Speeches & Floor Statements

Floor Remarks of U.S. Senator Lamar Alexander (R-Tenn.) -- Health Care Reform

Posted on July 21, 2009

Mr. President, I listened carefully to the Senator from Michigan. Republicans and I believe most Democrats want health care reform this year. The President said he wants health care reform this year. Republicans want health care reform this year. We want to make sure it is done right. Let me put it this way: If we were in an operating room and a seriously ill patient came in and we knew we had only one chance to save that patient's life and to make that patient healthy, our goal would not be to see if we could do it in the next week, it would be to see if we could get it right. So far, the proposals we have seen coming out of the committees have not gotten it right. One might say: Well, that is a Republican view of Democratic proposals. Perhaps it is. But the proposals we have seen coming out of the Senate HELP Committee and out of the House of Representatives flunk the most important test, which is cost. The most important test is whether Americans can afford their health care and, after we get through fixing it, whether they can afford their government. According to virtually everyone we have heard from, the legislation we have seen simply does not meet that test. In my opinion, what we should do instead is start with the framework of the bill sponsored by Democratic Senator Wyden and Republican Senator Bennett which has 14 cosponsors -- 8 Democrats, 6 Republicans. This is a different sort of framework that offers virtually every American coverage, does so without any Washington takeover or government-run programs without raising the debt one penny, according to the Congressional Budget Office. Remember, I said that is a framework. I do not agree with every single part of that bill, although I am a cosponsor, but it may be a much better place to start than what we have seen so far. That is not just my opinion. Lately, we have heard a lot about the Mayo Clinic in Rochester, MN. President Obama has talked a lot about the Mayo Clinic. The point is, at the Mayo Clinic and a few other clinics around the country, there have been significantly better outcomes. In other words, if you go there and come out, you are more likely to be well, and at a lower cost. And the question is, Why? The President has repeatedly pointed to the Mayo Clinic, Democratic Senators point to the Mayo Clinic, and Republican Senators point to the Mayo Clinic. Here is what the Mayo Clinic had to say on Friday about the legislation that is being considered in the House of Representatives: Although there are some positives in the current House Tri-committee bill, including insurance for all and payment reform demonstration projects - the proposed legislation misses the opportunity to help create higher quality, more affordable health care for patients. In fact, it will do the opposite. That is the Mayo Clinic talking. In general, the proposals under discussion are not patient focused or results oriented. Lawmakers have failed to use a fundamental lever - a change in Medicare payment policy - to help drive necessary improvements in American health care. Unless legislators create payment systems that pay for good patient results at reasonable costs, the promise of transformation in American health care will wither. The real losers will be the citizens of the United States of America. That is the Mayo Clinic talking about the bill we are beginning to see in the House of Representatives. I think the prudent thing to do is to try to make that bill better or start over and certainly not try to pass a 1,000-page or 2,000-page bill in 1 week or 10 days without knowing what is in it, as we did with the stimulus bill earlier this year. That is not just the opinion of the Mayo Clinic. Here is a letter to House Members on July 16, a few days ago, from a number of clinics, including the Mayo Clinic. These are the Intermountain Healthcare, Gundersen Lutheran Health System, the Iowa Clinic, the Marshfield Clinic, the Rural Wisconsin Health Cooperative, ThedaCare, and Wisconsin Hospital Association. I ask unanimous consent to have this letter printed in the Record following my remarks. It goes on to say: On behalf of some of the nation's leaders in health care delivery --These are the people whose hospitals we go to, whose clinics we go to when we are sick or when we hope to stay well -- we write to you to comment on the House bill. They say: We applaud the Congress for working on this. However, we have got significant concerns. They go on to say there are three of them. The first is about the Medicare-like public plan, as they call it, a public plan with rates based on Medicare. They say it will have a severe negative effect on their facilities, that they lose a lot of money every year, hundreds of millions of dollars. Because what happens is that Medicare, a government-run plan, pays its doctors and its clinics and its hospitals about 80 percent of what private insurance companies are paying. So roughly 177 million of us have private insurance of one kind or another. If a doctor sees you, he gets paid 100 percent. But if you go to one of these clinics and hospitals, they are paid according to the government rate, which is roughly 80 percent of the private rate. These clinics say that is not sustainable for them, and that if that continues, some of those providers, such as the Mayo Clinic, will eventually be driven out of the market. What market? The market for Medicare patients. Those are the 45 million senior Americans who absolutely depend on Medicare for their service because for most of them, that is their only option. If that is the case, what that means is they will not be able to go to the Mayo Clinic or to the MeritCare Health System or to the Iowa Clinic or to the doctor they choose because that doctor will not be a part of the Medicare system because of low reimbursement. So that is the first objection these clinics make to the bill they see coming because the bill they see coming proposes to create another government-run plan with government-set rates. The second objection they have is geographic payment disparities. They say that we are a big country and there ought to be differences in the pay among different geographies. Third, and maybe this is the most important of all, that the President has said and many of us in the Senate have said we need to change the way we pay for medical care, and we ought to pay more for value, for quality, for results, and less for volume -- in plain English, not how many patients a doctor can see but how many of his or her patients stay well or get well. We have talked about that for weeks here in our hearings. But what these respected voices in medicine are saying is that the legislation we see today -- and understand, this is not even in a bill that has presented to us in the Senate yet in a way upon which we can act -- does not meet the test for that. The legislation we have seen so far is running into a lot of trouble. David Broder, the respected columnist from the Washington Post, said that the plans which have been passed in a partisan way are "badly flawed" and "overly expensive." I mean, the Democratic plans; we have Republican plans that we would like to be considered. I mentioned that the Wyden-Bennett plan, which is the only really bipartisan plan here, has not been given one bit of consideration so far in the Senate. And then Senator Burr and Senator Coburn have a plan, Senator Gregg has a plan, and Senator Hatch has a plan. We all have different ideas. As I said, we would like for them to be considered, today I’m talking about the Democratic plans that are now being considered. The Congressional Budget Office, of course, is the nonpartisan office in this Congress that we count on as an umpire to tell us what we are really doing. It is not supposed to have any political rhetoric. Last Thursday, the head of the Congressional Budget Office, Douglas Elmendorf was asked at a Senate Budget Committee hearing what he thought about the bills which had begun to emerge. He said: The legislation significantly expands the Federal responsibility for health care costs. In other words, here we go, at a time when we are in a recession and where the President's proposals for other programs will add more to the debt in the next 10 years, three times as much as we spent in World War II, and we are talking about legislation that would add another $2 trillion. We haven't dealt with cost which is where we ought to start. Look at the 250 million who have health care and ask the question: Can you afford it? Then after we get through fixing it, can you afford your government? And what the head of the CBO is saying, as far as the government goes, the answer is no. Then the Lewin Group, a well-respected private agency, was asked what would happen if we had a government-run program which many of us believe will lead to another Washington takeover. We are getting accustomed to this, Washington takeovers of banks, of insurance companies, of student loans, of car companies, now maybe of health care. The Lewin Group said 88 million people will lose their private employer-sponsored insurance. How could that happen? It could happen because a small employer or a big employer would see one of these plans that is beginning to come out take place. To be specific, the Senate HELP Committee plan says you either have to provide everybody who works for you insurance or pay $750. There are a lot of employers who cannot afford to provide everybody the kind of insurance that is envisioned. So they will say: OK, we will pay the $750 fine to the government. What happens? All those employees lose their health insurance. Where do they go? Into the Government plan. That is their option. Some of them may have a choice of other plans, but if they do have a choice and one of the choices is a government-run plan, it may have the same future the Mayo Clinic and others were saying Medicare was causing to them. The government will set a low price for the doctors and a low price for the clinics. So all these employees who now have insurance that they like will lose that insurance because of the passage of this bill. The government will set the provider rates and physician rates low, and so they will be part of a government plan for which many doctors and many hospitals and many clinics will not offer services. It is similar to giving somebody a bus ticket to a bus station with no busses. Then there are the Medicare cuts. According to the Washington Post last week, Medicare cuts will pay for one-half the cost of health care for the uninsured in one of the bills being proposed. If we are to find savings in Medicare and take from the 45 million elderly people who depend on Medicare, every bit of those savings ought to be put back into Medicare and not spent on some new program. I don't think legislation that is paid for half by Medicare cuts is going to go very far in this Chamber. Then there are the employer taxes. According to the National Federation of Independent Businesses, the House version has an 8-percent Federal payroll tax. I mentioned the Senate version, a $750 annual fine per employee, if the employer doesn't offer insurance. The NFIB, small businesses, estimates that will lose about 1.6 million jobs. How could that be? Well, if a small employer or even a large one has government-mandated costs added and they have less money, they will hire less employees. That is one of the options they have. Then there is the income surtax. There is a whole string of trouble for these bills. USA Today on Monday said: It is the highest tax rate in a quarter of a century that is proposed: A 45-percent top tax rate with all taxes included. Then rationing, there are provisions in this bill which would have the government make decisions about which treatment you will have and how long you will have to wait to see a doctor. Finally -- I say "finally" because this is the subject I want to spend a moment on -- there is the Medicaid State taxes. Sometimes this gets confusing. Mr. President, 177 million Americans have private insurance, but a lot of people have government insurance now. Veterans do. Military people have TRICARE insurance. About 45 million older people have Medicare. But then there is a program called Medicaid, which is the largest government-run program. About 60 million people are in it now. The Federal Government pays about 57 percent of it, and the States pay 43 percent. Every Governor I know -- and I was once one -- has struggled with the Medicaid Program. I once came up here in the early 1980s and asked President Reagan to take it all, let the Federal Government run it and give us Governors all of kindergarten through the 12th grade. I thought that would be a good swap. I saw a couple of Democratic Governors earlier today, and we talked about the story every Governor faces. If you have an extra dollar and you want to put it in higher education so you can improve the quality of the University of Colorado or Tennessee or keep tuition from going up, what happens to it? That dollar is stolen because it has to go in the increasing Medicaid cost. It is an inefficiently managed program. The Federal Government keeps changing the rules. The Governors have to get permission from Washington whenever they make minor changes. It is demolishing State governments right and left. If our real goal is to help people, then why under these new plans do we say to low-income people -- defined as, say, a family of four who makes less than $32,000 -- your only option is going to be to go in the Medicaid Program under this plan. It is estimated by the Congressional Budget Office and others that 15 or 20 million Americans will be added to the 60 million in the Medicaid Program. What will they find when they get there? They will find that 40 percent of the doctors don't see Medicaid patients. When we add another 15 or 20 million people to it, it may be a larger number. Why don't they do see Medicaid patients? For the same reason the Mayo Clinic warned about this government plan in its letter. It is because Medicaid only pays its doctors and its hospitals about 72 percent of what Medicare pays. If you are confused by that, it works out pretty simply. Medicare pays 80 percent of what the private insurers pay, and Medicaid pays about 72 percent of what Medicare pays. If you are a doctor or a clinic or a hospital, you get paid about 60 percent, if you are helping a Medicaid patient, of what you would if you were helping one of us who has his or her own private health care. You can see that will be a pernicious trend. If we continue to dump low-income people into a government-run Medicaid Program, that is what will happen. There is another thing that happens with Medicaid. Many members of the committees working on this bill said: We can't let that happen. We can't be inhumane and just say we are out here to help people who are uninsured, and we are going to dump 20 million of them into a government-run program that doesn't have enough doctors and hospitals and clinics. We will have to raise what we pay to doctors and clinics. That sounds good, but that is very expensive, particularly for a program such as Medicaid that, according to the Government Accountability Office, $1 out of every $10 is fraudulent, is wasted. That is $32 billion a year. That is the program we are going to expand? That is the program we are going to say to low-income people: Congratulations, go into this program where you are not likely to find a doctor every time you want one, and there are a lot of hospitals and clinics that will not take you because we will not pay them for that. Because Senators and Congressmen hear that, they say: We will raise the rates. Here is the proposal: The proposal is, we are going to increase the number of people who are eligible for Medicaid by 133 to 150 percent of the Federal poverty level. That is a substantial increase. Then, if we are going to do that and put many more people into the program, we are going to have to order an increase in what we pay the doctors and the clinics to serve them, maybe up to 83 or 85 percent of the Medicare level. Let me talk about what that would do in one State. We called the State Medicaid director in Tennessee. Our program is called TennCare. We said: What would it cost Tennessee if we increase coverage of Medicaid up to 150 percent of the Federal poverty level? The answer came back, nearly $600 million a year. That is the State's share of the cost which is a little more than a third. The Federal Government's share is twice that. So the Federal Government is saying: That is all right. We know Tennessee doesn't have the money to do that, so we will pay it all for the first 5 years. Then, after 5 years, so the talk goes -- and we were told, when we were working on this bill, this is an assumption -- we will shift these costs back to Colorado, back to Tennessee. Back comes what in today's dollars is about $600 million to the State of Tennessee. Remember what I said. This is a program doctors don't want to go to because they don't get paid very well. So we will have to increase the amount of money we pay doctors. So if States are required to pay doctors and providers under the Medicaid system 110 percent of what Medicare is paid, that still isn't what doctors and hospitals get, if they see somebody with private health insurance. That is about the same amount of money, about $600 million added just for the State cost, which brings the total new state cost for paying physicians and hospitals more and for all the new people in the Medicaid Program to $1.2 billion. That is a huge amount of money. We throw around dollars up here and figures that make any amount of money seem unimaginable. What is $1 trillion, what is $10 trillion, what is $40 billion. We former Governors can imagine it. I figured it out. If in 5 years you shifted back to the State of Tennessee just its share of those costs from the expansion of Medicaid and paying the doctors and hospitals more, the bill for the State of Tennessee to pay the increased Medicaid costs would be an amount of money that equals a new 10-percent State income tax. The truth is, for our State -- and I believe for almost every State -- it is an amount of money that nobody has enough taxes to pay. You can run politicians in and out and defeat them for raising taxes all day long, and they still couldn't come up with ways to pay for it. In other words, these bills are based on a premise and assumption that will either bankrupt the States or, if the Federal Government says we will pay for it all, it will add $5, $6, $700 billion more over 10 years to the legislation we are considering. We need to think that through. Is that the best way to help people who are low income? I don't think so. I think there are much better ways. The Wyden-Bennett framework is a better way. It rearranges the tax deductions we have for people who have health insurance from their employers and it says: Let's take the available money and give the money to low-income people who then buy private health insurance. It may be a very basic plan. But at least they would have health insurance, and they wouldn't be stuffed in a government program 40 percent of the doctors wouldn't see and that many of the best clinics and hospitals wouldn't allow them to come in. We have been told already by the Congressional Budget Office that proposal would not add a penny to the debt. Not only does it not create a new government program, it actually makes the Medicaid Program, except for Americans with Disabilities, history. In other words, if you are poor, you are not stuffed into a program that nobody else would want to join anyway. You have a chance to buy your own insurance, and you are not consigned to the worst run government program we have today. So there are some real possibilities with health care, and there are some plans on the table that will lead us in the right direction. We have advice from distinguished Americans with a stake in this -- which is every single one of us -- but the most distinguished are those who deal with it every day. The Mayo Clinic is saying the proposed legislation misses the opportunity to help create higher quality, more affordable health care for patients. In fact, it will do the opposite. Shouldn't we slow down and get it right? Shouldn't we get it right? This is the only chance we have to do this. If we do it wrong, we will not be able to undo it. This is 16, 18 percent of the American economy we are talking about. People have tried to do it for 60 years, and they failed. The only way we will do it is if we do it together. The Democrats have big majorities over on that side. They do in the House. But that is not the way things usually happen around here. The President has said -- and I take him at his word -- and many of the leaders have said -- and I take them at their word -- that we would like to get 70, 80 votes for the health care result. We would too. But in order to do that, we are going to have to do it the way we usually do when we have bipartisan events around here. We get some Democrats and some Republicans and they sit down with the President and they share ideas and they agree on some things. They don't just say: OK, here it is, and we are going to vote down almost every significant idea you have on the way through. I respect the fact that Senator Baucus is trying to do that in the Finance Committee, and perhaps he will succeed, working with Senator Grassley and others. But this is going to take some time. It cannot be done overnight. There are many sections to this bill. Each of them might be 500 pages long. They have enormous consequences to individuals. That is why we have all these clinics writing and saying: If you do it the way it looks like you are going to do it, you may drive us out of the business of helping Medicare patients. Do we really want to do that? Do we really want to say to 45 million Americans who depend on Medicare: We are going to pass a bill that will accelerate the process whereby respected clinics and the doctor you might choose will not see you anymore because they cannot afford to because the government will not pay them under the system we have? So I would suggest we start over, literally, conceptually; start over and listen to these clinics and doctors and focus on the delivery system and focus, first, on those 250 million Americans who already have health insurance and ask the question: Can they afford it? And, what could we do to make it possible for those Americans to afford it? And can we do it in a way that permits us to be able to honestly say when we are through that those same 250 million Americans can afford their government when we are through without adding to the debt? Then let's look at the 46 million people who are uninsured. Of course, we need for them to be insured. But the fact is, 11 million of the uninsured are already eligible for programs we already have; 10 million or so are noncitizens -- half of them legally here, half of them not; a large number of them are making $75,000 a year and could afford it but just do not buy it; and another significant number are college students. So we are going to have to go step by step by step and see in what low-cost way we can include a large number of these 46 million Americans, who are not part of the system, in the system. But that is the wrong place to start. That is the place to end. So, Mr. President, all I am saying is, on the Republican side of the aisle we can tell you what we are for. Some of us are for the Wyden-Bennett bill with our Democratic colleagues. That is the only bipartisan bill before us today. It has not even been seriously considered by this body, but it is there, and it has significant support in the House. We have two doctors over here: Dr. Barrasso, who has been an orthopedic surgeon for 25 years, and Dr. Coburn from Oklahoma, an OB/GYN doctor. They would like to be involved in the process. So far their ideas are not really being adopted in the result we might have. We have Senator Gregg from New Hampshire, one of the most respected Senators, who has been a part of many bipartisan efforts, and he has his own bill. He would like to be more a part of it, but his ideas do not fit the way things are going. But the way things are going are too expensive for the Congressional Budget Office and take us in the wrong direction, according to the Mayo Clinic. So maybe we ought to step back and say: Well, let's listen to these other ideas. Let's go very carefully. Let's work with the President. Let's see if we can get a result. Let's keep a four-letter word out there that is a good word; and that is "cost," and make sure we focus first on the 250 million Americans who have health insurance and make sure they can afford it; and, second, make sure when we finish fixing health care that those same Americans can afford their government. I thank the Presiding Officer, and I yield the floor.