not available to him at American institutions, so he went to 
France and Germany and did his study there in order to get the 
credentials to be seen as a credible researcher.
  But that changed in the 1940s, and it changed because of the efforts 
of Congress in funding research at the National Institutes of Health, 
and developing the types of programs that now allow America to be at 
the forefront of research across the globe. And scientists come here to 
train, come here to get those credentials, those same credentials that 
Dr. DeBakey had to cross the ocean to receive a half century ago.
  So he told me, Congress can do this and I know Congress can do this 
because they've done it in the past. They've tackled big things and 
they've come to the right conclusion.

[[Page 4914]]

  Well, I pray that he's right. I wouldn't be here if I didn't believe 
that he was right. But it is going to be difficult to do that.
  Now, I can't make all of these things happen by myself. And one of 
the reasons you're in Congress is because you want to work with others. 
Well, maybe that's not the reason you're in Congress. But nevertheless, 
Mr. Speaker, you're in Congress and you do work with others, as is the 
nature of this body. There's 434 other individuals who have to be 
consulted, whose vote has to be one before you're going to be able to 
see your policies become law.
  So I will just tell you one of the things I've learned. You can have 
the best ideas in the world, and you can have all of the enthusiasm and 
all of the energy required to get those things over the line, but if 
you don't have people working with you, if you don't have people 
helping you, it's going to be very difficult to get those things done.
  So I am very grateful, with the legislation that I have, to help 
reform the Medicare payment formula, the bill Number 5545, I do have 
help. I've got help now over in the Senate. I've got help from the 
doctors in the American Medical Association. And very important to me, 
I've got help from my doctors with the Texas Medical Association. And I 
think together we can get this work done.
  There's not a Member of Congress that I've talked to when I've asked 
them how things are going with their doctors back home who doesn't 
bring up the problems that their doctors bring in to them about the 
Medicare payment formula. So the groundwork has been done, and now it's 
up to us in this Congress to get that accomplished.
  And a little preventive medicine will go a long way, will go a long 
way in fixing some of these problems.
  And if you know that two trains are coming at each other down the 
track and it looks like tragedy's inevitable, what do you do? What does 
this responsible person do? Do they run down to the track and see if 
they can find the appropriate switch, or warn somebody off to avert the 
disaster? Or do you run home and get your video camera so you'll be the 
first one to get it up on YouTube? I would submit the responsible thing 
to do is to try to avert the disaster, and not simply document its 
destructive events.
  Mr. Speaker, as our time draws short and this week is going to draw 
to a close, let me just reflect on a couple of things from the last 
century of medicine. The last century of medicine I do feel I have some 
interest in, some ability to talk about that. My father was a 
physician. His father before him was a physician, so between the three 
of us, we pretty much occupied the last century in the delivery of 
health care.
  And over the last century, we saw some incredibly transformative 
things occur within the science of medicine, and we saw some incredibly 
transformative things occur at the social level, at the legislative 
level.

                              {time}  1530

  And you think back to what the state of medicine was coming into at 
the end of the first decade of the last century, what things were like 
coming up to 1910, medical schools across the country where the 
curricula was so varied. There was no standardization. The graduate of 
one medical school could be well-trained and the graduate of another 
medical school could be woefully inadequate.
  We were right upon the time of intense scientific discovery: 
Anesthesia was coming into its own, the ability to administer a blood 
transfusion, the knowledge about blood blanking was coming into its 
own. Immunizations, the whole science of immunology was just coming 
upon the scene. And at the same time, from Congress, a group of 
individuals were convened called the Flexner Commission. They came up 
with a report called the Flexner Report which called for the 
standardization of medical school curricula across the country, and 
that stabilization of medical school curricula allowed for the stable 
platform on which those scientific discoveries could be based and set 
the stage for some of the great scientific breakthroughs that were yet 
to come.
  And right around the corner, some 30 years later, we were engaged in 
the activities of the second world war. A scientist in great Britain 
had found an odd thing had happened when he grew a mold in a petri dish 
and it inhibited the growth of bacteria. And he had discovered 
Penicillin. That was 1928. But that was a little more than a laboratory 
curiosity. There wasn't really anything you could do with it on a 
commercial basis. There certainly wasn't any patient application for 
this until American scientists discovered in the 1940s how to produce 
this on a mass scale, the cost came way down, and the first antibiotic 
became commercially available, and relatively cheaply, to large numbers 
of people.
  It changed the course of things in the second world war. This 
happened right before D-Day. And think of the life and limb that was 
saved by the ability to fight inspection reliably for the first time 
with a chemotherapeutic agent.
  Also, around the same time, cortisone had been discovered earlier, 
but cortisone was one of those things that was very rare, very 
difficult to get. You obtained it at the slaughter house. Very, very 
labor intensive. A Ph.D. chemist, a gentleman that we honored in this 
House last Congress, Percy Julian, an African American scientist, found 
a way to extract cortisone from soy beans. Well, that changed the 
course. Suddenly this very potent anti-inflammatory agent became 
readily available in large quantities at a relatively low cost.
  On the social side in the 1940s, we saw some big changes in the 
practice of medicine because we were in the middle of the Second World 
War. President Roosevelt wanted to keep down trouble from inflation so 
he put wage and price controls in place across the land. Employers 
wanted to keep the few employees who were still able to work for them. 
They wanted to keep them coming to work. So they said, can we provide 
benefits to our employees since we can't raise their wages? Can we 
provide them benefits?
  The Supreme Court ruled that, indeed, did not violate the spirit of 
the wage and price controls. Those benefits could be given to 
individuals and, oh, by the way, they could be given with pre-tax 
dollars. And that set the stage for employer-derived insurance, and 
some people would argue it has given us some of the difficulties that 
we now encounter 60 or 70 years later.
  But nevertheless, in the 1940s we saw for the first time commercially 
available, large-scale quantities of antibiotics, anti-inflammatory and 
health insurance. And think about how the next several decades were 
changed.
  In the 1960s, we saw similar changes. For the first time we saw 
reliable drugs to fight hypertension become available. Anti-psychotics 
became available. Antidepressants became available. And in the midst of 
all of that scientific change, there also occurred a big change in that 
this Congress, or this House of Representatives, passed a bill that we 
now know as the Medicare bill.
  In 1965 when Medicare was enacted, for the first time the Federal 
Government had a large footprint in health care in this country, and, 
of course, it has grown significantly since that time in ways that 
probably most of the people who are on the floor of this House voted 
for that bill would never have imagined that it would spend in excess 
of $300 billion a year, but that's where we find ourselves now.
  Think of where we are now on just the beginning of the dawn of the 
21st century. The human genome has been sequenced. You can go on line 
and find a place that, for a little less than a thousand dollars, will 
investigate your human genome, will tell you your risk factors for 
diseases like multiple sclerosis, heart disease, diabetes, even being 
overweight. It's phenomenal to have that information literally at our 
fingertips. When I was a resident at Parkland Hospital in the 1970s, I 
never would have imagined that that type of information would be 
available to people so cheaply and so easily. I never would have 
imagined that there was anything called the Internet, but nevertheless, 
that information that could be so easily accessed.

[[Page 4915]]

  We are indeed at a transformative time in medicine in this country. I 
referenced information technology. Think of the speed of change of 
information technology, how things are progressing and evolving so 
rapidly that it really isn't reasonable to ask the Federal Government 
to keep up and moderate those changes. We need to depend on the private 
sector to do that because it's happening so fast.
  But as medicine is transformative, Congress, by its very nature, 
can't be transformative. We are transactional. We take money from one 
group and we give it to the next. That's what we do. We collect the 
taxes, we spend the money. Congress is inherently a transactional body. 
But Dr. DeBakey said Congress can do this; Congress can participate in 
the transformation of delivering health care in this country.
  Well, I thank Dr. DeBakey for his wise counsel. I thank the American 
Medical Association for being up here this week. It is not easy taking 
time away from their families and their practices and their practices 
to come here and interact with legislators such as myself and other 
Members on both sides of the aisle to help explain and help us 
understand some of the very complex issues that they face on a day-to-
day basis, yes, dealing with sick people but also dealing with this 
vast morass of regulations and rules that we lay at their feet every 
year.
  And most of all, I want the American people over this next year's 
time to focus on this grand debate that we are going to have at the 
national level. Your future is dependent upon it. Certainly your 
children's future and your children's children's future is dependent 
upon it.
  Think of the Congress back in 1965. It enacted Medicare and had no 
idea what it would be like 40 years hence. The same things apply today. 
The decisions we make on the floor of this body today, 30 and 40 years 
from now are going to look decidedly different. And I would say help us 
to make the right kinds of decisions so that the American citizens, 30 
and 40 years' time from now, will look back and say the 110th Congress 
stepped up and did the right thing.
  Mr. Speaker, it has been a long week, and with that, I am going to 
yield back the balance of my time.

                          ____________________