[Congressional Record (Bound Edition), Volume 155 (2009), Part 11]
[Senate]
[Pages 14721-14724]
[From the U.S. Government Publishing Office, www.gpo.gov]




                           HEALTH CARE REFORM

  Ms. KLOBUCHAR. Madam President, the time for health care reform is 
now. We cannot afford to wait any longer. For some time, Peter Orszag, 
now President Obama's Budget Director, has warned that rising health 
costs are unsustainable and represent the central fiscal challenge 
facing the country.
  At $2.4 trillion per year, health care spending represents close to 
17 percent of the American economy, and it will exceed 20 percent by 
2018 if current trends continue. Hospitals and clinics are also 
providing an estimated $56 billion in uncompensated care. Meanwhile, 
businesses are squeezed on the bottom line, forced to reduce or drop 
health coverage for their employees. Without action, costs will 
continue to rise and waste will proliferate.
  We need to make health care affordable for everyone, and we need to 
reduce the waste and fraud that plagues the current system.
  To my colleagues who are conjuring up reasons not to pass reform this 
year, using scare tactics about nationalized health care and engaging 
in fear mongering, I say we cannot stay where we are. We cannot stay 
where we are. They must be getting different mail than I am. I am 
getting mail, and I am getting people coming up to me all over the 
State. Even though our State has some of the most affordable health 
care in the country, people know their money is being spent in other 
States that are not as efficient. They know health care coverage when 
the economy is tough is very difficult to come by, and that is what 
they are coming up to me and talking about. They are not saying let's 
stay the way we are. They are saying reform this system.
  In 2008, employee health premiums increased by 5 percent, two times 
the rate of inflation, and the annual premium for an employer health 
plan covering a family of four averaged nearly $12,700.
  Families cannot continue to bear the burden of runaway health costs. 
If we do not act, these costs are going to break the backs of the 
American people. We must remain committed to enacting a uniquely 
American solution to our Nation's health care problem. We must keep 
what works and fix what is broken.
  As Congress prepares to take up landmark health care legislation, 
many in Washington are looking to my State, the State of Minnesota, as 
a leader. Among them is the President of the United States. President 
Obama has provided leadership and vision on this issue, and in a recent 
weekly radio address, he has highlighted how the Mayo Clinic and other 
innovative health care organizations succeed in providing high-quality 
care at relatively low cost. As he has said, we should learn from the 
successes and promote the best practices, not the most expensive ones.
  In Minnesota, the Mayo Clinic is not alone. Health partners Park 
Nicollet and Essensia Health are already among those working to deliver 
the best health care at the least price. At 92 percent of the State 
covered by some kind of health care insurance, Minnesota has a strong 
history making sure the health care system promotes both quality care 
and access--92 percent coverage.
  Minnesota, Washington, Wisconsin, Iowa, Utah, and North Dakota are 
just a few of the States that can help provide leadership to help 
Congress and the administration as we work to develop a quality 
integrated health care system that reduces cost to the taxpayer and 
improves health care outcomes.
  It is no coincidence that as we speak, the President is in Wisconsin, 
another State that understands to have high-quality care, you do not 
necessarily have to have high prices. In fact, it is the opposite.
  I will distill this cost issue into some understandable language. I 
grew up watching the Minnesota Vikings. Year after year, our State has 
waited for the Vikings to win the Super Bowl. We have been to the Super 
Bowl four times, and we have never won the Super Bowl. All during that 
same amount of time, the people of our country have been waiting for 
health care reform. They have been waiting for something to happen to 
make health care more affordable. The people of this country cannot 
wait any longer. We might be able to wait on the Vikings; the people 
cannot wait any longer.
  The importance of Minnesota's best practices can be outlined in a 
game plan for national health care reform with a few key pointers: 
rewarding quality, not quantity; promoting coordinated, integrated 
care; and focusing on prevention and disease management.
  We are never going to be able to move the ball for that next first 
down unless we start talking about costs; otherwise, we are simply 
going to have different people pay for the same expensive health care 
but not do anything to reduce the cost.
  First, our game plan for health care reform to reduce costs is to be 
sure to keep score. That means measuring outcomes and rewarding 
providers who deliver quality results. Right now in many places, we are 
not getting our money's worth from our health care dollars. In Miami, 
Medicare spends twice as much on the average patient as it does in 
Minneapolis, even though quality is much better in Minnesota--twice as 
much.
  If we look at this chart, we will see that the areas in dark blue are 
the higher spending regions of the country. They receive the lion's 
share of Medicare payments. The light blue areas--States such as 
Minnesota, Montana, and Iowa--are areas where Medicare spending is low 
but quality of care is often high.
  In a recent New York Times article, some explained these differences 
in spending as they were trying to explain how can this happen that you 
have twice the Medicare, twice the taxpayers' dollars for the same kind 
of medical treatments as you would in another part of the country. Some 
said it is a difference in cost of living, sicker people, more teaching 
hospitals. But research shows those factors only explain 18 percent of 
the variation in spending.
  It is no surprise. Most health care is purchased on a fee-for-service 
basis, so more tests and more surgeries mean more money. Quantity, not 
quality, pays.
  According to research at Dartmouth Medical School, nearly $700 
billion per year is wasted on unnecessary or ineffective health care--
$700 billion per year. That is 30 percent of total health care 
spending. So to my colleagues who are fear mongering and saying we 
should do nothing, I say how about $700 billion, 30 percent of total 
health care spending that we have the opportunity to change around to 
benefit the people of this country?
  Just look at this fact, if you want to look at quality care. The Mayo 
Clinic

[[Page 14722]]

ranked as one of the highest quality institutions in this country. If 
you look at the last 4 years of the lives of chronically ill patients, 
some of the most difficult times for people in this country, an 
independent study from Dartmouth came out after they looked at what the 
Mayo Clinic did. They have a team of doctors working together with 
quality ratings incredibly high. Then they looked at what was going on 
in other regions of the country.
  If all the hospitals in this country used the same protocol that Mayo 
Clinic used in the last 4 years of a patient's life, where the quality 
rating is incredibly high, we would save $50 billion every 5 years in 
Medicare spending--$50 billion.
  So, no, I don't think the answer is just to throw away health care 
reform and do a lot of fear mongering. I think the answer is to work 
together to bring this kind of cost savings to the rest of the country.
  There is general consensus that Medicare should reward value, and 
value consists of both quality and efficiency. However, value is not 
taken into account when Medicare determines payment for providers.
  To begin reining in costs, we need to have all health care providers 
aiming for high quality, cost-effective results. That is why I plan to 
introduce legislation with Senator Cantwell and others that would 
authorize the U.S. Health and Human Services Secretary to create a 
value index as part of a formula used to determine Medicare's fee 
schedule--paying for value. This indexing will help regulate 
overutilization because those who produce more volume will need to also 
improve care or the increased volume will negatively impact fees. You 
have to have those incentives in place in how you do the payments or 
you are never going to reduce costs.
  In adding a value index, my bill would give physicians a financial 
incentive to maximize quality and value of their services instead of 
volume. Linking rewards to the outcomes for the entire payment area 
creates the incentive for physicians and hospitals to work together to 
improve quality and efficiency.
  I am also interested in the idea that the President has proposed to 
give increased consideration to recommendations made by the Medicare 
Payment Advisory Committee, MedPAC, a commission created by a 
Republican Congress. MedPAC's recommendations for payment reform 
include bundling, which has potential significant cost savings. Giving 
the recommendations made by experts increased authority could be a 
valuable tool to help rein in health care spending and improve quality 
in a responsible way.
  So the first part of our game plan for reducing costs for health care 
is focusing on value. The second part of the game plan for making 
health care more affordable is to focus on teamwork.
  Understandably, patients like it when their health care providers 
talk with one another and even work together. This means higher quality 
care, as well as more efficient care. In too many places, however, 
patients must struggle against a fragmented delivery system where 
providers duplicate services and sometimes work at cross-purposes--an x 
ray here, an x ray there, an expert here, an expert there. It is like a 
football team with 11 quarterbacks but no wide receivers, no running 
backs and no offensive line. This does not work in football, and it is 
not going to work in health care.
  The beauty of integrated care systems is that a patient's overall 
care is managed by a primary care physician in coordination with 
specialists, nurses, and other care providers as needed. It is one-stop 
shopping. In our rural communities, critical access hospitals utilize 
this model and provide quality health care for residents in their 
community with a team of providers.
  To better reward and encourage this collaboration, we also need to 
have better coordination of care and less incentive to bill Medicare by 
volume. Increasing the bundling of services in Medicare's payment 
system has the potential to deliver savings and start encouraging 
quality, integrated care.
  When it comes to improving care, changing who pays a doctor will make 
no more difference. The lesson of high-quality, efficient States such 
as Minnesota and Wisconsin is that someone has to be responsible for 
the care of the patient from start to finish, from one goal line to the 
other. Bundling will ensure that practice is rewarded.
  This is a very interesting chart. It does not look interesting, but 
it is. A lot of people think the more you pay, the better quality care 
you get. This was a MedPAC analysis of county level fee-for-service 
expenditures, a national study.
  Do you know what they found? They found that those areas of the 
country, those counties that had low utilization--in other words, maybe 
someone called a nurse line or a doctor referred them to one specialist 
instead of them going to three on their own--they found they had the 
highest quality care. Why is that? It makes sense. You have one primary 
doctor who knows exactly what is going on, is checking your charts and 
can send them to one specialist so mistakes are not make. You go to one 
specialist who does not know you are taking a certain medication and 
you are allergic to another. High-quality care with low utilization; 
lowest quality care with high utilization.
  That is probably the opposite of what most people in this country 
think. But, literally, you get the highest quality care in those parts 
of the country where you are paying less money.
  As I said, if people start to say our area of the country is so 
expensive, only 18 percent of that difference with the high-quality, 
low-cost States and the low-quality, high-cost States can be attributed 
to cost of living.
  Research has shown that moving toward a better integrated and 
coordinated delivery system would save Medicare alone up to $100 
billion per year. So if people don't want to talk about reform and they 
want to make a bunch of fear-mongering statements, let them explain to 
the American people why we are not going to save $100 billion per year.
  Finally, the last game pointer is that the best offense is a good 
defense. My dad covered football his whole life for the newspaper, and 
this is what he would always say to me: It works on the football field 
and it works in health care. It is a lot better for both the patient 
and the patient's pocketbook if a chronic medical problem can be 
prevented or managed early to stave off complications and the need for 
costly care. Right now, physicians are paid to treat diseases, not 
prevent them. Yet a payment system that encourages prevention and 
disease management could generate enormous savings because a large 
portion of health care spending is devoted to treating a relatively 
small number of people with chronic medical conditions.
  Let me give an example of this. This is Health Partners, which is a 
clinic in Minnesota--all over our State. A lot of patients are members 
of it. They started looking at how can we do a better job with 
diabetes. They did this back in the fourth quarter of 2004 compared to 
the fourth quarter of 2008. You see here an increase in quality for the 
patients, an increase in percentage of patients with optimal diabetes 
control, because they put in some practical protocols.
  What do you see with costs? You see an actual major decrease in the 
cost per patient. That is the green line. The yellow line is an 
increase in the patients with optimal diabetes control, as the doctors 
determined. The green line is a decrease in cost. The red line is 
patients with diabetes who had asked that they recommend Health 
Partners clinics. So even as they saw this dramatic reduction in cost, 
they were still on the up in terms of recommending using Health 
Partners clinics. Most people don't like their HMOs very much. They 
always have reasons to complain. So I think this is amazing that they 
were able to show this kind of result.
  At Park Nicollet in Minnesota, they have implemented a congestive 
heart failure program with Medicare. In the 3 years since the program 
began, Park Nicollet has saved nearly $5,000 per patient, per year.
  Diabetes, congestive heart disease, and back problems all contribute 
to

[[Page 14723]]

the excessive cost and growth in our health care system and cause 
decreased productivity in our economy. One study found that the most 
costly 20 percent of Medicare patients in a given year account for 84 
percent of total Medicare spending. By contrast, the least costly 40 
percent of Medicare patients accounted for just 1 percent of overall 
spending. As the examples from Minnesota and other places demonstrate, 
effectively managing these and other chronic illnesses is essential to 
health care reform.
  A recent New Yorker magazine article showcased the Mayo Clinic in the 
context of health care's cost conundrum.
  Madam President, I ask unanimous consent for 3 more minutes.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Ms. KLOBUCHAR. According to the author, a physician, we are in ``a 
battle for the soul of American medicine.'' On one side is a 
fragmented, volume-driven model that too often crosses into 
profiteering. There are good parts about our health care system, 
believe me. I know this because I live in Minnesota. We have to 
maintain those. But we have to fix this broken cost structure. On the 
other side, you see this model offered by Mayo and other peer 
institutions across the country where doctors collaborate to provide 
the best, most efficient care for their patients.
  On one side is more of the same, which is both financially and 
morally unsustainable; on the other side is a new direction that 
promises to curb cost while expanding affordable coverage. It is time 
to choose sides. For the sake of our fiscal health and for the sake of 
millions of Americans struggling to afford the care they need, I urge 
my colleagues to choose the latter.
  Yesterday, I met with a bipartisan group of Senators, and I have to 
tell you I still have hope that we are going to get this done and I 
have hope that there will be bipartisan support for this. What I am 
talking about today--cost reduction, putting these incentives in 
place--isn't a Democratic issue or a Republican issue. It is an 
American issue. This is an American cause, and we can find a uniquely 
American solution to this problem so that we can reduce costs and make 
health care better quality. I can tell you, having spent my entire life 
in the State of Minnesota and having a daughter who was born very sick, 
who couldn't even swallow when she was born, I know we can get high-
quality health care at lower cost. They do it every day in my State, 
and we can do it in the rest of the country.
  Madam President, I yield the floor.
  The PRESIDING OFFICER. The Senator from Arizona.
  Mr. KYL. Madam President, when it comes to health care, Republicans 
want reform that respects patient freedom and choice. We want to 
maintain the sanctity of the doctor-patient relationship. We believe 
doctors, not Washington, should tailor an individual's care. 
Washington-run health care would delay or deny care and would displace 
millions of Americans who are happy with their current health 
insurance. Federal bureaucracies are not known for being efficient, 
innovative, or hassle-free.
  On Wednesday, the majority whip said:

       Those who come to the floor of the Senate defending the 
     health insurance companies and saying they want no change in 
     the health care system have to defend the indefensible.

  Well, who exactly has come to the floor and said that? Who in the 
Senate has come to the floor and said they want no change? I know of no 
one who has done that. This is a straw man argument, usually made when 
you can't win an argument on the merits, but it has become a familiar 
refrain from some of our friends on the other side of the aisle. They 
present a false choice between doing what they want and doing nothing. 
When they don't want to listen to Republican ideas, they accuse us of 
wanting to do nothing. It happened with the stimulus bill, and it is 
happening now with health care.
  Republicans want health care reform. I have said this repeatedly, and 
so has Senator McConnell. I have noted that there are abundant problems 
in our current system, that a routine visit to the doctor can be 
surprisingly expensive. Too many people have to go without basic care 
for a host of reasons, whether they are unemployed or work for a 
business that doesn't have health care or perhaps have a preexisting 
condition.
  The task before us is to ensure that all Americans have access to 
quality health care without degrading the quality of care for anyone. 
In other words, those who are happy with their care--and that is the 
majority of Americans--don't want to have to sacrifice their care in 
order to take care of the problem of those who are having issues. And 
by access to care, I don't mean access to a government waiting list.
  There are two ways to approach health care reform while trying to 
keep costs in line. One, which President Obama says he rejects, is to 
create a competitive marketplace in which consumers get to pick the 
plan that works the best for their families. Competition helps the 
consumer. The more competition, the better. And this concept does not 
include a Washington-run plan.
  The other is for the government to ration care by deciding what 
treatments you can get and which medications you can have. Yes, you can 
cut costs this way, but it is not right, it is not what Americans want, 
nor is it what physicians want. The American Medical Association, an 
organization of 250,000 of America's physicians, said in a recent 
statement that it does not ``. . . believe that creating a public 
health insurance option for nondisabled individuals under the age of 65 
is the best way to expand health insurance coverage and lower costs.'' 
I agree. The doctors--those who provide the care--are concerned about 
what a Washington-run health care would mean for their patients and for 
the uninsured Americans who need to get in to see them.
  Republicans have been discussing the state of health care in Canada 
and the United Kingdom because those countries have government-run 
health care and they delay or deny treatment for many of their citizens 
in order to keep costs under control. The Canadian and British 
Governments created these systems with the best of intentions, but 
government-run care is not serving their citizens' needs, and we don't 
need to replicate their problems here in the United States. In fact, in 
Canada, Claude Castonguay, chair of the commission which recommended 
that Quebec establish a government-run system in the 1960s, declared 
last year that ``the system is in crisis''--his words. Private clinics 
are opening all over Canada at the rate of one per week to treat those 
who are on waiting lists at the public hospitals. Many Canadians who 
have the resources to get out of the bureaucratic government have 
chosen to do so.
  As the Republican leader pointed out today, Britain's National 
Institute for Health and Clinical Excellence--the entity responsible 
for setting guidelines on pharmaceuticals and treatments for British 
patients--last year denied patients in that country access to four 
kidney cancer drugs that have the potential to elongate patients' 
lives. The institute explained it this way:

       Although these treatments are clinically effective, 
     regrettably, the cost is such that they are not a cost-
     effective use of resources.

  A chilling statement, indeed. The stories of patients being denied 
treatment by their governments are real.
  President Obama and some of my colleagues in the Senate have argued--
as the majority whip has--that a public or a government-run option can 
compete with other insurers and that this government-run option would 
be only one choice of many. My question is, Why is it needed?
  And what will it do? Government-run health care would crowd out other 
insurers, quickly becoming a monopoly. I have cited these statistics 
from the Lewin Group, which has made this point. Someone who has 
insurance through his or her company could be forced into the 
government's plan if the employer decides it is simpler and cheaper to 
pay a fine to the government and eliminate its coverage. A

[[Page 14724]]

company might say: Why bother with the paperwork and administration 
when we can just pay a fine and tell people to get onto the government 
insurance rolls? As I said, that is what health experts say will 
happen. The Lewin Group I cited before has estimated that 119 million 
people will be shifted from a private plan onto a government plan if it 
is created. That would affect two-thirds of the 170 million Americans 
who currently have private insurance, all but ending private insurance 
in America.
  President Obama said recently:

       If we don't get this done this year we're not going to get 
     it done.

  Well, why is that? Why does that have to be so? Could it be because 
the President would prefer that we rush a bill through before Americans 
get a chance to absorb what Washington-run health care would mean for 
their families? If this is worth doing, it is worth doing right. It is 
worth taking the time to do it right.
  Americans are compassionate, and we want coverage for our neighbors 
just as much as we want it for our own families. But I will tell you 
that my constituents worry about the cost, and they do not want the 
Federal Government to cover others at their expense, both in cost and 
in the form of rationed care. So one of the first questions for this 
program is, How much is it going to cost and who is going to pay it? 
Another question is, What is going to be the effect on seniors who are 
in Medicare? Do they have anything to worry about? And my answer to 
that is, absolutely, because some of the conversation has to do with 
``reforming the way our seniors get their health care.''
  We haven't heard much about the exact price of government-run health 
care, but we know the cost will be extremely high. And whatever we 
spend, it won't be enough to ensure all Americans get the care they 
need. So when we begin talking about cost and being more concerned 
about the cost than the quality of care, as was the institute in 
Britain I just quoted, then we get into a situation where we are going 
to have to ration care, and that is something neither our seniors nor 
families with coverage today want at all.
  We need a real marketplace of options. Choice, freedom, and 
competition should be guiding principles for the health care reform we 
all want.
  I reiterate that Republicans as well as Democrats want reforms in our 
health care system. There are people who need coverage, and we all 
understand there are ways we can save money. The question is, Do we do 
this through more government control, more government bureaucracy, 
government-run insurance companies, fines on employers, and raising 
taxes in order to add 40 or 50 million more people to insurance rolls 
or do we try to achieve the results through removing barriers to 
competition which currently exist?
  Republicans have noted a whole series of laws right now that could 
either be reformed or repealed in order to allow more competition, in 
order to reduce prices for those already in the market and give 
patients more choice. I don't know why the resistance to this insurance 
reform. I don't know of anybody who likes the way insurance companies 
always do their business. I know I don't. So why not reform and enable 
those who would do it the way people want to have products that could 
be offered to the public and which presumably the public would buy if 
they are concerned about the way their insurance is currently being 
offered?
  So this is not a matter of one side wanting reform and the other side 
not; it is a matter of different approaches. And from my constituents, 
I can tell you they are concerned about what they have and they are 
concerned about what they are going to have to pay. As much as they 
want to help other people have the same kind of coverage they do, they 
don't want it at the expense of their families, by having care rationed 
to them and their families as a result of the fact that it would cost 
more money than we are currently paying.
  Madam President, I suggest the absence of a quorum.
  The PRESIDING OFFICER. The clerk will call the roll.
  The legislative clerk proceeded to call the roll.
  Mr. BROWN. Madam President, I ask unanimous consent the order for the 
quorum call be rescinded.
  The PRESIDING OFFICER. Without objection, it is so ordered.

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