[Congressional Record (Bound Edition), Volume 156 (2010), Part 4]
[House]
[Pages 4537-4544]
[From the U.S. Government Publishing Office, www.gpo.gov]




                              HEALTH CARE

  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 as the designee of the minority leader.
  Mr. BURGESS. Mr. Speaker, I, too, am coming to the floor of the House 
tonight to try to clarify for the American people some of the things 
that have happened here over the weekend. As you know, we passed a very 
big bill last night, hasn't been quite 24 hours, it was about 11 p.m. 
Eastern time when everyone else in the country was watching basketball 
tournaments and otherwise engaged with weekend activities, this House 
was in full session, the place was packed, Democrats and Republicans, 
and we passed a bill that had been passed by the Senate on Christmas 
Eve.
  Now, I remember when I first got here, Republicans were in the 
majority, and when we would pass major pieces of legislation, if there 
was an all-day fight, we would be accused of waiting until the dark of 
night to try to sneak this legislation through. Now, I have never been 
one who would pass on the chance to attribute to coincidence that that 
can be adequately explained by conspiracy, but how is it that we 
passed, in the Senate, this very difficult legislation the day before 
Christmas when America was engaged in other activities, and then here 
on the floor of the House last night at 11 o'clock on a Sunday when 
most every other honest American was doing something other than 
watching their Congress.
  I do have to address some of the things that I just heard mentioned 
from the other side. Remember that there were two pieces of legislation 
passed here last night. One was the previously passed Senate bill which 
the House passed. That one is on its way down to the White House. 
That's going to be signed by the President. That's going to be the law.
  And then we also passed a sham bill, a bill that might be called a 
fig leaf because no one really likes the Senate bill. The Speaker of 
the House said that herself. No one wants to vote for the Senate bill, 
and I agree with the Speaker. No one wanted to vote for the Senate 
bill. So how did they get their side to vote for the Senate bill? Well, 
they said don't worry, we are going to fix the problems that you don't 
like in the Senate bill, and we will do that under reconciliation so 
it's only going to require 51 votes over in the other body, don't 
worry, we will get that taken care of.
  The only problem is, the Senate bill that we passed here last night 
had already passed the House before last summer--you might not 
recognize it because it was a housing bill then, but it passed the 
House last summer--went to the Senate, got changed into a health care 
bill and then got brought back to the House. And the question before 
the House, will the House now accept the amendment, the Senate 
amendment to H.R. 3590, the answer was affirmative, and the bill is on 
its way down to the White House for a big signing ceremony, probably 
tomorrow.
  Now, what's going to happen to the reconciliation bill? It also 
passed, and it passed, and went back to the Senate. And is there 
anything that compels the Senate to take up that bill and work on it? 
Why, no, there is not.
  In fact, the Senate might rationally argue, I am sorry, Mr. Speaker, 
the other body might rationally argue that, hey, we already passed our 
health care bill, we passed it on Christmas Eve, you guys apparently 
liked it because you ratified the amendments we had to it, and last we 
saw, it was on its way down to Pennsylvania Avenue to the White House. 
So why would we pick up this contentious package of fixes in the bill?
  You know, quite honestly, the oxygen may have all gone out of the 
room for health care legislation in this Congress. Fourteen months is a 
long time to have fought this thing, and the Senators may just not have 
the stomach to pick this thing up and fight through it again.
  So some of the things that we need to be careful about when people 
are talking about the bill--and I will do this too, many of us here in 
the House are not that familiar with the Senate bill that we just 
passed because it was the Senate bill. We had a health care bill that 
was marked up in my committee and passed out of committee over my 
objection July 31. I didn't like the bill, but I knew it. I submitted 
amendments and some of those were even accepted. So I had a lot of 
familiarity with that bill.
  Now, that bill went to the Speaker's office, sat there for a couple 
of months, got changed all around. All of my amendments got pulled out, 
every other Republican's amendments were pulled out of that bill. It 
became a 2,000-page bill, even with the loss of those amendments, and 
was brought back to this House in early November, and this House passed 
the House bill.

                              {time}  2100

  We knew the House bill. Many of us were--although we didn't like the 
House bill, we were fairly comfortable with what it contained and what 
it didn't contain. The Senate bill is completely different. Most of us 
did not ever see the Senate bill before the Senate brought it up on 
Thanksgiving and then passed it right before Christmas.
  Mr. Speaker, quite honestly, many of us felt like we'd already read a 
lot of health care bills this year; do we really need to read that 
Senate bill? Maybe not. Because the Senate will pass it and then the 
normal procedure is we call a conference committee. We go to conference 
committee and we debate both sides, get to debate the House bill, the 
Senate bill, Republicans and Democrats, a true bicameral process. We're 
finally going to have that open and

[[Page 4538]]

transparent process that was promised to us and we'll read the 
conference report. We won't have to worry about the Senate bill because 
it's all going to be changed anyway.
  Except that didn't happen because, for whatever reason, the Democrats 
did not want to do a conference report. They say it's because 
Republicans were going to block the appointment of conferees. But, Mr. 
Speaker, I would just point out to you that in December and early 
January there were 60 Democratic votes in the Senate, 256 Democratic 
votes here in the House. There wasn't much we could block, even if we 
wanted to. So how we would have blocked the appointment of conferees is 
anyone's guess, but I did hear that mentioned several times during the 
debate. So let me just set that point straight.
  They thought they could just put things together on their own outside 
of a conference, and they were doing a darn good job of it. The last 
week in December, the first week in January on into the second weekend 
in January, people were meeting in this Capitol, meeting in this 
building, in the new Capitol Visitors Center, and putting together the 
pieces, cutting secret deals with unions, cutting secret deals with 
this group and that group, and we were going to have a bill that would 
just be blessed by both sides. No conference report. Not necessary 
because we'll just bring a new bill to the floor that will be the 
amalgamated bill. The Senate will vote for it. They've got 60 votes. 
The House will vote for it. They've got 256. And if they don't lose too 
many, then they can pass pretty much whatever they want. Then we'll 
have a health care bill.
  What happened in that scenario was that the second Tuesday in January 
they had an election in the State of Massachusetts. As a consequence of 
that election, suddenly the Democrats' 60-vote supermajority in the 
Senate was no more. Now, the new Senator was not seated for several 
weeks after that election and there was still time to come together 
with a hasty conference committee and get that thing done or even push 
through that amalgamated bill, but, for whatever reason, they didn't do 
that. It really looked for a while like things might just languish 
indefinitely.
  Now we all know the story. In those last 10 days, the President 
really engaged, the White House engaged, and the Speaker's office 
engaged. They were just going to get this bill through the House 
because that was the quickest way--they always say a line is the 
shortest distance between two points. The shortest distance to getting 
health care legislation passed in this Congress, in this President's 
first half of his first term, was to pass the Senate bill through the 
House. It was something no one wanted to do. No one wanted to vote for 
that bill. It had awful things. Most of us don't know all of the awful 
things in that bill because it was the Senate bill. We passed House 
bills. We knew the House bill, but we heard the minority leader say it 
last night from this floor, Most of you on the Democratic side do not 
know what's in that bill.
  Now, I dare say, today you've learned a lot of what's in that bill 
because you've got the phone calls from the press the same as I have. 
Suddenly, the press got real curious about what was in the Senate bill 
and they're asking all kinds of questions. So tonight perhaps we can 
deal with some of those. But one of the things I wanted to point out at 
the very beginning, be careful what you talk about when you hear us 
talk about what's in the bills, because both sides of the aisle, both 
Democrats and Republicans, may not be quite sure what's in the bill.
  We heard testimony, or we heard the speeches on the other side here 
just a moment ago about how Medicaid rates now were going to be 
plussed-up for primary care doctors. Medicaid rates will become 
Medicare rates. Well, that actually, in fact, is only for primary care 
doctors and it is only for 2 years, but it is also only in the 
reconciliation bill. Did we pass the reconciliation bill? We did in the 
House. They haven't in the Senate. What did we pass that has passed the 
Senate? The Senate bill. And that does not have that plus-up in 
Medicaid rates. In fact, the expansions of Medicaid that we have now 
put forward that were in the Senate bill, the expansion of Medicaid, 
will be reimbursed at standard Medicaid rates, which vary from State to 
State. But I will tell you, as a medical provider, those put a lot of 
providers back on their heels, because those rates do not pay the cost 
of delivering the care, and there is only so much of that kind of 
business you can do in an average day and still keep your doors open.
  So there is a problem with expanding Medicaid to larger and larger 
populations. The provider community is going to find it difficult to be 
able to absorb that many more Medicaid patients into their practices 
because the reimbursement rates are going to remain low. In fairness, 
it was fixed in the reconciliation bill, but if the Senate doesn't take 
that up, it never happens. It was the skinniest of fig leafs because 
it's not there when you need it. What is there is the Senate bill, 
which is on its way down to the White House, and that will be the law 
of the land, which will expand Medicaid, to be sure, but does it have 
the enhanced Federal matching in there for Medicaid? In one State it 
does. In one State it does. The reconciliation bill was going to fix 
that so all States would have what that one State now has in the Senate 
bill, but it is the Senate bill, and only one State has that enhanced 
Federal match for Medicaid: the State of Nebraska. The famous 
Cornhusker kickback.
  So what happened here last night, what transpired on the floor of the 
House last night was really dramatic and, in many ways, a fitting end 
to the 14 months of chaotic process that had brought us to this point. 
We've heard over and over and over again--and I don't want to belabor 
the point, and this may well be the last time that I discuss the 
process that brought us here. But it is worth mentioning, because over 
and over and over again last night during the debate we heard, You 
Republicans obstructed at every step of the way. Remember, there's 177 
of us; there's 256 of you. We can't obstruct anything, particularly the 
House of Representatives, where majority rules on almost everything.
  And, oh, by the way, the Rules Committee really rules. And the Rules 
Committee has a nine-to-four advantage for the Speaker. There's not 
much you can do with 177 Republicans in the House of Representatives if 
you want to obstruct. Well, you can all hang together and make a 
principled vote that we're all against this. And that's indeed what has 
happened.
  But the real debate was an internal debate within the Democratic 
caucus, because had they had the votes, they could have done this in 
February. Had they had the votes, they could have done this in January. 
They could have done it in December, the day after Christmas, as 
opposed to the day before Christmas when the Senate bill was passed. If 
they'd known this was what they were going to end up with, maybe they 
should have just done that and saved everybody 3 months of additional 
anxiety.
  The fact of the matter remains, Republicans did not obstruct this 
bill. Democrats obstructed this bill. Democrats and, oh, yeah, one 
other thing. They never had the popular support of the American people. 
Now think about that for a minute. We passed a bill that's going to 
affect in a very profound and personal way the next three generations 
of Americans. That's a pretty big bill. One-sixth or one-seventh of the 
Nation's economy. That's a pretty big bill.
  Now, we've heard over and over again, if you're going to do something 
like that, it needs to be bipartisan. So Republicans should have signed 
onto the bill. Republicans should have backed the bill. Republicans 
should have been there. But, wait a minute. The people did not want 
this bill. Poll after poll after poll has shown--fill in the blanks--52 
percent, 55 percent, 60 percent of the people did not want this House-
passed bill, did not want the Senate-passed bill, did not want what the 
United States Congress was going to do to health care.

[[Page 4539]]

  Now, if you don't have popular support, then even if you've got 256 
Democrats and, now, 59 Senators and the White House, it's very 
difficult to get your Members to--it's a very technical term we use 
here in the House of Representatives. It's called, ``walking the plank 
for your leadership.'' It's very difficult to get your Members to walk 
the plank for leadership when everybody back at home is howling mad 
because of what you're doing. And I'm sure many people felt--the old 
saying that Everett Dirksen used to have, ``When I feel the heat, I see 
the light.''
  A lot of people saw the light when they went back home. Now they came 
back to Washington and got their arms twisted and things promised and 
things promised to be withheld and goodness knows what and they lined 
up and walked the plank last night. That's what we saw.

                              {time}  2110

  People are voting in favor of things they said they would never do. 
They misled their constituents back home. People turning at 90-degree 
intersections to principles that they've held for a long time. It was 
painful to watch. I felt some sorrow for people I saw on the Democratic 
side having to make these very tough gut-wrenching decisions.
  These are good people that are well intentioned, but they got pushed 
into a corner from which there was no escape. And that corner was the 
Speaker of the House and the President of the United States. And as a 
consequence, this bill passed, a pretty slim majority. Not a single 
Republican. In fact, the only thing that was bipartisan about this bill 
last night was the opposition because you had 30 Democrats standing 
with 177, or 178 now, Republicans. That was the bipartisan block on 
this bill, but they were in opposition.
  This bill presents a real problem for the American people. The 
American people don't like it. The American people don't want it, but 
now the American people have it. Now ideally--and people have asked me 
all day long, Well, what are you, as a Republican, going to do about 
this now? And the answer is, You fix what you can, and you work toward 
repeal of the bill.
  Now working toward repeal of the bill, you've got to ask yourself. 
There likely will be bills introduced today and bills introduced 
tomorrow that will call for the repeal of the bill. I may very well 
sign on to one or more of those bills. But with the same vote total 
that we had last night, do you think any of those bills are even going 
to be brought up for debate? Is the Speaker of the House, is the 
majority leader going to bring up one of those repealed bills and say, 
Let's go through this argument and see if any of our Members now feel 
differently? Well, they could. And there is history there. There is 
precedent there.
  In the late 1980s, this House passed a seriously flawed catastrophic 
coverage bill for Medicare. They charged Medicare recipients the 
premium for that catastrophic insurance; and all across the country, 
people said, Wait a minute, we didn't want that. We didn't ask for 
that. You're charging us for something we didn't ask for or want. And 
the seniors in this country rose up, and the very famous pictures of 
then-chairman of the Ways and Means Committee, Dan Rostenkowski, being 
chased out of his own town hall by senior citizens who objected to what 
they had done. And Congress did come back in short order and repeal 
that bill. Will that happen now? I don't know. That's a pretty painful 
thing for people to have to go through. We'll see.
  We've got an Easter recess coming up. If people do town halls and 
they get that kind of reaction, maybe we'll be back here talking about 
one of those repealed bills. But honestly, Mr. Speaker, I think that's 
a pretty heavy lift to repeal this bill that we passed last night, this 
bill that's now on its way to the White House to become public law. 
It's pretty difficult to do that in this Congress because it's not 
likely that there will be the votes. And then, of course, on the Senate 
side, it's really not likely that there would be the votes. And if it 
happened, the President likely would feel differently about it and 
would exercise his authority to veto that repealed bill, and it is 
unlikely to get to the threshold of a veto override, two-thirds of the 
House and two-thirds of the Senate to override a Presidential veto.
  In fact, if America has the reaction to this bill that I think 
they're going to have, there may be many more Republicans and many 
fewer Democrats here in the House of Representatives next year. I don't 
know if that number will be enough to change the majority control of 
the House. It sure could be. It certainly looks increasingly likely 
from the degree of anger and how upset people are that talk about this 
bill out in the middle part of America. But I don't know if there is 
the political will to change the majority makeup of the House. Again, 
even if there is, sure, we'll bring that repealed bill up. We'll bring 
it up pretty quickly and send it down to the White House, and the White 
House will veto it. I doubt that there will be a new Congress that's 
seated that will also have the ability to override a President's veto. 
Again, that's a tall order, two-thirds of the House, two-thirds of the 
Senate. So I don't know within the time frame between now and January 
of 2013, if the numbers work out, for this Congress to have the ability 
to repeal the bill. It's worth trying. It's worth testing. But I don't 
know if that's a realistic trajectory.
  Well, then, what can we do? I think it is extremely important to at 
least begin to work on some of the more egregious portions of this 
bill. And I will just tell you, one of the things that really bothers 
me about this bill that we did is the instituting of an individual 
mandate to purchase health insurance. Now surely it is the responsible 
thing for every American, every family to have health insurance against 
the unlikely but frightening occurrence of some of the diseases that 
can happen to us as human beings. It's the responsible thing to do. But 
just because it's the responsible thing to do does not mean that your 
Federal Government has the responsibility to require you to buy it. 
We've never done that in this country. Simply as a consequence of being 
born or living in this country, your Federal Government now says that 
you're going to buy this product.
  In fact, when the bill was passed, people said, Well, under the 
commerce clause, we have the authority to do that. But that kind of 
turns the commerce clause on its head. The commerce clause is there to 
protect commerce, but coercing someone to buy a good or service or 
product and then invoking the commerce clause to protect that 
transaction really seems to be going at things the wrong way. Now, if 
an individual State wants to say as a condition of living in our State, 
there is a mandate that you will buy health insurance--and there are 
States that have done that, and if their State legislature passes that 
legislation, and their Governor signs it, and the citizens of that 
State are okay with that, then good on 'em. That's fine. That is their 
prerogative. That's one of the things that a State government is there 
for. If they pass an individual mandate, and the people turn out the 
State legislature, well, then they learned their lesson. But that's a 
different set of circumstances than having the Federal Government make 
that decision that we're going to require everyone to purchase 
insurance. In my opinion, mandates have no place in a free society; and 
in my opinion, mandates are not going to get us the kind of coverage 
numbers that people expect it to.
  You stop and think for just a minute, for a mandate to work, there 
has to be general knowledge that this mandate is there; there has to be 
general knowledge of the penalties that one would possibly incur for 
not complying with the mandate; and there must be general knowledge 
that those penalties will be swiftly and surely administered.
  Now, we do have a model for that in this country, and that is called 
the Internal Revenue Service. The Internal Revenue Service says that 
everyone who earns income has to pay a percentage of that income in 
income tax. In fact, it's withheld from most of us from our paychecks 
every month. But that income tax must be paid, and we all know that, 
and we all know that if we

[[Page 4540]]

don't pay our taxes, we may not know exactly what's around the corner, 
but most of us know it's something we really don't want to find out 
about.
  Now, with such a draconian mandate for Federal income taxes 
administered by the Internal Revenue Service with such a mandate, you 
would expect the compliance rate to be pretty high. Well, it is. But it 
might be lower than what you might think. The compliance rate is around 
the order of 85, 86 percent. That's with a pretty severe mandate.
  What about health insurance? Right now it's voluntary. As I said, 
it's the responsible thing to do. People should have coverage. People 
want to have coverage. In this country, most people are covered by 
employer-sponsored insurance. There is another 8 to 15 percent covered 
in the individual market. But insurance is a responsible thing to do. 
And in the voluntary program of insurance that we have in this country, 
what is the problem that we hear about over and over again? We've got 
15 percent of our population without health insurance. Well, that does 
mean conversely you have 85 percent with insurance. And what is the 
compliance rate with the IRS? It's pretty close to the same number.

                              {time}  2120

  So are you going to get more of that 15 percent to sign up for health 
insurance if you put this very draconian, liberty-stealing mandate from 
the Federal Government out there? I don't think so. I think mandates 
have no place in a free society; and as a consequence, I don't think 
they belonged in this bill.
  Further, what did the stock market do today? It jumped up a bunch, 
didn't it. You might say, well, see that proves the point, Americans so 
wanted this health care bill to pass the House of Representatives that 
they rejoiced by going out and running up the stock market. Or perhaps 
because insurance companies and pharmaceutical companies are going to 
profit so much by the fact that you now have to buy health insurance, 
that their prices went up. Their stock went up because people looked at 
futures and forecasting and said, wait a minute, insurance might be a 
good stock to buy because in just a short period of time, everybody in 
the country is going to have to buy insurance.
  Wouldn't it be a better approach, instead of mandating people to buy 
insurance, and again, I don't believe you are going to get a reduction 
in insurance rates by demanding that everyone buy health insurance, 
because what incentive is there for the insurance company to hold the 
price down? There isn't any. If anything, there is an incentive to 
raise rates because you have to buy it, otherwise the IRS is coming to 
visit grief upon your household. So the insurance companies may be 
feeling pretty good about this bill that we just passed last night 
because they are going to sell a ton of product. You are going to have 
to buy it, or you get into all kinds of trouble. The IRS is going to 
come and raise billycane on your head if you don't buy this insurance. 
So the insurance companies are feeling okay with this.
  And the pharmaceutical companies, yes, they came to the table with a 
big bunch of money, and they gave up something to get this health care 
bill passed. But at the end of the day, the closure of the doughnut 
hole, yes, but it is for brand name products you get that discount, so 
they will sell more of that branded product which is the most expensive 
product, and people are going to blow through that area where they have 
to match some of the expenses and the catastrophic coverage will kick 
in pretty darn quick. Pharmaceutical companies may stand to gain a 
great deal from the passage of this bill. So it is really no surprise 
that the stock market went up today. Drug companies and insurance 
companies, they may look to be doing okay in this brave new world order 
that we gave to the American people last night.
  A very famous quote from the Speaker earlier in the debate on all of 
this was: We need to go ahead and pass this bill so people can find out 
what is in it, and then they will really like it after the fog of the 
discussion is removed.
  In fact, I have heard essentially that same statement on the floor 
here today. One of my friends on the Democrat side said, You know, 
finally, all of the rhetoric can be put aside and people will see what 
is in this bill, and they will really like it.
  So let's talk about what is really in this bill, and I will leave it 
up to the American people how much they like it. We have already talked 
about the individual mandate. Absolutely unprecedented. The government 
has never required people to buy a good or service as a condition of 
lawful residence in the United States. That is a quote from the 
Congressional Budget Office.
  It will be invoked under the commerce clause. The power to regulate 
commerce among the States is not unlimited. And here is a thought: What 
if the courts allowed this to stand? What if that power was in fact 
unlimited? Your imagination almost cannot handle what some of the 
things that your Federal Government might decide to do if we removed 
that power, or we removed that condition on exercising that power.
  Some of the other things that are going to be found in this bill are 
tax increases. I know I heard it over and over again during the debate 
that the Republicans shouldn't mislead people about tax increases in 
the bill, but they are there for all to see. Go to the Web site Thomas, 
the Library of Congress Web site, and download the CBO letter on S. 
3590, the Senate-passed bill, and look at some of the tax increases 
that are there.
  Medicare cuts, are they there? Yesterday the Democrats kept saying, 
There are no cuts to Medicare in this bill. Well, there darn sure are. 
Again, looking at the tables at the back of the CBO report, some of 
them look to be pretty darn significant. Reductions in annual updates 
to Medicare fee-for-service payment rates over the period 2010 to 2019, 
that is a 10-year budget cycle, that is a cut of $86 billion. Medicare 
Advantage rates based on plan bids, that is cut $118 billion. Medicare 
and Medicaid disproportionate share hospital payments, that is cut $43 
billion over that 10 years. Community living assistance services and 
supports, that is cut $70 billion over 10 years.
  One of the things that is really disingenuous about these cuts, and 
they have it laid out year over year in the Congressional Budget Office 
report, and the next 4 or 5 years those cuts are actually pretty 
modest, and then they really kick in the last 5 or 6 years. And we all 
know there is a big Presidential election coming up again in 2012, and 
so perhaps it is no accident that those cuts are diminished in the 
early years and then expanded in the out-years.
  Payment adjustments for home health care, that is almost $40 billion 
in reduction. Again, Medicare disproportionate share hospital payments 
down significantly. That is one of the significant things. It is hard 
for people to understand what is a disproportionate share hospital 
payment. Some hospitals see--and remember I told you that Medicaid 
doesn't really reimburse providers the cost of providing their care. 
Now no one cares so much about the doctor because who needs doctors in 
the health care system anyway, but we do care about hospitals. And 
hospitals historically have been protected. If they see what is called 
a disproportionate share of uninsured patients or underinsured 
patients, Medicaid where the reimbursement rate is low, they get a 
plus-up from the Federal Government, and it is called a 
disproportionate share payment.
  One of the things that they did in the State of Massachusetts, they 
said we are giving all of this money to hospitals for disproportionate 
share payments, what if we just took that money and helped people buy 
insurance? Everybody is insured, and then you don't need to provide the 
disproportionate share payments any longer.
  But you take a State like mine, a State like Texas, where a great 
number of the uninsured happen to be in the country without a valid 
Social Security number, for whatever reason. Now we heard the President 
of the United States stand here in this House in September and say very 
clearly that no

[[Page 4541]]

one who is in this country illegally will be able to participate in any 
of these benefits. If that is correct, and Texas has a problem with 
people who are in the country without the benefit of a Social Security 
number who also happen to be uninsured, they won't be eligible for any 
of these benefits. They won't be eligible for any of the subsidies in 
the exchanges. They won't be able to access the insurance that Congress 
is passing. That is not necessarily a bad thing. You don't want to 
provide an incentive for someone to come into the country without going 
through the proper channels. So what are we going to do in a State like 
Texas where we have vast numbers of uninsured who are there without 
benefit of a Social Security number? They are still going to access 
care through the emergency rooms of our safety net hospitals, but we 
are also at the same time cutting those disproportionate share payments 
to those hospitals. So the hospitals are actually catching the grief 
from both sides. Their uninsured and underinsured populations are going 
to go up, and their reimbursement rates are likely to stay low, and 
disproportionate share payments are going to go down. That is a 
business plan that may make sense to the Federal Government, but I bet 
it doesn't make sense to most hospital administrators who run our 
safety net hospitals around the country.
  So anyway, when people tell you that the Republicans are misleading, 
we are trying to scare you on the Medicare cuts, they are outlined in 
the Congressional Budget Office report, and they are as plain as day 
for everybody to see. The subtotal for Medicare cuts: A negative $430 
billion over 10 years. Add the other community-living reductions of $70 
billion, and that is $500 billion. That is what you have heard 
Republicans saying for the last several months. You are going to cut 
Medicare by $500 billion. At the same time, you have more people coming 
into the Medicare system, and you are really doing nothing to hold down 
the cost of delivering medical care.

                              {time}  2130

  You're creating a situation where you're actually going to increase 
the stress on the system, not decrease the stress on the system; 
additionally, $500 billion in new taxes coupled with that $500 billion 
of Medicare cuts. The President stands in front of us and says, And 
this bill will be paid for; in fact, this bill will reduce the deficit.
  Well, you're leaving out a big part of one of the things that didn't 
get fixed in the Senate bill. You've heard me talk before about what's 
called the sustainable growth rate formula. This is the formula under 
which doctors are reimbursed in Medicare.
  Back in 1988, the institution of the, what's called, relative value 
payment scale, RBRVS, whatever that acronym stands for, every year we 
tended to try to ratchet down reimbursements to physicians because we 
felt, if we didn't, they'd just spend too much money.
  Well, what has happened over time, of course, as doctors' 
reimbursement rates have gone down, they've tried to see more and more 
patients so that their bottom line didn't suffer. And, as a 
consequence, the spending has gone up and the SGR has had exactly the 
opposite effect of what was intended.
  We are in a real problem with this formula right now. This year, 
there were projected to be cuts of almost 21 percent to doctors who 
provide services to our Medicare patients. The payment rates for part B 
in Medicare were going to go down by one-fifth. For some specialties, 
it was going to go down even more than that. But just in general, it 
was going to go down about 21 percent.
  We put a stay on that just about a week ago with a bill that passed 
by voice vote in this Congress, so it wasn't a recorded vote, and this 
put a stay on that cut until November. What happens then is anyone's 
guess because we didn't fix the problem in the House-passed bill. I 
mean, we didn't fix the problem in the Senate-passed bill. That bill's 
going down to the President for his signature.
  What's going to happen to the doctors in Medicare? Well, Congress 
needs to fix that. Why hasn't Congress fixed that, by the way? It's 
been going on for years. Started with the Democrats, then it got worse 
under Republicans, and it's getting a whole lot worse now that the 
Democrats have retaken the majority.
  Well, why didn't anybody fix that? The reason they don't fix it is 
because it scores, by the Congressional Budget Office, as a cost, a 
cost that is, no one really agrees upon the price, but it's somewhere 
between $250 billion to $350 billion. It could even be more than that 
if you tried to protect some part B premium payers from the rapid 
expansion of Medicare costs, Medicare part B costs caused by the rapid 
increase in repealing the SGR.
  Remember that part B premiums are based on a formula: 25 percent of 
the actual cost of administering the part B program. We add another big 
cost to the part B program in the repeal of the sustainable growth rate 
formula, and Medicare recipients, Medicare participants in the part B 
program may see their premiums go up even faster than they've seen them 
go up the past several years.
  So that's a problem. If we are honest about addressing the problem, 
it is likely to be $350 billion to $400 billion. But it could be scored 
as low as $250 billion if you use some smoke and mirrors, which we try 
to do when we do budget things.
  Nevertheless, it's still a big amount of money that will have to be 
added to this bill, and we didn't do it. We just simply didn't do it. 
The congressional Democrats told the Congressional Budget Office, don't 
score the SGR repeal in this bill.
  Now, the House will tell you that, Hey, we passed an SGR repeal last 
November, didn't get any Republican support. Oh, wait, they got one. 
Okay. It was me. But that bill was going nowhere and everybody in this 
House knew that was going nowhere. In fact, the Senate had previously 
rejected the same bill 10 days before. So that was another fig leaf.
  Oh, we're going to take care of the doctors. Let's pass this SGR 
repeal. And, Oh, the rascals in the Senate or the rascals on the 
Republican side wouldn't let this thing stand.
  But the fact of the matter is it hasn't been fixed. The fact of the 
matter is the Democrats are in charge. The fact of the matter is they 
need to tell us how they propose to deal with that. This kicking the 
can down the road--and we did it, too, when we were in power. But this 
kicking the can down the road is making the problem a lot worse, and it 
is really putting our seniors at risk of not being able to access 
physicians. Just look at the statistics out there.
  A company called Medicus that is a doctor search firm did a survey in 
December. And kind of depending upon how you ask the question, they 
said, If the Democrats' health care bill passes, will that affect your 
decision to retire or continue practicing medicine? If the public 
option was contained within the bill, almost 45 percent of physicians 
said they would consider retirement. That doesn't mean 45 percent of 
doctors will retire, but it meant nearly half of the doctors in this 
country would seriously look at it. Doctors who were near retirement 
age, about a quarter of them, about a quarter said, Seriously consider 
retiring early. Doctors who were nowhere near retirement age, about a 
fifth of those said, Yeah, I could see myself having to get out of 
this.
  Now, if you remove the public option from the equation, if you remove 
the public option, the number goes down, and it's about 30, 31, 32 
percent of doctors who would consider retiring early. A significant 
number of those who are already near retirement age, about 20 percent 
of doctors who were near retirement age would consider retiring early, 
even with the public option out of the Democrats' health care plan. And 
about 7 percent, 7 or 8 percent would if they were nowhere near 
retirement age. But still, that's a lot of doctors who are considering 
retiring if we pass one or two of these bills.
  Let's leave the public option question alone for just a minute. We 
need to come back to that later because that is a significant part of 
this, but amongst

[[Page 4542]]

the things that are in the bill that people may want to know about are 
these tax increases, are the Medicare cuts.
  Of course, one of the big fights here last night was would the bill 
contain what's called the Hyde amendment language that would prevent 
Federal funding for abortion. A lot of controversy ensued. The bottom 
line is the Senate-passed bill did not contain the Hyde amendment 
language. The Stupak language that passed in the House bill in November 
did, but that wasn't the bill we were debating. That wasn't the bill we 
were passing.
  Again, another fig leaf was trotted out in the form of an Executive 
order. But how many Executive orders did President Obama repeal on his 
first day of office, Executive orders that President Bush had had in 
place? It was a ton of them.
  Now, the President, to his credit, did say that he would not tear up 
the Executive order the first day after the bill is passed, but I don't 
recall if he made a promise about the second day or the third day or 
the fourth day.
  The fact of the matter remains that protection against using Federal 
funds for abortion, for paying for abortion is pretty tenuous right 
now, and that thread could be snapped at any time. And the fact is the 
American people just don't know at this point. And it's a shame, 
because we could have had that argument. We could have had a more solid 
amendment. But the fact of the matter is we didn't do that.
  Other things in the Senate-passed bill:
  The special deal for Nebraska, the Cornhusker kickback, it is in the 
Senate bill. It did pass. It's on its way down to the President for 
signature. Does that violate any constitutional principle like equal 
protection under the law? It might. It might. If the good, long-
suffering, taxpaying citizens of Texas now have to subsidize Medicaid 
in Nebraska, that might get some suspicion from the Supreme Court of 
violating the 14th Amendment, but we'll have to see.
  A special deal for Florida where their Medicare Advantage would not 
be cut in certain counties in southern Florida. Medicare Advantage 
cuts, as I pointed out to you, are going to be steep and significant in 
this bill, but the three counties in Florida will not sustain those 
cuts. Again, equal protection under the law. That may be a violation of 
the equal protection clause of the Constitution.
  In fact, my attorney general back home in Texas said the Federal 
health care legislation passed tonight violates the United States 
Constitution and unconstitutionally infringes upon Texans' individual 
liberties.

                              {time}  2140

  To protect all Texans' constitutional rights, preserve the 
constitutional framework intended by our Nation's Founders, defend our 
State from further infringement by the Federal Government, the State of 
Texas and other States will legally challenge the Federal health care 
legislation.
  So what looked like a Federal health care bill may in fact have 
represented a bill for full employment for lawyers in this country.
  There are some other bad provisions. There is a tax on the so-called 
Cadillac health insurance plans. Remember that was supposed to be fixed 
in the reconciliation bill, but the reconciliation bill is not the law 
of the land. The Senate bill is the law of the land and that Cadillac 
tax is in there. So for individuals with incomes under $250,000, 
they're going to get a significant tax if they have one of the high-end 
insurance policies. Clearly, that is a broken promise by the 
administration.
  Boy, construction firms. I mean, who did they irritate in the Senate? 
Construction firms were singled out for higher taxes. In the Senate 
language, the employer mandate only exists or a fine if you don't 
provide--if your employees have to access care under the exchanges with 
subsidies. The fines don't kick in until you have more than 50 
employees, but construction firms, there is a much smaller number. 
Single digits. If they're employed by a construction firm, they will 
have to pay an employer mandate or an employer fine.
  Now, here's one of the provisions that is really--I don't think 
people know about it. I'm not sure if they do know about it and they 
understand it, but this new board that has been created in the Senate 
bill. One of the ways that they attempted to deal with Medicare 
spending was to assemble this board, this board of commissars and 
commissioners who are going to set Medicare spending targets, and they 
will do that and they will set those targets. Yes, they have to come 
back and be voted on by Congress, but we just have to vote them up-or-
down. We can't amend them. We can't say, well, we're just going to plus 
them up a little bit and reduce this one down a bit. We've got to take 
the whole board of recommendation as a slate. It's an up-or-down vote 
here on the floor of the House.
  I will just tell you when Congress has to be the enforcers on these 
things, look what we've done with doctor payments over the years. We're 
supposed to reduce them, but we really didn't because we didn't want to 
face the wrath from doctors for seniors so we took the easy way out and 
gave them a 1-year stay on that. And the consequence on that is the tab 
continued to run on those doctor payments. So now it's as high as $20 
billion that--I am sorry, a 20-percent cut that will have to come out 
of doctor payments.
  We might do the same thing with this independent board, or we would 
lack the courage to vote on the cuts anyway if we didn't like the way 
they came down to us. Congress does have a history of doing that.
  Some other provisions of the bill double-counts some Social Security 
payroll tax revenues, double-counts the premiums collected for what was 
called the CLASS Act. That was one of the great bait-and-switch things 
that was included in this bill. We're going to provide long-term care 
insurance. You pay for that $50 a month and then you can get a benefit 
of $50 a day if you need to access long-term care insurance. Well, this 
actually scores as a savings because for the first several years it is 
in play, more premiums are collected than money is paid out. But guess 
what happens in the second half of, or the second 10 years of, these 
expenditures? Those payouts are going to exceed the premiums paid. And 
that is going to be an unmitigated disaster.
  And the real pernicious part of the CLASS Act--look, people my age, 
if they can afford it, they should buy long-term care insurance. Don't 
wait on the Federal Government to give it to you. Don't believe you're 
going to get it from Medicare for you. It's only for a short period of 
time. Yes, you can get long-term care under Medicaid, but you've got to 
spend yourself to near bankruptcy before you get any of that benefit.
  The sensible thing to do if you can afford the premium is to buy a 
long-term care policy.
  The CLASS Act is going to tell people, Hey, you don't have to worry 
about that. Pay your $50 a month for long-term care. You're covered. 
That's nonsense. The coverage is thin. It will not be there after a 
period of time because that program is going to pay way too much money 
after a few years. And the problem with long-term care insurance is the 
longer you wait to buy it, the higher the premiums are going to be. For 
people who are in their early fifties, it's something worthwhile to 
look into.
  But we're going to send a message to the next 10 years of Americans 
who are turning--Don't worry about it; We've got you covered with the 
CLASS Act. There is no coverage at all there. In fact, it is going to 
be an unmitigated disaster when people start trying to access that. 
Besides that, anyone who's paid for long-term care, anyone who's had a 
family member in a long-term care facility, does 50 bucks a day really 
take care of what you need in a long-term care facility? It's nowhere 
even close.
  The bill double-counts some of the Medicare cuts. So we get to count 
them once, and we get to count them a second time.
  Texas is really going to suffer under a reduction in disproportionate 
share funding. Drug makers will face an annual fee of $2.5 billion. But 
you know

[[Page 4543]]

what? That $2.5 billion is not doing to come out of the CEO salaries. 
It's going to come out of product sales. So that will be passed on to 
the consumer. So although they look like they're being all great and 
helping out the President and putting out $2.5 billion, this goes back 
to the Americans who buy their product.
  In 2011, this bill will limit flexible spending accounts to $2,500 
per year. Yeah, you'll still be able to have your FSA, but you will be 
limited on the amount you can put into it.
  Here's one that really most people are not aware of. There is a 
medical device manufacturers' fee which is again going to be passed on 
to the end user, the consumer, the patient, which is you. Continuing on 
the time line in 2011, there is a health insurance provider fee--$2 
billion in 2011, $4 billion in 2012, and then it goes up from there 
rather dramatically. Again, a tax on health insurance providers.
  Who do you think is going to pay that, the CEO of the big insurance 
company? Probably not. The guy that's buying the insurance? Probably. 
Again, I talked about this before. In 2013, the excise tax of 40 
percent will be imposed on the Cadillac plans. In 2013, new Medicare 
taxes on individuals earning more than $200,000 a year and couples 
making more than $250,000 a year, the Medicare tax on your withholding 
is going to rise to 2.35 percent. There is going to be a new 3.8 
percent tax. Starting in 2013, a new 3.8 percent tax on unearned 
income. Dividends, interest, capital gains. 2013, an excise tax of 2.9 
percent imposed on the sale of immediate medical devices.
  Now, not all medical devices--and we all heard the stories about the 
Band-Aids when the Senate was talking about this. There will not be a 
Band-Aid tax. This will be for so-called class 2 and 3 medical devices. 
Class 2 devices would be syringes, sutures, some testing that a doctor 
might do in their office. Some of those testing kits will be taxed at 
that 2.9 percent rate.
  Let me tell you something here. As a doctor, you don't get to pass 
that tax on to your patient because most of your patients that come in 
that are insured, you actually see them at a contractual rate. So 
whatever the code is, there is a contractual rate for that code and it 
doesn't include that 2.9 percent tax. And employers with more than 50 
employees must pay a fine of up to $3,000 if employees receive tax 
credits to purchase insurance.
  So billions of dollars are going to be spent to hire thousands of new 
IRS employees needed to collect the taxes. Yet three out of 10 doctors 
says if Congress goes against their will and the will of the American 
people and passes this bill, they may retire from practicing medicine. 
So that's what the people are going to get--more IRS agents, less 
doctors.
  Simple equation. How does that equal health care reform?
  Ideally, we would repeal the entire bill and start over with real 
reforms. It seems unlikely that's going to be able to happen. Really, 
Members on both sides of the aisle that were concerned about this bill 
last night need to work together to repeal the more egregious portions 
of this bill and ultimately work toward the repeal of the entire bill 
when the make-up of the Congress and the White House has sufficiently 
changed to allow that to happen.
  Let me talk a little bit again about the Senate-passed bill. We're 
not talking about the reconciliation bill. We're not talking about the 
House-passed bill. Remember the Senate-passed bill in December? There 
was a Senator from Connecticut who said, I cannot vote for a bill if 
it's got a public option in it.

                              {time}  2150

  Maybe it's because there are a lot of insurance companies in 
Connecticut, I don't know what the reasoning was, but that Senator was 
very firm that they would not have his vote, and they needed every vote 
they could to get to 60, so the public option was very reluctantly 
stripped out of the Senate bill. But is it really going? And the answer 
is it might not be.
  Now, you have heard that several States around the country are 
looking at, I believe it's up to 37, was the last count, are looking at 
either filing a constitutional challenge or somehow exempting their 
State from participating in this new Federal legislation, and that also 
means that they may not set up the State-based exchange that the bill, 
the Senate bill, calls for.
  Well, what happens in a State that doesn't set up an exchange? Is 
there not going to be any exchange, so there won't be any insurance in 
the exchange available to citizens of those States? You would think so, 
because States should ultimately have sovereignty, except that there is 
a little known Federal agency called the Office of Personnel Management 
that is going to be charged with setting up a State-based exchange or a 
national exchange that every State that doesn't have a State-based 
exchange, that their citizens can buy through this national exchange. 
And the Office of Personnel Management, in the language of the bill, is 
required to set up one insurance company, one for-profit insurance 
company, and one not-for-profit.
  Does this federally administered, national exchange, not-for-profit, 
insurance company begin to look a lot like the public option that was 
discussed in the Democrat's bill in the House? The answer is, of course 
it does.
  The Office of Personnel Management currently administers the Federal 
employee health benefits plan here for all Federal employees, not just 
in Congress, but all employees. So they are a relatively small agency. 
That's a big insurance plan, but still, as Federal agencies go, that's 
a relatively small agency.
  It is going to have to rapidly ramp up with a great number of new 
employees. Perhaps that's one of the ways we are going to deal with 
unemployment is to hire more people in the Federal Government. But the 
Office of Personnel Management will have to get considerably larger, 
and this Office of Personnel Management will now be the de facto public 
option as it administers the not-for-profit that's in the national 
exchange that is available to people who are in States that don't set 
up a State-based exchange.
  It is a public option by another name. Unfortunately, the Senator 
that sought to prevent that from happening did not see the way this was 
going to work out in their own Senate bill. So when I say the doctors 
who look at retiring from practice, if there is a public option in the 
bill, perhaps the more they get to understand that this public option 
is really in the bill, maybe they will rethink their willingness to 
continue to work within the system.
  Are there other ways to change this bill that we passed last night? 
Certainly, everyone ought to be treated equally under this bill, and 
they haven't been. Maybe that's one of the technical fixes we could 
work on so that there is no geographic disparity, there is no racial 
disparity. People, equals, ought to be treated equally, and that is one 
of the things that really we should work on.
  I think we should work on getting rid of the individual mandates and 
the employer mandates. Certainly we could encourage comprehensive 
coverage for seniors. Right now, look what we are doing to Medicare 
Advantage. Look what we are doing to putting the tax on the 
supplemental insurance.
  We really should, rather than discouraging seniors from having a 
Medicare Advantage plan or a supplemental plan, maybe we ought to 
encourage that. After all, the Medicare Advantage plans are doing what 
we asked them to do. We asked them for care, coordination, disease 
management, expanded health IT, expanded use of physician assistants, 
nurse practitioners, paraprofessionals.
  Medicare Advantage plans are performing those functions. They are 
just now getting to the point where they are really starting to see the 
cost savings that we all said would be there if they would do those 
things, and now we are going to take them away. Okay, never mind, we 
shouldn't have done it anyway, so sorry about that.
  Allow health insurance to be sold across State lines. We have talked 
about this a lot. If you want competition, don't have the Office of 
Personnel Management create a nonprofit that

[[Page 4544]]

everyone is going to compete with. That's only one other bit of 
competition. Let the 1,300 insurance companies that exist in this 
country, let them compete. Let them compete up on the Internet, let 
them compete across State lines.
  The portability of insurance, Congress attempted to address that back 
in 1996, arguably made kind of a mess of things. But if we would do 
things that would establish and create an enhanced portability of 
insurance, we would go a long way towards establishing a longitudinal 
relationship, a patient with their insurance company.
  If you go from job to job, you don't change insurance companies. You 
have your insurance company, and you can take it with you. Allow 
private insurance and alternatives to Medicaid and SCHIP, special 
health savings account for the chronically ill, health insurance plans 
to specialize in solving problems for the chronically ill.
  All of these things are out there and within our purview. These are 
all things we should undertake to fix the egregious problems that are 
in the Senate bill.

                          ____________________