[Congressional Record (Bound Edition), Volume 155 (2009), Part 23]
[Senate]
[Pages 31676-31678]
[From the U.S. Government Publishing Office, www.gpo.gov]




                           HEALTH CARE REFORM

  Mr. UDALL of New Mexico. Mr. President, this effort to reform our 
Nation's health care system is finding ways to make quality health 
coverage affordable and accessible to all Americans. I believe the bill 
we are considering in this Chamber as it currently stands goes a long 
way toward making that vision a reality. But even with this solid 
legislation, there is still a large group of Americans who continue to 
be left behind. I am talking about our country's first Americans, the 
1.9 million American Indian and Alaska Natives who are suffering 
because the Federal Government isn't living up to its propositions.
  The law that provides the framework under which the health care 
programs for Native Americans are delivered hasn't been reauthorized 
for more than 10 years.
  This means that the Indian Health Services' delivery system is 
chronically underfunded and, given the rapid advance of health care 
technology, outdated. As a result, too many Native Americans are 
struggling to receive quality, timely health care.
  This agency is supposed to be the principal health care provider and 
health advocate for Indian people. Yet every day, because we fail to 
act, the health care situation in Indian Country grows more urgent. 
Native Americans are diagnosed with diabetes at almost three times the 
rate of any other ethnic group. They often don't have access to 
preventive care. And Native American youth are attempting and 
committing suicide at devastating and alarming rates. Just 2 months 
ago, in New Mexico, a 14-year-old girl from the Mescalero Apache 
Reservation became the fourth young person from that tribe to take her 
own life--in a little more than 1 month. That is four young people in 1 
month on one reservation. Tell me this doesn't cry out for action.
  The Senate Indian Affairs Committee has reported the reauthorization 
bill. The House has put in its health care package the same kind of 
reauthorization bill. Both of these bills would bring us much-needed 
reform to the Indian health care system.
  This legislation, the Senate must act upon it. We can no longer 
delay. For the past several years, Congress has failed to get this 
legislation across the finish line. It has passed both bodies in the 
last several years--the House at one point and the Senate at one 
point--but it is still not law. Now is the time to put this in the 
health care bill and get the job done.
  I know my colleagues on both sides of the aisle are in agreement that 
our Nation's health care system needs reform. We know health care 
reform is needed now. We know the status quo is unacceptable. But what 
is missing is the same sense of urgency for our Native American 
community, this despite the alarming statistics from the Civil Rights 
Commission several years ago that the United States spent more than 
twice the amount on a Federal prisoner's health care than that of a 
Native American man, woman, or child; that is, $3,800 per year per 
Federal inmate, versus $1,900 per year per Native American. That is 
right, our inmates have better health care than the population with 
whom we signed treaties and made a promise to provide health services. 
American Indian and Alaskan Natives are three times as likely as Whites 
to be uninsured, and almost half of our low-income American Indians and 
Alaskan Natives lack health coverage.
  The longer we wait, the more Native Americans suffer needlessly. The 
longer way wait, the more Native Americans go without treatment for 
chronic conditions such as diabetes and heart disease. The longer we 
wait, the more Native American teens who may take their own lives 
because they are not getting the help they need.
  America has an obligation to provide quality, accessible health care 
for our country's first Americans. So I say again, it is time to act on 
this important piece of legislation. It is time to reform the Indian 
health care system and permanently reauthorize the Indian Health Care 
Improvement Act.
  Mr. President, I yield the floor.
  The PRESIDING OFFICER. The Senator from New Hampshire is recognized.
  Mrs. SHAHEEN. Mr. President, I rise today to support the health care 
reform legislation that is before us. I want to talk a little bit, 
specifically, about what the bill does to reform our health care 
delivery system. That is really health care jargon for the way we 
provide health care to people who need it.
  I heard a lot of debate earlier this afternoon about the fact that 
the health care bill doesn't do anything to address costs. I think that 
is just wrong. The fact is, this health care bill does begin to address 
costs in our system. That is one of the reasons we have to pass it. In 
fact, we know that over the next 10 years it is going to reduce our 
deficit by $130 billion.
  But more important than that are the changes that I believe this is 
going to begin to make in how we provide health care for the people of 
this country. The fact is--we all know it, even our colleagues on the 
other side of the aisle--our current health care system is not working; 
it costs too much; and for too many families quality health care is 
simply out of reach. One of the problems is that 30 percent of the $2.5 
trillion we spend right now each year on health care goes to 
unnecessary, inappropriate care and administrative functions that do 
little to improve our health.
  Our health care system didn't get this way overnight. Years of 
perverse incentives have encouraged health care professionals to 
practice more medicine rather than better medicine. They struggle to 
see more patients and do more procedures to keep up. Hospitals race to 
build new wings and state-of-the-art units. As patients, we too often 
live unhealthy lifestyles, and we expect the newest high-tech services 
to fix it. In the meantime, we have undervalued things such as primary 
care, preventive care, and mental health services. Despite all of our 
spending, we are not any healthier.
  Over the past few months, I have joined, as the Presiding Officer 
has, with all of our freshman colleagues on the floor to discuss why we 
can't continue this current system. It is too costly and too 
inefficient.
  Last week, the freshman Senators introduced a package of amendments 
that emphasizes cost containment. The provisions contained in our 
package may not be those that are currently grabbing headlines, but I 
believe they really go to the crux of our reform efforts. They are the 
delivery system reforms that will improve quality and control costs 
over the long run. How are these going to work? Well, our delivery 
system reforms build upon the current underlying bill. They reward 
improvement in providing care for a better health outcome.
  One way we can be more efficient in delivering care is through what 
are called accountable care organizations or ACOs. These ACOs allow 
medical providers to work in teams, to take responsibility for 
decisionmaking, and they offer financial rewards for better health 
outcomes. Our amendments allow medical providers to align Medicare, 
Medicaid, and private sector strategies for improving care. Doing this 
will help ensure all Americans receive high-quality care no matter how 
they are insured. ACOs provide the right kind of incentives and promote 
value over volume.
  For years, the Dartmouth Institute of Health Policy and Clinical 
Practice has shown us that there are regional differences in the way 
care is delivered and how health care dollars are spent. Over the 
summer, Dr. Atul Gawande eloquently highlighted Dartmouth's findings in 
an article he wrote for New Yorker Magazine. He clearly made the case 
that higher quantity do not necessarily translate into higher quality, 
so that more procedures do not necessarily mean better care. Dr. 
Gawande's article has had a tremendous influence on the health care 
debate. It has been quoted frequently by

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President Obama and referenced right here on the floor of the Senate.
  In his latest article, which just came out recently, Dr. Gawande has 
once again made an important contribution to the health care reform 
dialog. In this article, he emphasizes the importance of delivery 
system reforms and fixing our health care system. He points out that 
there is not one single answer, there is no silver bullet to what we 
need to do to change our health care system.
  While we can all agree that something must be done, what we can't 
agree on is what specific model or provision will be the best and have 
the most desirable outcomes.
  Dr. Gawande pointed out that our country faced a similar challenge 
before. In the article, Dr. Gawande draws a parallel between our 
current health care system--one that is very costly, a money drain, one 
that is fragmented, disorganized, and inconsistent. He compares our 
current health care system to the agricultural system at the start of 
the 20th century. At that time, more than 40 percent of a family's 
income went to paying for food. The inefficiency of farms meant lower 
crop yields, higher prices, limited choice, and uneven quality. 
Agriculture was on an unsustainable path. Dr. Gawande points out that 
the Federal Government did not, however, offer a grand solution; 
rather, it provided incentives to change the way farmers produced 
crops. Through innovation, the promotion of best practices, and smart 
dissemination, today food only accounts for about 8 percent of a 
family's income compared to that 40 percent at the start of the last 
century.
  As you know, as we have heard discussed on the floor, we have 
examples of great innovation and excellence in health care, such as 
Dartmouth in my State; the Mayo Clinic in Minnesota, which Senator 
Klobuchar can speak to; Intermountain in Utah, and numerous other 
places of excellence around the country. These institutions have 
developed integrated health care systems that are patient focused. 
Their practices have promoted high value and excellent outcomes, best 
practices, which should be shared throughout the country.
  The Patient Protection and Affordable Choices Act identifies some of 
these best practices and provides the types of incentives for doctors, 
nurses, and patients to change the status quo and to experiment with 
innovation and excellence. The many programs supported in the bill 
before us move us in the direction of delivery system reform, which is 
so important to our effort.
  By promoting innovative practices, such as accountable care 
organizations, payment reform, and medical homes, we can move away from 
the current fee-for-service system that rewards volume over value. That 
is true reform.
  I urge my colleagues to support the bill.
  The PRESIDING OFFICER. The Senator from Minnesota is recognized.
  Ms. KLOBUCHAR. Mr. President, I thank the Senator from New Hampshire 
for mentioning the Mayo Clinic, along with several other great 
facilities in this country that have done things a little differently. 
They have done it by focusing on the patient, by saying what is best 
for the patient is best for all of us. When you do what is best for the 
patient, you get higher quality care. When you get higher quality care, 
you actually get lower costs.
  I think of people when they go in to pay for a hotel room and they 
say: If I pay more, I will get a better view and a bigger room. That is 
usually true. Not in health care. If you look at trends across the 
country, the States, the metropolitan areas that have the least 
efficient health care tend to cost the most. That is what we need to 
change if we want true cost reform. It is good in States such as 
Minnesota, New Hampshire, and Wisconsin. Why? Because we tend to have 
higher quality care at lower costs. We are rewarded for that.
  It is also good for the States that need to get their quality of care 
up, so that we don't see massive readmissions to hospitals. Who, when 
they go to a hospital and are sick, wants to go back in because they 
get sick in the hospital? Who wants to have something go wrong in the 
hospital so they have to go back? Who wants to go to an area where they 
have massive fraud, so all this money gets drained in the amount of $62 
billion a year in Medicare fraud? That is what happens.
  That is why, on delivery system reform, the courageous thing is to 
step back and say: How do we do this better? How do we do it so we are 
rewarding quality and not just quantity, so that we are putting the 
patients first?
  That is what this bill is about. Why does this matter? I think 
anybody who has a checkbook understands what this means. At $2.4 
trillion a year, health care spending represents close to 17 percent of 
the American economy, and it will exceed 20 percent by 2018 if the 
current trend continues. Hospitals and clinics in every part of the 
country are providing an estimated $56 billion in uncompensated care. 
That is taxpayer money going down the tubes--$2.4 trillion per year. 
That is where we are now. Everybody knows it is costing them and making 
it very difficult for big businesses to compete against businesses from 
other countries that have more efficient health care systems. It is 
making it impossible for small businesses to keep all of their 
employees on health care. Why? Well, their costs are 20 percent more 
than big businesses.
  The small businesses have created 64 percent of the jobs in the last 
decades in this country. We have to allow them to continue to thrive, 
not with these health care costs that are a drag on these small 
businesses.
  I always tell people to remember three numbers: 6, 12, and 24. Ten 
years ago, the average American family was paying about $6,000 in 
premiums. Now they are paying $12,000. That is average. We have a lot 
of small business owners all over our State paying $20,000 a year, 
$23,000 a year. If we do not do anything, if we do not do anything at 
all, 10 years from now it is going to cost between $24,000 and $36,000 
average in this country for individual families to buy health care--
$24,000 to $36,000 average per family. That is why we must act. We know 
inaction is not an option. If we do not act, costs will continue to 
skyrocket, and 14,000 Americans will continue to lose their health 
insurance every single day.
  What does this bill do? First, it gives coverage to 31 million people 
who do not have coverage now. People are saying: Wow, where are they 
getting health care now? I will tell you where: the emergency room, 
such as in the hospital I used to represent when I was the county 
attorney for the biggest county in Minnesota. That was paid for by the 
taxpayers. When someone does not have insurance, when they don't have a 
doctor, they have diabetes, they are supposed to be doing their insulin 
and watching their diet and they wait and wait and they end up in the 
emergency room and they get their leg cut off and have big costs for 
all taxpayers, not to mention the disastrous quality of life for the 
person involved. That is going on in this country.
  Last year, I was down in one of our smaller towns in southern 
Minnesota. I heard how one science hospital had three people come in 
with stomach problems, appendicitis attacks. Their appendixes burst. 
This was over a period of several months. They asked: How come you 
didn't come in earlier? Two of them said: We work at a small business; 
we didn't want the premiums to go up. It would hurt everyone at the 
small business. Another said: I had such high premiums I would have to 
pay I didn't want to come in and have it checked out.
  If you do not have that kind of safety net in place for people, you 
get more expenses on the far end. That is what this bill does. It 
changes the delivery system, insuring 31 million more people.
  What else does it do? It helps to reduce the deficit. That is what I 
said from the beginning. I do not want to support a bill that adds to 
the deficit. Actually, this bill we are talking about--some changes are 
being made--reduces the deficit by billions and billions of dollars.
  A third thing: What does this bill have? Insurance reforms. What does 
that mean? It means if you have a sick

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kid, you no longer are going to lose your insurance. You cannot be 
pushed off, put off in the deep end all by yourself if your kid gets 
sick. It means if you have a kid going to college, you can keep them on 
your insurance until they are 26 years old. That is what the bill does. 
It gives a safety net, consumer protections that people in this country 
have demanded.
  Finally, with Medicare, it adds 9 years onto the life of Medicare. 
Right now, Medicare is scheduled to go into the red by 2017. No one 
wants to talk about it. We need to talk about it. What this bill does 
is keep it solvent for 9 more years.
  I can tell you, my mom, who is 82, wants to stay on Medicare until 
she is way into her nineties. People in their fifties who want to get 
on Medicare at 65 want to make sure it is there for them, that it is 
solvent.
  What this bill does with the reforms that are in it, with the 
promotion of high quality, closing that doughnut hole, which is 
difficult for seniors, it helps our seniors. This is an idea, someone 
said today--I was listening to other Members--whose time has come. This 
bill is not going to be perfect for everyone. I think about the people 
I heard from, such as the woman who wrote to me from northern 
Minnesota. She wrote this heartfelt letter about how she had gotten a 
call from her daughter whose husband worked at a small business. She 
said that husband, her son-in-law, had just found out they were not 
going to have insurance anymore at his small business. The woman who 
wrote, the mom, said she couldn't even understand her daughter. The 
daughter was sobbing, sobbing: What is wrong? What is wrong? What 
happened? I lost my insurance.
  Do you know why this mattered so much for her family? Her daughter 
has cystic fibrosis. Her daughter needs this insurance every moment of 
her life. When that small business yanked that insurance coverage 
because they probably had to--I am sure they didn't want to, but they 
just couldn't afford it anymore--that daughter has to go on the open 
market now which, if you have a preexisting condition, is not an easy 
thing to do. She may not get insurance. That is what we are talking 
about when we talk about this bill.
  At the end of the letter, the mom said: I need you to be my 
daughter's voice. She is not going to be able to go to Washington, DC, 
and lobby for this like all the companies that have come over here and 
lobbied for this thing and that thing. She needs us to be her voice, 
and that is what this is about.
  The good thing here is that, as we look at some of the things in the 
bill, I didn't get everything I wanted to reduce costs, I can tell you 
that right now. But there are some great provisions in this bill.
  Look at this. According to researchers at Dartmouth Medical School, 
nearly $700 billion per year is wasted on unnecessary or ineffective 
health care. That is 30 percent of total health care spending.
  To rein in costs, we introduced a value index. I introduced a bill--
Senator Cantwell, Senator Gregg are coauthors of this bill. Senator 
Cantwell got it on the Finance Committee bill and it is still in the 
merged bill today. What that does is it says, when you look at the 
Medicare fees, evaluate them on a lot of things but make sure you 
evaluate them on value. This indexing will help reduce unnecessary 
procedures because those who produce more volume will need to also 
improve care or the increased volume will negatively impact their fees.
  Doctors will have a financial incentive to maximize quality and value 
of their services instead of quantity. My doctors in the State of 
Minnesota support this. They have supported this bill. They have 
endorsed this bill. They understand that if we want to get that high-
quality care like we see in Minnesota in places such as the Mayo 
Clinic, the Cleveland Clinic, Intermountain, Kaiser--all over the 
country--you have to have those kinds of incentives in place.
  This bill also focuses on bundling and integrated care. I was 
thinking, as I watched the Vikings game this weekend--I do not know if 
you noticed, but the Vikings won again; Brett Favre is quarterback--we 
are talking about a primary care provider who works with a team. We do 
not have 15 wide receivers running into each other. We have one person 
in charge--a quarterback in football, a primary care doctor in 
medicine--working with a team, with a wide receiver, with a tight end, 
with all the team they have working together, whether it is a 
cardiologist, whether it is a urologist, whether it is any kind of a 
doctor they want to work with as a team, depending on what the illness 
is. That is what integrated care is. You work as a team, share medical 
records. Patients do not get lost in the shuffle. They do not get sent 
to one specialist and another specialist without anyone watching over 
their care. That is what integrated care is about, a quarterback with a 
team.
  The other thing about this bill is, we start to focus much more, as I 
mentioned, on reducing readmissions, on rewarding places such as Health 
Partners or St. Mary's in Duluth, places that work to have this 
integrated care, places that make sure we have less readmissions in the 
hospitals.
  Finally--and I am pleased we got this in the freshman package that is 
coming out--there is a much bigger focus on fraud in the system. Mr. 
President, $60 billion a year is going down the tubes, going to 
fraudsters, to con men, siphoning off the system by storefronts that 
are not doctors' clinics that claim they should get some of the 
reimbursements that should be going to our seniors. That is $60 billion 
in Medicare fraud alone every single year.
  There are increased penalties with tools to make sure we are better 
enforcing the law. We can reclaim some of that money and give it to the 
American taxpayers, give it to our seniors.
  Those are a few things. I will be talking more about this, this week, 
when we focus on and talk about cost control in this bill.
  Thank you for allowing me to share some of my thoughts on cost. 
Again, remember 6, 12, 24. Ten years ago, the average American family 
was paying $6,000 for their premiums. Now what are they spending? They 
are spending $12,000. What are they going to spend 10 years from now if 
we don't do anything? They will spend $24,000 to $36,000 a year. We 
know this is not going to be easy to bend this cost curve. We know 
there are going to be bumps in the road. We know it is not going to 
automatically turn itself around. To do nothing, to put our heads in 
the sand at this moment in history is just plain wrong. The American 
people deserve to have better health care. They deserve to have that 
high-quality, low-cost care, and this bill is the beginning.
  I yield the floor.

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