[Congressional Record (Bound Edition), Volume 155 (2009), Part 14]
[House]
[Pages 18550-18555]
[From the U.S. Government Publishing Office, www.gpo.gov]




                            POPULIST CAUCUS

  The SPEAKER pro tempore. Under the Speaker's announced policy of 
January 6, 2009, the gentleman from Iowa (Mr. Braley) is recognized for 
60 minutes.
  Mr. BRALEY of Iowa. Mr. Speaker, I'm here tonight on behalf of the 
Populist Caucus, which is a caucus that I founded this year, along with 
many of my colleagues, who felt that there was not enough emphasis in 
this Chamber on discussing values that promote and expand the middle 
class.
  So one of the reasons that we founded this caucus was to find a voice 
that was going to be consistent in pursuing policies and adopting 
legislation that we're going to help promote opportunities for middle 
class families to survive, and also to expand opportunities for people 
to enter at the middle class because we all feel, and this country's 
history has shown, that this country does best when we have a large, 
robust middle class.
  And that's why, when we passed the Populist Caucus values, these are 
the primary things that we wanted to focus on: good jobs, middle class 
tax cuts, affordable health care, quality education, fair trade, 
consumer protection, and corporate accountability.
  Now, some of those basic values have been part of the ongoing 
discussion in terms of our health care reform bill that is currently 
pending in the House of Representatives. And as a member of the House 
Energy and Commerce Committee and the Health Subcommittee, much of my 
time this year has been consumed in making sure that the health care 
bill that we are putting forward addresses these values, particularly 
affordable health care, consumer protection, and corporate 
accountability.
  So today, the Populist Caucus announced its health reform principles, 
and I'm going to spend some time tonight talking about those 
principles, talking about the importance of these principles to middle 
class families and those seeking to enter the middle class, and then 
sharing some stories from some constituents of mine back in Iowa's 
First District who are struggling right now to provide for their 
families, and address growing health care burdens that affect every 
American no matter where they live, no matter what they do.
  As we have seen over and over and over again, health care costs 
continue to grow every year. They represent a larger and larger share 
of our gross domestic product. We see more and more families faced with 
the burden of bankruptcy because of unsustainable health care costs 
that aren't covered by their insurance plans. We see more and more 
Americans without any insurance at all, almost 50 million uninsured 
Americans. We also see many Americans who are underinsured; that is, 
they are taking policies out that don't provide them the type of 
coverage they need because they can't afford either to buy their own 
coverage if they're self-employed or if they're without employment, or 
many of them have insurance offered through their employers who are 
increasingly forced to put more and more of the burden of that 
insurance coverage on to their employees.

                              {time}  2300

  And so one of the reasons why we've been having this national 
conversation about health care reform is because we have to come up 
with a system that works for the American people and finally realizes 
the goal of universal coverage.
  Now, some people who have health insurance and are sitting well in 
their own financial circumstances wonder why should I care about this; 
this doesn't affect me; this doesn't affect my family. But the reality 
is that each one of us in this country pays a hidden tax right now of 
$1,200 a year so that people with no health insurance who go to the 
hospital emergency room and will be given treatment, because those 
hospitals cannot turn them away, somebody pays for that care, and we 
all pay for it in the form of higher tax burdens and in the form of 
higher insurance premiums for the coverage that we have.
  So that's why this issue is so compelling, and it's something that we 
have to address, and the sooner we address it the better.
  The reason why it affects us all is because 7 out of every 10 cents 
spent on health care goes to cover chronic diseases, things like 
diabetes and obesity and all of the complications that can come from 
them including congestive heart failure, high blood pressure, problems 
with vision and foot care and on and on and on.
  Now, the thing about chronic disease is that most of them are 
preventable through education and early intervention, and that's why 
our system right now is broken, because we pay for health care on a 
fee-for-services basis, which means if you get sick and you seek 
medical treatment, we will pay for that treatment. But we don't provide 
incentives to individuals to get healthy before they need a doctor or 
have to go to the hospital.
  And that's why a national health care policy that makes sense has to 
emphasize prevention and wellness. That has to be one of the 
cornerstones of how we reduce that enormous burden of chronic disease 
in this country.
  So let me start by briefly reviewing the Populist Caucus health care 
reform principles, and then I will spend time talking more about the 
details of each one.
  The first goal of the Populist Caucus in addressing health care is 
providing more affordable health care, and we recommend a values system 
in this health care bill that ensures that every American has access to 
affordable, quality health care coverage. Now, that sounds simple in 
theory. In reality, it is a challenge that has faced this country since 
its founding.
  The second component of our health care reform principles for the 
Populist Caucus centers around choices for families, populist values. 
The first aspect

[[Page 18551]]

of our values for health care reform under choices for family is keep 
your coverage if you like it, and that is included in the House version 
of the health care reform bill. It allows consumers to keep their 
current coverage if they like it.
  So if you have an employer who's currently providing you high-quality 
health care at an affordable price, like maybe a company like John 
Deere which employs many people in the First District of Iowa, nothing 
in this health care reform bill is going to change your ability to keep 
that coverage. If you like it, you get to keep it.
  Second, one of the most important factors in choices for families is 
no discrimination, and you have to have a populist value that says, in 
insurance coverage, you have to eliminate discrimination that allows 
insurance companies to exclude people from coverage based upon 
preexisting conditions.
  Now, we know this is an enormous problem in many different ways. 
There are millions of Americans who are denied health insurance 
coverage right now because of preexisting conditions.
  I have a nephew who lives in Malcolm, Iowa. He has a young son named 
Tucker Wright, and when Tucker was a year and a half, he was diagnosed 
with liver cancer, and he was very, very fortunate that he was 
diagnosed and had an opportunity to have two-thirds of his liver 
removed at a very young age to save his life. But Tucker also faces a 
very bleak future because he has a long history, a long life of 
expensive medical care ahead of him.
  Many of the existing health care policies have a cap on lifetime 
benefits; and once you meet that cap, you get no more coverage, no 
matter how sick you are, no matter how old you are, no matter what your 
medical needs are. And if you have been diagnosed with a serious 
disease like liver cancer, and your family wants to move or your 
parents want to look at other job opportunities right now, there's very 
little chance that you're going to be able to make that switch and get 
coverage because they will write an exclusion in the policy based upon 
preexisting conditions that say we're not going to cover you because 
you have this expensive treatment.
  That's one of the major problems with health care in America today, 
and it's not just on access to care. It has enormous implications for 
employers and employees because right now in this country, literally 
hundreds of thousands, if not millions, of workers are working in jobs 
they don't like. And the only reason they're there is because those 
jobs offer them some level of health care coverage, and they know that 
if they leave the job they have, there's a very good chance that a 
family member, a loved one, won't be able to get coverage under a new 
plan at a new employer because of preexisting conditions.
  And this bill that we are considering in the House right now 
eliminates discrimination in health care coverage based upon 
preexisting conditions.
  One of the other very important elements of our Populist Caucus 
family values emphasis is including a robust and meaningful public 
health insurance option that operates on a level playing field with 
private insurance companies, increases consumer choice through a public 
option for insurance coverage that does these things--and these are 
critical achievements--one, competes on a level playing field; two, 
maintains minimal levels of coverage that ensure quality care for its 
enrollees.
  And in the House plan, there are three basic forms of coverage that 
will be available: a basic plan, an enhanced plan, and a premium plan. 
And then there will also be something called the premium plus plan, and 
all of those plans will provide a minimal level of coverage designed to 
provide basic and emergency types of health care coverage for every 
person in America.
  Another component that emphasizes these family values of the Populist 
Caucus is that this public plan option must reimburse health care 
providers adequately and equitably, and we're going to spend some time 
talking about what that means.
  Another family value in the Populist Caucus health care package, it 
helps address current geographic disparities in health care. This is 
one of the most significant challenges that we face and one of the most 
significant problems with our health care delivery system.
  Another key family value is that the existing infrastructure of 
Medicare which will be used under the current plan, a Medicare plus 5 
percent reimbursement payment system, that that existing infrastructure 
has to be used to create a viable provider network; but it should only 
use Medicare as long as improvements are made in the way that 
Medicare's reimbursement structure and geographic disparity issues are 
addressed, and I'm going to be spending time talking about the 
challenges that we face and the problems we currently have in Medicare 
reimbursement.
  Now, I want to move on to another key component of the Populist 
Caucus health care values: saving taxpayers money. Every medical 
economist who looks at our current health care delivery system is in 
agreement that the number one problem is a problem called 
overutilization, using too many medical services that aren't necessary, 
that waste money and result in worse outcomes. We have to address the 
problem of overutilization of care. It creates unnecessary costs and 
adds hundreds of billions of dollars and can lead to harmful medical 
errors.
  Now, medical economists at the Dartmouth Atlas Project and places 
like the Commonwealth Fund who have looked at this estimate that every 
year in our health care delivery system we lose between $500 billion 
and $700 billion every year due to overutilization, and they have also 
analyzed patient outcomes arising from that overutilization, and the 
figures are shocking.
  They estimate that every year 30,000 people die in this country 
because of too much medicine that exposes them to risks and actually 
results in their death. There are hundreds of thousands more who are 
injured because of overutilization, and it's not achieving the desired 
goal of medicine, which is to cure patients who need help and to 
provide it in a meaningful fashion.

                              {time}  2310

  One of the other concerns about saving taxpayer money is emphasizing 
prevention and quality care. We have talked about that. We need to 
shift to a health care delivery system that moves toward incentives, 
toward high-quality care prevention, nutrition, and wellness. And we 
have to reform Medicare part D, the drug package for seniors and people 
on Medicare. One of the most essential components of that is to close 
the doughnut hole, give Medicare the ability to negotiate with drug 
manufacturers, and to seek rebates for all Medicare beneficiaries from 
those pharmaceutical manufacturers.
  Now I want to talk for a moment about this problem that I mentioned 
called geographic disparities in payment for health care. This chart 
was prepared by The Commonwealth Fund to focus on the relationship 
between the quality of care and Medicare spending.
  So, on this bottom axis it provides cost numbers to show annual 
Medicare spending per beneficiary in dollar amounts for every State in 
the country and places them on the chart according to that axis. The 
vertical axis has an overall quality ranking. And those quality 
rankings are taken directly from Medicare administrative claims data 
and the Medicare Quality Improvement Organizations Program data. So 
it's information already collected by Medicare.
  The chart numbers are shocking in terms of showing the existing 
disparity in how we pay for Medicare and the direct correlation between 
how much we spend and the quality we get for our Medicare dollars.
  Many of us who represent States who are up in the top 5 to 10--not 
top 5 to 10 percent, but the top 5 to 10 in rankings, these States 
right here inside this pink circle, States like New Hampshire, Vermont, 
Maine, North Dakota, Iowa, Wisconsin, Utah, Minnesota, Oregon, and 
Montana, are consistently providing the highest quality of care to 
Medicare patients at the lowest cost, because they also rank in the 
bottom 5 to 10 States in Medicare payments per beneficiary.

[[Page 18552]]

  Then, contrast with what we see at this end of the chart. This chart 
reveals that the most expensive of States in terms of what we pay for 
Medicare per patient is the State of Louisiana, where we pay right now 
about $8,500 per patient. Guess which State is also ranking 50th in 
terms of quality outcomes, according to Medicare data? Louisiana.
  That is the hallmark of an inefficient payment system for health care 
delivery and it's a symbol of what is wrong with our health care 
payment system in this country. That's why we have to address this 
problem of over utilization, which is directly driving up these costs; 
rein in unnecessary and wasteful spending so we can use those savings 
to pay for a comprehensive health care reform package that provides 
access to care for all Americans.
  So I want to move on and talk about some of the stories from my 
district that have shaped my commitment to making change in health care 
delivery.
  Since I was elected to Congress in 2006, and was sworn in in 2007, I 
have received almost 12,000 letters and e-mails on health care. Health 
care is the number one issue that my constituents write to me about. 
And this year alone, I have received over 4,000 letters and e-mails 
relating to health care. In fact, this small stack represents just a 
small portion of my constituents who have had serious issues with our 
health care system. And just in my hand I have over 200 stories from 
constituents of mine who have taken the time to write to me and explain 
their frustrations and concerns with our health care system.
  These stories are the backdrop and provide the compelling evidence on 
why we need true health care reform in this country.
  So let me start with this compelling story from Sandy Ingram in 
Davenport, Iowa, which is right on the Mississippi River, beautiful old 
city in Iowa, largest city in the First District.
  Sandy starts her story: My story is not unlike many others who are 
struggling with their health insurance problem. In August of 2007, I 
was diagnosed with stage III breast cancer. Until that time, I was 
rarely ever ill, and I looked forward to retiring, like most other 
women in their sixties.
  Until January 31, 2009, I worked for a company and was employed as an 
executive assistant to the CEO. I raised three children, all now 
educators, as a single mom and I finished a four-year degree at St. 
Ambrose University.
  In the spring of 2007, I had my usual mammogram, and I told the 
technician I had a sore spot, and she made note of it. It came back as 
no change. As the weeks went by, it became more pronounced and painful, 
and I went to a nurse practitioner, who sent me for another mammogram 
immediately.
  Over time, it was discovered that my mammogram test was positive and 
I received a call at my office with the news that every patient dreads: 
I'm sorry to tell you that you have cancer.
  I set up an appointment with the surgeon and, with the help of my 
nurse practitioner, I found a wonderful young surgeon, Dr. Melinda Hass 
of Trinity Hospital. I met with her, went through all the necessary 
workup, and later received a followup phone call saying my cancer was 
much worse than they thought, and I could have cancer in both breasts. 
They found out the cancer had spread to my lymph nodes, and so I began 
chemotherapy.
  The beginning of the third week, my hair began to fall out in the 
shower. I shaved my head, bought some caps and scarves, and moved on. I 
worked throughout the chemo by scheduling time off and going to work 
when I began to turn the corner from the side effects.
  In December 26, 2007, I had bilateral breast surgery to remove both 
breasts. I made this difficult decision because I didn't want to have 
the chance of reoccurrence in the other breast. During the surgery, 22 
lymph nodes were removed. However, 17 of the lymph nodes still had 
cancer. The feeling that I had that morning still gives me chills. My 
fight wasn't over yet.
  I underwent another round of chemotherapy a few weeks after the 
surgery, followed by 36 radiation treatments. I was physically spent 
and took a medical leave of absence and returned to work in August of 
2008, ready to hit the ground running. Needless to say, I love my job, 
the people that I worked with, and was looking forward to being there 
until I was old enough to retire.
  I was so pumped up that I unlocked my office door and prepared for a 
busy day when I came back to work. About an hour later, I had a phone 
call from a friend in customer service saying their assistant had just 
been let go. A few minutes later, my phone rang and it was my boss, 
asking me to come to the conference room upstairs.
  What happened is my boss greeted me with tears in her eyes, a big 
white envelope in front of her. Seated at the table was the VP of 
manufacturing and the two of them broke the news to me that my job had 
been eliminated. It was only weeks after I had been declared cancer 
free by the 60-day checkups.
  I was stunned. They both assured me it had nothing to do with my 
performance. The response was predictable. They told me that I would 
have to leave the building immediately and could return to the office 
later to pack up my office. Everybody in the whole office was very 
shaken.
  So now I'm unemployed. I have unemployment insurance and through 
COBRA continue to pay for health insurance on my own. That will last 
through July of 2010. At that point I will have to have some kind of 
insurance until my 65th birthday in November of 2010.

                              {time}  2320

  I continued to look for a new position. I have applied for several 
and may try to work part time to help pay for the COBRA coverage. I 
have done research about getting further coverage, and I have found I 
cannot get coverage due to my preexisting condition. There is some kind 
of stopgap health coverage through HIP of Iowa; however, since I paid 
health insurance premiums for nearly 20 years, I feel I should be able 
to keep it until I am old enough for Medicare. Health care reform is 
essential to all Americans. The time is now, and I am willing to help 
tell my story to get the bill passed.
  Here is another story. This one is from Elle in northeast Iowa. She 
is 1 year old and has been diagnosed with cystic fibrosis. Her family 
had COBRA insurance, which is an extension of your insurance after you 
leave your job until you find more employment, from her dad's former 
employer in Minnesota. Her dad's employer offered a more affordable 
plan to the family, but when they realized the family resided in Iowa, 
they reversed the offer. Because of Elle's diagnosis, this family was 
unable to get private insurance in Iowa.
  Her mother quit her job so that their income would decrease enough to 
get Elle on Medicaid. Quite understandably, Elle's parents are 
frustrated because they believed they shouldn't have to quit their jobs 
to get health care coverage for their daughter. They believe that 
insurance needs to be accessible for all children, including those with 
chronic health conditions, and that is one of the number one objectives 
of the health care reform bill we're considering right now.
  Here is another contact I got from Mark in Davenport. Mark was doing 
insulation in his mother's home so that she could take advantage of 
some energy savings rebates, which is something every American should 
be encouraged to do. Unfortunately, while Mark was putting the 
insulation in his mother's home, he fell through the ceiling and 
severely injured himself, suffering a collapsed lung, broken ribs, and 
dislocating most of the ribs from his vertebra. He was lucky to 
survive, but he had no health insurance because he was a self-employed 
private contractor. His medical bills were over $20,000, and because of 
those high costs, he was forced to file for bankruptcy so he could get 
out from under his debts.
  Here is another contact from Cynthia in Denver, Iowa, who 3\1/2\ 
years ago lost her husband to diabetes and heart disease. Since then, 
she's had to deal with major debts because they, like millions of 
Americans, did not have health insurance. When they tried to get 
coverage, they were told that because of

[[Page 18553]]

her husband's preexisting condition, they would have to pay for 
premiums for a year without coverage for those claims. She continues to 
be without coverage because she is still paying off the bills from her 
husband's doctor and hospital costs.
  Here is another story from Gus in Waverly. His daughter Jamie lives 
in Des Moines and works for a life insurance company. Jamie, like many 
Americans, has cerebral palsy and is confined full time to a 
wheelchair. But even with her limitations, Jamie chooses to work, and 
the only type of insurance help that she gets is through a Miller 
Medical Trust that allows her to work, but she can't work full time.
  Because of the limitations of that trust, she has lost a much-
deserved promotion. She hasn't taken a pay raise in years so she can 
choose to work and be a taxpaying citizen. Many of her advisers and 
social workers have told her that she should just go on full disability 
and her benefits would increase and be easy to get since she qualifies 
as a quadriplegic; yet Jamie is a perfect example of the American 
spirit. She wants to work, and she continues to work and does 
everything she can.
  Her father doesn't understand why we would punish people like Jamie 
who want to work but still need critical access to health care. Let 
them earn more money that pays more taxes and help them support their 
own services. Who could argue with that? And that's what we want to do 
with comprehensive, meaningful health care that addresses these 
Populous Caucus values.
  Here is another letter from Julie in Cedar Falls, Iowa. Several years 
ago when Julie was mowing her lawn, she was severely injured when a 
bolt on the lawnmower cut her arm. She had to go to the emergency room 
for stitches. Later she learned that her emergency room visit was not 
covered by her health care coverage because, according to them, she 
should have waited to cut her arm when the doctor's office was open 
instead of visiting the emergency room. Given the severity of her 
wound, she couldn't have waited until Monday to see her doctor. The 
emergency room was the only option available for her at the time. Julie 
believes that the problem with health insurance companies is they look 
for any excuse to deny payment for an existing claim.
  This is a letter from Mic in Davenport who was born with congenital 
heart disease. Mic has had three open-heart surgeries, the first at age 
3 weeks, the second at 16, and the last at age 45. He owns his own 
company, employs 11 people, and provides group health insurance to his 
employees because it's the right thing to do, but also because he can't 
buy an individual health insurance policy with his congenital heart 
disease because it would be a preexisting condition.
  Mic says, We're charged at the highest rate possible, and our rates 
go up by the maximum amount allowed per year because of my heart 
disease. In the past 2 years, we've risen to 60 percent and 75 percent 
increases. In order to keep providing insurance to my employees, I will 
have to drop out of the program next year to keep the rates manageable.
  This story is from Randal Wehrman from LeClaire, Iowa. His wife, 
Beth, died from pancreatic cancer in August 2008 at the age of 56. And 
like many couples, during her illness, Randal had his own health 
emergency. He was diagnosed with prostate cancer, and as he describes 
it, we were launched into a health care arena and were impacted 
dramatically by how our health insurance performed.
  Randal, like many Americans, tells me that he was reasonably 
satisfied before this point with how his health care insurance carrier 
had functioned. His wife was a registered nurse, so she was a very good 
medical consumer. He was in the property and casualty insurance 
business and had been a certified paramedic in the State of Iowa for 
the last 25 years, and as he notes, this would suggest that Beth and I 
were above average medical consumers. It also means, according to his 
background and his business, including a BA with a business 
administration degree from Simpson College, that he would have been an 
above average medical insurance consumer.
  Here is the problem: Even though the Wehrmans' health care plan said 
it had a maximum out-of-pocket of $1,500 per person in network and 
$3,000 per person out of network, we paid just over $10,000 out of 
pocket during calendar year 2008 for our health care. Here is how 
Randal describes it:
  ``You see, one has to read the fine print to find out doctor office 
copays, prescription copays and emergency copays do not fall under the 
maximum out-of-pocket expenses referred to in the bold print. While 
Beth's care included an out-of-pocket network expenses, mine did not, 
which means that we spent an additional $5,500 of out-of-pocket items 
that were not included in our limits. We are fortunate that we could 
pay the additional, although not easily, but some cannot. For some, 
this situation could be financially devastating. And we know that by 
the high number of medical expense-related bankruptcies we see every 
year. This should be clearer and more concise, as it can have a 
substantial impact on the financial futures of many citizens.''
  Well, Randal, you are absolutely right, and one of the reasons why I 
introduced a bill to incorporate plain language into every insurance 
policy sold under the national health insurance exchange that's part of 
this health care bill is because I have had my own experience, not just 
as a consumer of health care, but helping clients, in the 23 years I 
practiced law before I came here, who had disputes with their insurance 
companies over coverage benefits.
  One of the things I learned is that when you force insurance 
companies to write those policies in language that insureds can 
understand, you eliminate the type of confusion that highly 
sophisticated health care consumers, like Randal and Beth Wehrman, 
brought to the table and still wound up with unfair treatment based 
upon language in their policy that was difficult to understand and not 
part of the clearly stated coverage.

                              {time}  2330

  I'm very proud of the fact that my plain language amendment is 
incorporated in the American Health Care bill that we are currently 
considering in the House of Representatives. And I want American health 
consumers like Randall and Beth Wehrman to be able to look at that 
policy and see it written in language that is specifically intended to 
be understood by them so they have a deep appreciation for what they 
have, and they also have the ability to go into that National Health 
Insurance Exchange and compare it to other policies that provide the 
same basic types of coverage and say, is this policy a better policy 
for me than the one next to it? Does it provide better coverage? Does 
it have fewer exclusions? Does it cost less? And will it guarantee me 
the access to health care that my family needs? That's one of the major 
focuses of the populist values approach to health care reform.
  So what else is important? Well, we spent time talking about how we 
can move from a system that rewards volume of medical care to a new 
model, a new system that rewards value outcomes. And we pay for 
performance.
  And I am very proud to be introducing an amendment, along with my 
friends Lee Terry from Nebraska, a Republican, and Bart Stupak from 
Michigan, who is the Chair of the Oversight and Investigations 
Committee on the Energy and Commerce Committee, the Medicare Payment 
Improvement amendment, which has a very simple goal, to increase the 
quality of health care in America and create long-term substantial cost 
savings.
  So what will this amendment do? Well, it starts by restructuring the 
Medicare payment system that I talked about earlier, by finally adding 
an incentive for physicians to provide high-quality care and decrease 
costs. And the way the bill does it, it adds a figure that measures 
value and includes it in the Medicare reimbursement equation. That 
value figure measures both quality of care and the cost of care, two 
components that directly relate to the overutilization of medical 
services that dries up our national health care costs.

[[Page 18554]]

  One of the things we know is that regions that provide high-quality 
care at low cost will see their Medicare reimbursements improve and 
increase because it's a reward for providing value in the system. In 
contrast, regions that provide low-quality care at high cost will see 
their reimbursements decrease.
  Now, this may come as a shock to most people, but that's the way an 
economic system is supposed to work: you provide incentives so that 
people in a marketplace who provide the highest quality at the lowest 
cost will create the most demand and drive consumers to their product 
or services. Every student of economics 101 can tell you that's the way 
economic models are supposed to work in this country.
  But our health care payment system is flawed and it's reflected in 
this chart, and it's reflected in the hundreds of billions of dollars 
of waste in the system.
  Now, one of the things that we can do is to shift from a fee-for-
service reimbursement model to one that rewards quality and shifts the 
focus to provide efficient care.
  Now, a lot of people mistakenly believe that when you're talking 
about efficiencies, you're only talking about cutting cost. That is not 
what I'm talking about, and that is not what the Populist Caucus values 
are based upon, because true efficiency in a health care delivery 
system is a system that consistently provides the lowest possible cost 
for the highest possible value over the lifetime of a patient's care. 
That is efficiency in health care delivery.
  So this bill, the Braley-Terry-Stupak Medicare Payment Improvement 
amendment accomplishes that and provides a transition from our current 
quantity-based system to a value-based system.
  How do we do that? Well, here's how: our amendment instructs the 
Secretary of Health and Human Services to measure quality and cost for 
hospital fee schedule areas, which have already been established, or 
other more narrow areas if the Secretary deems that appropriate. That 
could include hospital referral regions or even on down to the 
individual provider.
  Two, our amendment instructs the Secretary to create a quality 
component to measure quality and to do that in consultation with the 
already existing Agency for Health Care Quality and Research, and an 
advisory group consisting of health care providers, health care plans, 
and other government agencies and other knowledgeable entities, 
including consumer groups that have knowledge about how to build 
efficiency and reward value.
  Three, the Braley-Terry-Stupak Medicare Improvement amendment ensures 
an open and transparent process in the development of this quality 
component. And during some of our conversations about how you could 
possibly do this, we hear concerns expressed from people in this part 
of the country: you're not taking into account this factor. We hear 
concerns expressed from people in another part of the country: you're 
not taking into account this factor.
  Well, the harsh reality is the medical economists who've been 
studying this issue for decades have already looked at every possible 
racial, ethnic, socioeconomic, regional, cost-of-living, cost-of-
workforce factor and can find nothing to justify the reimbursement 
disparities we see right now.
  To give you an example of that, one of the most significant factors 
contributing to overutilization in this country is what we pay for end-
of-life care. And one of the things that researchers have discovered is 
spending more for end-of-life care does not yield better results and 
does not make people more satisfied and their families more satisfied 
with the care that they got. And, in fact, the exact opposite is true.
  So let's talk about geographic disparities and how it relates to this 
problem of overutilization. Researchers and medical economists who 
looked at the last 2 years of spending in the life of Medicare patients 
at Garfield Hospital in Los Angeles, concluded that, on average, we 
were spending $106,000 per Medicare patient in the last 2 years of 
their life. That was contrasted with the Mayo Clinic in Rochester, 
Minnesota, 2 hours from where I live, another world class medical 
facility, a teaching hospital. At the Mayo Clinic, patients in their 
last 2 years of life, Medicare paid, on average, $33,000, a three-fold 
decrease from what's being spent in Los Angeles.
  And you can look at all those other factors I laid out earlier, and 
none of them can justify that kind of a payment disparity. And, in 
fact, when you look at the regions of the country that are spending the 
most on those last 2 years of patient care in a patient's life, and you 
look at the quality assessments that are used, you'll learn that 
patients in the areas that spend much less are much more pleased with 
their quality of life at that end-stage phase because more attention is 
placed on providing hospice care, providing a way for those patients to 
interact with their family on a meaningful basis, to be able to return 
to their homes and spend as much time there as possible without a lot 
of unnecessary tests and medical procedures that are very costly and do 
very little to improve the length of the patient's life or the quality 
of their life.

                              {time}  2340

  That's why this bill, this amendment--the Braley, Terry, Stupak 
Medicare Payment Improvement amendment--focuses on how we motivate 
health care providers to get better outcomes, to spend less and to get 
better quality care.
  So, going back to my example, according to the 17 existing quality 
factors that Medicare uses to assess facilities, the Mayo Clinic ranked 
above Garfield Hospital in every single one of those quality 
assessments. That is what we're focusing on--quality outcomes at the 
best possible price over the life of a patient. That is efficiency.
  Another component of the Braley, Terry, Stupak Medicare Payment 
Improvement amendment is that it instructs the Secretary to create a 
cost component to measure cost based upon the hospital fee schedule 
area or upon other more narrow areas. That cost component is the cost 
per Medicare beneficiary compared to the national average, which should 
be a reasonable thing for anybody looking at how we spend money and at 
how we decide who is outside the norm, who is below the norm, and 
whether they're getting the types of results that they should.
  The Braley, Terry, Stupak Medicare Payment Improvement amendment also 
includes a risk adjuster in determining the cost component. This 
ensures that any area with a significant at-risk population--high rates 
of obesity and other socioeconomic risk factors that bill into the 
system--shall have them taken into account when determining the cost 
for that area.
  Then the sixth component is to provide a transitional period from 
2012-2014 when this quality cost figure is applied to the Medicare part 
B reimbursement equation in place of the current work geographic 
practice index. The work gypsy, as it's known, is currently used to 
measure the value of a physician's work only through the amount of 
inputs. Our amendment shifts the emphasis to a measure of value that is 
quality and cost.
  So you may be asking yourself: Well, how in the world do you measure 
for quality in a system that has so many variables? Here is how the 
Braley, Terry, Stupak Medicare Payment Improvement amendment measures 
quality:
  First, we look at health outcomes and at the health status for the 
entire Medicare population. We also focus on patient safety, which 
could fill up another hour by itself. Why? Because the Institute of 
Medicine has published three seminal reports on patient safety, and it 
has identified the enormous problem in this country with patient 
safety. In fact, the Institute estimates that, every year, as many as 
98,000 patients die because of preventable errors. This is the 
Institute of Medicine, which is not a partisan entity. They also 
estimate that, each year, over 1.5 million medication errors occur and 
that every hospital patient is subjected to some type of medication 
error every day they're in the hospital.
  Patient satisfaction. This gets back to what we were talking about 
with end-of-life treatment. Increasingly,

[[Page 18555]]

how patients receive care and respond to care is directly related to 
how they perceive their access and quality of care. It also measures 
hospital readmission rates because we know that one of the biggest 
drivers of cost is that of patients who are discharged from the 
hospital and who are later readmitted for conditions that may have been 
prevented if there had been better information communicated to them or 
if there had been better coordination of care upon their discharge.
  Another factor we look at is mortality related to health care. Are 
patients dying in greater numbers as a complication of a specific 
problem? We know, for example, that hospital infections are an enormous 
problem. They lead to many hospital readmissions, to prolonged patient 
stays, to increased costs of care, and in the worst outcomes, to death. 
We also know that many hospital infections are entirely preventable 
from standard, simple precautions like hand-washing procedures that are 
not only adopted but that are enforced.
  Then other things that we use to measure quality are other items 
determined by the Department of Health and Human Services, and if the 
advisory group has other recommendations, we certainly want the 
Secretary to take those into account.
  How do you measure cost? Well, the cost component is measured through 
the total annual, per-beneficiary Medicare expenditures under part A 
for that area, and it also allows the Secretary to use other methods if 
it's appropriate.
  So how much cost savings are we talking about? Hundreds of billions 
of dollars. We know that, by changing the incentives away from a fee-
for-service toward a fee-for-high-quality and low-cost model, we create 
incentives for health care providers to improve their outcomes and to 
decrease their costs. We can use those cost savings to build a health 
care system that truly is universal and that helps us all.
  Nobody said this challenge would be easy. Yet those of us who are 
committed to comprehensive, universal health care that is paid for, 
that is reliable, affordable, efficient, and high quality are committed 
to spending the time necessary to improve this bill and to make it work 
the way it needs to work. It has to work if we are to function as a 
country.
  So I ask you to join the Populist Caucus, to call your Representative 
or your Senator and to make sure that they know how important health 
care is to you, just the way my constituents called me, wrote me and 
sent me e-mails.
  This is a challenge. The time has come for bold action. Americans 
deserve better. Americans demand better, and it is our responsibility 
in this Chamber, Mr. Speaker, to finally deliver on the promise of 
health care for all that is high in quality and that is low in cost.
  With that, I yield back the balance of my time.

                          ____________________