[Congressional Record (Bound Edition), Volume 155 (2009), Part 11]
[Senate]
[Pages 15347-15350]
[From the U.S. Government Publishing Office, www.gpo.gov]




                           HEALTH CARE REFORM

  Mr. JOHANNS. Mr. President, as the rhetoric over health care reform 
starts to heat up--and, of course, it has--I find myself trying to 
determine exactly what we are trying to accomplish with this debate. 
Are we attempting to put together what I think is the right approach--a 
bipartisan solution to a problem that is affecting every American 
family and business--or are we caught up in pushing something through 
this body with little deliberation and little regard for the 
consequences of our hurried action? And the consequences are great.
  I fear we are leaning toward the latter statement, based upon the 
time limits and the rush in the committees charged with producing very 
complex health care legislation. I do not envy them their task. I would 
argue that it is more important to craft a very good, very solid bill 
that actually will solve the problem instead of forcing a not-well-
thought-out, half-analyzed bill onto the backs of the American people. 
What we do in this arena will affect every American. I believe our 
constituents deserve so much more from us, and we should think twice 
before we proceed down a path that is wrong.
  The American people deserve to know the truth about what is included 
in the bills that are being considered. They have a right to know how 
this will affect the long-term health not only of their families but of 
the Nation. Of course, in that arena, they need to know the long-term 
health of this Nation, both physically and financially.
  We can find many points of agreement on how to reform our health care 
system. I have heard countless speeches about the need to eliminate 
waste and fraud and abuse--and it does exist in this system. Many agree 
we should use technology to eliminate administrative costs and to 
eliminate errors. There is much talk about the need to enhance 
transparency within the system, as well as the need to increase health 
and wellness efforts to lead to a healthier society. I have heard the 
valid points made about needing to stem the rising cost of health care 
and bending the health care cost curve. These are easy areas to agree. 
I think there is a middle ground, and I think we should all be standing 
upon it when we are viewing health care reform.
  However, I am disappointed by the recent health care proposal 
emanating from the HELP Committee--the Affordable Health Choices Act. 
The legislation does not seem to capture the spirit of the bipartisan 
effort the President indicated he wanted to have in order to accomplish 
this important task. Instead, the Affordable Health Choices Act is just 
another government takeover of the health care system. This is not the 
health care reform that Americans have asked for, in my opinion.
  Americans have been promised some things already. They have been 
promised that everyone will receive health care; that they would get to 
keep their insurance, if they like it; and the government will be 
responsible and act responsibly in using taxpayer dollars. 
Unfortunately, the current legislation simply doesn't live up to the 
promises.
  In fact, the legislation has a number of proposals that not only 
don't live up to the promises, they directly contradict those promises. 
For example, the report by the Congressional Budget Office states that 
15 million Americans who currently have employer-sponsored insurance 
will lose that coverage under this proposal. I can rise today and very 
safely say this isn't a talking point that came off of somebody's 
sheet. This is actually an analysis done by a body that we all rely 
upon--the Congressional Budget Office.
  These numbers are likely to increase as soon as the figures for the 
government-run public plan are included. After all, the Lewin Group--
which does research in this area--has issued a forecast that a public 
plan would probably cause 119 million people who have employer-provided 
health insurance to shift over to the public plan.
  So let's take a moment to recap. The administration's promise: 
Citizens will get to keep their employer-provided health insurance, if 
they choose. Reality: CBO says 15 million people will be displaced from 
that coverage. Reality: The Lewin Group, in its estimate, says that 
could climb to 119 million Americans dumped from their private 
insurance onto a government system.
  Furthermore, CBO indicated that about 39 million individuals would 
receive coverage through the government insurance exchange. That is the 
concept in this complex legislation. However, after you factor in those 
who would lose their employer-based coverage and those who would switch 
from other government programs, we are actually only bringing 16 
million currently uninsured people into the fold. In other words, our 
country would still have an uninsured rate--after spending over $1 
trillion--of 13 percent when the bill is fully implemented.
  The administration promised coverage for all. Reality: CBO estimates 
13 percent uninsured Americans. That is millions of Americans still not 
having access to health care in any meaningful way.
  Some do claim the analysis doesn't reflect the full proposal. They 
will make the case that the final report will show that more of the 
uninsured will, in fact, be covered. However, this proposal is already 
estimated to cost $1 trillion over 10 years--a huge pricetag. Not 
surprisingly, this pricetag is expected to increase. Spending this kind 
of money to only insure 16 million people should be disappointing to 
everybody--disappointing to every American. Just when our economy is 
trying to achieve some equilibrium, slamming it with these kinds of 
costs for these few results I don't believe is even a good-faith effort 
on our part.
  I believe everyone wants to solve these complex health care 
challenges, but I think it is so important to be thoughtful, careful, 
and to take a moment to step back and take a deep breath. It makes no 
sense from a policy standpoint to rush these enormously complex 
decisions with unbelievable results just to finish by the August 
recess. It doesn't make any sense. We are talking, Mr. President, about 
people's health care. We are talking about the health and safety of 
their families. As the adage goes: It is better to invest the time to 
get it right the first time instead of getting it wrong expeditiously.
  We need to get back to a middle ground and follow through on the 
promises that have already been made to provide real health care 
reform--sustainable health care reform. The American people deserve a 
thorough, bipartisan debate on health care, not a rushed, ill-advised 
piecemeal approach to an enormously serious problem. I hope we have 
that opportunity because this is too important to get wrong.
  Mr. President, I appreciate the opportunity to offer my thoughts. I 
yield the floor, and I suggest the absence of a quorum.
  The PRESIDING OFFICER (Mr. Kaufman). The clerk will call the roll.
  The assistant legislative clerk proceeded to call the roll.
  Mr. DURBIN. Mr. President, I ask unanimous consent that the order for 
the quorum call be rescinded.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. DURBIN. I ask consent to speak as in morning business.

[[Page 15348]]

  The PRESIDING OFFICER. Without objection, it is so ordered. The 
Senator is recognized.
  Mr. DURBIN. Mr. President, as we meet on the floor of the Senate, we 
are deliberating a bill about promoting tourism in America, which turns 
out to be a way to increase economic activity, create some business 
activity, keep people in their jobs, and maybe attract folks from 
overseas to see this beautiful land of ours. We are now in a procedural 
holding pattern. The minority party has asked us to wait 30 hours 
before we talk about it. It is unfortunate because we are prepared to 
go and are ready and we have a lot of things to do, but the rules of 
the Senate are available for them as for us, and they are utilizing 
them now to delay and stop action on this bill which is very routine, 
bipartisan, and enjoyed the support of over 90 Senators when it was 
called yesterday on a procedural vote.
  In the meantime, as we are waiting on the floor for the Republicans 
to give us permission to go forward, the committees are at work. I left 
the Judiciary Committee where the Presiding Officer is also a member, 
with the Attorney General, where we spoke about some critical issues.
  Right across the hall from us is the Finance Committee, and they are 
debating the future of health care in America, and that is a debate 
which we are all following very closely.
  It is clearly time for us to acknowledge the obvious. Although we 
have some of the best hospitals and doctors in the world, the fact is 
the cost of health care in America is spinning out of control and if we 
do not have the political will and courage to step up at this moment in 
time and address that, it is going to get much worse. People will find 
that there will be more uninsured people, people with health insurance 
that is not worth much, and that the cost of what you can buy will be 
so expensive that average people cannot afford it. You will find, if we 
do not do something, that health insurance companies will continue to 
exclude people because of preexisting conditions, continue to argue 
incessantly with doctors over what the right procedure will be. We will 
find unfortunately that there will be a situation where we do not have 
the chance to utilize the very best health care in this country for 
needed procedures.
  Many Senators say: I have listened to that but count me out. I have a 
great health insurance plan. I don't need to be part of your debate.
  What President Obama has said and what we have said in Congress is: 
OK, we accept that. If you have health insurance that you like, that 
you want to keep, you can keep it. There will not be any change. But if 
you happen to be one of those Americans who think they can do better 
for something more affordable or, sadly, if you are one of the 48 
million Americans with no health insurance, for you, we think we have 
to change some of the ways we do business in this country.
  One of the key elements here, as I mentioned already, is what to do 
with 48 million uninsured. If these uninsured people had their own 
health insurance, it would be a benefit to all the rest of us who 
happen to have health insurance.
  Some of these political commentators like to write that Members of 
the Senate have some special health insurance plans. We are fortunate 
to have one of the best in the world, but it is the same plan Federal 
employees have across America. Eight million Federal employees and 
their families, and Members of Congress who opt to buy into it, have a 
wonderful plan. I am lucky; my wife and I are very fortunate to have 
that kind of coverage. But for a lot of people, they don't have that 
kind of luxury. Once each year, I can choose from nine different health 
insurance plans that sell to Federal employees who live in the State of 
Illinois. That is quite a good deal. If I don't like the way I was 
treated last year by my health insurance company, I can change. It is 
like buying a car; I have a lot of places to shop and look. But most 
Americans don't have that. Most Americans do not have the option of 
looking for health insurance, and if they do, they cannot afford it. If 
you have to pay for it out of pocket, you may find yourself unable, and 
small businesses which want to provide health insurance, not only for 
the owners but the workers, say: It is just too darned expensive, we 
cannot afford to do it.
  That is why 48 million Americans--not the poorest because we cover 
them with Medicaid, and not those lucky enough to have health 
insurance, but those smack-dab in the middle who get up and work every 
day at businesses, maybe businesses they own, and do not have health 
insurance. One out of four realtors in America has no health insurance. 
You don't think of that, but it is a fact. So we work with them to try 
to come up with an approach--that is now being debated by the Finance 
Committee--to have small businesses and self-employed people have a 
chance to buy health insurance just like Federal employees can buy 
health insurance.
  But we really have to get to the bottom line of this issue. It is not 
enough to just say we are going to cover 48 million Americans currently 
not covered. That is important because uninsured people who show up at 
the hospital in America today are not turned away, they are treated. 
Who pays for them if they cannot pay for themselves? The rest of us--
taxpayers and people with health insurance. It is estimated that the 
average family pays an additional $1,000 a year--almost $100 a month--
for coverage for uninsured people. We are picking up their health 
expenses because they do not have health insurance. That is a hidden 
tax. So when we talk about the cost of health care reform, there is a 
real cost of doing nothing--about $1,000 a year out-of-pocket for most 
American families.
  We need to move on to the tougher issue, and this is the one debated 
at length here on the floor. The bottom line here is the cost of 
medical care. We spend twice as much as any other nation on Earth for 
medical care for our citizens. Sadly, we do not have the results to 
show for it. If you look at the basic health indicators, many countries 
that spend far less per person than the United States have much better 
outcomes. You wonder, why is that the case? We have the best hospitals, 
we have the best doctors, we have all the technology, all the drug 
companies. Why are we not the healthiest people in the world?
  Some of it is our own fault. When you look at the chronic conditions 
that cost so much in our health care system, it is the choice of the 
person who decides, I am going to keep smoking cigarettes. That is a 
terrible choice. It can lead to sickness and disease and even death, 
and that is a lifestyle choice people should not make, and they do and 
we pay dearly for it.
  Other people do not watch their diets closely. I am certainly no one 
to preach on that. But when we suffer from obesity in this country, 
people end up in the hospital and end up in doctors' offices 10 times 
more frequently than people who are not obese. Diabetes comes from 
that, high cholesterol, high blood pressure, heart problems--all these 
can be managed with lifestyle choices and preventive medicine, which we 
do not focus on in America today, so we need to do more of that.
  But the other element is we need to have buy-in from doctors and 
hospitals and medical professionals to bring down the cost of health 
care.
  There is a widely read article which has been referred to over and 
over, worth repeating, published by a doctor who is a surgeon in 
Boston. His name is Atul Gawande. The article was published in the New 
Yorker on June 1. I commend it to everyone following this debate 
because most Members of Congress are reading it closely. Dr. Gawande 
went to McAllen, TX, and wanted to know why the average cost for a 
Medicare patient treatment in that town was $15,000 a year while the 
average cost in El Paso--and Chicago, I might add--was right at $10,000 
a year. Why did it cost 50 percent more to treat a Medicare patient in 
McAllen, TX? He took a look and sat down with doctors, and being a 
surgeon he knew what questions to ask.
  The first response was: Defensive medicine. We have to order extra 
tests because those lawyers will sue us.

[[Page 15349]]

  Another Doctor said: You know that is not true, Texas has the 
toughest medical malpractice law in America, limiting pain and 
suffering awards to $250,000.
  This doctor went on to say: Nobody is suing us around here. It is not 
about defensive medicine. If it is, it is a tiny part of it.
  What it turns out is many of the doctors in that community, and 
hospitals, are ordering more procedures than are needed. If you are a 
patient or the parent of a patient, you are not going to question it 
when a doctor says: I think we need an MRI. Are you going to say: 
Doctor, are you sure we need an MRI? You trust his judgment, and that 
judgment, unfortunately, can be very expensive because the doctors in 
that town are motivated by more procedures, more billing, more money, 
more profit. That is the wrong motivation. The motivation should be a 
healthy patient, a good medical outcome.
  Dr. Gawande contrasted McAllen, TX, with the Mayo Clinic, a fantastic 
medical resource in Rochester, MN. It treated members of my family, and 
it is one of the best in the Nation. The Mayo Clinic hires the best 
doctors they can find and pays them by salary. They are not paid by 
patient or how much they bill. So these salaried doctors are looking 
for good outcomes. They don't want to order anything more than a 
patient needs. They want to get a good outcome. Think of the difference 
in motivation between the doctors in McAllen, TX, and the doctors in 
Rochester, MN.
  The Congressional Budget Office sent a report to us yesterday, and it 
says if you really want to reduce the costs of health care in America, 
you have to get to the question of reimbursement. When you talk about 
that, you will get everybody at the American Medical Association on 
their feet, shaking their fists, saying if you cut back on compensation 
and reimbursement for doctors, fewer people will go into the 
profession, you will not be able to get the best procedures--you 
understand what they are going to say. I have heard it. Many of us have 
heard it. But we have to find a good way to approach this. We have to 
bring down the rising cost of health care in this country.
  One of the suggestions is that in addition to private health 
insurance companies offering health insurance, we have a public option, 
that we have a plan that really is not motivated by profit, whether it 
is a government-sponsored plan like Medicare or whether it is some 
other plan, a cooperative, which Senator Conrad has proposed, that 
really says: Let's take the profit out of it and see if we can move 
toward the best health care outcomes and reduce the costs of health 
insurance so we get a good medical outcome at a reasonable cost.
  Some have come to the floor and criticized that idea. I think they 
are wrong. I think if you look at the Medicare system, 45 years after 
we enacted it, it has been an unqualified success. Just look at how 
long seniors are living because they have good medical care after they 
reach the age of 65. It is not a question of whether you are rich or 
poor.
  I run into people in my State of Illinois--a woman, a Realtor who 
said to me in Harrisburg, IL: Senator, I want you to meet me. She said: 
I am 64 years old. I have never had health insurance 1 day in my life.
  I could not believe that. But she said: Next year I am 65. I am going 
to have Medicare. And finally I can breathe a little easier knowing 
that the savings I have put together are not going to be wiped out with 
one trip to the doctor.
  So we understand that Medicare has worked. And it has created quality 
care and good outcomes. We also know the Veterans' Administration, 
another government health insurance approach for the men and women who 
served our country, whom we honor with a medical system that is there 
for them, provides some of the best care in our country.
  We need to find a way to work out these differences. Believe me, at 
the end of the day there will always be a reason to do nothing. There 
will be political risk in doing something. But the American people have 
to stick with us in this debate and understand that if we do not 
address the fundamental issue, it is not just a question of whether we 
will have deficits as far as the eye can see from medical costs or a 
program going through the roof, it is a question of whether we will all 
have peace of mind of health insurance protection for ourselves and our 
families that makes sure we have something we can afford, based on 
quality that will provide the kind of health care we need. It all comes 
around. Every family faces it. And when that day comes, we want to make 
sure we have done our part. This year, President Obama has challenged 
us, though we are sitting idly on the floor today doing virtually 
nothing except giving speeches. He has told us: Do not go home this 
year without health care reform.
  He is right. It is time to roll up our sleeves and get that done.
  I ask unanimous consent that an article from the New York Times on 
June 17, this morning, by David Leonhardt entitled ``Health Care 
Rationing Rhetoric Overlooks Reality'' be printed in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                [From the New York Times, June 17, 2009]

            Health Care Rationing Rhetoric Overlooks Reality

                          (By David Leonhardt)

       Rationing.
       More to the point: Rationing!
       As in: Wait, are you talking about rationing medical care? 
     Access to medical care is a fundamental right. And rationing 
     sounds like something out of the Soviet Union. Or at least 
     Canada.
       The r-word has become a rejoinder to anyone who says that 
     this country must reduce its runaway health spending, 
     especially anyone who favors cutting back on treatments that 
     don't have scientific evidence behind them. You can expect to 
     hear a lot more about rationing as health care becomes the 
     dominant issue in Washington this summer.
       Today, I want to try to explain why the case against 
     rationing isn't really a substantive argument. It's a clever 
     set of buzzwords that tries to hide the fact that societies 
     must make choices.
       In truth, rationing is an inescapable part of economic 
     life. It is the process of allocating scarce resources. Even 
     in the United States, the richest society in human history, 
     we are constantly rationing. We ration spots in good public 
     high schools. We ration lakefront homes. We ration the best 
     cuts of steak and wild-caught salmon.
       Health care, I realize, seems as if it should be different. 
     But it isn't. Already, we cannot afford every form of medical 
     care that we might like. So we ration.
       We spend billions of dollars on operations, tests and drugs 
     that haven't been proved to make people healthier. Yet we 
     have not spent the money to install computerized medical 
     records--and we suffer more medical errors than many other 
     countries.
       We underpay primary care doctors, relative to specialists, 
     and they keep us stewing in waiting rooms while they try to 
     see as many patients as possible. We don't reimburse 
     different specialists for time spent collaborating with one 
     another, and many hard-to-diagnose conditions go untreated. 
     We don't pay nurses to counsel people on how to improve their 
     diets or remember to take their pills, and manageable cases 
     of diabetes and heart disease become fatal.
       ``Just because there isn't some government agency 
     specifically telling you which treatments you can have based 
     on cost-effectiveness,'' as Dr. Mark McClellan, head of 
     Medicare in the Bush administration, says, ``that doesn't 
     mean you aren't getting some treatments.''
       Milton Friedman's beloved line is a good way to frame the 
     issue: There is no such thing as a free lunch. The choice 
     isn't between rationing and not rationing. It's between 
     rationing well and rationing badly. Given that the United 
     States devotes far more of its economy to health care than 
     other rich countries, and gets worse results by many 
     measures, it's hard to argue that we are now rationing very 
     rationally.
       On Wednesday, a bipartisan panel led by four former Senate 
     majority leaders--Howard Baker, Tom Daschle, Bob Dole and 
     George Mitchell--will release a solid proposal for health 
     care reform. Among other things, it would call on the federal 
     government to do more research on which treatments actually 
     work. An ``independent health care council'' would also be 
     established, charged with helping the government avoid 
     unnecessary health costs. The Obama administration supports a 
     similar approach.
       And connecting the dots is easy enough. Armed with better 
     information, Medicare could pay more for effective 
     treatments--and no longer pay quite so much for health care 
     that doesn't make people healthier.
       Mr. Baker, Mr. Daschle, Mr. Dole and Mr. Mitchell: I accuse 
     you of rationing.
       There are three main ways that the health care system 
     already imposes rationing on us. The first is the most 
     counterintuitive, because it doesn't involve denying medical

[[Page 15350]]

     care. It involves denying just about everything else.
       The rapid rise in medical costs has put many employers in a 
     tough spot. They have had to pay much higher insurance 
     premiums, which have increased their labor costs. To make up 
     for these increases, many have given meager pay raises.
       This tradeoff is often explicit during contract 
     negotiations between a company and a labor union. For 
     nonunionized workers, the tradeoff tends to be invisible. It 
     happens behind closed doors in the human resources 
     department. But it still happens.
       Research by Katherine Baicker and Amitabh Chandra of 
     Harvard has found that, on average, a 10 percent increase in 
     health premiums leads to a 2.3 percent decline in inflation-
     adjusted pay. Victor Fuchs, a Stanford economist, and Ezekiel 
     Emanuel, an oncologist now in the Obama administration, 
     published an article in The Journal of the American Medical 
     Association last year that nicely captured the tradeoff. When 
     health costs have grown fastest over the last two decades, 
     they wrote, wages have grown slowest, and vice versa.
       So when middle-class families complain about being 
     stretched thin, they're really complaining about rationing. 
     Our expensive, inefficient health care system is eating up 
     money that could otherwise pay for a mortgage, a car, a 
     vacation or college tuition.
       The second kind of rationing involves the uninsured. The 
     high cost of care means that some employers can't afford to 
     offer health insurance and still pay a competitive wage. 
     Those high costs mean that individuals can't buy insurance on 
     their own.
       The uninsured still receive some health care, obviously. 
     But they get less care, and worse care, than they need. The 
     Institute of Medicine has estimated that 18,000 people died 
     in 2000 because they lacked insurance. By 2006, the number 
     had risen to 22,000, according to the Urban Institute.
       The final form of rationing is the one I described near the 
     beginning of this column: the failure to provide certain 
     types of care, even to people with health insurance. Doctors 
     are generally not paid to do the blocking and tackling of 
     medicine: collaboration, probing conversations with patients, 
     small steps that avoid medical errors. Many doctors still do 
     such things, out of professional pride. But the full medical 
     system doesn't do nearly enough.
       That's rationing--and it has real consequences.
       In Australia, 81 percent of primary care doctors have set 
     up a way for their patients to get after-hours care, 
     according to the Commonwealth Fund. In the United States, 
     only 40 percent have. Overall, the survival rates for many 
     diseases in this country are no better than they are in 
     countries that spend far less on health care. People here are 
     less likely to have long-term survival after colorectal 
     cancer, childhood leukemia or a kidney transplant than they 
     are in Canada--that bastion of rationing.
       None of this means that reducing health costs will be easy. 
     The comparative-effectiveness research favored by the former 
     Senate majority leaders and the White House has inspired 
     opposition from some doctors, members of Congress and patient 
     groups. Certainly, the critics are right to demand that the 
     research be done carefully. It should examine different forms 
     of a disease and, ideally, various subpopulations who have 
     the disease. Just as important, scientists--not political 
     appointees or Congress--should be in charge of the research.
       But flat-out opposition to comparative effectiveness is, in 
     the end, opposition to making good choices. And all the noise 
     about rationing is not really a courageous stand against less 
     medical care. It's a utopian stand against better medical 
     care.

  Mr. DURBIN. Mr. President, I yield the floor, and I suggest the 
absence of a quorum.
  The PRESIDING OFFICER. The clerk will call the roll.
  The legislative clerk proceeded to call the roll.
  Ms. COLLINS. I ask unanimous consent that the order for the quorum 
call be rescinded.
  The PRESIDING OFFICER (Mrs. Hagan). Without objection, it is so 
ordered.
  Ms. COLLINS. Madam President, I ask unanimous consent that I be 
permitted to speak as in morning business for 15 minutes.
  The PRESIDING OFFICER. Without objection, it is so ordered.

                          ____________________