[Congressional Record (Bound Edition), Volume 158 (2012), Part 9]
[House]
[Pages 12042-12047]
[From the U.S. Government Publishing Office, www.gpo.gov]




                           GOP DOCTORS CAUCUS

  The SPEAKER pro tempore. Under the Speaker's announced policy of 
January 5, 2011, the gentleman from Louisiana (Mr. Cassidy) is 
recognized for 55 minutes as the designee of the majority leader.
  Mr. CASSIDY. Mr. Speaker, an issue tonight that is much more 
important to the American people than many realize is Medicaid. Now, 
for folks who don't understand this, and you really had no need to 
until this health care debate began, but, if you will, there are three 
types of coverage for folks who have insurance. One is Medicare. 
Medicare is the program for folks who are typically 65 and above. It is 
the program that all of us pay into, having a certain amount deducted 
from our paycheck, and it goes into this account. The second is private 
insurance. Ninety percent of Americans have their private insurance 
policy through their employer. And then the last group is Medicaid.
  Now Medicaid is a program designed to support those of lower income 
as well as those who are elderly and, again, of lower income and long-
term care--think nursing homes. And lastly, it supports the blind and 
disabled. The financing in Medicaid comes from your tax dollars, but it 
can be your tax dollars either funneled through the Federal Government 
paying a portion to the State, which is matched by what is called the 
State match, which is from the State itself.
  So Medicaid is a program for lower income which receives about, on 
average, 57 percent of the money that goes towards it from the Federal 
Government and 43 percent on average from the State government. The 
State administers the program to take care of, again, low income for 
acute medical services, long-term care, think nursing homes for the 
elderly, and then the blind and disabled. Tonight's discussion will be 
about Medicaid.
  Now, the importance of Medicaid is that 16 percent of the health care 
dollar in the United States goes towards Medicaid. So almost a little 
bit over one-eighth of the money our country spends is on this combined 
Federal-State program that provides health insurance, if you will, for 
the poor.
  Additionally, Medicaid is important because right now Medicaid is 
consuming an ever larger portion of both the Federal Government's 
budget as well as the State government's budget. One example of this: 
the Simpson-Bowles bipartisan debt commission, which President Obama 
appointed to help give guidance as to how our country could get out of 
our indebtedness, pinpointed Medicaid as one of the drivers of our 
national debt. So first, we know that on a national level, Medicaid has 
been pinpointed as a driver of our national debt. On a State level, 
Medicaid is consuming an ever larger portion of State budgets.
  Now, there are many examples of the importance of this, but as 
Medicaid is costing more and more, State dollars for other programs are 
less and less. Senator Lamar Alexandria from Tennessee said that the 
reason that tuition is increasing at universities in Tennessee is 
because there is less public support. More tax dollars are going to 
Medicaid, and so therefore, to make up the budget for the universities 
in Tennessee, they have to increase tuition.
  One example of this, as well, for K-12 is that for the first time 
beginning around 2009, States spent more of their income upon Medicaid 
than on education. And so this is a chart from the National Association 
of State Budget Officers, and it shows how total State spending on 
Medicaid now surpasses K-12 education, and K-12 is kindergarten to 12th 
grade. So this is primary and secondary education. In this blue line 
you see funding for education, and you can see the percent of total 
State expenditures devoted to, in this case, education.
  So in 2008 it peaked at around 22 percent, and now in 2011, it has 
decreased down to roughly 20 percent. Here you can see that in 2008, 
Medicaid expenditures were about 20.7 percent of the State budget, and 
they are rapidly rising. They are now up to almost 24 percent.
  We are now spending more money providing Medicaid services for those 
who are eligible than we are educating our children. Now, it isn't as 
if this is something that is temporary, related to the recession; this 
is actually expected to continue to worsen. So Medicaid, again the 
program that both the Federal and State Governments--which means both 
taxpayers paying to the State and taxpayers paying to the Federal 
Government--finance, is growing so rapidly that it is cannibalizing the 
rest of the State budget.
  An example of this is that expenditures for primary and secondary 
education now for the first time in history are lower than those 
expenditures for Medicaid. And this is expected to worsen.
  So if you will, we have this program which is important. It's a 
safety net program. But under its current construction, it's costing 
more and more.
  Now I'm joined by a couple of my colleagues, and I will first go to 
Dr. Nan Hayworth, who is an ophthalmologist--she held up a note earlier 
that my eyes are not good enough to read--an ophthalmologist from New 
York, and she can discuss how President Obama's health care plan 
expands Medicaid, a program which is rapidly expanding in cost but 
nonetheless will be further expanded in terms of those who benefit.
  Ms. HAYWORTH. I thank our colleague, Dr. Cassidy, and I understand 
that your time may be slightly limited this evening, Doctor, so Dr. 
Harris and I will be more than happy to lead this discussion as we go 
along, and I thank you for all the work you do on this very important 
subject.
  The American public has much to be concerned about with regard to the 
massive 2010 health law, and this was, of course, passed on a party 
line basis, unfortunately. I and Dr. Harris are two of the 
representatives who were elected in part in response to the public's 
grave concerns about this act. And if I can direct everyone's attention 
to the chart that Dr. Cassidy has revealed next to him, you can see 
what is projected to happen in terms of Medicaid spending alone as the 
years go by and, of course, under the terms of the Affordable Care Act, 
it is like putting gasoline on a fire, unfortunately.

                              {time}  1910

  Mr. CASSIDY. Will the gentlelady yield?
  Ms. HAYWORTH. Yes, absolutely.
  Mr. CASSIDY. Federal and State Medicaid spending in billions of 2010 
dollars by 2009. It's down here, the year. So 1993, 2009, going out to 
2081. And so here is about $400 billion. This is combined Federal and 
State spending. By 2017, this rises to $750 billion. By 2025--obviously 
within our lifetime--that will rise close to $1 trillion. And 
projections are by 2081, it will be over $4.5 trillion.
  Ms. HAYWORTH. I'm going to imagine, Dr. Cassidy, that this chart does

[[Page 12043]]

not take into account--because it could be, indeed, very difficult to 
do so, but it has to enter the public mind when we think about these 
things. The enormous cost on the American public of the well-
intentioned, but poorly designed, 2010 health law will make our economy 
weaker. So it's fair to anticipate that there will be a further impetus 
to acceleration of Medicaid spending merely because of the imposition 
of that $2 trillion or more of Washington-generated cost due to the 
terms of the Affordable Care Act.
  So this is an issue that concerns every one of us, not only people 
who are truly in need and unable to sustain a job or their health 
care--and we've all met these fellow citizens. I have in my own 
district, the Hudson Valley of New York. These are people like the 
folks I met at Park, which is a center that provides for people who are 
severely disabled by developmental disabilities, such as autism, but 
not only autism. These are good people who, no matter how robust the 
economy is, will not be able to afford the kind of care that they need. 
And those are the people in particular who Medicaid was initially 
intended to help.
  Mr. CASSIDY. Will the gentlelady yield?
  Ms. HAYWORTH. Yes, sir, absolutely.
  Mr. CASSIDY. So just to emphasize, Medicaid is an important safety 
net program for those folks without means. It was traditionally 
designed to take care of the blind and the disabled, the elderly and 
long-term care, and then oftentimes focused upon pregnant women and 
upon children. So the importance of making sure the program is sound is 
that we continue to care for these people.
  Ms. HAYWORTH. Precisely. So we need to be able to provide for the 
people who are most in need. That is a reasonable role for government 
in a great Nation. But what we don't want to do, what we want to avoid 
is creating economic hardship that will push more Americans into this 
category. We see that phenomenon happening across our economy as we 
speak, and it's one of the reasons why so many States have said, we 
cannot possibly afford to expand our Medicaid programs.
  Indeed, Dr. Cassidy, you, being the good teacher that you are, 
provided me with an example from the State of Connecticut, with their 
recent experience in opening up their Medicaid program and opening up 
the enrollment because they had such a dramatic increase--I think it 
was something like 70 percent increase in the number of enrollees--that 
the State actually couldn't handle that increase in any way readily. So 
their services to all of their Medicaid recipients, unfortunately, of 
necessity, were compromised.
  Mr. CASSIDY. If the gentlelady will yield, I'd like to bring in Dr. 
Harris, who is an anesthesiologist from Maryland, the Eastern Shore.
  You just mentioned how Medicaid, as it attempts to expand and be all 
things to all people, becomes stressed and in that stress becomes less 
capable of being anything to anybody.
  Ms. HAYWORTH. Exactly.
  Mr. CASSIDY. So the concern regarding a program which becomes, again, 
too stretched, too unfocused is that it becomes ineffective at its 
original mission.
  Dr. Harris, I can leave this one or go to the next one.
  Mr. HARRIS. If the gentleman from Louisiana will just leave that one 
up so the American public that is watching just understands because a 
picture says a thousand words.
  That picture is the growth of Medicaid for the next generation. My 
son is 12 now. When he reaches age 65, he'll be at the right-hand side 
of that graph. And although none of us like to think of it, we all 
remember when we were 12, we never thought we would retire, but here we 
are nearing retirement age. So it's not that far off in the future.
  If I read that graph correctly, our current entire budget, in 2010 
dollars, is $3.5 trillion--our entire Federal budget, paying for 
everything. That graph indicates that by the time my child reaches 
retirement age, every penny of that budget would be taken up by 
Medicaid, every penny--not a single penny for Medicare; not a single 
penny left over for Social Security; not a single penny left over for 
interest on a debt that is now $16 trillion and growing; not a single 
penny left for defense; not a single penny left for Pell Grants; not a 
single penny left for anything.
  Mr. CASSIDY. I think the point being made is that not only will the 
safety net become tattered in and of itself, but, rather, even though 
tattered, it will destroy our ability to finance these other 
governmental functions.
  Mr. HARRIS. The gentleman is correct. Every single program that we 
have, whether it's the elderly with health care, the elderly with 
Social Security, whether it's food stamps, whether it's unemployment 
insurance, whether it's to do the things this government has to do, 
like pay the interest on an ever-growing debt, whether it's Pell 
Grants, whether it's K-12 education, which your last slide showed, 
every single program that we have is threatened by this one single 
program, a program that the President's Affordable Care Act ballooned 
out of control.
  Mr. CASSIDY. Reclaiming my time, if you could elaborate. We know that 
under the President's health care proposal, Medicaid--a program which 
right now is driving Federal indebtedness and which is threatening to 
bankrupt States, despite that was greatly expanded under the 
President's health care proposal to include people up to 133 percent of 
Federal poverty level. So I'll yield back to the gentleman if he will 
just comment if this is what he is referring to regarding expansion, 
and if so, any further thoughts he has.
  Mr. HARRIS. The gentleman is absolutely right. What we have done is 
we have once again made promises to people we know we can't keep. We 
know because that graph--and I'll yield to the gentleman to answer the 
question--that's from the Congressional Budget Office. That's a non-
partisan group that objectively looks at the effect of Federal laws and 
policies and projects the anticipated costs. Is that correct?
  Mr. CASSIDY. That is correct.
  Mr. HARRIS. So what we have here is we have a third party looking at 
what's going on and saying the emperor has no clothes; that, in fact, 
if we continue the current policy with Medicaid--which, as the 
gentleman well knows, roughly doubles the number of people eligible for 
the safety net program under the Affordable Care Act--we will not only 
bankrupt the Medicaid program, future generations will no longer have 
the ability to be confident that Social Security will be there when 
they retire, that Medicare will be there when they retire.
  The ratings agencies, whether it's Moody's, Standard and Poor's, all 
the various rating agencies will look at us and say: you don't have the 
ability to pay the interest back on your debt.
  We know when that bill was passed, we know what happened. We know the 
cornhusker kickback. We know what went on--the buying and selling of 
votes at the expense of future generations and the ability of the 
Federal Government to keep their promises to future generations--the 
promises of Medicare, Medicaid, again, Pell Grants, K-12 education.
  The gentleman showed a slide that showed a 3 percent increase in the 
cost--an average of 3 percent in the States' budgets--the cost of 
Medicaid over the past only 3 years before the President's health care 
bill kicks in. Well, as the President may know, 3 percent doesn't sound 
like much, but in Maryland that's a $1 billion increase. That's an 
increase we can't afford. That's an increase that means that property 
or income taxes would have to go up, further strangling our economy.
  As the gentleman fully recognizes, this is why the President's policy 
with regard to Medicare and the Affordable Care Act is poorly thought 
out, is going to bankrupt the Nation, and really ought to be repealed 
and rethought.

                              {time}  1920

  Mr. CASSIDY. Now, if the gentleman will yield, I'll go to Dr. 
DesJarlais who joined us, who although he has a French last name and 
you would think he is from Louisiana is actually from Tennessee.

[[Page 12044]]

  Now, Dr. DesJarlais, obviously, to you and me, but perhaps not to 
those who are listening, Tennessee experimented with using Medicaid as 
a safety net program back in the nineties and, if you will, extended it 
to many others. If I can yield to you, please, could you please comment 
as to the results of that.
  Mr. DesJARLAIS. I thank the gentleman for yielding.
  And you're absolutely right. I moved to start my practice in 
Tennessee in the fall of '93, and our program, TennCare, was 
implemented somewhat as an experiment in '94, January '94. So I 
witnessed it from its inception through what I would call its 
continuous failure.
  The program continued to grow and expand, continued, as I think you 
referenced earlier, as substantiated by Senator Lamar Alexander, has 
drained our State's educational resources. And it got so bad that, in 
2007, Governor Bredesen actually had to remove about 270,000 people 
from the program just to keep the State from going bankrupt.
  So clearly, it was an example of how the program and the system does 
not work and did not work. And that's maybe a glimpse of what we can 
expect to see moving forward with the President's health care law. So 
it failed to accomplish its objectives, and just as we would have 
suspected, the costs grew exponentially. And so we have a great example 
in Tennessee of how the system does not work. So clearly, we need 
alternative reforms.
  I would be happy to yield to the gentleman from Georgia, Dr. Broun.
  Mr. BROUN of Georgia. Thank you, Dr. DesJarlais. I appreciate your 
yielding.
  In fact, Medicaid is going to destroy the Federal budget and create a 
total economic collapse of America if we don't change it from the 
present system. That's before ObamaCare even takes place and markedly 
expands the States having to cover many more people, as my good friend 
from Maryland, Dr. Harris, was just explaining.
  But there are alternatives. Hopefully, we can repeal ObamaCare and 
replace it with something that makes sense. But there is a solution 
today. And, in fact, the Republican Study Committee, several us in the 
Republican Study Committee--Jim Jordan, our chairman, Todd Rokita, Tim 
Huelskamp, and I--introduced the State Health Flexibility Act, which 
would freeze Medicaid spending at the current level and will block 
grant those funds to the States with no strings attached. Not only for 
Medicaid, but also for the State Child Health Insurance Program. And 
what the States would do is utilize those funds in any manner that they 
want to. If they want to do drug testing on Medicaid or SCHIP 
recipients, they can. They can organize the program any way they want 
to, which is going to be the solution because it freezes spending at 
current levels.
  Mr. CASSIDY. If the gentleman will yield.
  Mr. BROUN of Georgia. Absolutely.
  Mr. CASSIDY. I'll say, just out of pride of authorship, there's 
another alternative, a Republican Medicaid proposal, one that I and 
others are sponsoring, and it does, if you will, similar to the block 
grant, it readjusts as your population changes.
  I'm from Louisiana. When Hurricane Katrina hit, we had lots of folks 
who moved to Atlanta and moved to Houston. If you will, the dollar 
would follow the patient. It wouldn't just stay in Louisiana. I love my 
State, and it would be nice to have the extra money. But it is more 
important that, where the patient is, have the money. It's a variation 
on the theme. But also part of it is that the State has flexibility, 
freeing them from the money-consuming regulations that the Federal 
Government puts on how those monies are applied.
  Mr. BROUN of Georgia. Absolutely. In fact, the State Health 
Flexibility Act does that same thing, and the only growth is due to 
population in any State, so it does account for that change in the 
population of any given State.
  But we have solutions. We have economically viable solutions that 
Republicans are submitting and, hopefully, we can get passed into law. 
But of course we've got to have a Senate that will even take up those 
kinds of bills, because the House has passed bill after bill after bill 
to create a stronger economy, to create jobs here in America, to lower 
the cost of gasoline, to develop all our energy resources.
  We've got these bills that will solve the problems for Medicaid. Even 
my Patient Option Act is across-the-board health care reform. It 
repeals ObamaCare and replaces it with policy that makes health care 
cheaper for everyone, provides coverage for all Americans, and will 
save Medicare from going broke. And you add that, with the State Health 
Flexibility Act, it covers everybody.
  We have solutions, but Harry Reid is an obstructionist. He's acting 
as a puppet for this President, and they throw in the trash can every 
bill we send over there.
  We've got to create jobs. We've got to create a stronger economy. We 
have solutions to the health care problem.
  All of us are physicians. All of us are physicians out here that are 
talking tonight. We've just been joined by one nonphysician, but she's 
been a strong supporter of the Doctors Caucus, and we've seen her here 
many times, Mrs. Lummis from Wyoming.
  But we have solutions. The American people need to understand, 
Republicans have solutions, and we need to have the ability to pass 
those solutions into law so that we can have policy that's not going to 
break the bank. We're going into an economic collapse of America if we 
don't stop this inanity.
  Mr. CASSIDY. I thank the gentleman.
  One thing I am struck by--and I'd like to bring Mrs. Lummis in--
oftentimes it is, when folks say, Wait a second, it's Medicaid and the 
government will pay for it, or the State should enroll because the 
Federal Government is going to pay so much more, and there's a sense 
that it is the government that is paying for it but not the taxpayer. 
Now, what we know is the government is nothing but an aggregator of our 
pocketbooks, and it will take that money and bequeath it.
  I asked Mrs. Lummis to come tonight because she is a former State 
treasurer in Wyoming and will discuss the impact this program is having 
upon State budgets and, therefore, other State services.
  Mr. BROUN of Georgia. Before you go to Mrs. Lummis, I'd like to 
reclaim my time and just say this: Our State of Georgia is struggling. 
We have a balanced budget amendment to our State constitution. We're 
having a difficult time dealing with the extra cost, not only of 
Medicaid, but all these government mandates that are foisted upon our 
State from the Federal Government.
  It has to stop. And the only way we're going to stop it is for we, 
the people, across this country to demand a different kind of 
governance from their Senators and Congressmen, and particularly from 
the President of the United States.
  Mr. CASSIDY. Thank you, Dr. Broun.
  Mr. Speaker, I yield back the balance of my time.
  The SPEAKER pro tempore. Under the Speaker's announced policy of 
January 5, 2011, the gentleman from Maryland (Mr. Harris) is recognized 
for 28 minutes as the designee of the majority leader.
  Mr. HARRIS. Thank you very much, Mr. Speaker, and I will yield to the 
gentlelady from Wyoming.
  Mrs. LUMMIS. I thank the gentleman for inviting me to participate, 
although a non-physician, the only non-physician here.
  I thank Dr. Harris, and I want to thank Dr. Cassidy. I have seen Dr. 
Cassidy in the cloakroom talking on the phone, pro bono, to patients 
that he used to serve in Louisiana, and I have seen other members of 
our Doctors Caucus do the same thing.
  These are people who care about their patients. And even though 
they're here, working for the people of the United States and their 
district, and not compensated financially, they are still here caring 
about their patients, working without compensation,

[[Page 12045]]

pro bono, to help people that they used to serve, to make sure their 
lives are better and their health care is better.

                              {time}  1930

  So I want to compliment the physicians in this conference who have 
made such a difference to my life and to other people's health care 
lives, and I want to thank them for serving in Congress. They make a 
huge difference in the dialogue, the debate, the nurturing, the care, 
the tenderness, and in what we all experience because of their training 
and because of their love of the people of this country and the manner 
in which they serve their patients.
  Mr. Speaker, I was the State treasurer of my State. I have seen 
Medicaid and other programs soak up the compensation that taxpayers in 
every State provide through taxes to their States, preventing States 
from being able to allocate more money to education and other State-
based functions, and Medicaid is definitely one of them. In addition, 
States care for their working poor. States want to see their low-
income, Medicaid-eligible people have access to high-quality health 
care and support the Medicaid program but to not support it in a way 
that requires these rigid handcuffs on States in a one-size-fits-all 
program that prevents States from innovating and from providing quality 
care to their people.
  Case in point: My State of Wyoming has the smallest population in the 
Nation. As a consequence, we have the opportunity to study things that 
other States cannot study because their populations are so large. My 
State of Wyoming, through its own health care commission, studied every 
single Medicaid-eligible child under the age of 18. It determined that 
it would be over 2\1/2\ times cheaper to buy each one of those children 
a standard Blue Cross-Blue Shield policy than it would be to provide 
health care through Medicaid.
  These are the kinds of things that States are studying, that they are 
learning, that they are innovating. Furthermore, there are places in 
the country that are dealing with different health care problems than 
other places in the country.
  Case in point: The Rocky Mountain West has a much higher incidence of 
multiple sclerosis than has other parts of the United States. No one 
knows why, but it's a fact. So Wyoming and other Rocky Mountain States 
should be able to concentrate on MS. Other States, perhaps Southern 
States, may have more problems with diabetes.
  I recently was in Saudi Arabia. There is a tremendous diabetes 
problem there. They are spending tremendous amounts of money at their 
brand new higher education university, at which they partner with 
businesses, in order to study diabetes in a way that will help the 
great number and growing number of people who are affected by diabetes.
  These should be things that regions of our country are allowed to 
work together on and to create programs for in order to innovate and to 
be the great incubators of innovation that States are. So that's why I 
do want to compliment the U.S. Supreme Court in the portion of the 
decision on ObamaCare that provided that States do not have to be held 
hostage under the ObamaCare law, that they do not have to expand beyond 
the original intent of the Medicaid-eligible population to accommodate 
its expansion under the ObamaCare law. They can still concentrate, if 
they choose, on the Medicaid-eligible population as it exists today and 
can continue to provide quality Medicaid to low-income, eligible 
constituents within their States.
  That doesn't mean they should be under the same constraints they are 
under now to provide Medicaid to their populations--because of the 
variance and the kinds of diseases that are cropping up in different 
parts of the country and because of the different innovations that 
States are able to use if they are not constrained by the shackles of 
the Federal one size fits all.
  I want to thank the physicians in our conference for continuing to 
raise these issues, to discuss these issues. You discuss them to the 
benefit of those of us who are not physicians who serve with you in 
Congress. You discuss these issues to the benefit of the people to whom 
you provide health care in this Nation, and you do it as a service to 
the people of this country. I thank all of the physicians who are here 
tonight to discuss this issue.
  Mr. HARRIS. Thank you very much to the gentlelady from Wyoming for 
bringing up that point about what Medicaid does to State governments 
and about what the potential is to State governments and all the other 
programs that they have to fund.
  I will tell you that, with regard to what happens, what we know is 
that access under the Medicaid program is already suffering, the access 
of patients. Again, passing the Affordable Care Act puts an insurance 
card--a Medicaid card--in the hands of probably 10 to 12 million 
Americans, but that doesn't guarantee access to health care.
  As a physician, I've taken care of Medicaid patients for almost 30 
years, but increasingly what I'm finding is my colleagues who are 
facing decreased payment reimbursements by the governments that are 
under financial hardship now. Even under current conditions, as this 
chart will show, there are very few States in the Union that actually 
have extra money around to fund that Medicaid increase. This chart 
shows various specialties and how Medicaid patients have access to 
them.
  Under the current reimbursement, which of course will get nothing but 
worse for specialists under the new Affordable Care Act, among all 
specialists, 89 percent of patients with private insurance have access 
to all specialists and only 34 percent of medical assistance patients, 
or Medicaid patients. That's true whether it's orthopedics, psychiatry, 
asthma, neurology, endocrinology, ear, nose and throat, or dermatology. 
In all cases, access to a physician is restricted because, when a 
government controls the health care budget, the way it contains costs 
is by decreasing reimbursements to providers.
  Those are the facts. That's what happens. That's what's going to 
happen under Medicaid. We know, with the Independent Payment Advisory 
Board, that that's what's going to happen under Medicare.
  I yield to the physician from Tennessee.
  Mr. DesJARLAIS. Thank you for yielding.
  I just want to expound on your comments and on, actually, what the 
gentlelady from Wyoming talked about in terms of the efficiency in her 
study, where they could actually buy a policy for those cheaper than 
what the Federal Government has implemented.
  We were promised better access to care at a lower cost with the 
Affordable Care Act, and the TennCare program in Tennessee really was 
an experiment of nationalized health care confined to one State. What 
we found was that more and more physicians, as you stated, were 
dropping out of the TennCare program because of reimbursement issues 
and also because of the bureaucracy and the frustration with trying to 
find specialists.
  I had a primary care practice, and I actually had to hire an extra 
staff member, which drove up my costs, to sit after hours to try to 
find specialists to take care of these patients. It was very 
frustrating for us. It was very frustrating for them. Yet the 
reimbursement, compared to a privately paid patient versus a Medicare 
patient versus a TennCare patient, continually was less money.
  Mr. HARRIS. So what you're saying is that you had patients under 
TennCare who had insurance cards. You just couldn't find anyone to take 
care of them.
  Mr. DesJARLAIS. Right, which is exactly what we're going to see under 
the President's plan. You're going to see people who allegedly now have 
access to care, but they really don't because the reimbursement rates 
are so low that physicians really aren't even able to keep their doors 
open. The reimbursement rate for a TennCare patient in Tennessee was 
almost half of that from a private patient. It's not that physicians 
don't want to help and take care of these people. They do. It's just 
financially unfeasible, especially in solo practices, which are common 
in rural areas.

[[Page 12046]]


  Mr. HARRIS. You may or may not be aware of the study done early last 
year that showed that, actually, whether patients have private 
insurance or no insurance or Medicare or Medicaid, when you compare the 
outcomes, Medicaid patients have the worst outcomes. In fact, they are 
93 percent more likely to die of their illnesses than patients with 
private insurance. They were more likely to die than even patients who 
had no insurance. I don't know. Is the gentleman aware of that finding?
  Mr. DesJARLAIS. I have heard of that study as well. Again, I think it 
is an access to care issue, and that's certainly a problem that has not 
been addressed.
  The ObamaCare law does nothing to address access to care, and it does 
nothing to address the cost of health care. Frankly, we all know that 
the cost of health care is driving our national debt, so we need to 
look at solutions that have been offered by the Republican caucus and 
the Doctors Caucus that will make real reforms to health care: that 
will make it more affordable and involve a greater attempt to get 
government out of the way. Just like in small businesses, the number 
one complaint is that government bureaucracy is driving down the 
profitability. It remains the same in health care as well, and we need 
to look at more free market options in health care if we're going to 
actually reduce costs.

                              {time}  1940

  Mr. HARRIS. I thank the gentleman.
  I would love to bring the gentleman from Texas into the discussion, 
because women actually are specifically affected by the shortfalls in 
Medicaid because the reimbursement rates for women's health care is 
frequently so low that it's actually hard to find an obstetrician to 
take care of those patients. I know in Maryland this is a problem we 
had.
  In the First Congressional District on the eastern shore of Maryland 
for a while, before we did Medicaid payment reform, women who were 
pregnant in that part of the State had to drive 3 hours to find an 
obstetrician to take care of them because the reimbursements were so 
low. And we know the Affordable Care Act does nothing for medical 
liability.
  We also know, for instance, that we have a cesarean section rate that 
is 35 percent now, the result of medical liability. We have 
obstetricians who have left the practice later in their careers of 
obstetrics and gravitate toward just doing gynecology where they join 
frequently large group practices. So we've left the practice of 
obstetrics to be an impersonal practice with people who generally don't 
have as much experience as those who have left the practice. And 
because of the lack of liability reform, we have a cesarean section 
rate that has roughly doubled over my career in dealing with obstetrics 
and obstetric anesthesiology.
  I would like to hear the gentleman's comments on medical assistance 
and what it's doing for this country and for the women's health care in 
this Nation.
  Mr. BURGESS. I thank the gentleman for yielding.
  Of course the doctor from Maryland makes an excellent point about 
having an insurance card--in this case, a Medicare card--that it does 
not necessarily guarantee access to care. I would see it literally 
every month in my practice. Being an obstetrician, if I'm called by the 
emergency room doctor to attend to a patient who is pregnant, under 
EMTALA laws I have got 30 minutes to show up or I get fined $50,000, so 
I would always show up.
  The difficulty is that, although she was pregnant, sometimes the 
problem that brought her to the emergency room was something unrelated 
to pregnancy, such as a heart murmur, tonsillitis, you name it. I may 
not be the best person to take care of that particular condition, but, 
just as the doctor from Tennessee pointed out, it was almost impossible 
to find someone in a specialty practice who would agree to see that 
patient. Oftentimes, you would find yourself admitting a patient who 
might otherwise not require admission but simply so that you could get 
them the specialist care that they needed. It's a very inefficient and 
very expensive way to go about getting that care.
  Mr. HARRIS. If the gentleman would just yield for a very brief 
question.
  Do you think that's the kind of health care that the women of America 
deserve?
  Mr. BURGESS. Look, it doesn't have to be this way. That's what's so 
disappointing about every aspect of the Affordable Care Act.
  I don't want to get too far into it, but we know now that this law 
was written by special interest groups, secret deals down closeted in 
the White House, Senate-constructed deals on Christmas Eve before a 
snowstorm to get out of town. This was constructed under the worst of 
possible circumstances. Should it be any surprise to us that the darn 
thing, regardless of how you feel about everything else, it's just not 
going to work? And yes, as the gentleman pointed out, the difficulties 
in obstetric care is just one aspect of that.
  If I could, I would like to bring up the point that I was in the 
Supreme Court the day the oral argument was heard on the individual 
mandate. I heard the Solicitor General make his argument that the cost 
of health care is going up because we have people showing up in the 
emergency room without insurance and everybody needs to be compelled to 
buy insurance and, by golly, that will fix our problem.
  Wait a minute. That ain't going to fix your problem because we know, 
in the State of Texas, only 31 percent of doctors will see a Medicaid 
patient. As a consequence, if you expand your numbers of Medicaid 
patients and you don't have the doctors there to see them, what are 
they to do? They've got this card in their hand, and they go to the 
emergency room to get the most expensive care.
  I wanted to bring this up because in the Austin American-Statesman 
this weekend, Dr. Tom Suehs, the executive director of the State 
Department of Health--or the Executive Commissioner of the Texas Health 
and Human Services had an op-ed in the Austin American-Statesman. I 
just want to read the first two paragraphs of his piece:

       Do you know how much a Medicaid client pays for an 
     emergency room visit? How about if the visit isn't an 
     emergency? The answer to both questions is the same: nothing. 
     Not one dime.
       The Texas Medicaid program paid $467 million for almost 2.5 
     million emergency visits in 2009, and half of those visits 
     weren't even for emergencies. Yet Federal law makes it 
     virtually impossible for States to charge even small copays 
     to discourage unnecessary emergency room utilization by 
     Medicaid clients.

  I think Dr. Suehs has hit the nail on the head here. We have to 
provide the flexibility back to our States.
  But it also belies the question: Who thought of taking a safety net 
program for blind and disabled nursing home residents, pregnant women, 
and children and then expanding that to cover 15 million more 
Americans? That wasn't the way to go about this. There were better 
ideas out there. For whatever reason, the Obama administration chose 
not to listen, not to solicit those ideas, and now we have the 
situation as it exists today.
  With that, I thank the gentleman for yielding. I thank him for 
allowing me to participate in this hour. This is an important subject, 
one that is not going to go away, and we're going to be talking about 
it a lot for the next several months and the next several years.
  Mr. HARRIS. I thank the gentleman from Texas.
  Again, we have on the floor with us now two obstetricians and an 
obstetric anesthesiologist. If women are ready for childbirth, we're 
ready on the floor of the House tonight.
  The gentleman makes a great point that in the end, having an 
insurance card doesn't guarantee access and having an insurance card 
doesn't guarantee affordable care. As we know, what the Affordable Care 
Act did is to again pretend that, really, economics don't exist, to 
pretend that the laws of mathematics don't count; that we can expand 
this program, as the gentleman pointed out, a program that was meant to 
be a safety net for the poor elderly, for women, for children, and we 
expanded it well beyond that to the point

[[Page 12047]]

where, as we brought up earlier in the hour, if gone unchecked, it will 
bankrupt everything else in government.
  The time has come, as the gentleman has pointed out, for us to 
reconsider whether that Affordable Care Act was the right approach.
  We know that just today the Congressional Budget Office has rescored 
the President's Affordable Care Act and has said that, as a result of 
the Supreme Court decision--because one of the goals was to insure as 
many Americans as possible--that an additional 3 to 4 million 
individuals will not be insured as a result of the Supreme Court, 
because the States will make a rational decision that they can't afford 
to let their budgets go bankrupt through this Federal Government-
mandated expansion that does nothing to control costs. It does nothing, 
really, to increase access, other than putting a card in someone's 
hand.
  And as the graph shows, that card doesn't help all the people who are 
in these pink bars. They're the ones with the Medicaid card currently, 
and their chance of seeing a specialist is somewhere between 17 percent 
and 57 percent because the government payment is so low and because 
these programs are so expensive and never adequately budgeted for, just 
as in the case of the Affordable Care Act.
  Now, we're joined this evening by my colleague from Georgia (Mr. 
Gingrey), who is also an obstetrician, who has spent years taking care 
of patients and understands what it will take to fix the health care 
system in the United States. I'm very interested to hear your 
perspective, Dr. Gingrey, on the topic we're discussing tonight, 
Medicaid and its expansion under the Affordable Care Act.
  Mr. GINGREY of Georgia. Mr. Speaker, I thank the gentleman from 
Maryland, my physician colleague, for yielding.
  I missed some of the hour. I regret that, and hopefully I'm not 
repeating some remarks that have already been made. Even if I am, I 
think it's important for people to understand that Medicaid expansion 
is threatening each and every one of our 50 States and the territories.
  The provision in the Affordable Care Act, ObamaCare, that's titled, 
``Maintenance of Effort''--actually, this maintenance of effort 
provision, Mr. Speaker, began even before the passage of ObamaCare. 
ObamaCare passed March 23, 2010, a little more than 2 years ago. It 
just extended this.
  But what happened with the stimulus package back in 2008 is that 
States were told that they would not be allowed to purge their rolls of 
people that were, at that point in time, under Medicaid to see if, per 
chance, they were in this country illegally and not eligible or their 
income level had risen to the point that they were doing just fine, 
thank you, maybe making $50,000 a year and could afford their own 
health insurance premiums not to be paid for by we, the taxpayer and 
the citizens of the State of Georgia, my great State. And then it was 
extended with the passage of ObamaCare to say that, through the year 
2013, these States could not do that.

                              {time}  1950

  Well, what's happened is, I've got some statistics. And just to quote 
from the National Governors' Association report, ``States are facing a 
collective $175 billion budget shortfall through 2013'' in large part 
because of this maintenance of effort requirement under Medicaid, that 
they're not allowed to make sure that the people on the Medicaid 
program are the ones that need to be there, the most needy that can't 
afford--their children can't afford health care. And now these rolls 
are sort of set in stone until the year 2013. And in many cases, Mr. 
Speaker, they include childless adults, childless adults who maybe were 
eligible to get on the program at a point where their income was very 
low or maybe they were out of work. But now, shouldn't the Governors be 
allowed--at least on an annual basis, if not every 6 months--to look at 
those rolls and make sure that the dollars for health care are going to 
the folks that really need it and their children? That's what the 
Medicaid program was all about when it was started as an amendment to 
the Social Security Act back in 1965.
  So I wanted to mention that. It may have already been talked about 
earlier. My colleagues in the Doctors Caucus of the House know of what 
they speak with regard to health care. There are a lot of other issues 
in Medicaid. But I thought, in particular, I would want to discuss 
that.
  But in conclusion, on this point, if allowing a State to improve its 
enrollment and its verification system saves enough money to keep our 
children's education program intact and the safety of its citizens, 
with regard to police and fire protection, intact, then why wouldn't we 
support this change? Why wouldn't we repeal this maintenance of effort?
  If giving Governors the ability to manage their own Medicaid programs 
prevents drastic cuts to education or job creation programs, why in the 
world would we not support that? The only reason I can think of would 
be to force, under ObamaCare, more and more people into the Medicaid 
program, where the States have to eventually do that FMAP and that 
sharing of the cost because, otherwise, they would be in the exchanges, 
and the subsidies, as we know, go up to 400 percent of the Federal 
poverty level. It's all part of this grand scheme to eventually have 
national health insurance, Medicare for all, if you will, and it's got 
to stop.
  Mr. HARRIS. I thank my colleague, the obstetrician from Georgia, who 
points out that on the graph, as the gentleman from Louisiana showed 
before, Medicaid expenditures now exceed K-12 education. And as the 
other chart we've seen shows, we're over at the left-hand side. It will 
only get worse over time.
  I yield to the obstetrician from Texas.
  Mr. BURGESS. I thank the gentleman for yielding.
  I wanted to make one point on this new Congressional Budget Office 
score that was provided today. And I know some people are looking at 
that and saying the cost for the program, for the Affordable Care Act 
over the next 10 years, was only scored I think at $1.16 trillion--if I 
can use the words ``only'' and ``trillion'' together in a sentence.
  But what many people overlook is that the Congressional Budget Office 
must score under existing law. And one of the things that existing law 
does is it cuts physician reimbursement in Medicare by 35 percent on 
December 31 of this year. So add another $300 billion to $400 billion 
to that cost just for the so-called sustainable growth rate formula, 
which has not yet been repealed.
  Now we will fix that before the end of the year for at least 1 more 
year. But the Congressional Budget Office has no way of scoring that. 
They must go with existing law.
  And, of course, with the Independent Payment Advisory Board, the same 
thing applies. They have to think that those cuts that the Independent 
Payment Advisory Board is programmed to produce, that they are going to 
continue occur.
  The other thing the Congressional Budget Office cannot easily 
estimate is the number of people who will be moved off employer-
sponsored insurance onto the State exchanges or the Federal exchange. 
And that is a difficult number to know. The MacKenzie Corporation said 
it was going to be 30 percent. The Deloitte corporation has said 10 
percent. We don't know what that number is. CBO is scoring that at a 
very low 1 to 2 percent because historically, that is the average of 
the erosion of employer-sponsored insurance.
  Those points are important to remember in looking at these figures.
  Mr. HARRIS. I thank my colleagues for their participation, and I 
yield back the balance of my time.

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