poland will be taken to mom what reason is the gentleman from new york ross mr speaker i sent to the desk a privilege report from the committee on rules for filing under the rule the commit the clerk will report the title report to accompany thirty one resolution providing for consideration of the bill h r twenty six sixty nine to provide for the reconciliation pursuant to section six zero one of the concurrent resolution on the budget for fiscal year two thousand and eight this will be referred to the house calendar and ordered  printed the gentleman from texas for what reason this gentleman from texas ross is speaker as an end of consensus today following legislative business and any special orders heretofore entered into the following members may be permitted to address the house revise and extend the remarks that include there any extraneous material mr mccotter for to day for five minutes mr poe of texas today july eleventh twelfth and sixteenth for five minutes each mr jones of north carolina today july eleventh twelfth and thirteenth and sixteenth for five minutes each mr wolf july twelfth and thirteenth for five minutes each mr moran of kansas july eleventh for five minutes without objection consent to address the house for five minutes and revise and extend my remarks without objection gentle lady is recognized for five minutes mr speaker we're back from our fourth of july district work period but our home homecoming has not been a particularly happy one because we received even more bad news from the occupation in iraq yesterday the nonpartizan congressional research service reported that the cost of the occupation has soared to ten billion dollars a month which will add up to one half trillion dollars thanks to the administration's decision to send more troops and escalate the occupation can billion dollars a month i pulled out my calculator i did some division and found that ten billion dollars translates into twenty three million dollars per month per congressional district yes the president is sending a bill to our constituents in every district every month that says you owe twenty four million dollars and you'd better pay up because if you don't i'll borrow the money and stick to your children and your grandchildren with the bill plus plenty of interest and i'm going to send you another bill just like this one every single month from here on now some people call the spending on the war the burn rate but america doesn't have money to burn not when we have critically important investments to make in places that really make a difference for our country like education health care the environment energy independence and homeland security including better security at our ports at our airports and giving first responders the tools they need to keep our communities safe and here's what disturbs me the very most the very most about this burn rate while the administration throws a good money after add in iraq it wants to roll back health coverage for kids right here in america those are the wrong priorities they are the wrong values let's ask ourselves what are we getting for our ten billion dollars a month we're getting in iraq government that isn't meeting in any of the benchmarks we're contributing to a refugee crisis that has already forced at least four million iraqis out of their homes with tens of thousands leaving every month and we're stretching our military to the breaking point today the army announced that in june it missed its recruitment goal for the second month in a role war in a role in in a row it appears that parents alarmed about the bloodshed and never ending nature of this occupation are discouraging their children from signing up is not ironic that our involvement in iraq is turning out to be a bad recruiting tool for the united states but a great recruiting tool for al qaeda and other terrorists groups i'm encouraged however that a growing number of my colleagues on the other side of the aisle are turning against the occupation but at the same time the president gave a speech today in cleveland that showed he isn't budging an inch from his failed escalation strategy he said that congress should wait for general petraeus his report on the surge september before making any decision about iraq while admitting at the same time that september is a meaningless goal that's outrageous the american people didn't send us to congress to sit around and wait and wait to do nothing they sent us here to end the occupation and that is what we must do i proposed a bill that would achieve that h r five and wait it would fully fund bringing our troops home safely and soon it would accelerate international assistance for reconstruction and reconciliation in order to keep iraq as peaceful as possible and it would use diplomacy it would use diplomacy not more to teach political solutions to rid regional problems we don't have a golden opportunity in the days and weeks ahead to chart a new card i urge my colleagues to heed the call and listen to history and listen to the american people and to bring our troops home i yield back again ladies time has expired the gentleman from texas mr is recognized for five minutes speaker francis scott key is best known for being the author of our national anthem the star spangled banner during the second american revolution the war of eight hundred twelve the british reinvaded the united states captured washington d c burned this building the white house and most of the city the english then set sail for nearby baltimore and were determined to take the city but fort mchenry was blocking and protecting baltimore harbor key a lawyer had boldly gone on board a british ship to seek release of a captured united states citizen the royal navy held both key in his client and refused to release either until after the british naval attack on the fort completed during the night the british bombarded the fort with hundreds of shells rockets but it dawn's early light the american defender still held the fort refusing to surrender and a massive thirty foot by forty foot american flag still fl but mr speaker key also has a texas connection before saying houston made his way to texas he served with andrew jackson in the indian wars and was elected united states congressman from tennessee for two terms and served as governor of tennessee a governorship houston spent time in washington d c during the one thousand eight hundred thirty s advocating on behalf of the cherokee indian indians and announcing the corruption in the bureau of indian affairs and eight hundred thirty two congressman william stanbury from ohio made slanderous accusations about houston and the cherokees on the floor of congress one morning houston was leaving a boarding house on pennsylvania avenue and saw stanbury walking down the street  confrontation occurred between the two man over stanbury statement a street brawl it resulted sam houston thrashed in viciously be congressman stanbury with his hickory walking kang for stanbury derogatory remarks on this house floor stanbury then pulled a pistol put it to the chest of houston but the pistol misfired mr speaker fate say sam houston's life the united states congress ordered the arrest of sam houston charging him with assault and demeaning a member of congress houston was tried before congress in a joint session with the supreme court acting as judges the trial lasted a month houston spent one full day on this house floor and boisterous oratory stating his position is that he was defending his honor stanbury was the aggressor and anyway stanbury deserved a severe caning so what francis scott key have to do with any of this francis scott key was same houston's defense lawyer he did an admirable job in the defense of this later texas hero but after the trial was over houston was found guilty publicly reprimanded and ordered to pay a five hundred dollars fine houston refused to pay the fine and rather than face more problems with congress left washington that same year and began a new life and political career in texas and the rest i say is texas history general same houston was a successful commander of the texas army during the texas war of independence from mexico and eight hundred thirty six after only person to serve as governor and member of congress from two different states sam houston is troubles with the legislative bodies continued however when texas voted to leave the union and eight hundred sixty one the governor houston refused to take the oath to support the confederacy so the texas legislature removed legislature removed general sam from the office of governor to bad maybe a francis scott key had been same used his lawyer before the texas legislature the outcome not have been for what purpose is a gentle lady from california ross mr speaker i ask unanimous consent that today following legislative business in any special orders heretofore entered into the following members may be permitted to address the house for five minutes to mr jones of north carolina under the speaker's announced policy of january eighteenth two thousand and seven the gentleman from texas mr burgess is recognized for sixty minutes as the designee of the minority leader i think the speaker mr speaker the seeming i want to come to the floor of the house to talk once again a little bit about healthcare healthcare in this country is going to be something that is on the front pages during the next to eighteen months until the next presidential election i suspect it's something we're going to devote a great deal of time and energy to on the floor of this house perhaps even this month but as we debate the future of medical care in this country over the next eighteen months and through the presidential election that will follow in two thousand and eight in the congress that convenes in two thousand and nine we've got to decide on the avenues to which our healthcare system will be based and essentially mr speaker right now we have a system that is based on part on the part on the government part of the public sector and partly on the private sector sector the issue before us is do we expand the public sector to expand the government's involvement in health care do we expand the government's involvement in the delivery of health services a popular referred to as universal health care  back in the one nine hundred ninety s it was and hillary care or do we encourage and continue the private sector involvement in the delivery of health care the two options bring about a significant number of questions and a significant number of current cern's addressed on on both sides of the aisle but i'm hopeful that as we continue to study this problem and debate this problem in this body will shed some light on the direction that we should be taking and mr speaker i don't think there's any question that the united states has developed one of the best health care systems in the world access can be an issue but the quality of healthcare practiced in this country is is second to none you have people coming from all over the world when i was a medical student at the texas medical center down in houston texas you would have people come from all over the world to avail themselves of the medical care that was available at texas medical center in close to my district in north texas you have southwestern medical school in dallas a number of nobel laureates on the clinical faculty there unbelievable sources of of talent and and knowledge that are available to training the young physicians of tomorrow so these are the types of things we've got to be certain that we preserve protect and defend as we do things that will perhaps alter the way medicine is practiced in this country now there are a lot of people who take issue with the fact that i maintain that the united states has the best health care system in the world plenty of people here in this body would say that's an overstatement they but if you torture them long enough they'll admit to almost anything but we've got to dispense with a lot of the a lot of the platitudes in the sand bites and try to get to really what is causing the problems that we have here and how can we asked go about correcting those problems well up applying some some american ingenuity to getting those problems solved so tonight talking about the different principals guy in the debate about public versus private in the delivery of health care services it's important to concentrate a little bit on the background on how we got to the system that we have today and the idea that we have a problem to solve is not new secretary leavitt certainly agree with him when he made the remarks in a speech not to log go that tackling the decision between the two philosophies public versus private recently secretary said in a in a speech in an op ed piece he posed the question should the government own the system or should the government be responsible for some organization in the system and leave the proprietary standpoint to someone else now bespeak are coming out of world war two during world war two in fact this country was faced with some some significant problems and one of the problems was the specter of inflation so franklin roosevelt said look we're going to have wage and price controls in this country so that inflation doesn't get out of control employers employees found themselves highly sought after because the workforce a lot of the workforce was overseas fighting the war so employers wanted to keep their employees happy they wanted to keep them employed they wanted to keep them a loyal to their respective companies but they were unable to raise wages because there was a presidential decree that we were under wage and price controls so the supreme court rendered decisions that benefits things we talk about now as a benefits package health care retirement these things could be available it would not violate the spirit of president roosevelt's wage and price controls so that's the the era of health insurance benefits or employer drive health insurance was born and mr speaker it worked tremendously well so well that it persisted well after the the end of the second world war now a lot of people look at western europe and say eat you know they've got a government run system why don't we do what europe did how did europe develop a system a single payer government run system even though some of the countries in western europe were victorious at the end of the second world war the war was fought in their backyard their economies were devastated it was important for their governments to stand up a medical care system quickly to avert a humanitarian crisis and that is what led to the institution of single payer systems that you see in many countries in europe today but america by contrast came through the war with a benefits package if you will that was available to employees employees like that employers liked it because the employees were happy the employees stayed to some degree healthier and were able to work work more effectively and less time off for sick leave so the american system persisted and did very well for a number of years now fast forward some twenty years from the end of the war to the middle of the administration of lyndon johnson fellow texan former house member albeit on the other side of the aisle but during the tenure of president johnson he signed both the medicare and medicaid programs into law this was a large government program and represented a fundamental shift it was the first time that the that the government got involved in a big way in running running the practice of medicine but it was created to focus on on the elderly to focus on their hospital care and their and their doctor care and certainly make make sure that persons who who were going to be covered by medicare were left in the left in poverty in old age because of because of mounting medical bills but then fast forward another forty years two  hundred eight congress and we had a medicare system that was it was big and it was expensive and was very very slow to change is like trying to turn a battleship in two thousand and three in this in this house of representatives a president came to us and the very first state of the union message that that i attended as a as a member of congress in my first term and the president said he was going to or this congress was going to bring a medicare prescription drug benefit to medicare that people had waited too long for this it was too important to wait for another president or another congress and indeed congress set about the work of providing what we now know as the party benefit and within the the year we voted on that package and within the next year it was indeed it was it was starting to be run but the government system needed to needed to address some of the unit fission sees that were that were built into those were were built into the system now the medicare prescription drug plan has given seniors access to medications that they quite frankly they just didn't have available before and when you look at how medicine has changed from one thousand nine hundred sixty five to two thousand and five when the when the medicare drug plan took effect that the changes that had been brought about by the the advances in medical research are used my dad was a doctor as well and i used to tease in the back in one thousand nine hundred five doctors only had two pharmaceutical choices penicillin and cortisone and they were regarded as interchangeable now my dad didn't think that was very funny but the fact is you come to two thousand and five look at the lives that have been state saved by the introduction of a medicine like like statens of medicines  that are used for for reduction of cholesterol dr elias or who knew at the national institute of health estimates that eight hundred thousand premature deaths have been prevented between one hundred fifty five and two thousand and five with the introduction of medicines to  manage cholesterol in liquid levels and patient's blood that's a tremendous change in one thousand nine hundred eighty five some people simply had a heart attack and died in two thousand and five two thousand and seven that no longer happens but they are required to in order to maintain that state of health to be maintained on a medication wealth medicine is too expensive for the patient to buy they they don't take it and suffer the health consequences and as a consequence the system becomes more expensive because people become end up utilizing the system more frequently and the outcomes for disease management become much worse the program the medicare prescription drug program has been successful there's been a certain number of people who have been critical but it has been a great benefit for for seniors and in fact the the fact that it is up and running now for in it's well into its second year there's a great deal of satisfaction in the penetrance into the the number of people who have prescription drug benefits who are covered by medicare now is at an all time half all time high now in this country as i mentioned earlier the government pays for about half of our health care expenditures we have a g d p of roughly eleven trillion dollars in this country and us department of health and human services states that medicare  medicaid services alone in fact we vote on our labor h h s appropriations bill this year it will be significantly north of six hundred billion dollars so that's about a half of what we spend in health care the other half is broken down  primarily the wages borne by by commercial insurance by private insurance there's a significant number of dollars that are contributed as as charity care or uncompensated care and certainly there are some individuals who just do still simply just pay for their their medical care out of pocket but about half from a government source and a half from from private sources or the goodwill of america's physicians the numbers are going to increase because the overall dollar expenditure in health care is going to increase baby boomers are aging there are more and more advances discovered with every passing month and the federal government is going to continue to funnel taxpayer dollars into medicare we've got to ask ourselves are we getting value for the dollar are we doing the best that we possibly can do with that money is the government doing an excellent job of managing our health care dollars and do we think that the government is better suited to to be the arbiter of a person's health care needs or is that decision are those decisions better left up to an individual or their family and who at the fundamental end of it all who is better able who is going to be better able to handle the growing healthcare needs in this country i would argue that if you have a public only a government run system a universal single payer system that in america it's going to be a significant problem and in fact will have the perverse incentive of hampering our innovation and perhaps even hampering the delivery of of the most modern health care services available and as an example i would i would suggest that we have a model that we can examine that's our neighbor to the north in canada canada has a completely government run system the supreme court in canada in two thousand five however said that the waiting times in canada were unconscious level and access to a waiting list was not did not equate to the same thing as access to care now in canada they actually have a safety valve because if someone needs a medical procedure or needs a medical test done they actually do have an area where there is a a surplus of medical care available and that would be on their southern border the united states of america so if someone is has the ability to pay and wants to come from canada across to henry ford hospital in detroit they are very capable of doing that and i'm certain that the good folks at henry ford hospital welcomed their neighbors from toronto all the time to sell essentially excess capacity that they have whether it be an m r i or a c t scan or even a mammogram heart surgery artificial hips or things that are on the waiting list in canada might take months or even years can be accessed relatively  quickly simply by by crossing the border the waiting list is is significantly longer some procedures if we look across the ocean to to the country of great britain the national health service of course long been established in britain the citizens of that country regard their their health system with a good deal of affection but there is in fact a two tier system in england if someone is on a list for a hip replacement and has the money to pay for it they can go outside the system to a private orthopedic physician and have that surgery performed obviously someone who doesn't have the means to provide that for themselves will simply have to stay on the waiting list and you get into a little trouble with the the the fact that it takes so long if someone is of a certain age another year or two wait is a significant percentage of their remaining expected life years and in many ways that's not fair either a sad reality that exists but but it is true so in both instances you see where the single payer government run system is over is as has has over so been oversubscribed they have a private system either here in the united states or the country of canada or a two tier system in the country of great britain they have a private system to act as a backstop so the question i would ask is if the private sector is more nimble and more able to provide care on a timely basis why in the world would we would we do anything that would interfere with that system it is a complex relationship and how congress does its job and how we how we react to the situation can in fact have a significant impact on making sure that we have the best health care possible certainly i think it is incumbent upon congress to promote policies that keep the private sector involved in the delivery of health care in this country now you almost can't talk about health care in this country without talking about the problem of the uninsured and regardless of the number you use whether it's forty two forty five or forty six million it is it does become a question of access for people without insurance but i would also point out that health care is rendered all the time in this country to people who don't have insurance or don't have the means to pay for it it is not always rendered in the timeframe that would be most propitious for the best health outcome and certainly it's not always administered in the timeframe where it is the least expensive type of care but access to this kid to care in this country is in fact something that is that is generally available it is but it can become very expensive in the time involved can be significant now we have a program in this country it's about to be turned ten years old and in fact is a program that we have to reauthorize this year or it will expire at the end of september and that's a program that provides health insurance for children whose parents are in too much money for them to qualify for medicaid and not enough money to purchase health insurance so we have the program that operates as a joint federal state partnership it does provide some flexibility to states to determine the standards for providing health care funding for those children again who are not eligible for medicaid and whose parents have not been able to to get private insurance the program has been very well very well thought of has been very successful across the board this year and in fact before september thirtieth we have to authorize reauthorize the student the state children's health insurance program and you're going to be a lot of debate i suspect there'll be a lot of debate this month and in certainly in my committee of energy and commerce in the committee on ways and means there be a lot of debate on the best way to go forward with that one of the things that i have had a problem with sense coming to congress and examining the s chip system is the fact that it's a program that was built of designed to cover children but in fact we have some states that cover adults pregnant adults ok that's reasonable to have them covered under the s chip system but non pregnant adults it strains credulity to have a system that is there to provide health care for children and in four states in this country we actually have more adults covered under the s chip program than we do children certainly when you have a state where all of the uninsured children have been covered by the s chip program it may be appropriate to cover some adults but until that condition is met until let that trigger point is met it to me makes less sense to cover adults when there are children who would would benefit from having the coverage from the state children's health insurance program to have them remain done covered while we cover a population that was never intended the money was never intended to be used for that purpose a bill that i introduced h r ten thirteen would make certain that s chip sons are spending exclusively on children and pregnant women and not any other group i hope to be able to to have that considered or that concept considered when we go through the reauthorization of the s chip program and last year in congress we also debated and got through the committee process the reauthorization for federally qualified health centers we did not finish the work on that legislation so we are likely to have to take take that up again this year but what about someone who's not a child not a pregnant woman who who doesn't who doesn't have access to health insurance there are many places in the country where federally qualified health centers exist to give the patient access to health care without insurance gives them a medical home gives them continuity of care the place they can go in and see the same health care providers whether be a physician on earth crack nurse practitioner can see that person over and over again provides primary health oral and mental health and substance abuse services to persons at all stages in the lifecycle federally qualified health centers take care of fifteen million people in this country every year typically someone who who does not and does not have insurance and so would be counted as one of the insured uninsured but the reality is that they do have access to comprehensive and caught the continuity of care just just as someone who has insurance but both the s chip program in the federally qualified health center are designed to help the poorest youngest and neediest in our communities but what about for individuals who can afford to pay some for their health services but just choose not to well we need to get past that point and certainly there are two things that would make the access to health insurance would improve the access to health insurance for people who who do have the ability to pay something for their health care health savings accounts and association health plans health savings accounts or a tax advantage medical savings account available to taxpayers who are enrolled in a high deductible health plan a health insurance plan with lower premiums and a higher deductible in a traditional health plan the old days we used to refer to this is a catastrophic health plan now about one thousand nine hundred six or one nine hundred ninety seven long before i ever thought about running for congress i was a physician in practice back in texas the kennedy kassebaum bill was passed by the house in the senate and signed into law it had in it the what was called a demonstration project that would allow seven hundred fifty thousand people in the united states to sign up for at that time what were called medical savings accounts i subscribe to one of those i purchased one of those for my family the primary reason i did it was not even so much cost considerations but was because it kept me in control of making health care decisions those were the days when o s and one eight hundred numbers were the order of the day and i wanted to be certain that health care decisions that the health care to the decisions that were made in my family were made by my family and not by bureaucrats or an insurance executive the end of a one eight hundred number a medical savings account proved to have although a lot of restrictions on them infirm for that reason a lot of people shied away from them so i don't know that they ever got to their full enrollment of seven hundred fifty thousand but to me it was a another very viable form of insurance again the premiums were lower because the deductible was higher and you were able to put money into an account like an ira called a medical ira that would grow into tax free the interest in it would grow tax free y over year and this money could be used only for legitimate medical expenses but if you had to use it if you found yourself in a situation where you needed to pay for medical care yet you had a high deductible but now you've saved some money that they can offset the high deductible now with the medicare modernization act paxton two thousand and three we also did away with a lot of the the regulations or restrictions on medical savings accounts in the follow on for that are what are called health savings accounts or h s a s for an h s a the funds contributed to the count of the account are not subject to the income tax and can only be used to pay for medical expenses expenses but the one of the best parts about having an h s a is that all deposits stay the property of the policy holder they don't go to the insurance company they don't go to the government they state to the person who has put the state under the control and ownership of the person who's put those those funds regardless of the source of the deposit so that even if an employer makes a contribution to that the funds belong to the person who owns the insurance policy and additionally any funds deposited that are not use that year will stay in the fund and grow year over year different from the old use it or lose it programs that were so prevalent and popular during the one nine hundred ninety s now the popularity's of health savings accounts has grown considerably since its inception the only numbers are the latest numbers i have unfortunately couple of years older from two thousand and five but by december of that year three and a half million people had insurance coverage through an h s a and of that number forty two percent of the individuals or families where had income levels below fifty thousand dollars a year and were purchasing an h s a type of insurance additionally about another forty percent were individuals who who previously had not been insured so this allowed a way for people who who were previously uninsured to access insurance and a good number of those folks were between the ages of fifty and sixty giving or taking away some credence to the myth that h s a is are only for the healthy and the wealthy these programs have been will subscribe again the the numbers that i have are from two thousand and five i suspect they're much more robust at this point but when you consider a young person just getting out of college round about age twenty five if they don't want to go to work for a major corporation and therefore have employer derived insurance what are their options now i'll tell you ten years ago you didn't have many options i in fact tried to purchase a health insurance policy for an adult child in just in that situation you almost couldn't get an insurance policy for a single individual regardless of the price you're willing to pay now fast forward to two thousand and five two thousand and seven you can go on the internet type health savings account into the search engine of your choice and very quickly you'll be given a plethora of choices from from a different from a variety of different health plans and in my home state of texas a male age twenty five looking for health insurance can find a high deductible p p o plan from a reputable insurance provider for between sixty and seventy dollars a month so that eminently affordable sure there's a high deductible involved with that that means is every fall with you go get a flu shot you're probably going to pay for that flu shot either out pocket or or if you have money in your health savings account you can make a drawing that that type of expense is not going to be covered but if that individual's in an accident on the weekend and ends up spending three or four hours in the in emergency room  day or two in the intensive care unit they are going to be covered because those expenses very rapidly will will exceed their deductible and that individual will in fact be covered with health insurance and that is a concept that we need to make people aware that there are options even though you may work for a company that doesn't provide insurance or you're self employed and your a very very small group and otherwise would not have access to employer derived health insurance the concept of a health savings account is available marketed over the internet a lot of competition for those products and as a consequence of that competition the price on those has has come down in the years since they were introduced now speaker the other another concept that we've debated in this house at least every year that i've been here is the concept of association health plans association health plans allow small employers to band together to get the purchasing power of a much larger corporation when they go out in price insurance on the open market to date we have passed that legislation four times that i can recall in the house of representatives it never passed in the senate i would like to see us take up at and at least discuss that is a possibility this year i don't know in fact if that will happen but association health plans may not bring down the number of uninsured directly but it certainly would help bend the growth curve that's going inexorably upward of the number of people who are not covered by insurance because it allows for small employers again to get access to much more economic leverage in the market for buying insurance policies and allows them to to be able to offer that insurance policy to to their employees in any given the small group market it means that a group of perhaps chambers of commerce or group of of real tours could band together and offer health insurance to their employees where otherwise it might not have been available but all of these things are important another factor to consider and we've got to be careful here that we don't get the cart before the horse about a year and a half ago alan greenspan was talking to a group of us just before he left his position that the federal reserve board in the process of that discussion someone brought up the issue of medicare and how we're going to pay for medicare where is the funding going to come from and mr greenspan  after some reflection said i feel confident that at some point in the future congress will come to grips with this problem and we'll solve this problem he said but he went on to say what concerns me more is will there be anyone there to provide the service when you require it and those words really struck me what he's talking about is are going to be are going to be doctors there in the future are going to be nurses there in the future to provide for us when when we are the ones who are relying on medicare for our health services now back in my home state of texas texas medical association puts out up a journal the of every month called texas medicine and last march they had a special that was titled running out of doctors our country faces a potential crisis with a health care provider shortage or a physician shortage in the future so when we work on health care issues here in this body and on both sides of the aisle is going to be important when we work on health care issues in the congress we have to be certain that we retain the doctors of today that we encourage the doctors who are in training today and they were i encourage those young people who might consider a career in health care that we encourage them to pursue that dream and realize that dream certainly the doctors of today those at the peak of their clinical abilities it's incumbent upon us to make certain that they remain in practice and they continue to provide services services to our medicare patients services to patients who typically have one two three or more medical problems some of the most complex medical issues that they can face a practitioner today will occur in the medicare population well what steps do we need to take to make certain that we have doctors in practice that we have people there able to deliver those services that alan greenspan was talking about a year and a half ago well mr speaker you almost can't have this discussion without talking a little bit about medical liability now in the four years prior to this congress every year again we passed some type of medical liability reform bill in the house of representatives it never got never got enough votes in the senate to cut off debate and come to a vote i feel certain that it would have passed had it come to an up or down vote but they were never able to muster the the sixty votes we need common sense medical liability reform to protect patients to protect patients access to physicians to stop the the continuous escalation of costs associated with with medical liability it is in this country and in turn this makes health care more affordable for reform and more accessible for more americans because we keep the services available in the communities as they are needed they are needed and mr speaker i believe we need a national solution our state to state responses to this problem some areas my state of texas has has gone a long way to solving the problem but there are many areas in the to many areas in the country where the problem persists and it does remain a national problem we have an example i think a good example in my home state of texas of exactly the type of of legislation that we should be considering in the house of representatives texas in two thousand and three brought together the major stakeholders in the discussion they included the doctors patients hospitals nursing homes crafted legislation that  was modeled after the medical injury compensation reform act of one nine hundred seventy five that was passed in california in that year in seventy five some differences with the california law but but basically it's a cap on noneconomic damages in texas we had a significant problem with far as medical liability was concerned we had medical liability insurers that were leaving the state they just simply were not going to write any more policies they closed up and closed up shop and left town because they couldn't see a future  providing medical liability coverage in texas we went from seventeen insurers down to two at the end of two thousand and two the year that i first ran for congress the rates were increasing year over year my personal situation running my own practice back in two thousand and two my rates were increasing by thirty to fifty percent a year in two thousand and three the state legislature passed medical liability reform again based off the california law of one nine hundred seventy five the california law in one nine hundred seventy five was also a cap on noneconomic damages they had a single cap of two hundred fifty thousand dollars cap on all noneconomic damages in texas the cap was tracked for kate and in fact there's a two hundred fifty thousand dollars cap on noneconomic damages as it pertains to the physician two hundred fifty thousand dollars cap on noneconomic damages as it pertains to the hospital and a two hundred fifty thousand dollars cap on noneconomic damages as a pertains to a nursing home or a second hospital well  then of seven hundred fifty thousand dollars on noneconomic dam yes how's the texas plan fared remember that we've gone from seventeen insurers down to two because of the medical liability crisis in the state now we're back up to fourteen or fifteen carriers and most importantly those carriers have returned to the state without a premium increase in two thousand and six three years after the passage of the medical liability reform the insurance company called medical protective i had a policy with medical protective for years and years of medical protective company cut their rates ten percent which was the fourth reduction since april of two thousand  texas medical liability trust my last insurer of record when when i left practice in texas has had an aggregate cut of twenty two percent since the law was was passed advocate m d another insurance company has filed in one thousand point nine percent rate decrease another company called doctors company has announced a thirteen percent rate cut these are real numbers season fact real people in real practice situations in texas it's a significant reversal of the year i first came to congress we lost we lost one half of the neurosurgeons in the metroplex because of because of a medical liability expense problem the doctor simply looked at this let the at his bill what he got for the renewal of his policy and said i cannot possibly work enough to pay for this and pay for my practice and support my family so i will go elsewhere the net effect of that is what it would put the whole trauma system in north texas at risk because nerve surgeon was now going to have to do the work of two and you just can't physically work twenty four hours a day seven days a week delivering that type of care so the whole trauma system was was put at risk before this law went into effect in texas  a young man that i met during my first year in office who was the type of physician called perry nato logistics is an obstetrician like i was being gone on and gotten specialized training to care for those high risk pregnancies those those pregnancies that were really at risk well you can imagine his medical liability premiums were mine were high as an obstetrician his were even higher as an obstetrician who specialized only in high risk cases and in fact a a lecture in texas he came to me and said you know i'm just going to have to leave the practice medicine altogether because i did not question not being able to pay for insurance i just simply cannot get it well how are we furthering the cause of patient care if we take a young person who's very energetic and very dedicated to taking care of the the highest risk pregnancies in the metroplex and we say whoops sorry you can't practice because we can't get you insurance anywhere now happily in texas that situation is reversed and that doctor i know important issues that this medical liability reform brought to the state of texas one of the unintended beneficiaries of the of the legislation was the the benefit for community small mid sized community not for profit hospitals who were self insured as far as medical liability was concerned they had put so much money in in escrow to cover the potential bad outcome that that that money was just tied up that was not not available to them now they've been able to back some of that money out of those escrow accounts because of putting stability into the system with a cap on noneconomic damages and now they're able to use that money for capital expansion nurses salaries exactly the things you want your small community not for profit hospitals to be engaged in the very activities you want them to be engaged in they can now once again participate in because of because of benefit the benefits from the medical liability plan that was passed in texas so mr speaker i took the language of the texas medical liability plan worked with legislative council and made it so that it would conform with all of our constructs here in the house of representatives and although i didn't introduce that into legislation i offered it to the ranking member on our budget committee last spring when we did our r and we offered a republican budget here on the floor of the house and the mr ryan the ranking member had that scored by the congressional budget office and the texas plan as applied to the house of representatives legislative council and applied to the entire fifty states would yield a savings of three point eight billion dollars scored over a five year time span now that's not a mammoth amount of money when you talk about the types of dollars we talk about in our federal budget some two point nine nine nine nine nine trillion dollars but nevertheless three point eight billion dollars over five years is not insignificant and it's basically money that we left on the table because we did not include the language of that medical liability reform in the in the budget that was passed this year now when i say the problem although the problem in texas is measurably better than it was when the when i took office here consider in one thousand nine hundred six dudie dunne at stanford university there revealed with within the medicare system alone the cost of defensive medicine that's medicine that you practice so that you tone the charge and you look good if something goes wrong in this case is brought to tot trial if you practice satisfactory defensive medicine you'll be able to defend yourself in the case of a medical liability suit and a couple of doctors at stanford got together a couple of economists at stanford got together and put pencil a friend said well what does this cost medicare what does it cost for doctors to practice this type of defensive medicine and it cost about twenty eight billion dollars a year back in one thousand nine hundred six i would submit that the number is probably higher today if they were to revise and redo that study so that is a significant amount of money and the medicare system is the one that pays for that remember medicare runs about three hundred billion dollars a year that's almost ten percent of its budget that is being spent on defensive medicine because of the broken medical liability system we have here in this country we can scarcely afford to continue on that trajectory that we're on with the medical liability system in this country and you know another consideration mr speaker we talked a little bit about young people who are perhaps considering a career in in  medicine or nursing and the current system the current medical liability system is a deterrent for going into the practice of health care because they look at the burden that's placed on on young doctors and and nurses the burden that's put on them for the payment for for medical liability insurance and we keep people out of the system and that's something we we have to consider because again remember we're talking about physician workforce issues and how we how we keep the doctors of today in practice but how do we encourage that young person who's in middle school or high school today who's who's thinking who's thinking about a career in one of the health professions and we want them to be able to pursue that dream but currently they get to the end of college and they look at the expense for medical for getting medical training they look at the expense that they will the money they'll have to put up front to purchase their medical liability policy when they get out and they say it's it's maybe it's not worth it in the problem mr speaker the problem with that is these are our children's doctors and our children's children's doctors who perhaps are not going to go into the healing professions be was of because of problems within the medical liability system i could talk for that about about that a great deal longer but let me get to three specific pieces of legislation that really get to the to the core of dealing with the the physician workforce issues that i think the problems that i think we're going to face in the future if we don't we don't get our  arms around this problem a recent piece of legislation that i introduced h r twenty five eighty four so called physician workforce and graduate medical education enhancement act of two thousand and seven part of this legislation is to ensure the workforce in the future by helping young doctors with the availability of residency programs you know one thing about physicians is we tend to have a lot of inertia we tend to go into practice where we did our residency we tend to not go too far from home when it comes to to setting up a medical practice so with that in mind in fact that was one of the main thrusts of the article that was included in texas medics medicine is to develop more residency programs in the communities where the medical need is greatest and develop those residency programs with the type of physician that's needed in those medical communities primary care to be certain obstetrics to be certain general surgery again the types of physicians that that we want to be in the front line on the front lines practicing in our in our medium sized communities we need to get young doctors in training in locations where they're actually needed this bill the physician workforce bill would would develop a program that would permit hospitals that do not traditionally operate a residency training program the opportunity to start a residency training program and build a physician workforce of the future and build it from the ground up build it there it started home start right we're right where it's going to be needed on average it costs one hundred thousand dollars a year to two rayna resident and the cost for a smaller hospital that cost for a smaller hospital obviously can be prohibitive because of the cost consideration bill would create a loan fund available to hospitals to create residency training programs where none has operated in the past the program would require full accreditation and be generally focused in rural suburban inner community hospitals and focus on those specialties that are even in the greatest need and that will of necessity be some of the the primary care specialties that i just mentioned well what about  those people who may not yet be in medical school but may be contemplating a career in health care locating young doctors where they're needed is just part of solving the impending physician shortage crisis that i think will affect the entire healthcare system nationally another aspect that must be considered as training doctors for high needs specialties the second bill h r twenty five eighty three the high need physicians specially workforce incentive act of two thousand and seven well established a mix of scholarship loan repayment funds and tax incentives to entice more students to medical school and create incentives for those students and newly minted doctors to stay in those communities this program will have an established repayment program for students who agree to go into family practice internal medicine emergency medicine general surgery or o b jan and practice in a designated under served area it'll be a five year authorization at five million dollars per year it will provide additional educational scholarships in exchange for a commitment a commitment to serve in a public or private nonprofit health facility facility determined to where there's a health care create a critical shortage of primary care physician financial concerns of encouraging their zoc doctors to remain in high need specialties the next bill h r twenty five eighty five will address perhaps what is the largest group of doctors in this country what i like to call a mature physician and certainly the largest and still growing group of patients are baby boomers those who are just on medicare and those soon to be on medicare now i see that before i get too far him time to i talk first of this one to applaud you for your leadership on this issue as an o b g y n physician you know this issue probably better than anyone in this institution but i just want to share with you a perspective from the commonwealth of pennsylvania where we were a crisis state seventy s when no one would write insurance medical liability insurance and so we created a state fund and that was supposed to be a stopgap measure but we had to address that stopgap measure most thirty years later in the two thousand and two two thousand three but the point of the whole issue was you had to buy insurance from the state fund we call it the m cap fund has been renamed the m care fund and then you would buy additional insurance from the private sector the problem with the program was though that you would buy your insurance basically today if you're a young doctor you buy into the end care fund and you're really paying to for past claims unlike a traditional insurance product where you pay your premium today to pay against  future claim and so this is created enormous retention problem for us because over the years there are so many unsettled cases in this and cat fund that what would happen is that these these these claims a collected and we started settling these cases rather aggressively in the late ninety's and two thousand and one two thousand and two and so today's physicians were being assessed with an emergency surcharge to pay for previous medical liability incidents a major major problem and also in a city like philadelphia where the average jury verdict was more than double that of anywhere else in the commonwealth of pennsylvania where  on average as reported by jury verdict research and the rest of the commonwealth the the the verdicts were less than half that but my point again is this we created the state fund and unfunded liability accumulates today's doctors are paying for the liability situations of their predecessors creates an enormous physician recruitment problem of course is always a retention problem but the recruitment problem was enormously pronounced because of that policy change lee happened because the premiums became so high through the state fun that the ultimate the people who ultimately had to solve solve this problem for the physicians or the taxpayers and so the taxpayer cigarette taxes were used then to discussed here whether it's caps on non economic damages or collateral sources structured payments that some of the things that you've done in pennsylvania i mean in texas i'm not as familiar with all those changes but it certainly had an impact and so i just well in the applaud you for this and you know of course there's legislation pending in this congress from some of the legislation last session and i just want to thank you for yelling but i just again one applaud you for your leadership on this issue i'm glad you bring this issue once again the attention american people and i thank the gentleman for his input certainly the the ability to recruit doctors to texas from pennsylvania has been greatly enhanced by the passage of the texas medical liability bill but you point up a very real problem that the physicians in pennsylvania face and again it points up the need for a national solution to to to wait and and have the process work its way through every state legislature state by state it costs an enormous amount of money it costs an enormous amount of time and and and and just the the effort and the efficiency of those doctors affected is is going to be diminished so it is i really appreciate the gentleman taking the time to come down here and and add his his thoughts about what's happening in his his home state of pennsylvania which speaker let me let me go on and talk just a little bit about h r twenty five eighty five that will will address the problems of some of the problems that are faced by the physicians who are in practice now  primary source of care for our medicare patients baby boomers retire the demand for services are going to go nowhere but up and if the physician workforce trends of today continue we may not be talking about a medicare funding problem we may be talking about why there is no one there to take care of our seniors year after year there's a reduction in the reimbursement rates the reimbursement payments from the center of medicare and medicaid services to physicians for the services they provide for medicare patients it's not a question of doctors just simply want to make more money it's about a stabilized repayment for services that have already been rendered and it isn't just affecting doctors the problem also sex patients have becomes a real crisis of access not a week goes by that i don't get a letter from up from a physician from somewhere in the country or fax that says you know what i've just had it up to here and i'm going to stop seeing patients i'm going to retire early i'm no longer going to accept new medicare patients in my practice or i'm going to restrict those procedures that i offer to medicare patients and unfortunately i know this is happening because i saw it in the hospital environment before i left practice five years ago to come to congress and i hear it in virtually every town hall that i have in my district someone will raise their hand and say how come on medicare you turn sixty five and you've got to change doctors and the answer is because their doctor found it no longer economically viable to continue to see medicare patients because they weren't able to pay for the cost of delivering the care they weren't able to cover the cost of delivering the care now medicare payments to physicians are modified annually under a formula that's known as a sustainable growth rate because of flaws in the process and flaws built into the formula the s g r mandated physician fee cuts in recent years have only been moderately averted at the last minute and if long term congressional action is not implemented the s g r will continue to mandate physician cuts now unlike hospital reimbursement rates which closely follow the consumer price index  measures the care of costing the cost of providing care physician reimbursements do not have a graph here again from the texas medical association that shows in based on various calendar years what the cuts in the s g r formula have amounted to as far as physician reimbursement versus what the cost of living adjustment has been for medicare advantage the medicare h m o s for hospitals for nursing homes for for farmers circles now would be the  same type of formula only physicians are asked to are asked to live under this formula in fact ordinarily medicare payments do not cover or only cover about sixty five percent of the actual cost of providing the patient services can you imagine going to any industry or company and ask them to continue in business when you're only paying them sixty five percent of what it costs them to stay in business the s g r links physician payment to updates to the gross domestic product and the reality is that has no relationship to the cost of providing patient services but the simply simply the repeal of the s t r has been difficult because it costs a lot of money but perhaps if we do it over time perhaps we can bring that cost down to a level that's manageable paying physician fairly paying physicians fairly will extend the career practicing physicians who would otherwise opt out of the medicare program seek early retirement or severely restrict those procedures that they offer to their medicare patients it also has the effect of ensuring an adequate network of doctors available to older americans as this country makes a transition to the physician workforce of the future in the new physician fake physician payment stabilization bill the g r formula would be repealed in the year two thousand and ten two years from now but would also provide a cent of payments based on quality reporting and technology improvements these incentive payments would be installed to protect the practicing physician against that five percent cut that is estimated to current occur in two thousand and eight and two thousand and nine note that this would be voluntary no one be required to participate in either program that dealt with quality improvement or technology improvement but it would available to doctors for practices who want to offset the proposed cuts that will occur in physician reimbursement until the two years time to the physician payment formula can be repealed now i do know that a lot of doctors don't like the concept of postponing the repeal of the s t r by two years in fact in the bill twenty five eighty five by resetting the baseline of the s g r formula technique that we used in this congress back in two thousand and three by resetting the baseline the amount of cuts contemplated for two thousand and eight and two thousand and nine are actually modified significantly and in fact there may need there may not be a cut it all in two thousand and eight or two thousand and nine this could translate into an actual up  positive update for physicians in those two years but the critical thing in my mind is that we have to be we're guard most of what we decide to do over the next two years we've got to be working on a long term solution to get out from under the tyranny of the s g r formula now why do it this way not just but why not just bite the bullet and get the s g r out of the way and get it repealed once and for all the problem is that it costs a tremendous amount of money to do that and the problem we have in congress  that we're required to submit all legislation that we proposed to the congressional budget office to find out how much something costs for going to be spending the taxpayers money we've got to know how much we're going to spend over what time will we spend it because of constraints of the congressional budget office we're not allowed to do what's called dynamic scoring we can't look ahead and say you know if we do this we're going to save money gresham the congressional budget office doesn't work that way that's why postponing the repeal of the s g r by two years take that savings that is going to occur over those two years time sequester it in the aggregate aggregate that savings and put it towards paying for the repeal of the s g r and replacing it with a cost of living index the medicare economic index that would be much fundamentally much fairer one of the main thrust of the bill is to require the centers for medicare and medicaid services to do just exactly that and to look at that tim diagnostic codes for which most of the monetary expenditures are rendered in you know the old bank robber willie sutton when he would it would it was asked why he would rob the bank he said that's where the money is well let's go where the money is let's go to those top ten let's go to those top ten procedures or diagnoses that rip that spend the greatest amount of medicare and look for where the greatest amount of savings can can be found and in within that the same considerations actually apply to the medicaid program as well so it will be useful to go through this process and then to find those top ten conditions and trying to modify things so that the delivery of care for those top ten conditions actually ends up costing us less mrs speaker in the time i are there remains i know i've talked about a lot of a lot of stuff tonight a lot of it is technically very complex and i'll admit it a lot of it's actually boring to listen to but it is an incredibly important subject and it is an incredibly important story that we have to detail here in congress it's a story of how the most advanced most innovative and most appreciated health care system in the world actually needs a little help itself the end of the story should read happily ever after but how are we going to get to that conclusion in fact the last chapter may well read the private industry leads to a healthy ending at the beginning of this hour we talked about the debate that will forever change the face of health care in this country again i think it's important to understand that that we understand here in congress so we understand what's working in our system and what it's not we can't delay making the changes and bringing health care into the twenty first century i believe the only way we can make this work is if we allow the private sector to to be involved to stay involved volved and in fact lay the foundation for the improvements that we all want the pillars of this system are that we're going to have have to be rooted in the bedrock of a thriving private sector not the tenuous ground of a public system that has proven costly in a fish and in other countries i believe we need to devote our working congress to building a stronger system and involving the private sector within that system history has proven this to be a tried and true method we can bring down the number of insured we can increase patient access we can stabilize the physician workforce and we can modernize through technology and we can bring transparency into the system each of these goals is within our grasp if we only have the foresight and the determination the political courage to achieve each goal each goal again mr speaker i reference when i was a medical student in houston people come from around the world to come to the texas medical center for their care there's a reason that people come from around the world to the united states for their health care and for their treatments we are the best but we must remain adjustments to remain at the top of the game i thank the speaker and i'll yield back the balance of my time to the speaker's announced policy of january eighteenth two thousand and seven the chair recognizes the gentleman from washington mr inslee for sixty minutes without objection mr speaker i come to the floor of the house this evening to discuss the potential loss of internet radio by americans tremendous service that because of internet software musical geniuses seventy million americans now enjoy the ability to listen to music by web broadcasters over the internet it is a tremendous service it is as ingrained in a lot of americans daily lives as a cup of coffee and the morning newspaper and unfortunately i have to inform the house that that service may be gone in a matter of a few weeks if we don't reach a resolution of a frankly wrongly decided decision by a group called the copyright royalty board and what i've been disturbed to report to my colleagues is that some time ago march second two thousand and seven we had a decision by a federal agency the ramifications of which would be to shut down the ability of americans in a realistic basis to continue to enjoy internet based radio and the reason this happened is that this board was given the authority to set the royalty that should be paid by web casters who stream out this great music by the way tremendously diverse music one of the great thing americans love about internet radio is you've got such eclectic different types of music not just top forty you know i haven't progressed past the beach boys in the sixty's but there's a lot of the kinds of music and internet radio has been tremendous by allowing people to enjoy thousands of different genres and types of music but now this copyright royalty board has issued a decision which will explode the royalty that these web casters are forced to pay to those who generated the music to the extent that it will make it totally economically impossible for these businesses these web casters to continue to stream music to the seventy million americans who now enjoy it and we need to fix this problem we need to fix it urgent y because a the decision will this this get teen will come down on jan july fifteenth if either congress doesn't act or an agreement is not reached between the parties to adjust this copyright fee that is having to be will have to be paid by the web casters so we need to fix this problem in doing so we need to do it in a way that is fair to the musicians and artists who create the music that seventy million americans enjoy over the internet these artists work hard in producing this music they sure they're genius it's a artistic gift they have and they share it with americans and they need to be compensated fairly to allow them to maintain their business model as well unfortunately this was a wildly disproportionate decision by this board that is grossly unfair to the distributors of the music and simply will allow them not to continue in business and to give folks in order a feeling of how distorted this decision will be like to refer to this graph which shows the internet radio per song royalty rates under preexisting law starting in two thousand and five that started a point zero zero zero eight dollars in two thousand and five and by two thousand and ten we'll we'll have foisted on us one hundred forty nine percent increase in these royalty rates i'm not sure any business model that can can tolerate a three fold increase just in the purse on royalty rates that these folks are having to undergo in unfortunately this royalty rate means about a three hundred percent increase for big web casters but because of the particular rules here it's a twelve hundred percent increase for small web casters so the small web casters which are the vast majority web casters will be hit potentially by twelve hundred percent increases now this board this copyright roll t board has refused to reconsider their decision and what it means in in the real world is the internet going silent and many of these stations a few days ago went silent to demonstrate and protest its decision and i know americans are disturbed by this and they're now talking to my colleagues i know thousands of them to communicate with my call the league has a as a result of this so we need to fix this this this problem i know in my district i'm from an area just north of seattle first district state of washington we have an webcast are called big are radio and they stream to over fifteen thousand listeners and enjoy their product but because of this decision their rates are going to go up to a level and you've got understand how bad this is their rates they would have to pay just for their royalty not for their overhead their rent their salaries the royalties they would have to pay for this exceed by one hundred fifty percent the revenues that this business is getting in while the asli that's untenable and this company will have to either go offshore or simply shut down if this change is not some changes not made now that's bad for big our radio the company but it's but it's bad for the fifteen thousand people that enjoy their music right now we need to fix this problem so the first the first damage that was done is this person on radio royalty but there was another perhaps even more odious thing that this board did the preexisting rule required a five hundred dollars charge or sees me a per state minimum fee and this new ruling required a five hundred dollars charge for each streaming station that they offer the webcast was of course stream under certain channels but under this decision there was no limit on the amount total in this per streaming channel that would be placed in many if not most of web captures have multiple channels so if you look at what it will cost just three of these web casters pandora real networks and yahoo because are getting socked with this five hundred dollars per channel and they broadcast literally thousand lessons of channels with no limit just those three web casters would have to pay one point one five billion dollars with a b these rates will dwarf the radio related revenues by substantially more than a billion dollars in other words it'll charge these businesses more than a billion dollars more than the revenues they generate from this business that's absurd it's ridiculous it has no relationship to economic reality and it is a government glitch a foul up of the highest order that needs to get repaired this would result in sixty four times more  the total royalties collected by the group called sound exchange that collects these royalties in two thousand and six an increase of more than and is a pretty amazing number to me ten million percent over the minimum fee of twenty five hundred dollars per licensee clearly this is beyond the realm of economic reality finally this royalty burd board the third thing that they did they eliminated the percentage of revenue fee that many small boy castors used to determine their performance royalty which would be severely damaging to small web casters so to put this in perspective in a global sense i want to refer to what this will mean in total total royalties if you look at this chart you show total royalties a two thousand and four of ten million that  fee into the old royalty really rule in two thousand and six would be eighteen million but under this decision this flawed decision it will back surely be one thousand one hundred fifty million so if you want to see the difference graphically of what the old royalty would be in two thousand and six this bubble go to this supernova call it in two thousand and six this is untenable and needs to be fixed now in order to fix this represented manzullo and myself of introduce the internet radio equality act it's h r twenty sixty and this bill would fix this problem by doing something that appears eminently fair to me which would simply have the same rate to be paid by internet based web castors as broadcasters now pay over satellite radio over cable radio and over jukebox it's worse