[Congressional Record (Bound Edition), Volume 155 (2009), Part 12]
[Senate]
[Pages 15689-15695]
[From the U.S. Government Publishing Office, www.gpo.gov]




                              HEALTH CARE

  Mr. CASEY. Mr. President, I rise this afternoon, at the end of a week 
where--and the Presiding Officer knows this in his work representing 
the State of Oregon and in his work as a member of our Health, 
Education, Labor, and Pensions Committee--we have spent a lot of time 
on health care, as we did the week before and several weeks leading up 
to this time. But now we are at the point where in our committee we are 
actually voting--voting on amendments.
  We know this is a challenge that has faced America for decades: the 
challenge of covering people in our country who do not have coverage 
and making sure those who do have coverage have quality health care 
coverage that is affordable. So all these challenges are presented to 
us now.
  We have a situation in the country today--and Chairman Dodd mentioned 
this this morning in a hearing--that about 14,000 people a day lose 
their health care coverage. It is hard to comprehend that every single 
day that number of Americans are losing their health care coverage. 
Candidly, if the number was half that, it would be unacceptable--or 
even less than that--but that is, in a very real way, the status quo, 
where we are now. Thousands and thousands of people losing coverage 
every day, 14,000 by one count; people who might have coverage but it 
is hard for them to afford it or to continue to afford it, and 
sometimes people have coverage and it is not of the kind of quality 
that would ensure the best health care for them and for their families.
  We are at a point now where we are beginning to see a basic choice 
that the Congress has to make and the American people have to make. It 
is the status quo or change. It is the status quo--where we are now--
which, in my judgment, is unacceptable--or reform. It is coming down to 
a basic, fundamental choice.
  The status quo right now is the enemy of change. The status quo is 
the impediment in front of us, the tree across the road or whatever 
image you want to illustrate. So we have to get to work making sure 
that the status quo doesn't stay in place.
  There are so many ways to tell this story. Every Member of the Senate 
and every Member of the House and, frankly, virtually every American 
could tell a story about someone they know or someone they have read 
about and the challenges they face. In Pennsylvania, we have a lot of 
examples about people who are living the reality of a lack of coverage 
or bad quality coverage or coverage they cannot afford. One letter I 
got stood out for me, among many. It was written back in February of 
this year by Trisha Urban from Berks County, PA, the eastern side of 
Pennsylvania. I will read portions of her letter which I think tell the 
story about as well as anyone could; unfortunately, in this case, in a 
tragic circumstance. She wrote, talking about her husband Andrew, that 
he had to leave his job for 1 year to complete an internship 
requirement that he had to get his doctorate in psychology. The 
internship was unpaid and they could not afford COBRA coverage--
extended health care coverage. Now I am quoting from the middle of the 
letter. Trisha Urban says:

       Because of the preexisting conditions, neither my husband's 
     health issues----

  He had some heart trouble----

     neither my husband's health issues nor my pregnancy would be 
     covered under private insurance.

  Now I am quoting again:

       I worked 4 part-time jobs and was not eligible for any 
     health care benefits. We ended up with a second rate health 
     insurance plan through my husband's university. When medical 
     bills started to add up, the insurance company decided to 
     drop our coverage, stating that the internship did not 
     qualify us for the benefits. We were left with close to 
     $100,000 worth of medical bills. Concerned with the upcoming 
     financial responsibility of the birth of our daughter and the 
     burden of current medical expenses, my husband missed his 
     last doctor's appointment less than one month ago.

  Trisha Urban's letter goes on. She talks about what happened at one 
particular moment after summarizing their health care situation. She 
says, describing her pregnancy:

       My water had broke the night before. We were anxiously 
     awaiting the birth of our first child. A half-hour later, two 
     ambulances were in my driveway. As the paramedics were 
     assessing the health of my baby and me, the paramedic from 
     the other ambulance told me that my husband could not be 
     revived.

  She concludes her letter this way. Again, I am quoting Trisha Urban 
from Berks County, PA:

       I am a working class American and do not have the money or 
     the insight to legally fight the health insurance company. We 
     had no life insurance. I will probably lose my home and my 
     car. Everything we worked so hard to accumulate in our life 
     will be gone in an instant. If my story is heard, if 
     legislation can be changed to help other uninsured Americans 
     in a similar situation, I am willing to pay the price of 
     losing everything.

  Trisha Urban is telling us through that poignant but tragic story 
about her own circumstances and the circumstances surrounding the birth 
of her daughter and the death of her husband, all we need to know about 
this debate.
  Then, posing that question--or that challenge, I should say--to all 
of us, especially those of us who have a vote in the Senate:

       I am willing to pay the price of losing everything if my 
     story can be told and legislation can be enacted to deal with 
     health care.

  That is the basic challenge that Trisha Urban has put before the 
Senate and the Congress and the administration. It is the challenge we 
must respond to. We cannot pretend it is not there. We cannot pretend 
that the status quo I talked about a moment ago--14,000 people losing 
their health insurance every day; so many other people worried about 
the coverage they have--we cannot pretend that is not there. We cannot 
say to Trisha Urban that we are sorry about the circumstances of your 
story, but Congress can't get it done this year.
  We have to get it done. We have to pass a bill in our committee. We 
have to get a bill through the Finance Committee, and we have to make 
sure the Senate votes on this legislation this year--frankly, this 
summer; not late in the fall, not in the winter, not in 2010. Right now 
is the time for action.
  President Obama has led us in this effort. He has attached the same 
sense

[[Page 15690]]

of urgency to this issue that I know the American people feel.
  What is it about? Well, it is about an act that a lot of Americans 
are just hearing about, which goes by a very simple name: the 
Affordable Health Choices Act. That is the act that is presently before 
our committee. It does a couple of things. It focuses on some 
fundamentals to get at that change that should come to the status quo. 
First, it reduces costs by way of prevention. It is very important. We 
know that can reduce costs substantially. It also reduces costs by 
better quality and information technology. It is still hard to believe 
that when other industries such as banking and insurance and other 
parts of our economy have moved into the new era of technology that our 
health care system isn't anywhere near where it has to be to reduce 
medical errors and to provide better quality. So by focusing on 
information technology, we can reduce costs. That is in the bill.
  Also, the bill contemplates rooting out waste, fraud, and abuse--
another area of cost reduction. We know that the big questions on costs 
will be dealt with in the other committee--the Finance Committee--but 
there are elements in this bill that, in fact, reduce costs.
  Secondly, the bill preserves choice, that if you like what you have 
in your insurance plan and the coverage you have, you can keep it. 
There is no reason why that should change, and it won't change under 
this bill. But if you don't like the coverage you have, we want to give 
you options and we also want to give you an option in coverage if you 
obviously don't have any health insurance at all. So it does reduce 
costs, it does preserve choice, and, thirdly, it will ensure quality 
and affordable care for the American people.
  I believe, and I think most people in the Senate believe, that one 
ought to have the option of not just any health care but quality care 
that is affordable, that you can actually make work in your own budget. 
So we are going to build on the system we have. We are not going to 
throw the old system out; we are going to build on the system we have 
and make it better.
  We are also going to make sure that in this legislation, we protect 
the patient-doctor relationship. There is no reason why anyone should 
get in between those two, and this bill will not do that.
  Finally--this is a quick summary, I know--we are going to make sure 
that at long last, a preexisting condition does not prevent you from 
getting the kind of quality health care you have a right to expect in 
America today.
  As we move forward on this legislation, I want to make sure we 
highlight the fundamental obligation we have, not just in the bill--but 
especially in the bill--but even beyond this legislation, and that is 
the obligation we have to get this right for the American people, and 
to get it right especially for our children. The Presiding Officer 
knows of the great progress we made this year on children's health 
insurance. Thank goodness we got that done. Instead of having 6 million 
kids in America covered by the children's health insurance program, by 
way of the legislation we passed this year we are going to extend that 
to almost 11 million kids. That was wonderful. That is a big success 
and we should all be proud, but it is not enough. We should make sure 
that the other 5 million children out there who don't have coverage 
today will get it but especially a child who happens to be in a poor 
family, a low-income family, or a child with special needs.
  Here is what the rule ought to be. This is what should happen 
throughout this process while enacting health care reform, but 
certainly at the end of the road, so to speak, ideally this fall when 
we will have a bill the President can sign: The rule ought to be no 
child worse off, and especially no child who is poor or who has special 
needs or is disabled. The great line from the Scriptures that talks 
about a faithful friend--we have heard this over many years in the 
context of friendship, in the context of sometimes a reading at 
weddings, but I would like for us today to think about it in the 
context of our children. This is what the Scripture said: ``A faithful 
friend is a sturdy shelter''--a great image about what friendship 
means. There are a lot of us day in and day out, year in and year out, 
who talk about how important children are to us, that we are advocates 
for children--and we should be--that we have solidarity with our 
children, we are going to do everything we can to protect them. In 
essence, we are saying we are their friend, that those of us who are 
elected to public office have an obligation to be a friend of and an 
advocate for our children. Going back to that line from the Scriptures, 
if we are going to be a faithful friend to children, we better make 
sure that we provide a sturdy shelter; not just in the context of the 
obvious in health care. What is more fundamental than that, other than 
making sure that a child has enough to eat and making sure that child 
has an opportunity to learn? Other than those two, health care is 
essential in the life of a child, especially a vulnerable child, 
whether they are poor or have special needs or both. So if we are 
faithful friends in the Senate to our children, we better provide that 
sturdy shelter. We better make sure that at the end of the day, these 
children are not worse off because of our legislation.
  I wish to conclude with a thought from an expert--not someone who is 
just interested in children but someone who has an area of expertise 
which is probably unmatched. I am speaking of someone who testified 
last week--a week ago today, it was--in front of our committee. Her 
name is Dr. Judith Palfrey. She is a pediatrician, a child advocate, 
and happens to be president-elect of the American Academy of 
Pediatrics. She provided compelling testimony. I won't go through all 
of her testimony, but here is something she said which I think has 
relevance and resonance for the debate we are having on health care. 
She says--and I quote Dr. Palfrey's testimony:

       Sometimes we as childhood advocates find it hard to 
     understand why children's needs are such an afterthought; and 
     why, because children are little. Because children are 
     little, policymakers and insurers think that it should take 
     less effort and resources to provide them health care.

  Because children are little, we think that somehow less effort is 
required or less resources, less in the way of hard work. Well, none of 
us believes that, do we? We don't believe that. The health care we 
provide to our children, the protection, the shelter we provide them 
should be every bit as significant, every bit as fully resourced as the 
protection we give to adults. We might disagree about a lot of the 
details in the health care bill, but I think we all in this Chamber 
believe that children may be little but in God's eyes they are 7 feet 
tall and we must treat them accordingly, especially on legislation so 
significant as legislation on health care reform.
  So the rule ought to be no child worse off. It is that simple. I 
believe we can get it right. I believe we can enact health care reform 
that preserves choice, reduces costs, and enhances quality and 
affordable coverage for the American people, and that we can make sure 
every child is no worse off.
  This is a great challenge. We understand the difficulty of it. This 
is a great challenge, but it is a challenge worthy of a great nation. 
It is a challenge that will help us in our continuing struggle, our 
journey to make this a more perfect Union.
  Mr. President, I yield the floor.
  The PRESIDING OFFICER. The Senator from Ohio is recognized.
  Mr. BROWN. Mr. President, I will make a couple of comments on Senator 
Casey's comments. We sit next to each other in the HELP Committee, and 
Senator Casey reminds us almost every day, as we work on this health 
care bill, that ``no child should be worse off.'' That is something 
that, frankly, we all need to hear and every Member of this body and in 
the House of Representatives needs to hear. I appreciate Senator 
Casey's work. It is really our mission to do this right and to see that 
no child is left worse off.
  We spend more than $2 trillion a year on health care in this country, 
which is more than double any other industrial nation. Americans 
account for more

[[Page 15691]]

than 35 million hospital visits and more than 900 million office visits 
every year. More than 64 million surgical procedures are performed and 
more than 3.5 billion prescriptions are written. Health care is, in 
dollar terms, one-sixth of our national economy, and it is growing. 
Think about that--one-sixth of our economy and hundreds of billions of 
dollars. Yet millions of Americans are one illness away from 
bankruptcy.
  What we cannot forget as we debate health care reform are the 
millions of Americans who are depending on us to do the right thing. We 
cannot forget their stories. Chairman Dodd, in the HELP Committee 
today, reminded us that 14,000 Americans lose their health insurance 
every single day. So as our committee meets--and some people seem to be 
slowing this down a little, and they certainly have the right to offer 
amendments, but they get carried away and talk some of these amendments 
to death. Every day that we don't pass this health care bill, 14,000 
Americans are losing their insurance. I will tell you some of the 
stories I hear.
  Christopher, from Cincinnati, tells us that he and his wife are 
retired but are not yet 65, not yet Medicare-eligible. Without health 
care reform, they cannot afford health care insurance because of 
preexisting health conditions. Their 401(k)--their retirement--is 
bleeding. Their small pensions don't keep up with rising premiums. 
Chris puts off going to the doctor to save money. The annual premium 
increases will raise their out-of-pocket expenses by 45 percent.
  Our Nation spends in excess of $2 trillion annually in health care. 
Yet too many people are only a hospital visit away from financial 
disaster. We cannot afford to squander this opportunity for reform, nor 
settle for marginal improvements. Instead, we must fight for 
substantial reforms that will significantly improve our health care 
system.
  First of all, whatever plan you are in, if you are happy with it, you 
can keep your insurance. We want to fix what is broken and protect what 
works. That is why I am making a case for giving Americans a public 
health insurance option, not controlled by the health insurance 
industry.
  So many of us have had fights--even the President, when he was 
talking about his mother as she was dying of cancer during the campaign 
last year, about how while she was sick she had to fight insurance 
companies to be reimbursed and get payment for her illness. The public 
health insurance option is important, in part, because it is not 
controlled by the health insurance industry. It is a competitor. It can 
compete with private insurance plans. We must preserve access, but that 
is clearly not enough for what we do in health care. Giving Americans a 
choice to go with a private or public health insurance plan is good 
policy and good common sense.
  A public insurance option will make health care available and 
affordable for Americans like Michelle of Willoughby, OH, east of 
Cleveland. When she was first diagnosed with breast cancer, she had 
excellent coverage through her husband's insurance. But when her 
husband lost his job, she lost her insurance. Not yet eligible for 
Medicare, she started a consulting business and found an insurance 
plan--exorbitant as it was. With the economic downturn, Michelle writes 
that the ``sum of her work is to pay for insurance.''
  At a time when too many Americans struggle to pay health care costs, 
the public health insurance option will make health insurance more 
affordable.
  A public health insurance option would make insurance affordable for 
Americans like Gary from Toledo. Gary was laid off last year and 
couldn't afford the more than $800 a month COBRA costs. After obtaining 
health insurance from a company that promised equivalent payments of 
Medicare for surgeries, Gary's wife underwent surgery. After a week of 
recovery, they received a hospital bill of $210,000, with a hospital 
letter saying they lacked insurance. Gary talked to his provider, who 
agreed to pay only $400 out of $210,000. Fortunately for his family, 
the hospital absorbed the remaining costs. But that should not happen, 
either, because of what that means to the local hospital. With Gary and 
his wife still 3 years away from age 65, they deserve health reform 
that works for them now.
  A public health insurance option will also expand access to 
affordable health care in rural areas that are often ignored by a 
private insurance market that tends to target big cities with a more 
dense population and more consumers.
  Too often, as Randall of West Liberty, OH--a small town in our 
State--can explain, rural communities have a difficult time attracting 
even basic care. Randall oversees Ohio's only rural training track in 
family medicine. While his program has received awards for training 
excellence, he struggles to attract enough doctors for their rural 
residents. He wrote to me explaining the disincentives and 
misperceptions he has to overcome to attract the care needed to serve 
rural Ohio.
  A public health insurance option will not neglect rural areas. 
Insurance companies bail out in rural areas or the insurance companies 
that stay are so small in number that there is no real competition and 
they can charge rates that are too high. Instead, the public option 
would be consistently available in all markets, including rural eastern 
Oregon and rural western and southeastern Ohio.
  I stand ready to work with my colleagues to design a public insurance 
option as part of overall health care reform. The stories of millions 
of Americans behind spiraling costs of health care will no longer go 
unheard. The stories of Chris, Gary, Michelle, and Randall will guide 
this administration, this Congress, and this Nation to protect and 
provide health care for all Americans.
  I yield the floor and suggest the absence of a quorum.
  The PRESIDING OFFICER. The clerk will call the roll.
  The legislative clerk proceeded to call the roll.
  Mr. WHITEHOUSE. 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. WHITEHOUSE. Mr. President, we are now embarked in the Senate on 
one of the most important challenges that our country faces--we will 
begin to reform our tragically flawed and broken health care system to 
bring down its skyrocketing costs, to cover its tens of millions of 
Americans left uninsured, and to improve its way-below-average results 
so that high-quality health care comes within reach for every American 
family. The stakes are high.
  This week, in a speech before the American Medical Association, 
President Obama said:

       The cost of our health care is a threat to our economy. It 
     is an escalating burden on our families and businesses. It is 
     a ticking time bomb for the Federal budget. And it is 
     unsustainable for the United States of America.

  The President said:

       Health care reform is the single most important thing we 
     can do for America's long-term fiscal health.

  Savings in waste, confusion, unnecessary or defective care, and 
illness prevention could eventually well exceed $700 billion a year. It 
is not going to happen instantly, but it is a goal we can shoot for.
  I applaud President Obama's commitment and leadership, and I commend 
my Senate colleagues for their tireless efforts in the pursuit of 
meaningful, comprehensive reform. The new energy and focus we have seen 
in this debate isn't limited to us here in Washington. In recent 
months, doctors and hospitals, patients and insurance companies, labor 
unions and drug companies have all come together in support of the need 
for a restructure of our system.
  Amidst all this, it has been my great honor to join the Presiding 
Officer, the Senator from Oregon, on the HELP Committee, where he 
serves with such distinction and where much of the legislation to 
repair our broken health care system is being debated, written, and 
refined. In that capacity, I was recently invited to the White House to

[[Page 15692]]

meet with President Obama, his health care team, and all of our 
colleagues on the HELP and Finance Committees. We discussed our 
priorities for reform, and we reported on the progress each committee 
has made in the past several weeks.
  In the coming weeks, we will hear a lot about the details of health 
care reform legislation, and those details are very important. But even 
more important are the hundreds of millions of American families in 
each of our States all over the country who have experienced real 
anguish--coverage lost or denied, hospital stays extended due to 
complications or errors, prescription drug bills rising and rising, 
with no end in sight, even losing everything because a loved one fell 
ill.
  A few months ago, I launched a page on my Web site for Rhode 
Islanders to share their personal experiences with our broken health 
care system, and hundreds of people have written in from all over the 
State.
  Anita is a social worker and mental health professional in 
Providence. She shared what she describes as the ``sad and rude 
awakening'' she experienced after opening her own practice last year. 
As a provider, like all providers, she takes great pride in the quality 
of care and attention she gives to her patients. Yet she often found 
herself burdened with an endless trail of paperwork and the time-
consuming task of battling insurance companies and tracking down 
claims. Like so many of her colleagues, Anita is frustrated that she 
must spend so much time fighting administrative hurdles and navigating 
bureaucratic red tape. After years of training to become a health 
professional, Anita wishes she had more time to do just that--provide 
care to her patients. She writes:

       I would much rather spend the time seeing clients than 
     negotiating automated telephone systems and waiting to speak 
     to a person several hours per week. It is a total waste of 
     human time and talent.

  I heard from Melissa, a self-employed writer from Newport, whose 
unpredictable income leaves her unable to afford health insurance. 
Without coverage, Melissa knows that she risks being one serious 
illness away from what she calls the ``brink of disaster.'' Through the 
stress and fear of not having insurance--through that brink of disaster 
that she lives on--Melissa waits and hopes that she doesn't get sick 
because that is the only option she has in this, our great country.
  Rhonda is a mother in Coventry. She told me about her struggle to get 
health care coverage for her family. As if raising her two sons wasn't 
enough work, this single mother works two jobs to make ends meet. 
Although her employer offered health coverage at an affordable price, 
Rhonda's limited income could not be stretched to cover the additional 
cost of coverage for her children. So her sons went without insurance 
for 3 years. Rhonda, like so many hard-working Americans, was caught 
between a rock and a hard place--making slightly more than the eligible 
income to qualify for health coverage through State assistance plans, 
but not making enough money to afford health care coverage on her own. 
She prayed every day her children would be spared from sickness or 
injury.
  I also received a story from Richard, in Providence, who told me 
about his father--a hard-working man who left work for 6 months to 
concentrate on fighting a battle against cancer. Sadly, just when 
Richard's father needed the support the most, his company dropped him 
from their health plan. Without coverage and unable to pay the costs 
out of pocket, his father was forced off his chemotherapy treatment. 
Richard's father was very lucky. The doctors cleared him of cancer. 
However, the medical bills were so high that Richard's parents lost 
their home. Remarkably, after all his family has been through, Richard 
feels fortunate that at least his father was covered for part of his 
treatment, but he urged us to fix ``this old and broken system.''
  For these Rhode Islanders and for millions of more Americans silently 
suffering through their own personal catastrophes all over the country, 
we now have to be a voice. We must improve the quality of our health 
care, we must develop our Nation's health information infrastructure, 
and we must invest in preventing disease.
  We must protect existing coverage where it is good and improve it 
when it is not. As the President said, if you like your health plan, 
you get to keep it. We must dial down the paperwork wars, and dial up 
better information for American health care consumers. We must speak 
for the 46 million Americans, 9 million of whom are children, who right 
now as I stand here on the Senate floor have no health insurance at 
all.
  As Families USA reports, 47 million actually understates the problem 
because during the course of this year nearly 90 million Americans 
will, at one point or another, go without health insurance.
  We look around at dark and tumultuous economic times. Yet looking 
beyond the immediate economic perils we face, a $35 trillion unfunded 
liability for Medicare--not a penny set against it--is bearing down on 
us. As the President told the AMA earlier this week:

     . . . if we fail to act, Federal spending on Medicaid and 
     Medicare will grow, over the coming decades, by an amount 
     almost equal to the amount our government currently spends on 
     our Nation's defense. In fact, it will eventually grow larger 
     than what our government spends on anything else today. It's 
     a scenario that will swamp our Federal and State budgets and 
     impose a vicious choice of either unprecedented tax hikes, 
     overwhelming deficits, or drastic cuts in our Federal and 
     State budgets.

  We can only avoid that vicious choice by reforming the health care 
system. We are committed to making sure every American has health 
insurance coverage, but meaningful reform will take more than that. 
Think of it this way. If you had a boat out in the ocean and people 
overboard around it in danger of drowning, surely you would try to 
bring them all into the boat. But if the boat itself was sinking, if 
the boat itself was on fire, you would have to do more than just bring 
them on board. You have to repair the boat. You have to get it floating 
and moving forward.
  That is what we have to do with our health care system. It is not 
enough just to provide coverage for all Americans, we also have to 
right this ship. This means improving the quality of health care and 
investing in prevention, especially in those areas where improved 
quality of care and investment in prevention means lower cost so that, 
for instance, 100,000 Americans will no longer die each and every year 
because of entirely avoidable medical errors. This also means reforming 
how we pay for health care so what we pay for is what we want from 
health care.
  Government must act. At last, government must act. The problems of 
health care in America are rooted in market failures. We cannot wait 
for the market to cure a problem rooted in market failure. It is 
nonsense. We have to change the rules of the game.
  We also can't pay for one thing and expect another. We have to change 
the incentives. We do not expect Americans to go out and build our 
highway infrastructure for us. We do that through government. We can't 
sit around and wait for our health information infrastructure to build 
itself either. We cannot expect quality improvement and prevention of 
illness to flourish when we make it a money-losing proposition for the 
people who have to make it work. We have to change those incentives 
too.
  Opponents of reform are arguing that this process is going too 
quickly, that we need to slow down, wait, pause. They are loading down 
this bill with hundreds of amendments--170 amendments alone on the 
section that deals with preventive care. But haven't we waited long 
enough? Slow is what we have done for years, even decades. When I hear 
from Rhode Islanders with the stories I reported here, such as Richard 
and Rhonda and Melissa and Anita, I think not that we are going too 
fast, I think we are irresponsibly, even frighteningly late in getting 
after this problem and taking up this charge.
  If we wait much longer, we may be too late to avoid that tidal wave 
of costs that threatens to swamp our ship of state. To those who say 
slow down, I say keep up.
  Opponents of reform want people to believe that a system that costs 
too

[[Page 15693]]

much, that lets insurance company bureaucrats make decisions about our 
health care; that is riddled with error, duplication, and waste; that 
leaves nearly 50 million Americans without any health insurance, is 
acceptable. Everyone says they want reform, but unless we get moving, 
all we will end up with is more of the same. As President Obama said 
this week: The status quo is unsustainable.
  Some opponents want to slow this down because they know if they slow 
it down they can kill it. We cannot let that happen. The stakes are way 
too high.
  The anguish out there, as you know in Oregon, as I see in Rhode 
Island, as all our colleagues see across the country, is real and it is 
everywhere. At last we can do something about it. Now is the time. This 
is the moment. Let us make this work. Let us, together, find a way to 
make this work.
  I yield the floor.
  I suggest the absence of a quorum.
  The PRESIDING OFFICER. The clerk will call the roll.
  The assistant legislative clerk proceeded to call the roll.
  Mr. ROBERTS. Mr. President, I ask unanimous consent the order for the 
quorum call be rescinded.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. ROBERTS. I ask unanimous consent I may proceed as if in morning 
business for approximately 15 minutes.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. ROBERTS. Mr. President, and to all present in terms of staff, 
this is Friday, and here we are at 1:25. I apologize to the 
doorkeepers, I apologize to the elevator operators, I don't want to 
keep you here for a long time, so I will quit apologizing, but there 
have been some things happening with regard to health care.
  The distinguished Senator from Rhode Island indicated the need to 
move forward on health care. Everybody agrees to that. The pace of it, 
what is going on, is a real concern, so I do have some remarks to make. 
I will try to make this as quickly and succinctly as possible so 
everybody can go about their business. I see smiles from the pages, in 
regards if I can just hurry up and get through my comments.
  Yesterday, in the HELP Committee's markup of the Kennedy-Dodd health 
care reform bill, we had a very good discussion about the proper use 
and the objectives of something called government-conducted comparative 
effectiveness research.
  I know that is getting into the weeds in regard to health care 
language and health care acronyms. It is called CER; remember that 
term, ``CER.'' It is going to be around for a long time because it has 
become quite controversial in regard to our health care discussion and 
what eventually passes. CER is research that compares the relative 
outcomes of two medical treatments for the same condition to determine 
which one is better. That is a good thing. It is a good thing to 
disseminate and to inform doctors and everybody in the health care 
delivery system--nurses, health care providers, pharmacists, et 
cetera--it is a good thing. But the first problem with CER is that not 
every patient is the same. What is better for one patient may not be 
better, or could actually be worse, for another. For this reason 
doctors and patients must be able to deviate from the results of 
something called CER, or a master plan or a master evaluation that 
could come out of Washington from an outfit called CMS, under the 
Department of Health and Human Services.
  The situation is patients must be able to deviate from the results 
and make treatment decisions on a case-by-case individualized basis. 
That is what we all want in terms of our treatment with our doctors.
  The other major problem, I submit, is that CER has been used by other 
governments, such as the United Kingdom, to base treatment decisions 
not just on relative effectiveness but on relative cost. There is the 
rub. If CER is going to inform doctors and everybody in the medical 
community that this kind of treatment or this kind of best practice is 
the arena in which you should operate or pasture you should operate in, 
that is OK. But if it is used to control costs as opposed to care, then 
we have a problem.
  By giving priority to the relative costs of the treatments being 
compared, the government can deny access to health care based on what I 
would call pseudoscience, under the guise of CER. That brings me back 
to yesterday's discussion on CER on the health care markup. The 
Kennedy-Dodd bill includes a section that establishes a new Center for 
Health Outcomes Research and Evaluation. This outfit is to conduct and 
support comparative effectiveness research.
  Section 219(h)(1)--if that isn't getting into the weeds, I don't know 
what is--includes the following language relating to the practical 
effect of CER, or comparative effectiveness research. That would, 
again, be conducted by the center.

       Center reports and recommendations shall not be construed 
     as mandates for payment, coverage and treatment.

  That language was in there to get at this problem for those of us who 
worry that CER will be used by CMS--that is another acronym. That is 
the outfit that runs Medicaid and Medicare, in terms of services. These 
are the people who count the beans, these are the people who want to 
turn the red beans into black beans. These are the people into cost 
containment. These are the people who many times drive board members in 
small hospitals crazy.
  At any rate, to take away the worry, that language was put in there: 
Senate reports and recommendations shall not be construed as mandates 
for payments, coverage and treatment. They thought that was enough to 
protect us in regard to CER dictating medical care and stepping in 
between you and your doctor.
  Let's go back to those words ``shall not be construed as mandates.'' 
What does that mean? ``Mandate'' means to force, compel, bind. This 
language says the CER shall not be interpreted as forcing CMS, 
Veterans' Administration or the Department of Defense to restrict 
payments to doctors based on its results.
  Senator Mikulski and I and Dr. Coburn as well had a very lively 
discussion about the intent of this language. Senator Mikulski said the 
intent of the language was to keep the right to make treatment 
decisions with the doctor and the patient, not with the government. I 
certainly agree with that.
  Senator Mikulski has worked long and hard on this bill, and I respect 
her for that. She is a good colleague and a good friend. I agree with 
this intent.
  But as I pointed out to the Senator, the language in the Kennedy-Dodd 
bill does not accomplish our common intent of saying the government is 
not mandated or forced to use the results of this comparative 
effectiveness research to make payment decisions. Whether you are paid 
or not in regard to Medicare or, for that matter, Medicaid is not the 
same thing as prohibiting or preventing CMS from doing so.
  In order to vigorously protect the rights of patients and doctors to 
make treatment decisions against the danger that the government will 
interfere in that process, I believe the bill must prohibit the 
government from using the results of CER in making payment, coverage, 
or treatment decisions. Sorry, you cannot have that, you have got to 
have this treatment, because it is a best medicine practice, regardless 
of the fact that maybe you and your doctor have had that treatment 
before and the doctor thinks that treatment is the best treatment for 
you.
  I offered new language, and the new language would have placed a 
clear, bright-line firewall between the conduct of CER--which, by the 
way, I think is essential to advancing medical science; it is a good 
thing--and the use of its results to restrict your doctor from using 
his or her best judgment when treating you.
  My language, which I further modified at the suggestion of Senator 
Mikulski, read: ``Center reports and recommendations are prohibited 
from being used by any government entity for payment, coverage, or 
treatment decisions.''
  Senator Mikulski agreed to consider my suggestion over last night, 
along

[[Page 15694]]

with Senator Dodd. I appreciate that. But today when the HELP Committee 
reconvened in our markup, Senator Mikulski and the majority refused to 
accept my language and offered counterlanguage that would basically put 
us back to square one and, in my view, would do nothing to protect 
patients and doctors from CMS or any other government agency 
interfering in their treatment decisions.
  When I asked why my language was unacceptable, which I thought was 
acceptable for everybody when we left yesterday, I was told that the 
decision to say my language was not acceptable was based on concerns by 
``Washington policy experts.''
  I said: Who is that? Which Washington policy expert said my language 
was not acceptable?
  When pressed on which policy experts, we learned that the directive 
came straight down from the White House. Why would the White House be 
so concerned about prohibiting the Federal Government from using CER to 
restrict payments to doctors or to direct doctors to follow specific 
treatment orders? Why would the White House do this on this in-the-
weeds proposal, which is not an in-the-weeds proposal at all, it is 
about what the government is going to do or tell doctors and patients 
what they can expect.
  It is clear from statements made by this administration that they see 
CER as the golden ring for cost containment. The President said when 
asked, how on Earth are you going to pay for the health care bill, We 
are going to cut Medicare payments.
  How are you going to do that?
  Well, if you have a CER golden ring that comes down from CMS or the 
National Institutes of Health for cost containment, you can see: This 
research says that you should follow these practices, not those 
practices and those practices, or, these practices would certainly cost 
less.
  I do not think that is a good thing. From OMB Director Peter Orszag, 
to the NIH Director, going on to the National Economic Council 
Director, Larry Summers, and indications from our new Secretary of 
Health and Human Services, Kathleen Sebelius, a good friend, former 
Governor of Kansas, all have pointed to the huge potential of CER to be 
used to contain costs, not to recommend procedures best for patients 
and the doctors as determined by the patient and the doctor, but by CER 
to control costs.
  That is why the White House does not want to prohibit CMS or any 
government agency from using the results of CER to deny you and your 
doctor the right to choose the treatment that is best for you.
  After all of that was said and done, and a lot was said and not much 
done, I got quite a lecture this morning in regard to my use of the 
word ``rationing'' to describe what this could lead to. This lecture 
was referred to as a scare tactic. They indicated that I was using the 
word ``rationing'' out there as a scare tactic to scare people to say 
we do not want health care reform.
  I find that rather condescending. I find that demeaning. And it is 
certainly not accurate. You tell me, when Medicare refuses to pay your 
doctor if he or she decides you need a particular course of treatment 
that deviates from the government standard, what would you call it? I 
would call it rationing.
  That is the danger. It is not a scare tactic. Health care rationing 
is happening right now in this country. We may not have explicit 
rationing such as in the United Kingdom where the government refuses to 
give elderly people drugs to treat their macular degeneration until 
they have already gone blind in one eye--not making that up--or refuses 
kidney cancer drugs for terminal patients because it is not worth the 
money to extend their life by 6 months. That is rationing.
  But we do have de facto rationing, because Medicare and Medicaid 
refuse to pay doctors anything close to what their costs are. By the 
way, it's the same thing for pharmacists, the same thing for home 
health care, and for all of the providers who provide our health care 
treatment. This means those doctors cannot afford to take Medicare and 
Medicaid patients--they make the decision then--and it means that those 
individuals do not have access to care. That is rationing I am talking 
about.
  I am talking about a doctor who makes a decision: I am only getting 
paid about 70 cents in terms of the dollar in regard to my cost in 
regard to Medicare patients. I have to hire extra people to keep up 
with paperwork and regulations. Those people do not exist in the rural 
health care system. We have to try to find them. So it is a lot easier 
if I drop the Medicare Program.
  That comes as a sudden jolt and a sudden decision that is not fair in 
regard to the patients who were being treated by that doctor in terms 
of Medicare. That is what we call rationing right now in regard to the 
United States of America.
  We know the administration wants to use CER to contain costs. We know 
CMS has a history of denying full payment based on cost. I am not going 
to take the time on the Senate floor right now to go into all of the 
problems that CMS has posed for the health care delivery system. Again, 
these are folks who have a difficult task. They are trying to change 
the red beans into black beans so that health care does not cost so 
much. But in terms of their decisions here in Washington in regard to 
what care is going to be paid for and what is not, they are an absolute 
nightmare to every hospital administrator, every hospital board member 
in the 350 or so hospitals I have in Kansas, and the 83 critical access 
hospitals I have in Kansas.
  We do not have a very good relationship with CMS. What we have is a 
meaningful dialog, most of the time, when yet another regulation comes 
down the pike to contain cost, most of which the doctors have never 
heard of, not to mention everybody else in the health care delivery 
system. I can go into quite a rant, as you can expect from my comments 
in regard to CMS and what they do and what they do not do.
  Why is the majority, why are the Democrats, resisting any language to 
protect patients and their doctors, you and your doctor, and your right 
to make the right treatment decision for you? Why are they trying to 
muzzle my warnings that this could lead to the rationing of health 
care? It boils down to the fact that they do not want the American 
people to know what their true plans could actually be. That is why 
they are shoving this massive health care reform bill through Congress 
at warp speed, having markups before we even have complete language or 
cost estimates.
  We heard from the distinguished Senator from Rhode Island about the 
need for health care reform, and the fact that he was complaining about 
over 100 amendments in the HELP Committee. My goodness. Almost every 
major bill I have been associated with, you have literally hundreds of 
amendments. Many fall by the wayside, many are withdrawn. We have dealt 
with 17, 18 of them as of today.
  Senator Mikulski and Senator Dodd did a very good job in that 
respect, along with our ranking member, Senator Enzi from Wyoming. But 
it would be helpful, if we are going to move forward with the health 
care reform, if we had the bill. We do not have the bill in the HELP 
Committee. We have one section of the bill, and then we have a 
Congressional Budget Office score on one-sixth of the bill that is $1 
trillion. And, boy, did that shock everybody. Say $1 trillion for one-
sixth of the bill. What is the whole bill going to cost? That estimate 
is somewhere in the neighborhood of $4 trillion. How on Earth are you 
going to pay, in the Finance Committee, the pay-for committee, $4 
trillion for health care reform, and take it out of the health care 
delivery system?
  I do not think you can do it. But we do not know, because we have not 
seen the legislation. We are being asked to go on a deadline schedule 
to produce amendments on things such as CER that worry people in regard 
to possible rationing by a date certain or a time certain, and we have 
not even seen the bill we are amending.
  I have never been through a situation like that. Not to mention the 
specific cost estimates by CBO. This is not right. That is why Chairman 
Baucus in

[[Page 15695]]

the Finance Committee had at least the good sense to postpone the 
markup of his bill until we could work this out. That is why slowing 
down does not necessarily mean that everybody is opposed to health care 
reform. It means we ought to get it right.
  We at least ought to have a bill to read, to know what we are dealing 
with. I think it is because they know that if Americans knew what they 
were doing, they would never stand for it. I think we need to get this 
out to the public, and the public will hopefully fully understand it. I 
am not going to allow this. Personally, I am going to continue to shout 
it from the rooftops and beware of what lurks under the banner of 
``reform'' to tell every doctor, every hospital administrator, every 
hospital board member, anybody who has anything to do with the health 
care delivery system, watch out in regard to CER.
  It could be the golden ring of cost containment, and it could put you 
out of business. It could put you out of business. We have examples of 
CMS doing exactly that. So do not wake up one day and realize that the 
government has taken over your health care the same way they have taken 
over the banks and the auto industry. Do not let them ration your 
health care. Rationing is not what we need. It can be terribly 
counterproductive, and I hope we can do a better job in the future.
  I yield the floor and I suggest the absence of a quorum.
  The PRESIDING OFFICER. The clerk will call the roll.
  The assistant legislative clerk proceeded to call the roll.
  The PRESIDING OFFICER. In my capacity as a Senator from the State of 
Oregon, I ask unanimous consent that the order for the quorum call be 
rescinded.
  Without objection, it is so ordered.

                          ____________________