Speeches & Floor Statements

Colloquy Remarks of U.S. Senator Lamar Alexander (R-Tenn.) and Republican Colleagues -- Health Care Reform

Posted on December 14, 2009

Mr. CORKER. Mr. President, I rise today to speak about the health care bill that is before us. One of the major points of contention over the last 2 weeks has been the fact that Medicare savings are being utilized to leverage an entirely different entitlement and not even taking care of the SGR issue that is so important to physicians around our country.

The other important stat is the fact that half of the expansion in health care benefits that is occurring under this bill is under Medicaid, probably the worst health care program in America. After a year of discussions among many folks on a bipartisan basis, and ending up with a very partisan bill, the fact that half of the expansion is occurring in one of the worst programs that exist in our country, locking people at 133 percent of poverty into Medicaid, with no other choice, does not seem to me to be true health care reform.

I know the Senator from New Hampshire, who has spoken eloquently on this issue, has something to say about that.

Mr. GREGG. Well, I thank the Senator from Tennessee for opening this discussion on the issue of Medicaid. But I did want to ask a couple questions relative to what the Senate leader just said about the bill that is before us.

Now, we have to remember the bill that is before us -- all 2,074 pages, as I understand it, is not the bill we are going to actually consider. There is somewhere in this building a hidden bill, known as a managers' amendment, which is being drafted by one or two or three people on the other side of the aisle, and which is going to appear deus ex machina on our desks fairly soon. We do not know what is in it. A lot of the people on the other side do not know what is in it. The press does not know what is in it. The American people do not know what is in it.

Mr. CORKER. The President does not know what is in it.

Mr. GREGG. The President does not know what is in it.

Nobody knows what is in it. But they are designing this bill, which is going to be represented to expand Medicaid even further and to also offer the ability to people age 55 and over to buy into Medicare, which is going to have a huge impact.

But what the Senator from Nevada said, which I want to ask the Senator from Tennessee about, is, he said this bill before us -- this 2,074-page bill, which we know is what we are working off of -- is going to reduce health care costs. Is it not true that the President's Actuary -- the Actuary for CMS, who is the President's Actuary -- sent us a letter last week which said that health care costs in the first 10 years would go up by $235 billion?

The majority leader also said people will be able to keep their insurance. Is it not true that the President's Actuary said millions of people will lose their own insurance under this bill?
Further, is it not true, in the area of Medicare, that the President's Actuary actually said that the expansion in Medicare and the Medicare cuts in this bill that are before us in the Democratic bill would actually lead to a massive reduction in the number of providers for Medicare; that up to 20 percent of the providers in Medicare would become unprofitable and therefore they would have to leave Medicare, making Medicare unavailable to people because there would be no recipient?
Didn't the Actuary also say, in the area of Medicaid -- and I am quoting -- "it is reasonable to expect that a significant portion of the increased demand for Medicaid would be difficult to meet, particularly in the first few years," and that is because providers would no longer be profitable and would have to leave the business of providing -- doctors groups, hospitals, small clinics?
Are not all those three points true relative to what the President's Actuary has told us -- not us, not the Republican side -- but what the President's Actuary said? And don't all three points contradict the representations of the majority leader?

Mr. CORKER. Not just his representations, but the representations of the President of the United States. As a matter of fact, it is hard to understand any goal that is being achieved other than making sure our country has a huge indebtedness.

But the senior Senator from Tennessee has talked about this very subject the Senator is talking about -- about Medicaid, in essence, giving people a bus ticket, where there is no bus because of the fact that if we add these people to a system where 40 percent of physicians do not take it, 50 percent of specialists do not take it, in essence, you have people accessing a system where there are not providers to care for them.

I do not know if the senior Senator from Tennessee wants to expand on that.

Mr. ALEXANDER. I thank Senator Corker from Tennessee. We have our usual situation on the Republican side -- a lot of Senators who wish to speak on the subject of Medicaid -- so I am going to keep my remarks brief. But looking around I see one, two, three, four of us who have been Governors of a State. The Acting President pro tempore was the Governor of the State of Virginia. Senator Corker, himself, was mayor of Chattanooga and the chief operating officer of the Tennessee State government.

Why do I bring that up? Because the Medicaid Program we are discussing -- I know to many people listening to this debate, it gets confusing. Medicare is the program for seniors on which 40 million to 45 million people depend. We have talked about that a lot, and how the cuts to Medicare are going to be used to pay for this bill. But we have not talked as much about Medicaid, which is an even larger government program. Sixty million people depend on Medicaid, and they must be low-income people in order to qualify for the program. This bill would add 15 million more Americans to the Medicaid Program which, as Senator Corker said, is like giving someone a bus ticket to a bus line that only operates half the time, because about 50 percent of the time, doctors will not see new Medicaid patients.

But there is another problem with the Medicaid proposal, which all of the Governors here -- I know if they are like me, nothing made me any angrier than to see a bunch of Washington politicians come up with a big idea, announce it, take credit for it, and then send me the bill when I was Governor. Usually we would find them back at the Lincoln Day Dinner or the Jackson Day Dinner the next spring making a big speech about local control. Well, what happens here is a huge bill for this Medicaid expansion that is going to be sent to the States.

I would say to Senator Corker, hasn't our Governor, a Democratic Governor, Governor Bredesen -- who like all of us has struggled with paying for Medicaid -- has he not said this will cause about $750 million in added expense?

I would ask the Senator from Tennessee, wouldn't that require either big cuts to higher education or big tax increases to pay for it?

Mr. CORKER. As you pointed out, in California there was almost an insurrection among students there because of the high cost of tuition, because of the fact that other programs in the State were eating up money. It is the same kind of thing that is going to happen in States across this country. Our Governor, who is a Democrat and who probably knows as much about health care as anybody in the country, is very concerned about what this is going to do; hoping, by the way, that revenues in our State reach 2008 levels by the year 2013. So he is very concerned.
I know Senator Johanns from Nebraska has been a Governor. I am sure he has some things to add to this debate.

Mr. JOHANNS. I do have some things I wish to add to this debate. I have gone across the State. I have talked to hospital administrators and I always ask them the same question: If you had to keep your hospital open on Medicaid reimbursement, could you do that? With no exceptions whatsoever, from the largest to the smallest hospitals, they say, Mike, we would go broke because the Medicaid reimbursement is so bad. No question about it, that is bad news for the hospitals.

But ask any Governor. It doesn't matter if they are a Democrat or a Republican -- and the senior Senator from Tennessee is so right, nothing would irritate Governors more, nothing would get us in a more bipartisan furor than the politicians in Washington passing something, taking all the credit for it, and then sending the bill to the State taxpayers. I will give a speech on this to nail this down in the next couple of days.

The States have very limited options. They can raise taxes or they can cut very valuable programs such as education, K-12 education, higher education, and already States are struggling. In Nebraska we had a special session where our Governor and our legislature stood up and said, We have to cut spending, and they cut over $300 million. Can you imagine if I were to call up later on a couple of weeks from now and say, I know you did your very best at that special session, but we sent you another bill for millions and millions of dollars over the next 10 years that you have to deal with?

The final point I wish to make is, do my colleagues realize what we are doing to the people we will be putting on Medicaid? Already 35 to 40 percent of the physicians won't take Medicaid. Why? Because the reimbursement rates are so incredibly pitiful. So if you are at 133 percent of poverty, we basically lock you into Medicaid. It is like giving somebody a driver's license but then saying, there is no way you can ever get a car to drive, because, look, here is the problem: They can't get medical care no matter if they have that Medicaid card. What it will do to our health care system is literally bring it to its knees, because we are going to have this massive rush of people who have the Medicaid card in hand and we don't have the capacity to deal with that. The doctors, the hospitals are all going to be in trouble because of this. It is the wrong policy for a whole host of reasons.

Mr. CORKER. Mr. President, I read a story this weekend in the New York Times where Medicaid recipients, especially young Medicaid recipients, have huge prescriptions taken out on them for antipsychotic drugs because basically the physicians don't want to take the time to deal with them, and so they are huge users of them.

When we speak about physicians, I think it is always important to talk to one. Fortunately, we have one on our side, Senator Barrasso, who I know has treated many Medicaid recipients. I know he has a lot to say on this topic.

Mr. BARRASSO. I have a couple of things I wish to add because I think you made a point, as does Senator Johanns. The concern is are there going to be enough doctors to take care of these patients. We are talking about 18 million more people placed on the Medicaid rolls, which is a huge unfunded mandate to the States. Having practiced in Wyoming for 25 years, in Casper, taking care of families, taking care of lots of patients on Medicaid, it becomes harder and harder for doctors to take new patients.

There is an article in this week's Wyoming Tribune Eagle:

Doctor Shortage Will Worsen. As many as a third of today's practicing physicians will retire by the time all of these additional 18 million get on to Medicaid.

There is an article in the Wall Street Journal and it talks about a report from a research group, nonprofit, based in Washington, the Center for Studying Health System Change, and it says, as you have previously stated:

Nearly half of all the doctors polled said that they had stopped accepting or limited the number of new Medicaid patients. That is because many Medicaid programs, straining under surging costs, are balancing their budgets by freezing or reducing payments to doctors. That, in turn, is driving many doctors, particularly specialists, out of the program.

For people in Wyoming, whether in Cokeville or Kemmerer or Casper, in all of these communities we are looking to try to recruit physicians. It is making it much more difficult when we look at this health care proposal the Democrats have, which is going to raise taxes, cut Medicare, cause premiums to go up for people who have insurance, and one of the reasons is because it underpays so much for things such as Medicaid, yet they are talking about putting another 18 million people on Medicaid.

This morning I called one of the offices of a physician group in Wyoming and said, What are the differences in terms of Medicaid versus regular insurance? For something like carpal tunnel, we know about overuse of the wrist and carpal tunnel surgery where the normal fee is about $2,000 for the surgery. Medicaid itself reimburses less than $500. Medicare -- they are talking about putting a lot more people on Medicare -- reimburses less than $400.

It is very difficult if you are trying to run an office and you pay all of the overhead expenses and see everybody who wants to see you to do it on the fees alone that you get from Medicare or Medicaid. That is why I have great concerns. If we have all these people on Medicaid, will it actually help them get care?

I think this Democratic proposal we are looking at fails. It fails in terms of getting costs under control. It fails in terms of increasing quality or increasing access, but those are the things we need in health care reform.

I see my colleague from Florida is here, who has experience, having run a Governor's office as Chief of Staff. He may want to add to this discussion as well. I can't see any way this would be sustainable. As a matter of fact, a report that came out recently from the CMS, the group that oversees all of this, said it is not sustainable, that one out of five hospitals by the year 2020 and one out of five doctor groups will basically have to go out of business and close their doors.

Mr. CORKER. Mr. President, it is pretty amazing when you think about it. We have a 2,074-page bill that includes the largest expansion of Medicaid in the history of the program. It would take about 1 page of that 2,074 pages to expand Medicaid and do no reform, and yet that is where 50 percent of the expansion is taking place. Yet, the 2,073 pages remaining don't meet many goals that many -- any goals, really, other than access -- any goals that Americans would stand behind.
I know the Senator from Florida, who has spent a lot of time on this issue, wants to speak on this topic.

Mr. LeMIEUX. I appreciate my colleague from Tennessee. I didn't have the honor to be a Governor but I got to sit in the office next door to be the Governor's Chief of Staff. We had these issues of trying to balance budgets because, unlike the Federal Government which is out of control, States actually have to balance their budgets. Receipts have to meet expenditures. When your Medicaid budget grows and grows and grows -- and in Florida, $18 billion is what we pay in Medicaid. It is the largest expenditure in the Florida State budget. When it grows and grows and grows, what happens? You have to cut education. You have to cut public service programs that do things such as law enforcement, correctional facilities that hold prisoners. You hurt the other main functions of government if you keep adding in Medicaid.

I wish to highlight a point my colleague from Tennessee made. It occurred to me when I was going through the Chief Actuary's report we received last Friday from the Center for Medicaid and Medicare Services that all this plan the Democrats have put forward is the expansion of Medicaid. Let's be honest. This is Medicaid for the masses.

Thirty-three million people supposedly are going to be covered by this plan if it is implemented. How do those numbers add up? Eighteen million are Medicaid, 20 million go into this new exchange, and then we lose 5 million because their employer drops them because they can go into the exchange. So what are the majority of the people who are going to go under this new health care reform going to get? They are going to get the worst health care system in America, called Medicaid, a system where doctors won't participate. If the doctor is not in, it is not health care reform.

This is not all it is cracked up to be. I did a little back-of-the-envelope math: $2 1/2 trillion to put 18 million people into Medicaid. We could give all of those people $166,000 each, put it into an account and say: Here, fund your health care for the next 10 years. Or, we could create this huge government program that expands a program that most doctors won't accept.

My colleague Dr. Barrasso has it right. Forty percent of the doctors won't take Medicaid, and 50 percent of the specialists. How is this health care reform?

I know my colleagues here have a lot of experience on this issue. I see my colleague from Mississippi and it looks as though he has a great chart and is going to talk about increased Medicaid spending, so I am sure he has something great to say to us.

Mr. WICKER. Yes, and I appreciate so many of our colleagues being here today because I am glad we are getting into the Medicaid aspect of this bill. There has sort of been a feeling around this building the last couple of days that if we could only take care of the Medicare buy-in and the government-run option that this bill would be OK. So I think today we are bursting that myth and pointing out the huge unfunded mandate the Medicaid portion would put on almost all the States.

Every State in red as shown on this chart would be required under this bill to increase their Medicaid spending. Only Vermont and Massachusetts would not have to be mandated by us in Washington to do this additional spending. Of course, with the unfunded mandate, what the Federal Government is saying is, We think this is a great idea. We think people should be covered with additional Medicaid Programs and, by the way, you folks at the State level should come up with the funds to pay for it. That is the very nature of an unfunded mandate.

I am not a Governor nor have I been a Chief of Staff of a Governor, but I have a letter from my Governor, Gov. Haley Barbour, who says:

If the current bill, which would expand Medicaid up to 133 percent, were enacted into law, the number of Mississippians on Medicaid would increase to 1,037,000, or one in three of our citizens. Over 10 years this bill would cost Mississippi's taxpayers $1.3 billion –

The generosity of this Congress would be to tell the legislators and taxpayers of my State of Mississippi: Congratulations. We get more coverage and, by the way, you have to pay an additional $1.3 billion –

necessarily requiring Mississippi to raise taxes in order to continue vital programs such as education and public safety.

As has been pointed out, our State governents don't have a printing press. They have to balance the budget and make the numbers come out at the end of every year. We are putting a new burden, if we pass this legislation unamended, a tremendous burden on our Governors.

One other thing. There has been mention of the Governor of Tennessee who is a two-term, respected Democrat who knows a little something about health care. I think the actual quote last summer from Gov. Phil Bredesen was that he feared "Congress was about to bestow the mother of all unfunded mandates on the State of Tennessee."

I have here in my hand -- and we don't have time because we have so many people who want to speak -- I have 13 quotes, not from Republican Governors such as Gov. Haley Barbour of Mississippi, but Democratic Governors all across this Nation, including the newly elected Democratic Governor's Association chairman, Gov. Jack Markell, and 12 others saying, we cannot afford, we cannot accept, we cannot bear at the State level this unfunded mandate upon this number of States.

Mr. CORKER. Thank you. That was very good. I am hearing some comments about there being a wink and a nod process taking place which is sort of what we have happening right now with the bill. We don't know what is in it, but I understand there may have been a tilt by leaders of the Democratic party to say to Governors: If you won't raise much cain here, we are going to take care of you down the road on this issue. I don't know if I would trust something like that to happen in this body, but –

Mr. WICKER. Here is the problem there, Senator. If they take care of the Governors down the road by saying we are going to send the money from Washington to cover this, then all of this talk about the program cutting costs at the Federal level goes out the window. Something is going to have to pay for it. Either we are going to have to gin up the printing press here, borrow some more money from China and send it to the States, which I guess is what the Senator was referring to, or we are going to pass the unfunded mandate on to the taxpayers of 48 of our States.

Mr. CORKER. So many Senators, so much participation, so little time. I think there is about 6 minutes left. The distinguished Senator from Utah has not yet spoken. The distinguished Senator from Idaho -- a former Governor -- has not yet spoken. I wondered if the senior Senator from Utah might close us out in the remaining time, just to bring this all to a climactic conclusion.

Mr. HATCH. Mr. President, I appreciate the comments of my colleagues. They are right-on. They know what they are talking about regarding the Medicaid program.

If this bill becomes law, the CBO estimates that by the year 2019, 54 million nonelderly, nondisabled Americans will be locked into Medicaid. Think about that.

Americans with incomes below 133 percent of the Federal poverty level are not eligible for tax credits to purchase private coverage through the exchange.

I will take a few minutes to read part of a letter I received from our Governor in Utah, Gary Herbert -- who worked at almost every job from local government right up to Governor of the State -- about the Medicaid expansion included in the Reid bill. My Governor is deeply concerned about the impact the proposed Medicaid expansion would have on individual States.

Here is what he said: In Utah, we have a good system of public medical programs that provide for our neediest population.

The extension of Medicaid to additional populations, as discussed in proposed Federal healthcare legislation, will amount to an unfunded mandate that would create financial havoc for our state.

While I understand the idea that everyone must "share in the pain," and appreciate the Administration's commitment to reforming healthcare without increasing the size of the federal deficit, to force Medicaid cost increases onto states will simply shift massive cost increases to the states.

As we prepare the state's fiscal year 2011 budget, we face continued cuts to agency budgets and reduced government service on top of painful reductions made last year. The unfunded mandate of a forced Medicaid expansion will only exacerbate an already dire situation.

If required to increase our Medicaid program as envisioned in Washington, Utah and most every other state will be forced to fund the money to do so through other means. This will require states to either raise taxes or continue to cut budgets in areas currently suffering from a lack of funding, such as public and higher education. We must work together to ensure that no new requirements for states to fund healthcare for additional populations pass.

In summary, I ask my colleagues, if the Reid bill is signed into law and the Medicaid expansions go into effect, what will the States do to make their budgets work? According to Utah Governor Herbert, States will be looking at a variety of options, such as cutting education programs and raising taxes. It would devastate the State, as Governor Barbour has said and as almost every Governor would say. I thought that was an important point to make.


Mr. CORKER. Mr. President, I know the Senator has been a leader in making sure people throughout this country have appropriate health care. I thank the Senator for those comments. There is no one better to respond than a former Governor, the Senator from Idaho, Jim Risch.

Mr. RISCH. Mr. President, first of all, let me say this raid on the States is just that. This is going to be a tax increase, and it is not included anywhere, it is not talked about anywhere. There is no way the States can deal with this except with massive tax increases or massive cuts in education.

In most States, I am sure, like Idaho, about two-thirds of the budget is spent on education, about 10 percent of it is on public safety, and you have about 20 percent that is on social services. Unless you have been a Governor, you can't understand how difficult it is to control what has become an expanding black hole in Medicaid.

You know, the first social program this Congress came along with was Social Security. They decided they would do it, and they funded it. The second was Medicare. They decided they would do it, and they funded it. Along came Medicaid, and some genius here decided the Feds will only pay 70 percent or so and we will make the States pay 30 percent. Well, everywhere across this country, Governors are saying: Don't do this to us.

The dozen of us here who are former Governors were asked to participate in a conference call a couple weeks ago. I listened, but I didn't talk. I didn't need to because there was great bipartisan support for killing this bill. The most vocal people were Democrats. The most vocal Governors were Democrats, who were saying we cannot tolerate this kind of an increase. That is what is going to happen under this bill.

I am sorry none of my friends from the other side of the aisle are here, with the exception of the Presiding Officer.
Could the Senator from Mississippi take the top chart off. If my friends were here, I would tell them to pay attention to the polls because that is what America is going to look like on CNN next November 2, in the evening, if you continue down this road.

I thank the Chair.

Mr. CORKER. I thank the Senator. I know of nobody who has spoken more eloquently on this topic than the Senator from New Hampshire. Before I hand it off to him, when I was in my 40-something-plus townhall meeting since this debate began, our citizens said to me they wanted the same choices I had as a U.S. Senator. This expansion for the American people is mostly being done in the area of Medicaid.

I don't know if the Senator has any comment to that effect or a comment as to whether we Senators ought to be in Medicaid, if this is our idea of health care reform. I certainly hope he will close us out, and I thank him for his tremendous distribution.

Mr. GREGG. Mr. President, I thank all of the Senators here for their comments. I say this -- and I think the Senator from Tennessee was alluding to this at town meetings -- this expansion of Medicaid isn't good for people. It is not good for people on private insurance. Their insurance will go up, and a lot of employers will have to drop insurance because it is too expensive. It is not good for people getting Medicaid because the number of providers willing to see them will go down. That is what the Actuary tells us, and that is what common sense also tells you. When you are only paying 60 percent of the cost of seeing somebody, people will stop seeing them. It is not good for everybody in all those red States up there on the chart because their taxes will go up because the States are going to get the bill for this. States can do nothing but raise their taxes. So it is not good for people and not good for health care in this country, in my opinion.

Mr. CORKER. Mr. President, how much time remains?

The ACTING PRESIDENT pro tempore. Thirty minutes has been consumed.

Mr. CORKER. I am sure the Senator from Tennessee -- if there is time remaining and if nobody is here to claim it -- would like to speak. He is always good at explaining the deficiencies of this bill.

Mr. ALEXANDER. Mr. President, I thank the Senator. I am impressed with the number of Senators here this afternoon. One thought comes to mind, and I wonder if some of my colleagues may want to talk about it. I woke up one day and saw on television a sign that said "32 percent tuition increase for the students of California." The University of California could be the best public institution of higher education in the world.

One of the great things the United States has -- which keeps us competitive and gives us a chance to continue to grow and create new jobs -- is a superior system of higher education. About half of the best universities -- Harvard, Yale, and the private universities -- half or more than half are public universities, where tuition is a few thousand dollars a year. Well, what is going to happen with this? All of us who have been Governors have gone through this. You have a pot of money left, and it either goes into higher education or Medicaid. For the last 30 years, we have been having to fight to fund Medicaid, and as a result States have not been funding public higher education properly and the quality has gone down and the tuition has gone up.

What is this bill saying? It says that, after 3 years, we are going to dump a huge new cost on the States. I don't believe I am overstating it when I say that in our State of Tennessee, given the terrible fiscal condition our States are in today -- and our State is more conservatively run than most -- I believe our State could only fund this through a new State income tax and/or serious damage to higher education or both. I wonder if that is not the case in all of the other States represented here.

Mr. CORKER. Listening to what the Senator just said, I looked on the other side of the aisle and realized there is no one there. This is one of those issues. I know that on Medicare, the other side has been able to argue they are extending the life of Medicare. Yet Senator Gregg so clearly pointed out yesterday on national television that is impossible because they are taking those savings to pay for a new entitlement program. At the end of the day, it really will not be extending the life in any way. We all wonder why those savings are not being utilized now to make Medicare more solvent.

I wonder what my friends on the other side of the aisle would argue in favor of the largest expansion of Medicaid. I think that would be a pretty hollow argument. I think everyone knows that it was all about money, that this was the cheapest way to try to meet some goals -- by passing it off to States. I would love to hear somebody on the other side argue how health care reform, where 50 percent of the people being added are being thrown into the worst program that exists in America -- I would love to hear somebody over there argue how that is good for our country.

I know Senator Gregg, myself, and others have signed on to legislation that would give low-income citizens choices among private companies and, with that, vouchers, nonrefundable tax credits, and then to be able to pay for that -- that is health care reform. That is something that creates robust competition, and certainly we would not have these low-income individuals locked into the dungeon of the worst health care program that exists simply because it is cheap, making, in essence, the value of their health care less than the value of ours here in the Senate.

I would love to hear anybody on the other side of the aisle argue for expanding Medicaid -- how that is a good thing for the citizens it covers.

I see we have someone from the other side of the aisle here. Mr. President, I don't know if we still have time to talk. I know Senator Johanns has comments to make.