[Congressional Record (Bound Edition), Volume 159 (2013), Part 2]
[House]
[Pages 2344-2350]
[From the U.S. Government Publishing Office, www.gpo.gov]




                              {time}  1450
                        HOUSE GOP DOCTORS CAUCUS

  The SPEAKER pro tempore (Mrs. Walorski). Under the Speaker's 
announced policy of January 3, 2013, the gentleman from Georgia (Mr. 
Gingrey) is recognized for 60 minutes as the designee of the majority 
leader.
  Mr. GINGREY of Georgia. Madam Speaker, I thank the majority leader 
for yielding this time to discuss an extremely important issue facing 
the patients in this great country of ours that are going to have a 
very difficult time in finding a physician.
  Madam Speaker, in March of 2010, when the so-called Affordable Care 
Act, or PPACA, was passed into law, the purpose, of course, was to 
increase access to physicians for all patients across this country and 
also to bring down the cost of health care. Well, we're 2 years into 
this bill--which will become fully effective in January 2014--and what 
are we seeing?
  Madam Speaker, the CBO reported just recently that some 7 million 
people have actually lost their health insurance, the health insurance 
provided by their employer. For those who do still have health 
insurance--particularly those who get it maybe not from their employer 
but from the individual market, a small group policy--the cost has 
actually increased some $2,500 a year instead of coming down, as 
anticipated and predicted and promised, in fact, by President Obama, 
but that just absolutely is not happening.
  So what we're going to be talking about, Madam Speaker, is, again, 
what needs to be done to correct this situation. Because the thing that 
was never really discussed to my satisfaction when this bill was 
crafted was, how are you going to get the best and the brightest young 
men and women in this country to continue to go into the field of 
medicine, to become the doctors--particularly in primary care, internal 
medicine, and the pediatricians--to provide that care when the 
reimbursement system under Medicare, called the sustainable growth 
rate, year after year after year for the last 6 or 8 years we have 
actually cut the income to the providers, to the point, Madam Speaker, 
where they can't provide this care, they can't even break even? So this 
is what we're going to be talking about, this flawed sustainable growth 
system. It has certainly contributed to the physician shortage crisis 
that we see today.
  Now, I have a number of slides that I want to present to my 
colleagues, and

[[Page 2345]]

we'll go with some specifics on that. But I'm very pleased to be joined 
today in this House with the cochair of the House GOP Doctors Caucus, 
my good friend and fellow physician Member from Tennessee, Dr. Phil 
Roe, and I yield to Dr. Roe at this point.
  Mr. ROE of Tennessee. Dr. Gingrey, thank you, and it's good to see 
you moving your arm well and recovering from your surgery so well.
  I think the question that comes up, and Dr. Gingrey and other Members 
and I have discussed this, when I got here--and I've been here 4 years, 
and Dr. Gingrey came a couple terms before I did--we did this for a 
reason because we wanted to impact the health care system in our 
country. The problem with the health care system in our country was 
that costs were exploding.
  If you look, as he pointed out, the Affordable Care Act has been 
anything but affordable. It's suggested that by 2016 the average family 
of four, when you have to buy an essential benefits package--which the 
government will determine what that is--will cost a family of four 
$20,000. That's unbelievable when you think that the per capita income 
in my district is $33,000. So I think we're at a point or we're going 
to be at a point where no one can afford it.
  Well, what Dr. Gingrey is mentioning in the SGR, sustainable growth 
rate, what is that? What does that mean, and why should I care if I'm a 
senior? And Dr. Gingrey and I both have Medicare as our primary source 
of insurance. Well, Medicare started back in 1965, a great program for 
seniors who did not have access to care. It met a great need there and 
has met a great need since then. It started as a $3 billion program. 
The estimates were from the government estimators that in 25 years this 
program would be a $12 billion program--we don't do millions here, 
billions--and the real number in 1990, Madam Speaker, was $110 billion 
instead of $12 billion. They missed it almost 10 times.
  So there have been various schemes throughout this time in which to 
control the cost, always by reducing the payments to providers. And who 
are providers? Well, those are the folks who take care of us when we go 
to the doctor's office--nurse practitioners, it may be a chiropractor, 
it could be a podiatrist, and it can be your hospital. So when you say 
providers, those are the folks and institutions that care for us when 
we're ill.
  So in 1997, the Ways and Means Committee brought together something 
called the Budget Control Act. This is a very complex formula based on 
how you're going to pay doctors--their zip code, where they live, the 
cost of an office, the humidity in the air--I know it's an incredibly 
complicated scheme to pay doctors. The idea is this: We have this much 
money to spend in Medicare, and so we've put a formula together to only 
spend this much money. If we spend less than that money, that will go 
as a savings. If we spend more than that much money, then we will cut 
the doctors and the providers that amount of money to make that line 
balance.
  Mr. GINGREY of Georgia. Dr. Roe, if you would yield just for a 
second, I wanted to point out to my colleagues and to Dr. Roe the 
poster that we have before us. Because this is exactly what the good 
doctor is talking about right now in regard to what's been going on 
since the year 2000. Dr. Roe, you may want to refer to this slide.
  I yield to the gentleman.
  Mr. ROE of Tennessee. Well, the particular slide that Dr. Gingrey has 
down there is very telling. Basically what it says is that each year 
that we've recalculated what our physicians will be paid, we haven't 
met those metrics, which means that we have to cut.
  Well, what has Congress done? Well, Congress has realized that what 
we're talking about is not payments to doctors; what we're talking 
about is access to care for patients. What happens is if you go back to 
2003--I think it was 2003--when there was a 5 percent cut in Medicare 
payments, we realized at that point right there that if you continue to 
do that, that access would be lost.
  So let's fast forward to 2013, what we're just facing. Doctors were 
facing a 26.5 percent cut, the providers were.
  Mr. GINGREY of Georgia. Dr. Roe, that would be right here.
  Mr. ROE of Tennessee. That's correct, that number right there. That 
was avoided by a 1-year so-called ``doc fix.''
  What has happened over the last 15 or so, 16 now, years is that the 
Ways and Means Committee line--now law--says we have to spend this much 
money, but we've actually spent this much. That is a deficit in 
spending that we've got to make up somewhere in our budget or add it to 
the budget deficit.
  Now, I go back to when I was in practice just 5 years ago now in 
Johnson City, Tennessee. Dr. Gingrey, I don't know about you, but I was 
having a harder and harder time finding primary care access for my 
patients that I had operated on, or maybe someone who had been my 
patient for 30 years--if she was 40 years old when I started taking 
care of her, in 30 years she's 70 years old and needed a primary care 
doctor. That was getting harder and harder and harder to do.
  Now, when you look at today's young medical students, we're having a 
much harder time convincing these young people to go into primary care. 
What is primary care? Well, it's pediatrics. If you want someone to 
take care of your baby, it's family medicine. It's also internal 
medicine and also OB/GYN. I certainly served as a primary care doctor, 
as Dr. Gingrey did for his patients, for many, many years. That would 
be the only doctor that they would see. But that's getting harder for 
our patients to do. And Dr. Gingrey, that's my primary concern--access 
for seniors to their doctors.
  Mr. GINGREY of Georgia. Dr. Roe, if you will yield for just a second 
and then I will return to you, again, I wanted to point out to our 
colleagues that this poster, this slide that's on the easel before us 
is exactly what the gentleman from Tennessee is talking about in regard 
to shortage of primary care physicians. And as he pointed out, primary 
care is a family practitioner, is a general internist--of course 
pediatricians provide primary care to our children. But so many of 
these doctors are the very ones that take the Medicare, take the 
Medicaid, take the SCHIP, the State Health Insurance Program for 
children. They see them.

                              {time}  1500

  And what Dr. Roe is referring to, before I yield back to him, on this 
poster it shows in the dark blue the areas of these States, several 
States, including my own of Georgia--Tennessee is not quite as bad--but 
in my State of Georgia, there are anywhere from 145 to 508 areas of the 
State of Georgia where there are an insufficient number of doctors to 
take care of these folks. Tennessee is a little bit better. There are 
only 67 to 99 areas. But all of this blue are critical areas, are they 
not, Dr. Roe? And I yield back to you.
  Mr. ROE of Tennessee. That is correct. And so much so that in 
California, what they're recommending, I don't know whether they've 
carried it out or not, but they've recommended expanding the definition 
of ``primary care'' to a lower-level provider, that would be a nurse or 
nurse practitioner or PA or this sort of thing, this sort of 
designation.
  I think the other thing, Dr. Gingrey, that we haven't talked about, 
and we probably should spend some time on, is the age of our 
practitioners. In our State of Tennessee--where you see that we're not 
quite as dire in need as Georgia, our friends to the south--the problem 
with it is that 45 percent of our practicing physicians in the State of 
Tennessee are over 50 years of age. I'm concerned that with the advent 
of the Affordable Care Act, the complexity of that, the frustration 
that I see when I go out and talk to our providers is that I'm afraid 
that many of them are going to punch the button for the door.
  I know in my own practice, where we have now about 100 primary care 
providers in my program, in my OB/GYN group, in the last several years 
we've had over 120 years of experience walk out the door and retire. 
That's not a good thing for the American health care system that just 
lost access. Quite frankly, the crux of it all is that access. If you 
do not have access, you will

[[Page 2346]]

decrease quality, and you will increase cost. That is our concern. 
Ultimately, the cost will go up if our patients can't get in to see us.
  Mr. GINGREY of Georgia. I thank the gentleman, because what the 
gentleman from Tennessee is talking about is having an insurance card, 
a health insurance card--and indeed even having a Medicare card--does 
you very little good if you have to spend 2 hours going through the 
Yellow Pages trying to find some physician, primary care doctor in your 
area that you wouldn't have to get in your car and drive 50 miles--if 
you could even drive. If you don't have that access, then you don't 
have anything.
  So here again, this bill, this massive bill was passed 2 years ago at 
the cost of almost $1 trillion. Unfortunately, a lot of that money was 
taken out of Medicare to create this new entitlement program, if you 
will, for younger people so that they can have health insurance. But 
what we've done is we've just made the crisis in the Medicare system 
that much more difficult.
  What Dr. Roe was talking about, colleagues, is in regard to not just 
a shortage of the physicians, but what happens in the waiting rooms all 
across our country. This slide shows the number of primary care 
physicians per 1,000 population, the number of primary care physicians 
per 1,000 population.
  Now, we've already gone over, we're talking about, again, general 
internists and family practitioners, primarily, and pediatricians for 
SCHIP and Medicaid. If you look at that map across the country, again, 
look at my State of Georgia in the deep red, and there are several 
States, Texas, Oklahoma, Mississippi, Alabama, Utah, Nevada and Idaho 
in the West where the number of primary care physicians per 1,000 of 
the population is fewer than one. So less than one doctor per 1,000 
people that need that care. Many other States, including Tennessee, it 
is somewhere between one and 1.2. Now, I don't know how you get 1.2 
physicians. I don't know exactly what that provider looks like. But you 
know how that math is calculated. Clearly, the shortage is acute, and 
it's only going to get worse and worse.
  With that, I want to yield to one of my good colleagues, good friends 
on the Energy and Commerce Committee whose father actually was the 
chairman of the Health Subcommittee of the Energy and Commerce 
Committee for many, many years before he retired and his son took his 
place, and now the gentleman from Florida, Gus Bilirakis, is serving on 
that Health Subcommittee with me on Energy and Commerce.
  I yield to Representative Bilirakis.
  Mr. BILIRAKIS. Thank you, I appreciate it, Dr. Gingrey. Thank you, 
Dr. Roe, I appreciate it. Thanks for bringing up and sponsoring this 
Special Order that is so very important to our constituents. Thank you 
for informing them.
  This is a very, very serious issue. We must repeal this SGR and 
replace it. Again, since coming to Congress more than 6 years ago, 
doctors in my district have consistently stressed the unsustainability 
of the SGR and how it impedes them from developing long-term business 
models.
  Each year, Congress has implemented, of course, a temporary stopgap 
measure to avert the payment cliff, but the doctors have to have 
certainty. Again, we have a shortage of doctors in the State of 
Florida, and it's only going to get worse. We must repeal this SGR and 
replace it. It has led to uncertainty for medical providers, again, as 
I said, which threatens patient care. Again, access to care is what 
it's all about. I'm glad that the chairman of the Energy and Commerce 
Committee, of course, Chairman Upton, has made this a top priority in 
fixing, again, the SGR.
  Again, not only is the uncertainty associated with reimbursement 
rates impacting physician practices; it also impacts how the Centers 
for Medicare and Medicaid Services plans to update Medicare Advantage 
rates for 2014. That's a huge issue. I know that the seniors in my 
district love their Medicare Advantage. Even though, year after year, 
Congress has not only allowed the devastating SGR cuts to take effect, 
CMS is assuming these cuts will take place as it determines the 
Medicare Advantage adjustment. So in other words, we always fix it at 
the end of the year, but they're assuming that the cuts will take 
place. I worry this will result in reduced benefits and increased 
premiums for the many seniors who like--really love--their Medicare 
Advantage.
  Mr. GINGREY of Georgia. If the gentleman would yield, I want to thank 
the gentleman from Florida because what he is addressing right now goes 
back to the creation of this law, the Affordable Care Act, PPACA--
sometimes referred to as ObamaCare--where money was taken out of the 
Medicare program, the existing Medicare program, which is already 
strained almost to the bursting point, and the Medicare Advantage 
program. Probably 20 percent of Medicare recipients select that model 
because it gives them more bang for the buck. It gives them more 
coverage, and it includes things--and the gentleman from Florida knows 
this, and this is what he is referencing--it includes more than just an 
annual physical when you turn 65. It includes more than being able to 
go to see a doctor and have it reimbursed under Medicare when you have 
an episode of illness.
  There is a strong emphasis on Medicare Advantage to wellness. Let's 
say you do go and see the doctor because of an episode of illness, and 
maybe several prescriptions were written. It's very important that the 
patient take the medication on a regular basis and not run out of 
medication. So under Medicare Advantage, there would be a nurse maybe 
in the doctor's office who within just a few days of that encounter 
would call the patient to make sure that he or she could afford to get 
those prescriptions filled and they were taking them in the right way. 
That's what the word ``Advantage'' was all about, Medicare Advantage, 
rather than just a traditional fee-for-service Medicare.
  But this new law created 2 years ago, and will go into full effect in 
January, 2014, literately gutted that Medicare Advantage part, did it 
not, Representative Bilirakis? It cut that program 12 to 14 percent. I 
mean, it's just literally gutted. I'm talking about $130 billion was 
taken out of that one program.

                              {time}  1510

  So now seniors that were on Medicare Advantage are having to look for 
new doctors, look for new programs, try to again go through those 
Yellow Pages and find somebody that will see their momma who's been 
going to this other group for years and is totally satisfied.
  When the President said to the American public, If you like the 
health insurance plan you have, don't worry, you can keep it; you will 
not lose it, that just wasn't true. I don't think he deliberately told 
an untruth, but it clearly is not true. And as I said at the outset of 
this hour, some 7 million people have already lost insurance provided 
by their employer, and many more of these people that were getting 
their Medicare through the Advantage program, they have lost that 
through no choice, Madam Speaker, of their own. They have been forced 
out of those programs.
  I yield back to my colleague, and we will continue this colloquy.
  Mr. BILIRAKIS. I couldn't have said it better myself, Dr. Gingrey.
  Again, I have constituents in Florida, and it's above 20 percent in 
my district and closer to 40 percent, who have chosen Medicare 
Advantage.
  It's all about choices, as far as I'm concerned. If I want to get 
hearing aids, if I want to get a gym membership or eyeglasses, I should 
have the choice to choose my plan. It works so very well in our area, 
and we want to continue to give seniors that choice.
  I want to thank you guys.
  My father, as you referenced, worked so many years to fix this SGR, 
and I'm very proud now to serve on the Health Committee to contribute.
  But I appreciate the two doctors here and all the doctors who have 
really sacrificed to run for Congress and do what's good for our 
people, patients. Treating patients is what it's all about. So thank 
you very much for allowing me to participate.

[[Page 2347]]


  Mr. GINGREY of Georgia. I thank the gentleman from Florida and I 
thank his dad, Representative Mike Bilirakis, Madam Speaker, who served 
in this body for so many years with distinction. I hope that he is 
enjoying a happy and healthy retirement in the Sunshine State. And I 
hope he's able to find care, but I bet you it's not under Medicare 
Advantage, as his son just told us.
  At this point, I would like to yield back to the gentleman from 
Tennessee (Mr. Roe).
  Mr. ROE of Tennessee. I thank you.
  And thank you, Mr. Bilirakis, for being here. I appreciate your 
leadership on the committee, too.
  Why should I be concerned about this, and what experience do I have 
to say that if this is not fixed it will affect access and quality? 
I've had, I guess I could say, the misfortune in Tennessee of going 
through health care reform 20 years ago.
  What happened? What happened was we had a large group of people in 
our State who didn't have access to quality, affordable health care. We 
reformed our Medicaid program and opened it up. We had an open 
enrollment time where we were going to have these various plans compete 
against each other. It was very much like the public option I heard 
discussed during the debates 4 years ago.
  What happened? What happened to us was that our costs tripled in 10 
years in that plan. It went up three times. And you can already see in 
the Affordable Care Act, even before it's been fully implemented, the 
estimates of costs have already doubled. The costs to patients are 
going up and the costs to businesses are going up. It didn't do what it 
had to do to really help solve the problem, which is lower the cost, 
bend the cost curve down. It did not do that.
  When we saw those costs go up, what did we do? We started cutting our 
providers, and we cut our providers and we cut our hospitals and our 
doctors and our nurse anesthetists and our nurse practitioners and PAs 
and so forth. Guess what happened? Access got cut off. They stopped 
seeing those patients.
  Now, our practice where we were, we, as an obstetrician as you were, 
we took everyone, because pregnancy is one of those conditions where 
you either are or you're not. We felt like if those folks needed care, 
we kept seeing those critical-care patients like that. But many 
elective-type things--orthopedics and dermatology and those kinds of 
things--got cut off, and people would have to drive hours to see a 
specialist.
  So I saw access get denied in that system when the cost of the whole 
system went up to where no longer the State could afford it. I've seen 
that happen. That's why patients should be worried.
  Dr. Gingrey, you and I know these numbers. We have 10,000 people a 
day hitting Medicare age. That's 3\1/2\ million people this year that 
are going to be Medicare age. These are new people on the plan with 
less money. And if we have more people and we're not producing more 
doctors, do the math. In 10 years, we're going to have 35-plus more 
people on Medicare, and who is going to care for those people?
  Another thing I want to bring up is that we're not just talking about 
how doctors are paid. We're talking about increasing quality. One of 
the measures we're going to look at when we look at the new payment 
formula--right now the way you and I were paid when we were in practice 
was a patient came in and you got a fee for that visit. That's called 
fee-for-service medicine. That's going to change. We're going to look 
at quality outcomes and measures. I'll give you an example about why 
that's important.
  One percent of our Medicare recipients use 20 percent of all Medicare 
dollars, so we have to look at how we manage the care of those patients 
better. For instance, with congestive heart failure, when someone 
leaves the hospital, we know that certain metrics are taking place: 
weights are taken every day, blood pressure and so on. If you check in 
with a provider, you can prevent rehospitalizations and save tremendous 
morbidity, mortality, and cost. It also increases the quality of life 
that patient has and the quality of care they receive. So doctors are 
going to be evaluated on the kind of outcomes we have and the quality 
of care we provide our patients, which we all agree should be done.
  I think coordinating care, hopefully, with better electronic 
records--and I could spend an hour talking about that. If we have a 
coordinated electronic system where, when you order a test at your 
office or the hospital, we have access to it so that test is not 
repeated and duplicated, that will make a huge difference in cost.
  I just had a duplicated test, myself, done. You may have, too, when 
you had your procedure. I had a surgical procedure done 2 weeks ago 
this last Monday, and there was some testing on myself that really 
didn't have to be done. But because of various rules and regulations 
and the inability to get that information easily, it was easier to 
repeat it and pay for it than it was to go find it. I think that 
happens to 300 million people. Actually, it is 47 million of us who get 
Medicare now. We need to do that, better coordinate that information 
with sharing and transparency.
  Mr. GINGREY of Georgia. If the gentleman will yield for just a 
second, I want to weigh in on that issue of electronic medical records.
  I'm normally, as the good doctor from Tennessee knows, walking around 
here in a sling, as I have been for the last couple of weeks. Madam 
Speaker, I probably should have it on right now, but I'm resting my arm 
on the podium.
  But I just recently had rotator cuff surgery back home in Marietta, 
Georgia. Madam Speaker, I was blessed with a great physician who did a 
wonderful job and has a fabulous staff, but going through the process 
of doing the paperwork, I bet I filled out the exact same form four 
different times. That was wasting my time and that was wasting their 
time. Of course, what they want to make sure is that no mistakes are 
made. Obviously, they want to make sure they operate on the correct 
arm. So I understand why, and I'm sure many of you, your parents, your 
grandparents, and you yourselves, my colleagues, as patients have gone 
through all of that.
  But what Dr. Roe is talking about--and I will yield back to him--
electronic records are indeed, in my opinion, the wave of the future. 
Honestly, I believe if we had concentrated on that 2 years ago to make 
sure that it was fully implemented so that duplication of testing, 
unnecessary procedures, maybe medications prescribed to which the 
patient had a dangerous allergy, you really do ultimately save lives 
and save money by having an electronic medical record system.
  The other thing is if we had had medical liability reform. The 
President promised that before this ObamaCare bill of 2,700 pages was 
put into law, but there was nothing in there about medical liability 
reform.
  Here again, those were two things, and I think the gentleman from 
Tennessee would agree with me on that.
  I just wanted to interject my thoughts about electronic medical 
records, and I yield back to the gentleman.
  Mr. ROE of Tennessee. I had the misfortune of going from paper to an 
electronic record. I was in the process, at our practice, of 
converting. It's a very difficult conversion. I think if you started 
with just an electronic medical record, it would be much easier than 
transferring tens of thousands of patient charts to an EMR. But when 
you start from scratch, it's a little easier.
  Certainly I think the electronic ePrescribe, which I like, I didn't 
have the pharmacist call me and tell--I can't believe he couldn't read 
my prescription. Anyway, they claimed they couldn't, and this solves 
that problem.

                              {time}  1520

  I think there are some disadvantages to it, but overall, I think it 
is the wave of the future. I think you are correct.
  I'm going to bring up something now about: let's say we go ahead and 
we do fix the SGR payment that's based on quality and that's based on 
outcomes and transparency, on hospital re-admissions, and so forth--on 
all those metrics we've talked about to better serve our patients. 
There will still be fee-for-service. I'm sure, Dr. Gingrey, you're a 
rural Georgia Representative

[[Page 2348]]

as I'm a rural east Tennessee Representative. I have counties that have 
one doctor, and you can't do an accountable care organization--or all 
of these things--in a small, rural county. So fee-for-service medicine 
will still be there for those patients so they can have access in 
small, rural counties and don't have to drive long distances.
  Let's say we do all of this wonderful stuff and that we fix this 
payment model and that it all looks good. The Affordable Care Act has 
in it one little thing called the Independent Payment Advisory Board. 
This Independent Payment Advisory Board trumps what we just did--all of 
the things that you're going to do in your Energy and Commerce. Also, 
thank you very much for what you're doing on that. As to all of these 
cuts that you see right here, let me just give you the data.
  Mr. GINGREY of Georgia. The top of the green line is where we in the 
Congress mitigated these cuts because we can do that. That's what it 
says in the Constitution, that we're in charge of the purse strings. 
So, when there is a recommendation, as Dr. Roe is referring to, Madam 
Speaker, of the cuts in the pink--below the line, from 2001 to 2012, 
there is almost every year a 5 percent, 3 percent, 4 percent, 10 
percent--then in the aggregate, that number just keeps getting bigger 
and bigger.
  What Dr. Roe is about to explain to us is how we were heretofore able 
to mitigate, which is by making these changes above the line and by 
saying, no, we're not going to cut the doctors because we know, if we 
do that, they won't be there, that they won't be there for our parents 
and our grandparents and ourselves and our children.
  Mr. ROE of Tennessee. I think correctly the Congress, in its 
constitutional authority, has overridden the SGR 15 times since 2002. I 
think that's the correct data.
  What this IPAB does in the Affordable Care Act--it sets the same 
metric. It has a very complicated formula, which is the same as SGR, 
and if you have expenditures above those projections, cuts will be 
made. There is no judicial review, no administrative review, and it 
takes a 60-vote margin in the Senate to override this. Let me tell you 
how important this is, what Dr. Gingrey just pointed out.
  Whether you agree with the plan or don't agree with the plan, there 
was a great article in the New England Journal of Medicine, one of our 
premier medical journals, that was published in June of 2011. I would 
recommend this for anyone to read as it will take you 30 minutes or 
less. They went back with the CMS and looked at the last 25 years and 
said, What if we had IPAB then? What would it do? In 21 of the 25 
years, cuts would have occurred to providers--and I know exactly. 
Because of what I have seen in Tennessee, I know exactly what would 
happen. What would happen is you cut those providers right there. As 
you're seeing up there, Dr. Gingrey, I can tell you that, as to the 
access to care, that entire map of the United States right there would 
be a bright red because you would not have the providers to take care 
of those patients.
  That is a tremendous concern for me because it is current law. This 
year, those 15 bureaucrats are supposed to be nominated by the 
President. What happens if he doesn't nominate those 15 people? One 
person--that's the HHS Secretary, Secretary Sebelius--makes those 
decisions and recommendations. I hear it all the time. I go on the talk 
shows like you do, and they say, Well, in the bill right here, it says 
that you cannot ration care. That's true. This board can't ration care. 
What they can do is just not pay the providers. In 2017, I think, or in 
2018, the hospitals are included in this. They're not included first, 
but they will be in 5 short years.
  Mr. GINGREY of Georgia. Dr. Roe, what will happen in reference to 
this slide right here--if you look at these blue areas, these States 
that have the acute shortage areas, like Georgia and Florida--is that 
this whole map of the United States will be blue.
  Mr. ROE of Tennessee. That is correct, Dr. Gingrey.
  Unless you are very deeply buried into this--meaning, if you're a 
Medicare recipient out there today--you don't see this. I go home, and 
I see my physician friends and talk to my friends who are on Medicare. 
They don't know this has happened or that it could potentially happen 
to them, but it can and it will, and it is the law right now unless we 
change the law.
  I would strongly encourage my colleagues on both sides of the aisle--
and we have bipartisan support for the appeal of the IPAB--to put that 
constitutional authority back in the hands of the people who are 
directly responsible and responsive to the American people--us, the 
Representatives. Let us make those changes and, the Senate, the same 
thing.
  Mr. GINGREY of Georgia. I thank the gentleman, and I want to continue 
a colloquy with him and maybe even ask a question of him. Dr. Roe, 
Madam Speaker, explained very clearly how that is a section of 
ObamaCare, a very important section of a group of 15 bureaucrats 
appointed by the President.
  In regard to the IPAB, they basically can now say from year to year, 
Well, the doctors and the hospitals are going to be cut so much 
reimbursement. These cuts are going to occur.
  We showed in the first slide how over the years Congress has been 
able to mitigate. Read the Constitution. We, the Members of the 
Congress, control the purse strings. So, fortunately, we were able to 
make these changes into what was suggested; but this IPAB board of 15 
bureaucrats, they're not making a suggestion. They're telling us what 
has to be done.
  The question I wanted to ask of Dr. Roe, Madam Speaker, was: when 
this case went before the Supreme Court, questioning the 
constitutionality of the law and saying that if a Governor of a State, 
like the Governor of Georgia, Governor Nathan Deal--an 18-year Member 
of this body, by the way--makes a decision not to expand Medicaid 
because the State can't afford it as the State's already going broke on 
the current Medicaid program, is it constitutional for the Federal 
Government to say, If you won't expand the Medicaid program, we're 
going to make sure that you can't participate at all and that all of 
your current recipients of Medicaid in the State of Georgia are out on 
the street?
  That was a question that was asked of the Supreme Court as well as: 
was it constitutional to force people to engage in health care if they 
didn't want to, if they did not want to purchase health insurance? Now, 
I'm not recommending that they don't; but the question before the 
Supremes was: is it constitutional under the Commerce Clause to make 
people engage in commerce if they don't want to do it? The Supremes 
said, in a very pained, strained, pretzel-like decision, that that was 
constitutional.
  Dr. Roe, do you know whether or not this question about IPAB was 
addressed by the Supremes: is it constitutional or not? I'm not sure. 
I'm thinking it wasn't addressed. Would you speak to that.
  Mr. ROE of Tennessee. That's correct.
  I had the privilege of being in the chambers when a good part of this 
health care debate was going on in front of the Supreme Court. It was 
the first time I'd ever been there. Fascinating. I'd totally misread 
it.
  As you pointed out, it was the first time in American history that 
the Supreme Court said that you had to purchase a good or service--even 
if it's good for you, that you had to purchase it. We've never forced 
anybody into commerce before like this. As an individual, I think you 
have a right to make good decisions and bad decisions. I agree with 
you. I think a good decision is, if you can afford health insurance 
coverage, you should purchase it. I think there is no question. I have 
for my family my entire life, and I would recommend it strongly and 
encourage people to protect themselves in that way.
  But does the government have the right to do it?
  This Court said 5-4 that they did. The Court also said that they did 
not have the right to force States into expanding their Medicaid if 
they did not want to, and the IPAB specifically was not brought up.

[[Page 2349]]

  I believe it will be challenged and should be. No one has standing 
yet because it hasn't gone into effect. In other words, they haven't 
issued any rulings--or the Secretary hasn't--to say that I've been 
harmed by that ruling so that, therefore, now I have standing in the 
Court and that I can bring a case.

                              {time}  1530

  Mr. GINGREY of Georgia. So you're saying that it's in the law, but 
because it hasn't been applied yet. And, in fact, indeed, as Dr. Roe 
pointed out, Madam Speaker, the board, the IPAB board, 15 bureaucrats, 
have not even--not even one of them, their salary has been set, I think 
they're scheduled to make $150,000 a year and probably have a car and a 
driver and health insurance and retirement plan, and not too bad a gig 
if you can get it, but not so far I don't think any have been 
appointed. And so that's what Dr. Roe, Madam Speaker, was referring to 
when he said there's not standing yet. If you went to the Supreme 
Court, they would say the case is not ripe. I'm standing here as a 
physician trying to sound like an attorney, and I'm going to get myself 
in a lot of trouble here in a minute, Madam Speaker, and Dr. Roe 
explained that very well, but I do agree with him, colleagues. I do 
agree with Dr. Roe that that will be challenged and certainly should be 
struck down. You look at the Constitution, our fifth and sixth graders 
probably could make that decision, and it wouldn't be a 5-4 split 
decision; it would be 9-0.
  Mr. ROE of Tennessee. Actually, the IPAB board of 15 bureaucrats will 
make $165,000 a year with a 6-year term, and they can be appointed 
twice to that term. And it's something, and what bothers me about it 
is, no, it says in the bill you can't ration care, but we are the 
elected representatives. We should be able to go back home, as 
Congressman Bilirakis said, we should be able to go back home and face 
our constituents, and they're going to say: Dr. Roe, we have a 
situation where I can't go see my doctor. I can't go in and see them 
because they aren't accepting patients, and they aren't accepting 
patients because of this particular board that's cut their 
reimbursements enough to where they can't afford to see patients.
  Now, another couple of things I want to talk about in the Affordable 
Care Act, not just SGR formula effects, but there is a tax out there in 
the Affordable Care Act that hasn't been very well discussed, and that 
tax is on individual insurance accounts. For instance, there are 
companies out there that are self-insured, and they're going to get a 
bill for each person that has insurance. Let's say a family of four or 
five, they'll get a bill for four or five people, and one company in 
particular, this will add--and they have no reinsurance. They cover 
everything. They're totally self-insured, but this basically is a tax 
that will go into a fund to indemnify insurance companies so that they 
won't have a loss of more than $60,000 a year, and this is billions of 
dollars when you stretch it across the country.
  And these insurance companies are going to not have the loss to 
encourage them to accept patients on the exchange. That's as wrong as 
it gets to take a company that is doing everything right, they're going 
ahead and providing the health insurance coverage for their employees, 
and to penalize them for that.
  So there are many, many issues in the Affordable Care Act we could 
talk about, but I want to basically finish my comments on the 
sustainable growth rate by saying in the past, since 2001, just so that 
our viewers out there will understand this, since 2001, your Medicare 
doctor at home has gotten an average increase in his or her payments 
when you come see them of 0.29 percent per year, 0.29 percent per year. 
When you look at all that graph that Dr. Gingrey has down there and you 
do all the math, that's how much of an increase. It's a very minimal 
increase. It hasn't even come near to covering the cost of inflation.
  So again, Dr. Gingrey, I want to conclude by saying that the major 
concern I have, and I saw it in my practice, is the cost of care, and, 
number two, access to care. I'm concerned as our patients age and our 
population ages--and look, a good thing is happening in America: almost 
every 10 years we live, we're adding 3 years to our life expectancy. In 
1908, the life expectancy in America was 48 years old, 47-48. In 1922 
when my mother was born--and she's still living, I might add. She's 
living alone, by herself, doing great. She has Medicare. And I'm going 
to tell my mother now that later today I'm going to call her 
prescription in. She notified me today that she needed some medicine 
called in, and so I will do that for her today. I look at her and I 
think about her need for access to care, and if it's cut off, what does 
she do.
  Mr. GINGREY of Georgia. I thank the gentleman, Madam Speaker. And as 
he talked about his mom, I stand here thinking about my own mom, who's 
95 years old. Her body is getting a little frail, but Mom's mind is 
perfect. Perfect, Madam Speaker. She has enjoyed the benefit of 
Medicare and Social Security for many years. Many years. So these 
legacy programs are hugely important. They're hugely important to our 
side of the aisle.
  Madam Speaker and my colleagues, all of this Mediscare stuff, and 
things that you get all of this rhetoric about, they don't care about 
seniors and they're going to push somebody's grandmother over the cliff 
in a wheelchair, that's just a bunch of bull. I think every Member of 
this body and every Member of Congress cares about seniors and cares 
about these programs.
  But I also, Madam Speaker, have 13 grandchildren. I have 13 
grandchildren, and I want this Medicare program to be there for them 
some day, just like it has been there for Mom all these years.
  So as we talk about these issues, we would do nothing to harm current 
recipients of Medicare and Social Security. We used the term, the 
phrase I guess you'd say, ``hold harmless.'' Hold harmless. Any changes 
that we would make, whether it is the payment system to our doctors and 
our hospitals for providing the care, it would not take away any 
benefit. It would not cause our current seniors to have to pay a higher 
premium or copay or deductible. All we're doing is trying to come up 
with something that would save the program for them, but, most 
importantly, for these youngsters that are coming behind us, the next 
two generations. So that's what we're all about.
  My colleague, if he has some more comments, I would like to refer 
back to him, the gentleman from Tennessee.
  Mr. ROE of Tennessee. Dr. Gingrey, I think one of the things I know 
you did and I know one of the things that I did was to come here to 
this body, this great body, to work on the repair of our health care 
system and improve on it.
  One of the major pieces of our health care system is our Medicare 
system. I cannot tell you the patients I have seen in my career that 
have benefited, whose lives have been helped and saved by the Medicare 
system and by the doctors and nurses and hospitals and other providers 
who've cared for them. You have, too. I've operated on them, and I've 
seen them get cardiac care, renal, whatever it may be, that has 
improved the quality, improved and lengthened the quality of their 
life, not just to live longer, but to live better.
  My goodness, look at the number of patients that we see of our 
orthopedic friends that we have that are mobile, that are active who've 
had joint replacements and so forth. Look, if you're 80 years old, 75 
or 80 years old, you understand that your life is not going to be that 
much longer, but you also want the quality of that life to be the 
absolute best it can be. And it cannot be if you can't get your knee 
fixed if you're in pain, or your hip fixed if you're in pain. One of 
the things that I think our side of the aisle is committed to, I 
believe the other side, we may have differences of opinion, but one of 
the things I want to do is to be sure that we shore up and save this 
great system of Medicare.
  I had a meeting today just after lunch about the Medicare part D 
program that was passed by the Republicans at some political risk for 
them.

[[Page 2350]]

That's been a plan that has actually come in under-budget. It came in 
under-budget because seniors are able to go shop and purchase exactly 
what they want that meets their needs. That is exactly what we want to 
do in the Medicare system.
  And when our budget is published next week, we are going to look at a 
system where we help fix and save and sustain Medicare, as you pointed 
out, not only for your mother, who's 95, and my mother who is 90, but 
for my two grandchildren who are 7 and 9. They also deserve the same 
great system, and we're going to have to change it; but I think we can 
make it better. I really believe it can be more responsive. You see 
what patients do when they get Medicare Advantage. You saw what they 
did. There was a little confusion, I admit, when Medicare part D first 
came out. There is no confusion now. People shop for the best value 
that meets their needs, and that's exactly what we should do.
  Let me give you an example, Dr. Gingrey. I turned 65 a very short 
time ago. What happened to me when I turned 65? Nothing. I got one day 
older. Except what happened was I had a plan now that had an alphabet 
soup--A, B, C, D.

                              {time}  1540

  The day before I had a health care plan. Why, when you turn 65 years 
of age, don't you have a health care plan? And in that health care plan 
I can pick out I don't need fertility coverage at age 65, thank you 
very much. And I think that's the kind of thing--allow seniors to be 
able to pick what meets their needs and meets their family's needs at 
that particular point in their life; not just one-size-fits-all, but 
what they need.
  And seniors have done that. They do it with everything else in their 
life. There's no reason it should change when you hit 65. You should 
pick out what plan--just like you and I can do up here with the Federal 
Employees Health Benefits plan. There's no reason that a senior 
shouldn't have exactly the same plan. It will be cheaper. It will be a 
better plan for them, and that's one of the things I think we're going 
to be discussing in the next several months when the Republican budget 
is published.
  Mr. GINGREY of Georgia. I thank the gentleman.
  Madam Speaker, as we get near the closing of the hour, I wanted to 
just mention several things. Dr. Roe has alluded to these, talking 
about the Medicare Advantage and what a beneficial program that was. 
Unfortunately, it's now been gutted, literally gutted, cut at least 12 
percent, $130 billion, to create this whole new program that we call 
PPACA, or ObamaCare.
  Medicare Part D, Madam Speaker, the gentleman from Tennessee is 
talking about the prescription drug part of Medicare that we did my 
first year, when I first came here in 2003, the Medicare Modernization 
and Prescription Drug Act.
  Seniors, for many, many years, have wanted to be able to get their 
prescription drugs covered by Medicare but they couldn't. And of 
course, when you have to go to the drugstore and get five prescriptions 
filled, and most of them, brand name, not generic, some generic, maybe, 
but these brand name drugs are so expensive. And so we finally did this 
for our seniors.
  Now, we spent what--I don't know, maybe $750 billion--creating that 
program, and we got criticized for it because it wasn't paid for. We 
didn't offset by cutting spending somewhere else. And I think maybe 
that criticism, under the current system, is legitimate.
  But really, when you think about it, if you scored dynamically, and 
you realize that if people, seniors, all of a sudden could take their 
blood pressure medicine and not have to worry about a stroke, could 
take their diabetes medicine and not have to worry about eventually 
having renal failure from diabetes or an amputation, in the long run, 
what I'm saying, Madam Speaker, is this program, Medicare Part D, 
Medicare Advantage, electronic medical records, if we scored things in 
the right way, dynamically, at the end of the day, 10 years, 20 years, 
whatever, we're going to save money because people are not going to 
have coronary bypass surgery, they're not going to have to have these 
amputations, they're not going to end up the rest of their lives in a 
nursing home because they've had a catastrophic stroke that has left 
them totally incapacitated.
  I'm going to yield back to the gentleman from Tennessee to close us 
out.
  Mr. ROE of Tennessee. I have just one quick statement, Dr. Gingrey. 
And when you brought this up in 2003--and I want to thank you, because 
I can remember sitting at my desk in my office in 2003 working, and I 
could take this pen right here, and in about a minute or a minute and a 
half, I could write two or three prescriptions that might take up a 
patient's entire monthly income. That was the decision patients were 
having to have.
  And Republicans stepped up to the plate, made a very difficult 
decision. Like you said, maybe we should have some criticism for not 
having offsets. But seniors out there today don't have to make that 
decision about whether I break this pill in half or whether I don't 
take it today or whether I buy food.
  And you ran across that in your practice. I mean, I would look in our 
area, many widows that I would see would have a $600, $700 a month 
Social Security check and maybe a $100 or $200 a month pension. And you 
write three prescriptions, and the first thing they say is, Dr. Roe, 
it's gone. And you could easily do that. So I want to thank you for 
your vote.
  Mr. GINGREY of Georgia. I thank my colleague.
  And Madam Speaker, I thank you, and I thank the leadership of the 
Republican Party for allowing us to bring this information to our 
colleagues in a bipartisan way.
  We are all about solving these problems. We talked basically about 
the sustainable growth formula, the way we pay doctors for a volume of 
care.
  Clearly, we're going to have to go to paying for quality of care. We 
don't have time to get into all the details of that today, but in the 
next Special Order hour that the Doctors' Caucus leads, we'll get into 
more details about what we're going to recommend to our committees, to 
our leadership, to both sides of the aisle in regard to solving this 
program.
  And with that, I yield back the balance of my time.

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