[Congressional Record (Bound Edition), Volume 155 (2009), Part 9]
[House]
[Pages 11863-11869]
[From the U.S. Government Publishing Office, www.gpo.gov]




                              HEALTH CARE

  The SPEAKER pro tempore (Mr. Driehaus). Under the Speaker's announced 
policy of January 6, 2009, the gentleman from Texas (Mr. Burgess) is 
recognized for 60 minutes.
  Mr. BURGESS. I thank the Speaker for the recognition.
  Mr. Speaker, I thought I would come to the House floor this evening 
and talk for just a little while about health care, because there is a 
lot of talk going on about health care in this Congress, a lot of talk 
about the bills that we will see, we haven't seen, and bills that we 
may not see.
  I wanted to point out to the Members that yesterday I introduced a 
bill, H.R. 2249, which is a bill I had actually introduced in the 
previous Congress. It is the Health Care Price Transparency Promotion 
Act of 2009, updated from the last Congress and reintroduced this year. 
I urge Members on both sides to take a look at this because, after all, 
we hear a lot about the concept of transparency these days, and it is 
important for our constituents, for our consumers, for our patients in 
our districts to be able to access clear and timely information about 
physicians, hospitals, health care facilities in their areas, and 
understand and do some research on their own to find out which are the 
best facilities for them to use when they have occasion to need a 
doctor or a hospital.

                              {time}  1845

  So as we talk about health care--and it was, of course, all of the 
discussion during the Presidential campaign last year--I would just 
point out that there are good ideas that are coming from both sides of 
this House of Representatives. Certainly, Democrats are not the only 
ones with ideas on health care. There are Republican ideas. There are 
Republican ideas that really should shape the debate of health care 
reform or the natural evolution of health care that we see going on in 
our country at the present time.
  There are plenty of people working on health care reform. You know, 
when I take a step back and look at what should we be doing when we try 
to frame the debate, when we have our hearings in committee, when we 
mark up our bills in committee--really, when you look at the vast 
American medical machine, the widget that it produces, what we do on a 
daily basis in doctors' offices and hospitals across the country, it is 
that fundamental interaction that takes place between the doctor and 
the patient in the treatment room. That is the fundamental unit of 
production in American medicine. And when we look at it in that 
context, whether it be the treatment room, the emergency room, the 
operating room, that fundamental unit of interaction, are the things 
that we are doing here bringing value to that interaction or are they 
subtracting value from that interaction?
  And to the extent that, whether it is a Republican or Democratic 
idea, if it brings value to that interaction, that is something that I 
am going to have to look at quite critically and quite favorably. If it 
is something that subtracts value from that interaction, that is 
something that is going to be very difficult for me to be for. So I try 
to always look at it through that lens of, ultimately, it is about 
doctors taking care of patients, it is about hospitals helping people 
get well. And to the extent that we can encourage and enhance that 
process, where there are places where we can help, certainly we should. 
If there are places where we don't belong--that is, between the doctor 
and the patient--maybe we ought not to do that.
  Now, it comes to me frequently, not infrequently, when I'm sitting in 
committee--and I am fortunate enough to sit on a subcommittee that 
deals with health care, on the Committee on Energy and Commerce. In 
fact, in the last Congress I was the only physician to sit on that 
committee. And when we would deal with problems, when we would deal 
with issues that had to do with health care or the regulation of the 
Food and Drug Administration, I was always mindful, when I looked 
around the room, there is only one person in this room that has ever 
sat across from a patient, looked him in the eye, picked up a pen and 
written a prescription, counseled as to risks and benefits, torn off 
that prescription, and

[[Page 11864]]

sent the patient on the way. There is only one person in the room that 
has ever done that, and that was me. And yet here we were with a 
hearing or a bill that might have profound impact on how that doctor/
patient interaction was going to be carried out from that day forward 
for the next generation or two, and there is only one person in the 
room who has ever actually been there and done that. So I feel a 
tremendous amount of responsibility as we go through this health care 
debate.
  Yes, I have been joined by some other physicians on the committee. 
There are physicians on the Subcommittee on Health on Ways and Means. 
We all bear that special burden to ensure that the decisions that we 
make today do not negatively impact the next generation and the 
generation after that.
  Think back just 44 short years ago when Medicare was enacted in this 
body. The men and women who sat in this body at the time were the ones 
who crafted that legislation. And we are dealing with the good aspects 
and the bad aspects that have been dealt to us because of decisions 
that were made in our committees, in Congress, and in this body in the 
House of Representatives. So it is in that sort of context that we need 
to look at what we are doing.
  It is not about, and let me emphasize, it is not about the next 
election. It is not about who wins or loses seats in the great economy 
that goes on here in the House of Representatives or over in the other 
body on the other side of the Capitol. It is not about the next 
election; it is about the next generation. And that is why it is so 
important for us to get it right.
  That is why the American people get so frustrated with us as a group 
here when they see us fight about things and never work together. It is 
difficult, I know. It was difficult when we were in charge. When the 
Democrats were in the minority, it was difficult for them to understand 
how to work with us in the majority, and it is difficult for us to 
understand in the minority how to work with the Democrats, but it our 
obligation. That is why we were sent here. That is why we were elected, 
to do that hard work, and to work with each other where we can, to 
oppose each other where we must, but to always have focused not on 
November of 2010, but what is life going to be like when our children 
are the age we are now, when our children's children are the age we are 
now? What is it going to look like to them?
  What is health care going to look like in this country? Are they 
going to continue to be blessed with the stunning rate of advances that 
we have seen since the Second World War in the practice of medicine? 
And it has been stunning. The last 50 to 60 years has seen untold 
events. Think of the physician in practice right at the dawn of the 
antibiotic age, when a patient comes into the hospital, significant 
infection, and there is just not much they can do but keep them 
comfortable, perhaps drain an abscess if one is available. But the 
medications that they had were--at best you hoped they didn't do any 
harm to the patient. Now we have a vast array, a huge armamentarium of 
medicines to fight infections, bacterial infections to be sure, but 
also fungal infections and some viral infections. It is an incredible 
armamentarium that today's physician has. When you think of the young 
physician sitting in a medical school or attending to a patient in a 
clinic at a residency program today, think of the things that they are 
going to have, the tools that they are going to have at their disposal 
if only we don't screw it up for them today.
  So we always have to keep foremost in our minds and our imagination 
what that world is going to look like for the patients of tomorrow, for 
the young physicians and nurses, folks that work in the hospital that 
come after us. We have to keep them foremost in our minds.
  And how great it would be if we didn't even need a health care 
system, if we had a way to keep people healthy throughout their lives. 
We're not there yet. But we always need to stay focused on that goal 
because, after all, I would much rather have my health than my health 
care. If I have my health, I don't have to worry about my health care. 
But we know it doesn't always work out. We know that people do have 
problems, we know that illnesses do strike, we know that problems and 
complications do occur. So when health care is necessary, to the extent 
we can make it more affordable and more accessible, sure, we need to do 
the things we can to make that happen.
  Now, a lot of people are working on health care reform. A lot of 
people have been talking about it certainly throughout the last year or 
two on the floor of this House. I know I have come down several times a 
month to have this very discussion. Throughout the Presidential 
campaign last year I worked for the nominee of our party as a surrogate 
on the health care debates. I got to meet a great many of the 
surrogates on President Obama's team and heard their discussions for 
health care. And everyone talks about, well, where is the Republican 
plan? In fact, for that matter, where is the Democratic plan?
  I have to say that as I watched the health care debates really from 
the inside last fall as a surrogate working for Senator McCain, I 
thought that when this Congress convened with a referendum that was 
likely to be on health care in November, that they would be much 
further along as far as the development of a bill--maybe not from the 
Republican side, but certainly from the Democratic side.
  The Democratic chairman of the Senate Finance Committee last October 
convened a big group over at the Library of Congress one day, developed 
a white paper that really had all the look to it of a roadmap for 
legislation. I was fully prepared, after the election, for the chairman 
of the Finance Committee in the Senate to have a bill that would be 
sort of the model bill, if you will, that everyone in the Senate would 
support and then, likewise, everyone in the House. In fact, I counseled 
my colleagues to think in terms of having something, if there are 
things that concern you about that white paper, be certain you have 
your arguments all spiffed up and all toned up, because I thought we 
were going so see that perhaps even in the lame duck session last 
December.
  So I was very surprised that we didn't see anything in November or 
December. Well, surely we are going to see a bill before the 
inauguration; but in fact we didn't. And then of course the story 
continued to unfold. The nominee for the Secretary of Health and Human 
Services ended up withdrawing his name and there was a several-month 
gap until Secretary Sebelius was confirmed last week.
  So now we are near Mother's Day of 2009 and still no health care 
bill--from the Republicans, to be sure, but still no health care bill 
from the Democrats, either the Democrats in the House or the Democrats 
in the Senate.
  Now, I know that there was a letter sent to the President from the 
Democratic leadership in the other body last week or the week before 
that said we will have a bill that will be marked up in the Senate the 
first week in June. But that is a pretty long timeline from a white 
paper in October to having a bill on the floor of the Senate perhaps in 
a month that is going to be debated. I think what that shows us, it 
underscores how difficult this process is.
  There are many people in this body on both sides who have worked on 
this issue for years. There are many people in this body who have very 
set ideas of whatever this bill is when it comes forward--from whatever 
side that it comes from--they have very definite ideas of what it 
should look like. In fact, you stop and think; if you were to pick out 
six of us from either side of the aisle in this body, put us in a room 
by ourselves and say write the health care legislation that you would 
like to see, I have no question that there are six of us who could just 
sit down and do that really without any other help or any other input 
from anyone else. The problem is when you put all six of us in the room 
together and say now write a health care bill on which you all agree, 
that becomes much more difficult. And that is sort of the position that 
I know I see occur on my side of the aisle. I rather suspect that's the 
position we see on the other side of the aisle.

[[Page 11865]]

  And then you add into the mix all of the other things that go on here 
in the course of a normal week or a normal month, notwithstanding the 
scare we had with the flu last week, the cap-and-trade bill that is out 
there that at some point is going to come through, it is going to come 
through my committee. So that is going to take resources and time that 
the majority, the leadership of the committee, the majority leadership 
of the committee has to devote their time and resources to that as 
well. So really working on two tracks in tandem, two parallel tracks, 
one on energy and one on health care. And it's a tall order. Either one 
of those bills by themselves is a tall order, but put both of them 
together.
  And then you heard the discussion that just concluded from the last 
hour, what is going to happen as far as regulatory reform in the 
financial industry, in the banking industry? In fact, when President 
Obama gave his speech at Georgetown 2 or 3 weeks ago, he talked about 
how before the end of this year he will have a health care bill, he 
will have a climate change bill, and he will have a banking regulatory 
bill all signed before the end of December this year. That is an 
extremely tall order.
  And of course many of these things, as their work is in process, one 
affects the other. Certainly, when you look at the way the budget was 
constructed, the health care part of the budget is likely to depend 
upon the energy part of the budget, as some of the costs for health 
care are going to be offset by some of the revenue that is raised on 
the energy side. One can't proceed without the other. And it becomes 
very, very difficult then to marshal these things through and keep 
everyone on track and everyone on task.
  And then when you add to it the fact that, yes, by definition, the 
House of Representatives is a house that is divided between the two 
major political parties and we don't always work together, that just 
increases the amount of difficulty. It underscores to me why it is 
important for us to work together and why it is disappointing that 
sometimes we don't take those opportunities to work together. But a 
tall, tall order.
  And then add to all of that, when you think of the timeline that 
stretches out ahead of us on health care, remember there was, in this 
body--I think it was September 23, 1993, when then-President Bill 
Clinton stood at this very podium and gave a beautiful, eloquent speech 
that had people weeping for joy about how the President was going to 
change the delivery of health care in this country. I was just a 
regular guy sitting in labor and delivery back in Louisville, Texas, 
monitoring a labor and watching the speech on television, but a 
beautiful speech delivered. And everyone left this House thinking, oh, 
now we are well on the way to getting this done. But the reality hit 
that by the end of September of a nonelection year, you are very close 
to everyone getting ready for the next election. Because in the House 
of Representatives, we have 2-year terms. We really don't have an off 
year. Many of us are already thinking about the next election. So that 
is another consideration and another thing that makes it more difficult 
to get big things done because the time frame for getting those big 
things done between elections is relatively small. The off year, if you 
will, is condensed down to perhaps 6 months.
  Certainly by the end of July, when we leave for the August recess 
from this House, my impression is that the health care bill, whatever 
it is, likely will have to pass the House before then or it may become 
very problematic to get something done before the end of the year. And 
then of course you know what happens next year, it is all election all 
the time.

                              {time}  1900

  So even as late as the end of September of 1993, it turned out to be 
too late for then-President Clinton to get his vision of health care 
reform through the House of Representatives and the Senate because at 
the end of September, we were already into the electoral process, and 
by the time things were finally prepared and ready for a vote, it 
actually came too late.
  Look at the difference between 2009 and 1993, 15 to 16 years' 
difference. But you didn't have all the cable news shows back in 1993. 
You didn't have the instant analysis, the 24 hours of instant analysis, 
that we have today. So if anything, the time frame for development of a 
complex legislative issue like health care or energy or banking 
regulation, the time frame likely is even more condensed now than it 
was back in 1993.
  But I think back to 1993 and 1994. Again, I was just a regular guy 
working as a physician in a small town in north Texas. It wasn't like 
nothing got done during that interval. True enough, it wasn't the 
vision that was articulated by the President that night. But we do have 
now an entirely different type of insurance product called a health 
savings account that was actually a byproduct of having an alternative 
solution to offer to what the then-Democratic majority was offering in 
health care reform. So there are things that happen during the course 
of the normal evolution of things, and sometimes they work out to be 
good things. I would argue that the institution of a health savings 
account, the ability to buy a high-deductible insurance policy on the 
Internet, at least provides an option for insurance particularly for 
younger individuals just getting out of college but also people more in 
the middle of life, like in their 50s, who may find themselves between 
jobs.
  There are options out there for purchasing insurance. It actually 
didn't exist in 1994. And I know that because I tried to buy an 
insurance policy for a member of my family in 1994 and you couldn't do 
it at any price. Now you can go onto the Internet. You type ``health 
savings account'' into the search engine of choice, and you can get a 
variety of choices. The cost for a high-deductible health plan for 
someone in their mid-20s who's just getting out of college is very 
reasonable. It runs somewhere between $75 and $100 a month depending 
upon the policy that you select. These are reputable companies that are 
well recognized. Many of them are PPO plans with, again, a high 
deductible, but they are affordable and they are available. And it is 
not always necessary to go without insurance simply because we don't 
happen to be working for a company that provides insurance as one of 
its benefits.
  You know, you want to see a plan. You want to see a plan come from 
the Democratic side. You want to see a plan come from the Republican 
side. You want to see the merits of each argued and debated here on the 
floor of the House. You want to see the strongest points articulated 
well and perhaps incorporated into whatever the final product is. And 
then, of course, the other body that has its opportunity to work on the 
legislation comes together in a conference. And in an ideal world, 
going through that regular order, in an ideal world, you would get the 
best possible legislative product. And I do worry that we will adhere 
to regular order throughout that process, but at the same time, as we 
sit here today, I'm going to profess to some optimism that we will 
adhere to regular order, mark the bills up in the appropriate 
subcommittees, have the full committee markup, as we are supposed to, 
bring the bill through the Rules Committee to the House floor, have 
ample opportunity for debate and amendment. Then it goes over to the 
other body. After passage of the bill, it goes to the other body, a 
similar process, and we have a real conference committee, not a made-up 
conference committee but a real conference committee of appointed 
conferees that get together and work out the differences between the 
House and Senate version and ultimately then get a product that will 
serve the American people well. We really do our best work when we go 
about it that way.
  If we short-circuit the process, which we do--unfortunately, we do. 
We did it when we were in charge. And certainly the Democrats have done 
it in the last 2\1/2\ years since they have taken back the majority. 
When we short-circuit the process, that's when we get our less than 
perfect legislative products that are shoved out the door.

[[Page 11866]]

  Now, if I were one of those people that sat in a room by myself, what 
would I envision as a plan? How would I make things better? And bear in 
mind that for 63, 65 percent of the country who has primarily employer-
sponsored insurance, many people don't want to change from where they 
are now. So although people are concerned about where we are with 
what's happening in the health care system in America, those 
individuals who have employer-sponsored coverage or those individuals 
who have purchased their own coverage on their own may be quite 
satisfied with where they are today. So really it must be approached 
from building upon what is currently in place and working, building 
upon that platform, and making certain the problems that occur in the 
existing system today are mitigated or eliminated for the individuals 
who are feeling the effects of those problems.
  Well, what are some of those problems? Well, I mentioned someone who 
perhaps owns their own insurance policy. And there are, depending upon 
what you read, for round numbers, 10 million people in this country who 
own their own insurance policy. They are discriminated against in the 
Tax Code, and that's unfortunate. That has the effect of actually 
raising their cost for insurance, and there are things we could do to 
correct that. I'm not sure I have all the answers there. I'm not sure 
that Republicans have all the answers there or Democrats, but we could 
fix that. We could fix that. That would be one of the relatively easy 
fixes we could do. And certainly that's something that I think has to 
be one of the pieces. That's one of the things that needs to be debated 
in subcommittee, full committee, here on the House floor, and in 
conference committee, but we could fix that problem. It is within our 
power to do that.
  Now, one of the great fears that people have is that, yes, I've got 
health insurance now through my job, but I worry that if I get sick, I 
might lose it, or if I lose my job, I might lose my insurance and then 
I get sick, and then it will be difficult when I have a claims history, 
when I have got a preexisting condition. It will be difficult for me to 
get insurance after that. Again, we can fix that. There are things that 
could be done to address that segment of the population. We may not 
even necessarily need to change the whole structure to help that 
segment of the population that has a condition of medical fragility or 
a preexisting condition. Many of the States, 32 or 33 out of the 50 
States, already have some system in place for helping an individual 
with preexisting conditions. Certainly we as a body can look at the 
best practices from those States.
  Look at the States that are doing things well. North Carolina, Idaho 
come to mind. Look at the States that are doing things well. Take from 
those best practices. Is it going to be necessary to ask there to be 
some contribution from the private sector? There may be. So there may 
be a level at which the premiums cannot increase above. There may need 
to be some help as far as a voucher or subsidization of the premium 
from the Federal Government, from the State government. But this can be 
fixed. This can be addressed. And it doesn't mean that we don't act 
upon it just because it's not everything we want. We can help those 
individuals who find themselves between jobs, between insurance 
companies, then with a significant diagnosis who then fear that they're 
not going to be able to get insurance past that point. That can be 
dealt with. That can be fixed.
  Insurance reform, there's no question. Even the American Health 
Insurance Plan Organization admits that there is a need for insurance 
reform in this country.
  One of the things that has concerned me is that if an individual 
works for a large corporation in this country, if that corporation does 
business in multiple States, that individual can move from location to 
location throughout the several States and their insurance never 
changes. It never varies. It's the same insurance policy in one State 
as it is in the other.
  And think of the analogy of the National Football League. If there is 
a player that is traded from one city to another, their insurance goes 
with them. If they have a knee injury in one location, that knee injury 
is covered in their secondary location. But the fan, just the regular 
guy or woman who follows their favorite player from one city to the 
next, they've got to start all over again with their insurance policy. 
And that's one of the fundamental inequities. That inflexibility that 
we built into the system, that's one of the things people want to see 
us fix. So why not give the regular individual, why not give the little 
guy the same breaks we give the larger multi-State corporations? We can 
do that. That's within our power to do that.
  One of the biggest issues that we hear about all the time is 
affordability. Well, there are things we can do as far as providing 
benefits packages that are affordable, and it is within our power to do 
that. And, quite frankly, I don't understand why we haven't done that. 
We have at different times agreed on what basic benefit packages are. 
We did that 35 years ago when we created the Federally Qualified Health 
Centers across the country. Anyone who goes into a Federally Qualified 
Health Center knows exactly the benefits that are going to be available 
to them in that facility. But why don't we get together and do the same 
thing for now, not necessarily a bricks-and-mortar facility, but do the 
same thing for a policy that could follow a person from place to place, 
job to job, State to State, a policy that would be affordable that 
perhaps could build some longitudinal stability because it would be a 
policy that someone could keep throughout various phases of their life?
  We can do all of that. We don't need to endanger the current system 
that's in existence. We can build upon what is good in our system and 
add more choices and more options and more flexibility and ultimately 
more security for people within their health care.
  After all, that's what people are concerned about. They're concerned 
about if I lose my job, am I going to lose my health care? If I lose my 
job and lose my health care, there is no way I could afford a product 
out there. We can help with that. There are things that we can do. 
There are regulations that we can look at, that we can suspend, that we 
can pull back. There is flexibility we can build into the system if we 
only have the courage to do it. And there's the problem. We won't have 
the courage or we won't have the opportunity if one side won't talk to 
the other on this, if we craft our bills out of the public view, behind 
closed doors, committee staff rooms, Speaker's Office, wherever they 
are done, and don't do it in the light of day.
  Politics is a full-contact sport. I understand that. I didn't begin 
my life to live it in public service, but in the last 6\1/2\ years I 
have, and I understand the nature of the beast. I understand that there 
are going to be people who take issue with what I say who want to 
attack me personally because of it. That's okay, as long as we do that 
debate here in the public arena, as long we do it in the light of day 
and that we don't do it behind closed doors and then roll out something 
at the last minute that the American people had just better like 
because that's what they are going to get.
  It's wrong if we do it when we're in charge. It's wrong if they do it 
when they're in charge. That's not the type of legislative activity 
that the American people want to see. They want to see legislative 
activity that brings them peace of mind. They want to see legislative 
activity that saves them time and saves them money. And why wouldn't 
they? If we can deliver more care to more people at less cost with 
better quality, why wouldn't we do it? Why wouldn't we take that 
choice?
  In short, as I look at this and I look at how to craft particular 
legislation, there's also room for common ground, I think, on both 
sides. On both sides. People talk about how we want to see an expanded 
role for information technology in health care. Some of the easy 
discussions that we can have. We may disagree on how it's to be 
apportioned or how it's to be structured. I don't think we should be 
writing the codes. I

[[Page 11867]]

don't think we should be telling doctors and hospitals what type of 
platform they need to buy. But certainly we ought to be encouraging 
people to evolve into that next arena, which would include electronic 
medical records and electronic prescribing.
  What about things like medical homes? I don't think you would find a 
lot of disagreement throughout the body on whether or not this is a 
good thing. Care coordination, we talked about it when we were talking 
about the Medicare bill back in 2003 and 2004. Disease management care 
coordination, accountable care organizations, these are things that 
bring value to that doctor-patient interaction that I referenced at the 
beginning of this talk. So it's easy to be for that stuff, and I think 
you would find a good deal of common ground on both sides on that.
  Where the arguments occur is who is to be the owner and are we going 
to micro-manipulate these aspects of health care from here or from the 
committee room or are we, in fact, going to let the people know what 
they are doing, the doctors, the nurses, the hospitals, are we going to 
let them be in charge of the system?
  In short, the American people want everything but a Washington 
takeover. And that, I think, is the one place where the American people 
really draw the line, and they are concerned that Washington will 
overreach, that we will put that congressional committee between the 
doctor and the patient. We have no place between the doctor and the 
patient, that interaction in the treatment room. The doctor and the 
patient activity should be completely free from any congressional 
interference, and too often, too often, it is otherwise the case.

                              {time}  1915

  We hear about expanding a public program. We hear about perhaps 
expanding Medicaid, maybe expanding Medicare. Some of the more serious 
problems that we deal with in this body are problems that are brought 
to us because those two programs, for all the good that they do, they 
do have some problems.
  Medicare and Medicaid are programs where, unfortunately, the 
inefficiency, the duplication of services and sometimes just the actual 
theft of services occurs, and we don't do a good enough job to keep 
that under control. No one wants us to be spending money 
inappropriately in any of those programs.
  The problem is, with both of those programs, they do consume a lot of 
time, they do consume a lot of activity, and they consume a big portion 
of the budget every year, the so-called entitlement budget. And when 
Congress looks to control costs on those programs, the only lever we 
can pull is to restrain payments to doctors. The other lever we can 
pull is to restrain payments to hospitals.
  And the only problem there is you are going to be getting less, then, 
of the doctor's attention and less of the hospital's attention when you 
restrain those provider payments. And, unfortunately, we do that all 
the time.
  Medicare is notorious for every year coming up and having to face a 
reduction in the reimbursement rate to physicians across the country. 
Medicaid reimbursements vary from State to State, but in many States 
the reimbursement for Medicaid is a fraction of what it is for 
Medicare.
  And here is the hard truth of this. You can't run a medical practice 
off of what Medicare and Medicaid reimburse, at the levels where they 
reimburse. And you are sure not able to run a practice if we, in fact, 
restrain provider payments like we are scheduled to do later this year 
and like we are scheduled to do every year for the next several years.
  We had a pediatrician come and testify in my committee last year in 
Energy and Commerce, and she testified and really got my attention 
because she started practice the same year I did, 1981. Her practice 
was 70 percent Medicaid in rural Alabama. She was having to borrow 
money from her retirement fund to keep her practice open.
  That's a bad situation. If you are losing money on each patient, it's 
hard to make that up in volume, and that was the situation that she 
faced.
  You know, a physician in that kind of crisis, they are not going to 
be able to keep their doors open. And if they can't keep their doors 
open, that entire patient population in rural Alabama, that pediatric 
population is going to be put at risk. Because she didn't talk about 
how many other providers are in the area, but you can only imagine, if 
it's that hard to make a practice go in that environment, there may not 
be many pediatrician practices.
  If you don't have the private sector to cross-subsidize the public 
programs, the Medicare and Medicaid, a lot of practices just simply 
can't make it. Here was an individual who had cut expenses everywhere 
she could. She had let people go. She had reduced hours. She had 
reduced some of the services she provided, all in an effort to try to 
keep the doors open, but she was still unable do that.
  Therein is a problem. If we expand the public sector, and we depend 
upon cross-subsidization from the private sector to keep the public 
going, what's going to happen if you reduce the private sector? How are 
you going to get that money to cross-subsidize the public part of that?
  And the amount of subsidization varies from study to study on what 
you read, but it's about 9 or 10 percent that it costs the private 
sector to support the public sector to keep it going. So, on a 50/50 
mix, Medicare, Medicaid, private pay, you will likely be able to make 
the cash flow, but when you get to 70/30, it just doesn't work any 
longer, and that's a physician who is at risk of not being in practice 
this time next year.
  So those are some of the problems that we need to fix. We are 
obligated to fix those problems within our publicly administered health 
care plans before we expand them.
  And that is my concern when I hear us talk in this body about how we 
want to have an expanded public option that competes with the private 
sector. Right now it doesn't really compete with the private sector. It 
depends on the private sector in order to keep those practices open. So 
I think we are obligated to look at the job we are doing now before we 
reward ourselves with an ever-increasing or an ever-larger segment of 
that.
  You know, currently, we are close to about a 50/50 split in this 
country. About 50 cents out of every health care dollar that's spent 
comes from here, originates here in the House of Representatives. The 
other 50 cents of every dollar that's spent is self-pay private 
insurance or charitable gifting of a doctor who just doesn't expect to 
get reimbursed for what they do. Fifty percent comes from the Federal 
and State governments, 50 percent comes from the private. If we shift 
that balance, we are apt to find that we are no longer supporting the 
infrastructure we had hoped we would be able to continue to support.
  So adding to the public sector may, in fact, be detrimental. For 
people who want to keep what they have now, we say you can, right up 
until the time we make it unprofitable for that to continue.
  One of the things that concerns me greatly is, again, what we do with 
our provider payments. December 31 of this year, physicians across this 
country will face a reduction in reimbursement for Medicare patients of 
20 percent, a little over 20 percent. That's a significant and stark 
reality that's facing every doctor that sees Medicare patients 
throughout the country. And doctors are concerned about it, patients 
are concerned about it.
  Many patients will find they move locations, and finding a new doctor 
on Medicare becomes extremely difficult. There are stories in The 
Washington Post. I have seen stories in my hometown newspaper in Dallas 
and Fort Worth, extremely difficult to find a physician to take a new 
Medicare patient in many locations in the country.
  And the reason for that is what Congress has done the last several 
years where we say we are spending so much money on Medicare, we would 
like to hold the costs back a little bit, we will just hold the cost 
down or we will hold

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the price down by cutting payments to doctors a little bit each year. 
And that, over time, has become a very pernicious effect on people 
going into medicine, quite frankly.
  There are concerns that the physician workforce will continue to 
erode over time, such that just the sheer numbers of doctors available 
may not be enough to treat the patient load as us baby boomers get 
older, may not be enough to treat the patient load that emerges on the 
other side. So it's a problem that this Congress, this Congress, the 
one that's seated here, really has to face up to, because by the end of 
December, there will be a 20 percent pay cut across the board. We did a 
big Medicare bill July of 2008, big, big hoopla here on the day we did 
it. Yeah, we solved the problem for a little while.
  Every time we do that temporary fix, every single time we do that 
temporary fix, we make it harder, we dig the hole deeper and we make it 
harder to get out of that problem on the other end.
  Now, every Congress that I have been here, I have introduced 
legislation to deal with what's called the sustainable growth rate 
formula that creates that 5 percent, 10 percent or now 20 percent 
reduction in rates to physicians. I will be reintroducing a bill next 
week that will deal with this problem. I had a similar bill last year. 
There have been some changes made because of some of the changes in 
legislation that have happened over the past 24 months, but ultimately 
we are going to have to deal with this problem.
  We need to move physicians into the same type of payment formulas 
that we do for hospitals, that we do for insurance companies, that we 
do for drug companies, that we do for HMOs, and that's essentially a 
cost-of-living adjustment that occurs every year.
  There is no magic to it. I didn't invent it. It's called the Medicare 
Economic Index. It's about a 1 or 1.5 percent update that occurs every 
year to account for the increased cost of delivering that care.
  We haven't kept up with the cost of delivering that care. There are 
some years we have provided a zero percent update. There are some years 
we have allowed the cuts to go into effect. There are some years we 
have provided a 1 percent update, but it hasn't been enough.
  And as a consequence, it now costs doctors more to actually do the 
work of seeing the patient. It costs them more. It costs them money to 
see every patient on Medicare.
  We are not carrying our load. We are not paying our freight from 
Congress, and that has an extremely detrimental effect on the physician 
workforce, the morale of the physician workforce, and certainly the 
continued--it will lead to continued problems with physician--spot 
physician workforce shortages, some patients not being able to get in 
to see a Medicare provider.
  And it's up to us, up to us to address it. Doctors are seeing the 
patients we asked them to see, our Medicare patients. Congress in 1965 
said we are going to take over the care of individuals over the age of 
65 in this country, and we asked the doctors to see those patients.
  They are arguably sometimes the most complex and complicated patients 
that will be in a physician's practice. They are complicated because 
they have multiple medical problems. They may be on multiple 
medications. They are not necessarily the easiest patients to take care 
of, but they are important, because they are our parents, they are our 
colleagues. In fact, many of us, in a few short years, will be in that 
Medicare age group.
  It is critical that we provide the physicians the support they need 
to take care of those Medicare patients. And it's something I just 
frankly do not understand why this Congress is always so reluctant to 
deal with this problem and always pushes it off to the last minute.
  We push physicians in this country up to the brink every year, every 
6 months, every 12 months, every 18 months, whatever it is we decided 
to fix it for the last time. We don't even deal with it until we are 
right up against that problem again. Well, this time let's be different 
about it. We have 8 months till the end of the year, 7 months till the 
end of the year. Let's take that time to fix it and get it right and 
make certain that this time we don't leave our doctors waiting at the 
last minute to wonder if they are going to be able to keep their doors 
open January 1 or not.
  One of the last things I want to touch on, a few weeks ago in March, 
I was invited down to the White House to participate in the White House 
forum. And, again, as alluded to earlier, I have been concerned that 
there is a bill that's already been done and the rest of this is just 
for show. At the appropriate time, the Speaker's door will fly open, 
the health care bill will come out. It will roll down here to the floor 
of the House. We will have a brief time to debate it, no time to read 
it, and off we will send it to the Senate.
  I have been concerned about that. As I said, I am the eternal 
optimist, and I am going to be optimistic that we are going to go 
through regular order, but I also fear at some point there will be a 
bill that just comes crashing through with no time to read, evaluate or 
debate, and off it will go to the Senate and that will be that.
  Now, the President, to his credit, said that that was not the case, 
that we would go through regular order. In fact, as we wrapped up after 
the breakout sessions that afternoon in the White House, the President 
stood in the East Room and said that it will up to the congressional 
committees and congressional leadership to get this bill done through 
the regular order, that he would be glad to offer guideposts and 
guidelines, perhaps some budgetary boundaries, but he wanted that work 
done in the Congress, where it was supposed to be done.
  Again, I will take him at his word. In fact, I applaud his courage 
for saying so. He said at one point, I just want to find out what 
works. Well, I want to help the President find out what works, and to 
that end, I will continue to be involved in this debate.
  Now, let me just spend a few minutes talking about a caucus that is 
currently working in Congress to try to help inform on the health care 
debate. It's not a legislative caucus. It's not a legislative 
committee. It won't write legislation, but we do have forums. We do 
have hearings. We do have Member educational events. We do have 
educational events for staff, congressional staff, particularly on the 
communication side.
  On occasion, we go outside of the confines of Washington and talk to 
groups of doctors, nurses, hospital administrators, again, the people 
who are involved in taking care of our patients on a day-to-day basis. 
We like to solicit their input, to receive their advice and criticism 
on things they see happening from Congress.
  And the caucus is the congressional health care caucus, and it does 
have a Web site, www.healthcaucus.org, healthcaucus being all one word 
with no space or bar in between. I encourage people, Mr. Speaker, to 
look into this. It is a way for people to have their voices heard on 
this debate.
  We have had several good forums. I try not to make them one-sided. We 
try to have people who represent, perhaps, a left-of-center view and a 
right-of-center view. We had one forum on the options for reform that 
was attended by people from the Commonwealth Fund, by people from the 
Galen Institute and the Council for Affordable Health Insurance. It was 
a very instructive forum. The Webcast for that is, in fact, archived on 
the Web site if anyone is interested in that.
  We had another forum on improving affordability, listening to some of 
the people who have actually done the work of making health care 
affordable in their communities and for their groups of patients. We 
heard that time from Rick Scott, who runs a number of outpatient 
clinics in Florida. We heard from Greg Scandlen from the Consumers for 
Health Care Choices, and we heard from Dr. Nick Gettas, who is a chief 
medical officer at CIGNA. Again, on the Web site, the Webcast of that 
is archived and people are welcome to look at that and review that.
  When we do these forums, we do Webcast them from the Web site, and

[[Page 11869]]

they are available live and broadcast live on the Web site when they 
are done, and through the magic of Twitter, we are able to take 
questions from people who are not actually in the physical audience. We 
do take questions from the physical audience. We take questions from 
the virtual audience.

                              {time}  1930

  This can, again, sometimes lead to some quite lively debate.
  Upcoming within the balance of the month of May and into the month of 
June, we are going to be doing another forum, one dealing with the 
question of mandates and one dealing with the concept of health reform 
from the journalists' perspective. We have many good writers up here 
who write about this on a regular basis, and we want to bring them in, 
perhaps turn the tables and interview the interviewers for part of the 
morning on some of the aspects of the health care debate.
  And then finally, in the month of June, we are going to have another 
forum on promoting quality. And we have got a number of good people 
lined up for that. Again, some left of center, some right of center, 
but designed to give a balance of opinion as we have these forums. And 
again, as I mentioned, Mr. Speaker, if anyone were interested, they are 
available live on the Web site when we hold those.
  In short, Mr. Speaker, I did not leave a viable and active 25-year 
practice of medicine to come here and sit on the sidelines. I came here 
to be part of the debate as the debate was going on, and I intend to be 
fully engaged. I hope that both sides will stay lively and will stay 
engaged on this debate. I hope we can have this debate in the light of 
day and not in the dark of night. I hope we can have input from both 
sides when this bill ultimately comes forward from this and leaves the 
floor of this House and goes over to the Senate. Certainly I know the 
American people are depending upon Republicans and Democrats to work 
together. And it is my hope, my fervent hope and my prayer that that is 
indeed what happens.
  Mr. Speaker, you have been very generous, and I'm going to yield back 
the balance of my time.

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