[Congressional Record (Bound Edition), Volume 155 (2009), Part 7]
[House]
[Pages 9117-9124]
[From the U.S. Government Publishing Office, www.gpo.gov]




                 REPUBLICAN CONGRESSIONAL HEALTH CAUCUS

  The SPEAKER pro tempore. Under the Speaker's announced policy of 
January 6, 2009, the gentleman from Texas (Mr. Burgess) is recognized 
for 60 minutes.
  Mr. BURGESS. Mr. Speaker, I am coming to the floor of the House 
tonight to talk about health care. We had the occasion this morning 
over in the Library of Congress to have the first forum from the 
Republican Health Policy Caucus. This will be the first of several that 
we will do over the coming months. Obviously, health care is going to 
be a subject that receives a lot of discussion and a lot of debate, as 
it should. It's an important topic, and it is going to occupy a great 
deal of Congressional attention.
  Let me just speak a little bit about the Caucus, and then I want to 
talk about the event that occurred this morning.
  The Congressional Health Caucus was founded at the beginning of this 
Congress, the 111th Congress, and it was formed with several purposes 
in mind. It is a caucus on the Republican side, it is to educate 
members and their staff

[[Page 9118]]

on the issues surrounding health care policy, and certainly, Mr. 
Speaker, the purpose of the caucus is to equip those same members with 
the resources for fostering debate and, of course, ultimately serving 
the American people with the most effective policy. It is designed to 
help members and their staffs communicate effectively, and we do 
welcome debate. It is not a closed-end caucus. Certainly we welcome a 
variety of members.
  And perhaps one of the most important things that this caucus can do, 
this is an inclusive caucus. It does include members, is open to any 
member on the Republican side--I actually thought about the possibility 
of a bipartisan caucus but there wasn't much interest in that. But 
nevertheless, from our side of the aisle--and certainly we've had 
discussions with members of the other body as to whether they might be 
interested--but the idea is to have an inclusive discussion on the 
things surrounding health care reform.
  But perhaps one of the most important things that I envision--one of 
the most important roles that I envision for this caucus is to take the 
discussion beyond the Capitol, beyond Washington, beyond the Beltway, 
the Potomac and all of the accoutrements and all things that are 
Washingtonian and speak to those patients, those doctors, those nurses, 
those hospital administrators who are actually doing the work in the 
trenches day in and day out and are actually looking toward Washington 
and wondering just what it is that we're up to now because, of course, 
some of them have seen this before. And it caused a great deal of 
disruption within the medical community some 15 years ago. They didn't 
see much that changed that was positive. Perhaps we allowed HMOs to get 
a more greater foothold in many markets across the country after the 
failure of the plans of health care reform 15 years ago.
  So there is a great deal of interest but also a great deal of 
skepticism as people who work in the field--again, the doctors, the 
nurses, certainly the patients and their families, certainly the 
hospital administrators, people who work day in and day out delivering 
health care to our patients, our seniors, our youth, our families--
there is a great deal of skepticism about what they see going on in 
Washington right now.
  Well, in pursuit of those goals that I outlined, the events and 
resources provided by the caucus will be designed to prepare members to 
engage intelligently and effectively during this debate that we're 
going to see over the next several months and then beyond that. 
Whatever policies are arrived at or not arrived at, it will be the 
implementation of those policies, it will be the forward activity that 
occurs as a result of enactment of sweeping health care reform or the 
failure thereof.
  Remember back in 1993 and 1994 when the bills did not get out of 
the--the bills did not become law, what was the focus then of the 
United States Congress on health care going forward? What type of 
attention was paid? It will be the purpose of this caucus that 
regardless of what happens, whether reform is enacted or not, that we 
will not take our eyes off the ball, and we will continue to be 
vigilant for the sake of the American people.
  Now, Mr. Speaker, for reasons that I don't quite understand, I was 
invited down to the White House a couple of weeks ago to participate in 
the White House forum on health care reform, the White House Health 
Care Summit, and the President, in his remarks to us as the afternoon 
was concluding, was that it was his job to offer guideposts and 
guidelines, but principally he was there that day to try to find out 
what works. And to that end, I applaud the President for having an open 
mind and having a willingness to listen to a variety of points of view. 
And I intend to be a resource. I intend to help him find out what 
works.
  Yes, I have some ideas. They may not be mainstream Democratic ideas, 
but nevertheless, certainly they deserve some consideration. And many 
Members on both sides of the aisle have ideas, and we saw this very 
much in evidence in the break-out session that I attended.
  One of the concerns I had with going down to the White House that 
day--was I just another pretty face to be down at the White House? Had 
this reform bill, in fact, already been written, was it just basking up 
in the Speaker's office awaiting for the correct time to be visited 
here upon the House floor and then we would all vote on it--much as the 
children's health insurance program bill, the reauthorization for that 
bill, came forward in August of 2007?
  Well, is this bill already done? The President assured us it was not, 
that this would go through regular order, that he would look to the 
congressional committees and subcommittees to hold hearings to do the 
work to draft the legislation, to mark up the bills and do so under so-
called regular order.
  So I take the President at his word that--in fact, we're having a 
number of hearings in my subcommittee on health in the Energy and 
Commerce Committee, and I welcome that because I think these are 
important discussions for us to have.
  But the American people also feel that Congress should do its work in 
the appropriate way and not just simply allow a bill to be crafted out 
of the public domain and arrive fully formed from the Speaker's office 
and come to the House floor. But the public expects us to have the 
debate, to have the discussion, to work on this bill in a bipartisan 
fashion.
  Congress, in undertaking this project, must focus on solutions and 
not politics, and that's going to be very difficult for some of us to 
do. And, in fact, the later it gets in the 2-year cycle that the House 
lives with, the more difficult it is to separate politics from 
solutions. But still, we need to rise above that and work on those 
solutions, long overdue solutions, and focus on what is good for the 
American people.
  We need to keep the idea of patients and not payments uppermost in 
our mind.
  Now, the membership in the Republican Health Care Caucus is open to 
all members of the House Republican conference and their staff. We will 
host regular briefings and forums for members and staff as well as 
providing timely resources. This was the first today, the first policy 
forum that the caucus will host, and we were very fortunate. We were 
joined by three wonderful panelists whose ideas were not necessarily in 
concert with mine. Some I agreed with, some I disagreed with, but it 
was food for thought and very thought provoking; and I certainly 
learned some things as a result of the conference that we held today.
  There will be a follow-up document that will be posted on the caucus 
Web site. It's actually a tab that can be accessed through my official 
congressional House Web site that's Burgess.House.Gov, and there is a 
health care caucus tab that's pretty easy to see when you first go to 
the page and, in fact, by clicking on that page, there is the 
opportunity to visit a--we simulcast this on the Web and the archive of 
that simulcast is now available on the Web site.
  In fact, we did--to show that we were well into the 21st century, we 
took some questions from the audience and we took some that were sent 
to us over the new media phenomenon known as Twitter. So people outside 
the Beltway were able to send in questions which could then be posted 
to the panel. And I think that made for, again, a pretty lively 
question-and-answer period after the presenters did their formal 
preparation. We left about half the time for question and answer and 
again, not all of it came from the audience--or the physical audience--
some came from the virtual audience that was watching on the web and 
sent their comments or questions in through the phenomenon known as 
Twitter.
  So we came together actually in response to President Obama's desire 
to learn about what works. And with our assurances from the majority 
party that they are willing to work with Republicans as long as we 
negotiate in good faith, okay, great, and we wanted to get some ideas 
on the table, and I think we accomplished that this morning.
  We had several questions that we put forth as we started the forum. 
We

[[Page 9119]]

wanted to hear about what is being talked about as a so-called public 
health insurance option, the so-called government-run option, what the 
President's proposal for a government-run option could mean for health 
care in the future, what effect would this have on patients, what 
effect would this have on doctors, what effect would this have on the 
private market; and indeed, what effect would this have on those 
already-existing public programs such as Medicare, Medicaid, and SCHIP.
  We heard testimony relating to what is called a National Insurance 
Exchange, a so-called insurance connector that can bring people and 
insurance policies together, and what are the good things about an 
insurance connector and perhaps what are some of the drawbacks of an 
insurance connector.
  And we did hear discussion about what has been proposed as a national 
health board, a Federal-type of Federal Reserve board that would apply 
to health care and would this board have--how much power would it have, 
how much ability would it have to direct medical spending and medical 
decisions. All very important concepts that are all outlined or have 
been part of the discussion as far as what might be contained within 
the President's plan.
  Just off the subject for a moment. During the fall, I had an 
opportunity to hear about the President's plan in a variety of cities 
across the country in a series of debates that were held during the 
presidential election, and I got fairly familiar with what was being 
talked about on the other side as far as the concepts embraced by then-
presidential candidate Barack Obama as far as what his ideas were for 
health care reform.
  It is interesting, now that we're out of the campaign and into the 
legislation part, some of the things that we heard a great deal about 
during the fall, we don't hear about so much any more. And in fact, 
some of the things that were vilified on the other side are now perhaps 
being embraced as ideas that are worthy of study and worthy of merit.
  Specifically, during the fall we heard a great deal about a mandate 
for children, all children should be covered. I never could get a 
definition of what is a child. Is that a person who is under the age of 
18, 19, 25, or 30? And I heard all four ages mentioned at some point 
during the debates.
  Well, the mandate for children seems to have gotten lost in the 
translation. We expanded the State Children's Health Insurance Program 
in January. So I guess the assumption is that that box is checked and 
we have moved on to other things.
  The National Health Board received a lot of attention during the 
fall. It remains to be seen how big a role that will play in whatever 
legislation is going to be written, and certainly the concept of a 
public option was one that was out there and discussed at great length 
during the presidential debates of last fall.
  The public option plan, I can recall several statements that this 
would be a plan for people who right now lack health insurance, the so-
called 40 or 45 million of individuals in this country who lack the 
benefit of health insurance, and that everyone should be given a plan 
just as good as a Member of Congress. So that would be the Federal 
employee health benefit plan option, which is a fairly expensive way to 
approach that.
  Now, faced with the reality of what are some very significant budget 
deficits stretching ahead of us before we even get to anything beyond 
the preliminary discussions of health care reform, perhaps that is 
going to be, of necessity, be scaled back just a little bit and perhaps 
that public option, that government option, is going to look more like 
Medicare or perhaps even more like Medicaid going further into the 
discussion.

                              {time}  2215

  But it remains to be seen because that part of the story has not been 
written, but I bring it up because it's significant and it behooves 
people to pay attention to what those discussions are because it makes 
some difference.
  We have had multiple hearings, as I mentioned, in our Subcommittee on 
Health in the Committee on Energy and Commerce. We have multiple panels 
who will come and discuss various aspects of health care reform. We 
have Democratic witnesses. We have Republican witnesses. And out of 
perhaps somewhere between 10 and 15 witnesses that we have had come 
before our committee, I've only found one witness who would be willing 
to exchange their health insurance that they have today for a program 
such as Medicaid if that were to be the government-run option. Almost 
every other panelist who's come before us, whether it be Republican or 
Democrat who's presenting to the panel, has no interest in substituting 
their health insurance for a Medicaid-type program.
  Mr. Speaker, in fact, during the debate on the rule in Rules 
Committee leading up to the State Children's Health Insurance Program 
expansion, I offered an amendment in Rules Committee to allow Members 
of Congress the option for signing up for Medicaid as opposed to some 
of the other insurance products on the Federal Employee Health Benefits 
plan. Needless to say, that amendment was not adopted and received very 
little interest when I brought that up to the Rules Committee.
  But it brings up the point, if we're not willing as Members of 
Congress or the people who testify before our committees are not 
willing to take on a public option program, a government-run program 
like Medicaid for their health insurance, well, what does that say 
about what we are making available then to people who currently are 
covered under Medicaid and people who are currently uninsured who may 
be offered a government-run program if it is made to look very much 
like Medicaid looks today?
  I think we have a long way to go to fix some of those programs. 
Certainly, both Medicare and Medicaid have some significant problems. 
There are significant problems with finding providers. There's a 
significant problem that the funding for those programs falls far short 
of what it needs to be, and as a consequence, the private insurance in 
this country subsidizes or cross-subsidizes the Medicare and Medicaid 
programs to a significant degree, such that if you lost the option for 
private health insurance in this country it might be very very 
difficult indeed to pay for those public, government-run programs that 
are in place today.
  But I have gotten a little far afield. Let me bring it back to the 
things that we had before us in the forum this morning.
  We heard testimony on ways that our current system, public-private 
hybrid system, of insurance can be improved, and we heard about lessons 
from the States, lessons that we might look at very closely when we're 
formulating public policy. After all, in medicine we're always told you 
need to practice evidence-based medicine. You need to look at 
randomized clinical controlled, clinical trials before you make a 
decision about what to do.
  Well, if that's good for America's physicians and America's patients, 
might that not also be good for America's policy-makers? Should we not 
also ask ourselves what is the evidence for the best policy? In other 
words, can we practice evidence-based policy here in the House of 
Representatives, the same as we ask our physicians to practice 
evidence-based medicine?
  So, we are fortunate the States function as laboratories, as the 
Founding Fathers envisioned, and we did hear some testimony on lessons 
from the States.
  And then finally we heard about proposals for a consumer-driven, 
market-based approach to reform that really may hold out a great deal 
of promise as being the most affordable of all of the options that were 
out there.
  Our first presenter this morning was Dr. Karen Davis from the 
Commonwealth Fund, which is a private foundation that aims to promote a 
high-performing health care system that achieves better access, 
improves quality and greater efficiency. Dr. Davis

[[Page 9120]]

has a Ph.D. from Rice University, the recipient of many accolades, the 
author of many books, and we were very, very fortunate that she was 
willing to come down from New York and participate in the forum this 
morning.
  Dr. Davis talked a good deal about some of the problems that we have 
in our current system, and she spent a good deal of time discussing 
payment reform as a component of health care reform. Payment reform 
might reflect a new concept. The Medical Payment Advisory Commission, 
MedPAC, has talked about a concept called bundling, where we don't 
actually pay for individual treatments but that we bundle these 
services, doctor, hospital, laboratory, and there is a payment for an 
episode of care rather than a doctor billing for the doctor services, 
the hospital billing for the hospital services, the laboratory billing 
for the laboratory services. So there's more of a global fee, if you 
will, but bundling is even perhaps one step more than a global fee.
  And one of the concepts embodied therein is that perhaps there would 
be a payment for an episode of care that would comprise a period for as 
long as a month, because some of the really difficult payment 
difficulties we get into, in Medicare in particular, result from 
patients who have to come back into the hospital after being released, 
and those rehospitalizations tend to be very expensive. And so this was 
a way to bring that type of expenditure under control.
  Another concept that was discussed was a concept called gain-sharing; 
that is, if a medical group, hospital and doctor group could devise a 
method of delivering care in a more economic way, that part of the 
savings that that doctor group and hospital was able to demonstrate, 
part of that savings then could be shared with the medical group, the 
hospital that was involved in that episode of care.
  These are concepts that are--they have been tried in some 
demonstration projects. To be sure, there's some difficulties. 
Emotionally, I have some difficulties when we talk about bundling a 
doctor's payment with a hospital payment. Quite honestly, doctors don't 
trust hospitals and hospitals don't trust doctors, so there are some 
barriers to overcome there.
  The concept of gain-sharing, certainly if we're going to ask 
physician friends to do things smarter, cheaper, faster, perhaps we can 
include them in whatever benefit accrues to the government, i.e., the 
Medicare system. Perhaps we can include them in the distributional 
aspects of that.
  Dr. Davis did talk some about the concept of a health care connector 
or an insurance exchange, the advantages there that you bring together 
the patient and the insurance policy. Particularly for someone who 
doesn't have employer-sponsored insurance, it can be a confusing array 
of products that are out there, particularly now if we're going to have 
a government-run option out there. A public plan, a public government-
run plan out there, perhaps an insurance exchange may be a way to bring 
together the patient and the insurance company.
  So, to be sure, there's some people are skeptical of exchanges. The 
current experiment going on in the State of Massachusetts points out 
some of the benefits but also some of the pitfalls for insurance 
connectors and insurance exchanges.
  Part of the difficulty that has been discussed about is, is there an 
inherent conflict of interest having an umpire also play for the home 
team, and therein is the problem with the combination of a public, 
government-run plan and an insurance connector. The insurance exchange 
is going to set the rules by which coverage must be sold. It's going to 
set the rules as far as pricing is concerned, and oh, yes, it's also a 
competitor because the government-run option is going to also be part 
of that exchange.
  But nevertheless, all of these are ideas that are worthy of 
discussion because the concepts going forward, we need to have the 
discussion on these. We can't just accept them as good ideas because 
someone else thought of them, and it's a way out of our conundrum with 
the uninsured and it's a way perhaps to control costs, but certainly, 
these philosophies need to be fully vetted.
  We were then very fortunate to be joined by Dr. Merrill Matthews, 
who's the director for the Council of Affordable Health Insurance, and 
this is a Washington, DC-based research and advocacy organization 
promoting free market health insurance reform. Dr. Matthews earned his 
Ph.D. in philosophy and humanities from the University of Texas at 
Dallas.
  Now, Dr. Matthews had a very interesting discussion for us. He 
focused more on what was happening with the role of the States and 
brought to us current examples of six States that are doing things. 
Some are working well, some not so much, but nevertheless, the 
President did, in his charge to us as he finished up that day at the 
White House, he said, I want to learn from what works. And Dr. Matthews 
brought to our policy discussion this morning six examples of things 
that are going on in States around the country and how those might 
deliver to us ideas that may be worthy of study or ideas that perhaps 
deserve a great deal of scrutiny because they've already been tried 
somewhere and they're not working so well.
  The first State that Dr. Matthews mentioned was the State of Georgia. 
Georgia, of course, has a State income tax, and he highlighted the role 
of the tax system in providing for health care for the citizens of 
Georgia. A State tax credit for qualifying employers that offered 
health savings accounts and high deductible health plans was available. 
So an employer could get a tax credit off of their State income tax for 
offering a high deductible health plan or a health savings account, and 
for individuals, also, there was a State tax deductible for individuals 
purchasing health insurance, which begins to remove a little bit of the 
discrimination against an individual holding an insurance policy. But 
apparently, the preliminary results of Georgia are encouraging, and 
certainly that points the way to some discussion of some changes within 
our Federal tax code that may be more applicable to the national stage.
  The State of North Carolina really highlights the need and the 
benefits of having a robust safety net for patients who have a 
preexisting medical condition. This is always a great fear that people 
have, what if I lose my employer-sponsored health insurance, I can't 
keep up with the COBRA payments, I'm diagnosed with some serious 
illness in the meantime, and then I am thereafter uninsurable and will 
remain uninsured until I can get taken on a Federal program such as 
Medicaid or Medicare. North Carolina has now a program to deal with 
those individuals who, because of the condition of medical fragility, 
are uninsurable by really fine-tuning the State high-risk pools.
  This requires an assessment from the health plans that sell in the 
State. So each of the private entities are asked to contribute to the 
overall maintenance of this high-risk pool. To be sure, there is a 
sliding scale, Federal subsidy, State subsidy that can be made 
available, but it certainly shows with a little bit of planning and a 
little bit of willingness to work between the public and private sector 
that individuals with preexisting conditions do not need to be shut out 
of the health insurance system. There is a way, indeed, to provide 
insurance and bring people back into the fold.
  Dr. Matthews talked about the State of New Jersey and how New Jersey 
has some of the highest health insurance premiums because of various 
requirements on policies in New Jersey and how just across the State 
line in Pennsylvania the health insurance premiums are significantly 
lower. So, within the State of New Jersey, legislation has been 
introduced to allow individuals to purchase insurance in adjoining 
States, insurance that is under the control of the insurance 
commissioner in those States, that has been fully evaluated and vetted, 
but at the same time has relief from some of the mandates that drive 
the cost up so very high within that individual's home State.

[[Page 9121]]



                              {time}  2230

  Certainly, this is a concept that is worth exploring. And it will be 
interesting to see if this legislation is indeed enacted in New Jersey 
and, if it is, how does it fare for allowing more people to use their 
own money to purchase insurance when the cost is not set arbitrarily so 
high that it is beyond their ability to pay.
  Dr. Matthews also talked a little bit about what's going on in the 
State of Florida. Florida also highlights the issue of cost. They have 
required from the insurance companies within the States to sell 
insurance to anyone--the so-called guarantee issue--but it does focus 
on catastrophic coverage that is the high-deductible, low-premium type 
of insurance.
  Again, it will be interesting to see if this does indeed bring more 
people into a condition of coverage and remove those individuals from 
the ranks of the uninsured.
  Tennessee had an example with TennCare where virtually everything was 
offered to everybody for almost nothing. It really put severe financial 
constraint upon the State. So the Governor has now outlined a new 
plan--it's called Cover Tenn, which is a much more limited benefits 
plan. The premium is $150, which is split three ways--the individual, 
the employer, and the State all paying a share. There is a significant 
focus on preventive care and routine screenings.
  Somewhat controversial, there is a benefit cap. Benefits are capped 
at $25,000 dollars, which may seem like this is not providing enough 
care but, in actuality, only four out of several thousand people 
covered under this program have actually hit that ceiling.
  Clearly, this is a work in progress and this will have to be 
monitored. But it certainly shows we always talk about we need more 
preventive care, we need more disease management, we need medical homes 
so those so-called low dollar-expenditures you can make in health care 
perhaps, perhaps can deliver a significant benefit and prevent some of 
the high expenditure situations that people encounter.
  Finally, Dr. Matthews talked about what's going on in the State of 
Arizona where a State initiative has been in place that sort of deals 
with the issue of personal freedom. You can choose to have insurance or 
you can choose not to. It is important. It is not forcing someone to 
pay something that they don't want or feel they don't need.
  Now that initiative was put forward in the Arizona legislature. The 
initiative failed. But it's likely to see some additional activity in 
the coming legislative session.
  So those were the ideas brought to us by Dr. Merrill Matthews, who 
is, again, from the Council for Affordable Health Insurance, and 
certainly showed how the States can function as laboratories in the 
concept of creating new ideas in the arena of health reform.
  Finally, we heard from Dr. Grace-Marie Turner, the president of the 
Galen Institute, a public policy organization that promotes an informed 
debate over free-market ideas for health reform. Perhaps one of the 
most impressive statistics that Grace-Marie Turner has brought to the 
discussion is the percentage increase--the cost increase for regular 
indemnity insurance, the cost increase for PPOs, the cost increase for 
Medicare and Medicaid has all been 6 to 7 percent a year, well ahead of 
inflation, and it is that cost driver that is pushing the affordability 
of insurance past the reach of many patients.
  With so-called consumer-directed health plans or consumer-directed 
options, high-deductible health plans, the actual rate of increase is 
2\1/4\ percent. So about one-third of what it is for the public plans 
and the indemnity plans and the PPO plans.
  If indeed we want to find out what works and if indeed affordability 
is an issue, and I believe that it is because affordability is what is 
preventing many people from actually being able to afford or buy 
insurance, then why wouldn't we look at this type of data and why 
wouldn't we look at expanding, as Florida has done, as Arizona 
discussed doing, why wouldn't we look at expanding these so-called 
consumer-directed options that clearly the price goes up at a level 
much more in line with inflation and the consumer price index and not 
two to three times that level.
  So certainly Grace-Marie Turner brought some good ideas to the 
forefront. She did talk about there being a climate for innovation that 
is pervasive and the fact that everyone is talking about health care, 
everyone is talking about how do we reform and improve the system. So 
that climate for innovation is one that we should embrace and capture 
and utilize, not for political advantage, but for the advantage of, 
after all, the person who should be at the center of all of this is not 
an insurance executive, it's not the Secretary of Health and Human 
Services. The person at the center of all of this, ultimately, is the 
patient and their family.
  Now, Mr. Speaker, just to depart for a moment, I've spent a lifetime 
in health care and I know very well that you look at this vast machine 
that we call the American health care system and what is it that we 
produce, what is the widget that the American health care machine 
churns out at the other end?
  Well, the widget is the interaction that takes place between the 
doctor and the patient in the treatment room. It may very well be the 
operating room or the emergency room or the delivery room. But it is 
that fundamental action that occurs between doctor and patient.
  So when I think of things that deal with changing health care and how 
it's delivered in this country and how doctors are paid and how 
patients are cared for and how insurance companies are structured, you 
have to look at that fundamental interaction between the doctor and 
patient in the treatment room and does this change that we're talking 
about, does it bring value to that interaction or is it perhaps somehow 
injurious to that interaction.
  If it brings value then it really doesn't matter to me which side of 
the aisle the idea came from; it is one that is worthy of merit, it's 
worthy of study, it's one that perhaps is worthy of inclusion in 
whatever we eventually do in health care reform.
  On the contrary, if what we are proposing to do detracts from the 
level of value of that fundamental interaction between doctor and 
patient in the treatment room, then we have got to be very, very 
critical, very, very serious about how we look at that because, after 
all, if we devalue the interaction between the doctor and patient in 
the treatment room, ultimately we devalue the experience for the 
patient and ultimately we are causing more stress and more harm to the 
system.
  As we've talked about a number of things this evening and when Dr. 
Matthews was talking about his experience with the several States, I 
couldn't help but think of what has gone on in my own home State of 
Texas in the past 5 years since September of 2003, when the State 
passed what was then a very innovative, very forward leaning, extensive 
medical liability reform that really has been a game changer back home 
in Texas.
  When I ran for Congress in 2002, Texas was in the middle of a very 
serious medical liability crisis. We were losing medical liability 
insurers. They were leaving the State because the State's environment 
was so hostile. They were losing money so they left the State. We went 
from 17 insurers down to two in a very short period of time. I promise 
you--you don't get many competitive influences when you have only got 
two insurers out there writing medical liability insurance.
  Medical liability insurance was going up and up and up. Even for 
physicians who didn't have a claims history, just because you were 
practicing medicine in Texas, you were a significant risk to that 
insurance company. As a consequence, doctors all across the State saw 
their premiums go up, and some doctors simply could not find insurance 
at all, at any price.
  I talked to a number of doctors that year I was running in 2002 who 
had just simply left practice or never were able to start their 
practice and were just out of school and unable to set up their 
practice in their home State of Texas

[[Page 9122]]

because the medical liability climate was so severe that insurers were 
not willing to write them insurance policies at any price.
  The whole trauma network in the Dallas-Fort Worth area was brought 
down by the fact that one of the neurosurgeons got his premium bill to 
re-up his medical liability premium, looked at the six-digit figure and 
said, That's it. I can't do it any more. I can't earn enough money to 
pay this bill, and I will have to leave the State.
  When that happened, about 50 percent of the neurosurgeons then were 
gone from the trauma system, the trauma network in north Texas, putting 
that trauma network in serious jeopardy. How were they going to provide 
neurosurgical services 7 days a week, 24 hours a day, when they had but 
one physician remaining to provide those services?
  So we were under extreme stress in the State of Texas in the fall of 
2003. Then the State legislature passed a very forward leaning medical 
liability reform. It was a cap on noneconomic damages. It was a cap 
similar to the Medical Injury Compensation Reform Act of 1974, which 
has done such a good job in California, but perhaps modernized a little 
bit for the 21st century.
  The cap was trifurcated; that is, there was a $250,000 cap on the 
physician, a $250,000 cap on the hospital; and a second $250,000 cap on 
a secondary hospital or nursing home if one was involved.
  So an aggregate cap of $750,000 for pain and suffering. Actual 
damages, medical damages were not capped in any way. In fact, punitive 
damages, if gross negligence could be demonstrated, punitive damages 
were not capped.
  What this has done in the State of Texas has been nothing short of 
phenomenal. We have doctors coming to the State, a State that was 
losing doctors in 2002, is now seeing more and more doctors coming to 
the State. In fact, one of the bigger problems we have today is not the 
inability to find medical liability insurance; one of the bigger 
problems today is the State Board of Medical Examiners finds itself 
short-staffed and is having difficulty keeping up with the volume of 
applications for State licenses that are coming in from other States.
  As a consequence, Texas has gone from a situation where we were in 
fact getting into difficulty. We were in quite a fragile condition from 
the standpoint of providers. And now we find that that situation has 
been reversed.
  This is such a commonsense application of previous legislation, 
again, that was enacted out in California over 25 to 30 years ago, that 
now is working today in its modern iteration in the State of Texas. 
I've introduced a similar bill in Congress because I feel this is so 
important to be able to offer this same type of protection to other 
doctors in the country.
  There's no question that the concept of defensive medicine is a real 
one. When people look at the cost, escalating cost of medical care, one 
of the problems is that as a doctor you feel like you have got to do 
every test and every study so that if something goes wrong and you're 
called into court and that chart is put on the stand with you, that 
chart is going to be an A-plus and you've done every possible test 
right down the line and there can be no second-guessing. That's the 
onus, that's the burden that doctors practice with today in this 
medical liability climate.
  So the idea of being able to relieve some of that pressure from 
defensive medicine, it won't happen overnight. This will take a 
significant amount of time to reverse some of these work patterns and 
thought processes. But, as they say, the journey of a thousand miles 
starts with the first step. And this Texas legislation is a very, very 
good place to start.
  The legislation in fact saves money. As estimated by the 
Congressional Budget Office, it saves $3.8 billion, almost $4 billion 
over 5 years. I know that's not an enormous sum of money when you've 
got Congress writing a blank check for $787 billion in one weekend. I 
know a paltry little $5 billion doesn't look like much. But we are up 
in budget time and every little billion dollars adds up.
  So I have, with no thought to any personal aggrandizement, I have 
offered this concept to both sides in their budgetary process. I'm 
willing to give up my $5 billion to the cause. And I would like to see 
us seriously take on some type of meaningful medical liability reform.
  That brings up another issue. We've got 47 million people who are 
uninsured and we have got various proposals to bring more and more of 
those individuals into the ranks of the insured. You look at some of 
the graphs and people will talk about, ``well, we've got this plan, 
we've got that plan.''
  And look how the number of the uninsured just drops precipitously. 
But, unfortunately, the other line on that graph that no one ever pays 
any attention to is the number of doctors out there who are capable and 
willing and able to see patients. That's a relatively stable number.
  So what is the essential effect of bringing many, many more people 
into the ranks of the insured if we haven't impacted the physician 
workforce at the same time. No question we are going to put additional 
stress on the system.
  Now I do work on issues dealing with the physician workforce because 
I think that is so important. In the Health Care Caucus that will be 
the subject of one of our future forums because I do feel this is so 
important.
  Certainly, at the end of the scale that deals with the young person 
getting out of college and contemplating a career in health care, 
cost--the barrier to entry right now--is a huge barrier to entry. No 
one wants to end up with 8 or 12 years of professional education with a 
loan repayment plan that is structured such that it's almost impossible 
to repay.

                              {time}  2245

  We have got to pay attention to that. We have got to make more help 
available to those, the best and brightest of our young people who may 
be contemplating a career in health care.
  We passed a bill on the floor of this House just a couple of weeks 
ago that came through our Energy and Commerce Subcommittee on Health 
that dealt with the number of residencies out there for primary care 
physicians, pediatricians, OB/GYNs, family practice, internal medicine, 
general surgeons, the type of doctors that are going to be needed on 
the front lines of delivering care for generations to come. We are not 
making enough of them, and many communities just simply cannot attract 
a doctor.
  One of the things that we found in Texas, a study done by the Texas 
Medical Association, is that a lot of doctors, maybe it is because they 
don't have much imagination, but they tend to practice close to where 
they train. I am a very good example of that; I trained in Dallas and I 
practiced in Louisville, Texas, about 15 miles away. We tend not to go 
very far away from where it was that we took our training.
  As a consequence, if you can develop residencies in more communities 
where the actual need is high, those medically underserved areas, and 
you can develop residencies in those programs, pediatrics, general 
surgery, OB/GYN, family practice, internal medicine, if you can develop 
those residencies in hospitals or in those communities, you might be 
able to keep some of those physicians in the area, and that would be an 
innovative or a different way of trying to bring doctors or keep 
doctors in those communities.
  Now, there was a bill very similar to that that passed out of Energy 
and Commerce. It passed on the floor of the House here a couple of 
weeks ago. It is now over in the other body. We in fact passed it last 
year as well, and it made it over to the other body, but it didn't 
quite make it out of the other body. And it was late in the year and I 
understand that. It is certainly no criticism to our good friends in 
the other body. But this year we passed it relatively early in the 
111th Congress. We want to give them plenty of time to scrutinize it, 
plenty of time for the guys down at Office of Management and Budget and 
the White House to scrutinize it. But

[[Page 9123]]

ultimately I think they will see that this is a good program, and it is 
not an enormous program.
  The money that is going to be used for this will be a self-
replenishing loan program, so that as the program matures the money 
will constantly be repaid. But it removes some of the barriers to entry 
for a hospital that right now is not offering a residency program in a 
medium-sized community, in a smaller community, perhaps a rural 
community that has got a hospital with sufficient clinical material 
that can be accredited by the American Council of Graduate Medical 
Education but at the same time right now does not have a residency. 
This can help eliminate one of the barriers to entry for that hospital 
being able to set up a residency program and, ultimately, can bring 
more physicians to those communities that right now are medically 
underserved, particularly in the primary care specialties.
  Then, finally, and I talk about this frequently, we are going to talk 
about it I suspect many times this week because of the ongoing budget 
debate. But a formula that is used to calculate physician reimbursement 
for patient services in the Medicare program, the so-called sustainable 
growth rate formula which has programmed into it payment cuts for 
physicians, reimbursement reductions for physicians for years to come 
is a significant onerous burden on our physician community, and we do 
need to correct that problem.
  We did a temporary fix in July of last year, about 9 months ago; it 
was an 18-month fix. It expires December 31 of this year. And Members 
of Congress who are not paying attention to this may find themselves 
very unpleasantly surprised when they go home sometime after the August 
recess and their physician community is up in arms because Congress 
hasn't done anything about this 20 percent reimbursement reduction that 
they are facing New Year's eve of this year. This is a problem that is 
barreling down the pike at us, and so far this year we haven't spent a 
great deal of time or energy dealing with that.
  Now, to the President's credit he talked about dealing with that in 
some way in the budget, and indeed there was a line item in the budget 
that the President put forward, but it didn't really solve the problem. 
It extended this cliff that we fall off of every 6 months, 12 months, 
or 18 months. It extended it out for 10 years, but the cliff will be 
every bit very in evidence and in fact all that steeper because it is a 
10-year cliff as opposed to a 2-year cliff. We really need to 
fundamentally change that formula, pay doctors under what the Medicare 
Payment Advisory Commission has called the Medicare Economic Index. 
That is a cost of living adjustment for paying Medicare physicians that 
basically says if the cost of doing business increases, we are going to 
increase the amount of reimbursement. It is the same thing we do for 
hospitals, it is the same thing we do for drug companies, it is the 
same thing we do for HMOs. We ought to do the same thing for America's 
physicians; because if we don't, we are going to wake up some morning 
and find ourselves with an absolute lack of physicians that is going to 
be almost impossible to overcome, and then Congress will be left 
scrambling on how to fill that gap. Do we just simply ordain people as 
doctors and tell them to go to work? Do we open the borders and bring 
people and steal doctors from some other country? Who knows what the 
position of a future Congress might be.
  It is incumbent upon us to face that problem this year. It is 
important enough that we take care of it, that we not leave it for a 
future Congress, that we not postpone it 10 years, as was outlined in 
the President's budget. We just simply need to change this formula, and 
do it now. This is something that doctors are looking at the Congress 
and saying, well, you are talking about a public option government-run 
plan, you are talking about expanding Medicare, you are talking about 
all these things that you are going to do. But, Mister Member of 
Congress, when the only lever you have to pull to reduce cost is to 
restrain provider payments, that is going to make it pretty painful for 
those of us out here who are trying to earn a living taking care of 
your patients, the patients you asked us to take care of, the country's 
Medicare patients, arguably some of the most fragile and difficult 
patients to manage, and you are telling us you are going to cut our pay 
every year as far as the eye can see by 4 percent, 5 percent, 6 percent 
per year. This year, in fact, the aggregate will be a 20 percent 
reduction if we don't do something.
  Well, we have got to maintain our physician workforce, and those 
three areas, paying attention to the health profession scholarships, 
loans, and bringing that up into the 21st century, perhaps we can talk 
about additional tax benefits for people who are willing to go into the 
health professions, certainly looking at residency programs in areas 
that are currently in medically underserved areas with high-need 
specialties; and then finally fix, once and for all, this cockamamy 
idea of a sustainable growth rate formula which pays physicians under a 
formula that is clearly, clear unsustainable and it is unjust.
  Here is the secret about the sustainable growth rate formula. We talk 
about the fact, oh, it is so difficult to repeal because it costs so 
much. Guess what. That money that it supposedly costs is money that we 
have already spent. That is not money that is sitting in an earning 
account in some Federal T-bond somewhere. It is money we have already 
spent. It went out the door in 2001. We paid it out in 2005. Doctors 
were reimbursed that money in 2007. We just never accounted for it on 
the books. We sound like AIG.
  This is nuts. We have got to stop this. End the SGR formula. Be up 
front about it. If the Congressional Budget Office needs to be 
instructed through legislation to do directed scoring to wipe that debt 
off the books, and then going forward we play this game straight with 
our country's physicians, then that is what we have to do. I intend to 
be introducing a bill; I have done so every Congress that I have been 
here, and I intend to introduce a bill that will do just that, and I 
will be back on the floor to talk more about that when that time comes.
  We will hear some talk about mandates. When you hear the talk about 
the public option and mandates, you have got to ask yourself, what are 
we trying to do here?
  Now, with mandates you tell everyone that you have got to buy 
insurance. We either do it as an individual mandate or an employer 
mandate. Well, employers look at that as a tax that you are going to 
put on jobs for health insurance. And if we put a tax on jobs while we 
are trying to recover from a recession and we want jobs to be created 
and we are going to tax them, so the small business community will come 
to us and tell us: Don't put a tax on jobs with an employer mandate in 
health insurance.
  Now, an individual mandate says that everyone out there has the 
responsibility to have an insurance policy. The trouble with individual 
mandates is people don't always take them seriously. Look at the IRS, a 
pretty serious mandate, a pretty serious penalty if you don't comply. 
And what is our compliance rate with the IRS? About 85 percent. What is 
our compliance rate with voluntary health insurance right now? It is 
about 85 percent. So you don't get a lot of bang for your buck by 
putting in mandates.
  Now, mandates are great for insurance companies, because everyone has 
to have insurance so they like that. Everyone is going to buy their 
product. Yea, we all make money. Put a public option plan on the table, 
and then the insurance companies are not so happy because now that 
mandate may be satisfied by a public option. But now we are forcing our 
insurance companies to compete with insurance that we are putting on 
the table at the Federal Government. It is hard to compete with the 
Federal Government. We can write a check for any amount of money. We 
never go broke, we never run out of money, we just simply print more 
money when we need it. Well, the large health insurers in this country 
don't have that option. It is very, very

[[Page 9124]]

difficult for them to compete with a government option or a government-
run plan because they don't have the option of just simply printing 
more money when the time requires it.
  So we do have to be careful with how we institute, if that is the 
direction we are going to go. And certainly all through the campaign I 
heard President Candidate Obama say that, surely if you like what you 
have got, you are going to be able to keep it. Well, that is true, 
unless we run them all out of business, in which case it will be hard 
for you to keep what you have got in your employer-sponsored insurance, 
and the only option will be a public.
  Now, there are lots of moving parts to this debate. We are going to 
be back here frequently over the next several months. We are in the 
budgetary cycle now. As I understand, late in the night in the Budget 
Committee, the House Budget Committee, the House-passed budget did 
contain so-called language for reconciliation, which means that over on 
the Senate side they will only need 50 votes to pass whatever they want 
to pass.
  The way forward is set for almost any change the Democratic majority 
and the Democratic President want to make in health insurance. I hope 
they are going to make the right decisions. I take the President at his 
word that he wants to learn from what works. I think we have talked 
about some of those things this evening, what we have seen working as 
far as State plans are concerned, what we have seen working as far as 
the affordability concept in the consumer directed plans. Certainly we 
need to learn from what works as far as connectors, because we have a 
State, Massachusetts, that is currently using a connector, and we need 
to see what the effect has been on the cost and availability of 
insurance; and, are people in fact conforming with the individual 
mandate that the State of Massachusetts has imposed?
  If we look at all of these things in aggregate, we may not always 
make the right decision, but we will come closer to making that right 
decision than if we all just sit in a windowless room, as we all want 
to do here in the United States Congress. We love to do that down. We 
sit in a little windowless room down in the basement of the Capitol, we 
all talk about the things that matter to us. We never listen to anyone 
else's ideas. And is it any wonder that everything always looks the 
same when it comes out of the United States Congress?
  Let's do things differently this time. Let's listen to each other. 
Let's take the President at his word. Let's practice evidence-based 
policy, let's figure out what works, and then let's get on with it.
  Mr. Speaker, I yield back the balance of my time.

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