[Congressional Record (Bound Edition), Volume 159 (2013), Part 13]
[Senate]
[Pages 19330-19334]
[From the U.S. Government Publishing Office, www.gpo.gov]




                          AFFORDABLE CARE ACT

  Mr. WHITEHOUSE. Mr. President, I wish to engage for perhaps the next 
20 or so minutes with Senator Cantwell, who is arriving shortly. I will 
begin with some remarks and ask unanimous consent for us to engage in a 
colloquy.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. WHITEHOUSE. I am here today to talk about the health care problem 
in the country, because I think the fixation of this body on the health 
care Web site has taken our eye off the fact we have a very significant 
and fundamental health care problem.
  This graph represents how much we spend on health care as a country. 
It begins back here in 1960. I was 5 years old in 1960. So this is a 
lifetime: 50-some years, $27.4 billion. That is what we spent on health 
care. Now here we are. This is up to 2011, and $2.7 trillion is what we 
spend on health care. It is 100 times as much in 50 years. Granted, 
there are more Americans but not 100 times as many.
  This has been an explosive cost growth curve. When we were trying to 
pass the health care bill, that is what we were looking at for costs. 
It is a big competitive problem for our country.
  This is a really interesting graph. I wish every time anybody talked 
about health care they would take 1 minute and look at this graph. I 
will explain briefly what it is.
  This column is the up access and measures life expectancy in years, 
country by country, 65 to 85, where countries fall in terms of their 
average life expectancy for their population, for their citizens. This 
along the bottom is the cost, the health spending per capita per person 
in that country. So if you measure it all out, what you see is a great 
raft of countries all through here: Japan, Great Britain, Netherlands, 
Switzerland, Norway, Italy, Greece. There is a whole large group of 
countries right here, and all of them have a life expectancy 80 or 
older and they all spend between $6,000 and $2,000 per person on their 
country's health care. Essentially the entire modernized, civilized 
world is in that zone, from here to here.
  Guess where the United States of America is. Boom. Here. We are below 
them all in life expectancy. We are trailing the pack of modern 
industrialized nations in our life expectancy. We are competing with 
Chile and the Czech Republic. But Japan, Greece, Great Britain, France, 
Germany, Luxembourg, all manage with their health care systems to 
achieve longer lifespans for their people. And we are doing it at a 
cost of about $8,500 per person per year.
  To give a comparison, here are Switzerland and Norway. They are the 
other two most expensive countries in the world per capita on health 
care spending, and they are at about $5,700 per year. If we could bring 
our per capita health care spending in this country down to the most 
expensive countries in the world, if we could compete head to head with 
the most expensive countries in the world, we would save more than $1 
trillion a year.
  This is an interesting graph because it shows basically all the 
modern industrialized nations here, and it shows us here as a way 
outlier. It is a big deal for us to be an outlier here, because it 
means we blow about $1 trillion a year in wasteful and unnecessary 
health care which could be building infrastructure, solving problems, 
reducing the deficit, and could be doing other work. Instead, we spend 
it on a health care system which doesn't produce good health care 
results--at least not measured by life expectancy, which is a pretty 
good proxy.
  There is a huge $1 trillion a year cost to our society in being that 
bad of an outlier. The cost is also measured in lost lives and lost 
years of life, because we are averaging 77 years and these countries 
are averaging 82 years of life.
  We have a real problem on our hands, and obsessing about a Web site 
is a complete distraction from getting after this problem--5 years off 
every human's life in this country and $1 trillion a year. That is 
worth paying attention to.
  The health care changes we brought are actually making a difference. 
Here are some interesting graphs. Each one is a projection done by the 
nonpartisan Congressional Budget Office of what health care costs are 
going to look like in the future, and what you see is a progression. 
They did this graph in August of 2010. This was where they projected 
health care spending would go when they projected in August of 2010 for 
this period, from 2014 onward to the next decade. A year later they 
went back and they projected again, and they projected actually costs 
would be lower. Then they came back in August of 2012 and they did 
another projection, and their projection showed that these anticipated 
costs went down again, every year, lower and lower.
  Here is the big one. In May of this year, the Congressional Budget 
Office went back and redid its projections for Medicare and Medicaid 
spending from

[[Page 19331]]

2014 to 2023. Look how far below what they had projected 1 year ago, 2 
years ago, and 3 years ago the current projection. That is a saving of 
about $1.2 trillion in that decade.
  That is a long way from $1 trillion a year we could be saving if we 
just got back to where we were on this graph, if we got back from here 
to where Switzerland and Norway, the most expensive countries in the 
world, are. That is $1 trillion over 1 year. This is $1.2 trillion over 
10 years, but it is still a big change and it is still moving in the 
right direction. So we shouldn't be too quick to condemn ObamaCare when 
that kind of savings is already being projected.
  The last slide I will show before I go to Senator Cantwell, who has 
been good enough to join us, is this one. Why might it be that those 
costs went down so far in May of 2013? Why might it be that graph of 
projected costs keeps going down? It is because of changes in what is 
going on in the health care system.
  This is one good example. This shows the hospital readmission rate 
from January of 2007 until August of 2013. This is how often somebody 
was discharged from the hospital, went home, and then within 30 days 
had to come back and be readmitted.
  That could potentially be for a completely new reason, but usually it 
is because the discharge planning wasn't done well enough and there was 
a bad handoff between the hospital and the primary care physician or 
the nursing home. What we found is you could make that transition much 
better for patients. When you do, guess what. They don't get sent back 
to the hospital. When they don't get sent back to the hospital, you 
save money.
  That is just one way the kind of huge $1.2 trillion over 10-year 
savings CBO has already projected could be taking place, but this is 
clearly a part of it. It is improving the quality of care so people 
aren't going back into the hospital, aren't going to the emergency 
room, and you avoid that cost at all by having handled the patient 
better, by having given them better treatment and better care.
  It is pretty astounding. In 2007, right through here until the end of 
2011, it was a pretty steady readmission rate. Then when we changed the 
signal to the hospitals and cut their payment for readmissions, boom, 
down it fell. That represents a very significant savings in the system. 
And in the personal lives of those people and their families not having 
to go back to the hospital, that is a pretty big plus too.
  It was Senator Cantwell's idea that we should come down today and 
talk a little bit about the delivery system reform side of the health 
care discussion. I got started a little bit before she could get here, 
but my wonderful colleague now has arrived, so let me yield the floor 
to her. I will put this graph back because I want to leave this here 
for whenever the camera swings my way. I want people to see this graph. 
It is inexcusable that all of these competitive industrialized nations 
of ours should be able to deliver universal high-quality health care 
for what would be a $1 trillion a year savings if we could simply match 
them, and they produce a longer life expectancy for their people and we 
are stuck competing for life expectancy with Chile and the Czech 
Republic. Come on. We can do a lot better than that, and that should be 
the ball we have our eye on rather than obsessing about the ObamaCare 
Web site.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Washington.
  Ms. CANTWELL. Mr. President, I come to the floor to join my colleague 
from Rhode Island. I applaud him for his diligence, making sure this 
debate happened today, and for his leadership on this issue. It might 
sound kind of wonky to say there is a group of Senators that have a 
caucus called the Delivery System Reform Caucus, but we wear that 
banner with pride because we know that there are savings in our health 
care delivery system. We want to make sure that they are delivered for 
the American people.
  While some want to talk about cutting people off of service or 
raising certain ages, we are focused on the fact that there are 
hundreds of billions of dollars of savings in the delivery system and 
that it is our job to improve upon them. I like to say to my office 
team: There is a reason why Ma Bell doesn't exist anymore. The 
challenge is I have so many young people, and some of them don't 
remember Ma Bell. But the issue is the delivery system for 
telecommunications changed, and look at what it unleashed--a lot of 
great technology.
  Yes, change, but with ways to drive down costs and deliver better 
access. That is what we are talking about here with the health care 
system. My colleague from Rhode Island has had a group for more than a 
year that has been talking about these delivery system reforms. We are 
going to come out on a more frequent basis and try to have a dialog 
with our colleagues about why it is so important.
  We have taken a small but very important step led by our senior 
Senator from Washington Senator Murray on the budget. But there is so 
much more we can do if we can include these delivery system reforms. So 
I thank Senator Whitehouse, the Senator from Rhode Island, for his 
leadership.
  I want to talk about one area today, the area of long-term care 
services. I authored a provision in the Affordable Care Act called the 
Balancing Incentive Payments Program. While that sounds in and of 
itself like a wonky title, Balancing Incentive Payments Program, this 
program is really there to promote home and community-based care over 
nursing home care. If you ask any senior they will say of course they 
would like to receive health care services in their home or in their 
community. No, they do not want to go to a nursing home. But the 
discussion has been limited on how much cheaper it is and how much 
better the care could be for delivery in the home as opposed to nursing 
home care.
  According to a survey by AARP, over 90 percent of seniors age 50 or 
over desire to remain in their home as long as possible. We know that 
home and community-based care is 70 percent cheaper than nursing home 
care--70 percent cheaper. So for us in Washington State we thought 
about this long ago, and we decided that we were going to implement a 
system to reform our State and put more community-based care in our 
State and pull Medicaid patients away from nursing home care. We did 
that. We successfully made that transition. This chart shows you what I 
was just referring to, that home-based care can be as little as $1,200 
a person versus the same person getting care in an institutional 
facility at $6,000.
  We made the transition in Washington State to be predominantly a home 
and community-based care State. We did that with our own State dollars, 
our own program, and it was a transition that took place over many 
years. We are kind of the antithesis of what the Federal system is. It 
is still more weighted on a State by State basis towards nursing home 
care. That means people are going into nursing home care, and we are 
footing the bill for more expensive care at $6,000 per person when we 
could have services in the community that would allow them to stay in 
their home and get more efficient care. So in 2009, the long-term care 
budget overall for Medicaid accounted for 32 percent of the Medicaid 
expenditures or $360 billion a year. You can see that this is a very 
expensive area for us at the Federal level. If we could do anything to 
help change those numbers, we would be delivering an improvement to the 
system.
  When we first made this transition from 1995 to 2008, the State of 
Washington saved $243 million from this investment. But more important, 
even, than the money--in an article in 2010, the Spokesman Review in 
Spokane ran a story called ``Dying to live at home,'' the family of 
Nancy and Paul Dunham, a couple of more than 60 years, said they wanted 
to age at home. Because of the Medicaid funding for in-home services, 
they were able to stay. Mr. Dunham was able to stay in his home until 
the age of 83.
  I am sure many of my colleagues know people who are getting on in 
years who prefer to stay at home. But the Balancing Incentives Program,

[[Page 19332]]

which was in the Affordable Care Act, was the first Federal effort that 
we had that tried to assist States to move away from nursing home care 
and move towards community-based care. We put some incentives in the 
program. Here are the States so far that have taken up the Federal 
Government in the Affordable Care Act on this incentive program: New 
Hampshire, Maryland, Iowa, Mississippi, Missouri, Georgia, Texas, 
Indiana, Connecticut, Arkansas, New York, New Jersey, Louisiana, Ohio, 
Maine, and Illinois.
  It is a diverse group of States, I might add. Some States, probably, 
where Governors said they did not want to support the Affordable Care 
Act yet are taking advantage of this provision. Some States probably 
are forerunners of delivery system reform and have done lots of 
delivery system reform and want to do more. It is a mix of States. I 
think we have a lot of great examples in those States and what we can 
do to transition away from institutional care to home and community-
based care.
  The program authorizes grants to States to increase access to their 
non-institutional long-term care services, and it supports including 
structural changes that help streamline the system--conflict-free case 
management, core standardization of assessment instruments, single 
entry-point systems so it is not confusing, so that the system is very 
streamlined. States have until September of 2015 to increase their 
long-term care services in the community and support expenditures of 
these noninstitutional-based care facilities.
  We are very excited that it has had a robust uptake by these States. 
I am encouraged that there has been so much interest shown in changing 
the political orientation, if you will, of States, to how do you deal 
with long-term care. We know everybody is living longer. We know as 
baby boomers retire, it is going to be a bubble to our health care 
delivery system. But this is an excellent idea, a way for us to deliver 
better care.
  What does it do? As I said in the first chart, $1,200 versus $6,000 
in nursing home care. It reduces costs. Reducing those costs has to be 
a key focus for us.
  These Medicaid recipients are people who maybe even start on Medicare 
but because of the extreme cost of health care at the end of life, end 
up spending it out, end up on Medicaid, end up being a Federal 
responsibility. If we can reduce those costs by driving more community-
based care, it is a win-win situation.
  The second thing it does is it helps improve quality. If people can 
stay at home and get access to the delivery system by these new 
requirements, making sure it is case managed and has the single point 
of entry and standardization of the home care system, it helps us to be 
efficient about the quality of care that is being delivered. Again, 
when you have a community-based setting, either in the home or where 
care is delivered through the home, there are lots of ways for us to 
have checks and balances on the system.
  I have talked to many people who are in the nursing home industry. 
They will say we like the idea that we are only going to take the 
sickest patients. We like the idea we are only going to serve people 
who really need to be there as opposed to some people who may not be 
ready for those facilities but end up there anyway just because there 
are not the community efforts to support it.
  Besides reducing costs and improving quality, we save money. That is 
why we are here today, to talk about these important ideas that save 
money. This is a simple one, but it is already in place. It has already 
started. There are many States taking us up on this offer, but it is 
critical that we understand and score these costs because they can show 
how we can save billions of dollars in our health care delivery system.
  I know my colleagues, some of them on the other side of the aisle--
well, all of them on the other side of the aisle--didn't support the 
Affordable Care Act. Take a second look at what your States are doing. 
Your States are supporting the legislation, at least through one 
provision. I think when you check, you will see that one provision is 
going to save your State money. It is going to give your citizens 
better choice in their quality of care. It is going to help us reduce 
our Federal costs and expenditures as well, and that is what delivery 
system reform is all about.
  Mr. WHITEHOUSE. Will the Senator yield for a question?
  Ms. CANTWELL. Yes, I will.
  Mr. WHITEHOUSE. Isn't it the heart of what the Senator said just a 
moment ago that there is an area that actually touches on a lot of 
health care--it is a big area--where you can do two things at once? You 
can save significant money for taxpayers and insurance ratepayers, and 
at the same time you can improve the quality of care that people 
receive.
  So often in legislative matters it is a zero sum game. One wins so 
the other has to lose exactly by the same amount. This is not like 
that. This is a win-win situation. So there really should be energetic 
efforts to pursue these win-win opportunities.
  Ms. CANTWELL. I thank the Senator from Rhode Island for that 
question. I think his charts pointed to the fact that he was 
articulating, the fact that everybody is arguing about the Web site. As 
somebody who has been involved in a software company that wrote code, 
what happened is very unfortunate, but writing code and fixing it is a 
straightforward task that can be achieved. It is a little less 
difficult than cleaning up oil in the gulf or something of larger 
environmental impact.
  To me, we will get that fixed. In the meantime, there are a lot of 
things that have to happen, that need to change in our delivery system 
that are about saving costs, delivering better quality care, that we 
know are proven, successful answers to this question. We need to get 
more than just these States to take us up on this offer. We need to get 
CBO to actually give us a score on how much money this has the 
potential of saving, and then we have to figure out a way to 
incentivize all other States to implement this as soon as possible.
  When you think about our senior population, this is what they want. 
They want to stay at home as long as possible. It is so much cheaper 
per Medicaid beneficiary to do this.
  This is what we have to achieve. We hope by coming out here and 
educating people about the various aspects of the Affordable Care Act, 
the things in the delivery system reform that are on the agenda to 
improve access and help save costs, that this will start taking hold 
and we will get more people talking about these solutions. This is 
absolutely the direction we need to go.
  Mr. WHITEHOUSE. If I could ask the Senator another question in 
response to what she just said, not only is it a win-win, being lower 
cost and better quality care, but I believe the Senator said that there 
is actually a third win here. There is the win of lower cost, there is 
the win of better quality care, but for seniors there is a huge win of 
maintaining your independence and being able to stay at home. It is 
hard to put a price on that, but if you are facing the choice of having 
to leave your home and having to go to a more restrictive health care 
setting, being able to stay at home is a very big plus.
  Really, it is not win-win, it is win-win-win.
  Ms. CANTWELL. Mr. President, I thank the Senator from Rhode Island. 
He is correct. There are the individuals who win. The State in this 
case saves Medicaid dollars, and the Federal Government saves dollars 
as well. But to the individual, if you ask them, this is their choice. 
They want to stay at home. Nobody says they want to go into nursing 
care.
  We appreciate the nursing home care delivery aspect of health care. 
They deal with some of the most complex patients. But they do not need 
to deal with people who do not need to be there. We have to have a 
delivery system that helps support community-based care for long-term 
care. I hope that we will get more support for these ideas and that we 
will help figure out a way to get a score for them as well. I think 
that part of the misery in this

[[Page 19333]]

whole issue of health care savings is figuring out ways to do things 
that are not so complex in what they are doing. Moving from nursing 
home care to community-based care, $1,200 versus $6,000, that is not 
the hard part of the equation. What is hard is to get CBO to 
guesstimate how much population would be affected.
  We do know this. If you take the number of seniors to be affected as 
the baby boomer population reaches that retirement age, if you think 
they are going to be supported primarily by nursing home care--I think 
I am correct that our State has now made the shift so the majority of 
our people who are on Medicaid are taken care of by long-term care 
services in the community if they are seeking those services, versus 
the Federal numbers which are just the opposite. The majority of people 
seeking those Medicaid long-term care dollars, the average of those 
States is more towards nursing home care. We need to flip that. The 
Senator is right, it would be a win-win-win situation for all of us.
  I thank the Senator from Rhode Island for his leadership on this 
issue.
  Mr. WHITEHOUSE. Mr. President, in responding to what Senator Cantwell 
just said about the Congressional Budget Office, it indeed has been 
frustrating and bedeviling to run up against their inability to project 
these savings in a way that would allow us to--what we call in 
Washington--score them and get budget credit for them. But even though 
they have that difficulty, there are some very serious organizations 
that project that very significant savings of the kind I have 
mentioned--the $1 trillion savings--are possible.
  Some years ago the President's own Council of Economic Advisers 
estimated that we could do savings of $700 billion without affecting 
the quality of care in any way for the worse.
  The National Institute of Medicine has made several regular 
projections. The most recent one is $750 billion a year. The Institute 
of Medicine is pretty serious folks, and they are entitled to respect 
when they say we can have those kinds of savings.
  RAND Corporation--a lot of people know a lot about it--is a very 
expert organization. They have done two things. They looked at what we 
can save in health care, and then they looked at what we can save in 
health care plus an additional bit for dealing with waste and fraud. 
They gave ranges for the two. The midpoint of the range for savings is 
about $730 billion. If we add their suggestions on waste and fraud, the 
midpoint of their range goes to about $910 billion a year.
  The Lewin Group, which is another respected think tank that looks at 
health care issues, wrote a piece some time ago with George Bush's 
former Treasury Secretary, and they said it was $1 trillion.
  So is it $700 billion a year? Is it $750 billion a year? Is it 
somewhere between $730 and $910 billion a year depending on how you 
score the waste and fraud? Is it $1 trillion a year? Either way, I will 
take it. Those are big numbers, and wherever it falls in that range, we 
should be energetically fighting for it.
  I will close with the request I always make in these speeches--and 
this is a request to the President and to his administration--and that 
is to inspire us and set a bold national target. Sure, CBO, OMB, and 
our actuarial and accounting organizations cannot predict what these 
savings are going to be, but, by gosh, the President can direct his 
administration to target a savings goal and to go after it. I think if 
the President were to set a hard date and dollar target for delivery 
system savings--a couple of years out so we have a chance to do that--
that would make a big difference.
  The example that I use is of President Kennedy. Back in 1961, when it 
looked as if we were losing the space race to the Soviet Union, 
President Kennedy declared that within 10 years--he put a date on it--
he would put a man on the Moon and bring him back safely. He had a hard 
target, something specific so you would know if it was or wasn't 
achieved. The message was clear, the mission that was outlined was 
clear, and the result was a vast mobilization of private and public 
resources to achieve that purpose.
  It is not enough to talk about bending the health care cost curve. 
That catchphrase should be jettisoned and discarded. We should have a 
hard date and dollar figure, and that should be a target the entire 
administration aims toward.
  Had President Kennedy given that speech back in 1961 and declared as 
his purpose to bend the curve of space exploration, I very much doubt 
we would have put that man on the Moon within 10 years. It was his 
exercise of Presidential leadership and challenge--ahead of what the 
scientists knew could be done but with confidence and faith in our 
ability to achieve big things--that put the executive branch of 
government into focus so we could achieve exactly what he had directed. 
We can do the same with health care. We should do the same with health 
care. There is no downside to it because this is a win-win area, as I 
discussed with Senator Cantwell.
  On that note, I yield the floor and suggest the absence of a quorum.
  The PRESIDING OFFICER. The clerk will call the roll.
  The assistant bill clerk proceeded to call the roll.
  Mr. BLUMENTHAL. Mr. President, I ask unanimous consent that the order 
for the quorum call be rescinded.
  The PRESIDING OFFICER (Mr. Heinrich). Without objection, it is so 
ordered.
  Mr. BLUMENTHAL. Mr. President, I asked my colleague from Rhode Island 
to stay on the floor for a couple of minutes because I wanted to thank 
him for the erudite and eloquent explanation he has just given for why 
our focus should be so aggressively and unrelentingly on the tremendous 
opportunities for saving health care costs and raising health care 
quality at the same time. I am very proud to have joined him and other 
colleagues in a task force that is seeking commonsense solutions to 
lower the costs of health care and at the same time increase its 
efficiency and quality. The two go together.
  The phenomenon he just discussed of reducing readmissions to 
hospitals once patients are discharged also means that the quality of 
those discharges, the rehabilitation plans and hand-offs to primary 
physicians, and the suffering and pain for those patients is reduced, 
and that is just a microcosm of one example of how this goal can be 
accomplished.
  We are late in this year, and we have no real time remaining before 
the end of this year to do the kinds of reforms legislatively that will 
help advance this ball. But the attention we need to devote to this 
issue is clearly beyond this year and beyond the next year.
  We are making progress, and the graphs show it, but there is so much 
progress to be made in extending lifespans and quality of life as well 
as reducing the cost of health care.
  We need to make sure we seize this historic moment to show the rest 
of the world that we can do better and we will do better in providing 
health care delivery. The cause of health care delivery reform is one 
that cries out for a focused effort involving both branches of our 
government, executive and legislative, and both parties, as well as 
both Houses of this legislature.
  The kind of focus given by Senators Cantwell and Whitehouse so 
penetratingly and powerfully today is the kind of focus we should 
maintain. I hope in the days or months ahead we will devote more 
attention by coming to the floor, doing events in our States, and 
making sure the administration is aware of our concern in meetings. I 
look forward to continuing that effort in the time ahead.
  Again, I thank my colleague Senator Whitehouse, as well as others, 
such as Senator Schumer and my colleague from Connecticut Senator 
Murphy, as well as Senator Cantwell, for their devoted efforts. I am 
very proud to be working with them.
  I see my colleagues are on the Senate floor. It is late in the day, 
and I yield the floor.
  The PRESIDING OFFICER. The Senator from Mississippi.
  Mr. WICKER. Mr. President, I would point out that the distinguished 
Senator from Delaware was on his way to

[[Page 19334]]

speak and has graciously offered to defer for moment or two while I 
make my brief remarks.

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